HomeMy WebLinkAboutVALLEY VIEW TERRACE BLK 2 LT 1
/ '1 MUNICIPALITY OF ANCHORAGE ~ ~
· ..
DE~ART~£NT ~ HEA~T~ & ENV~RON~EN~A~ ~RO~£CT~N ~ ~-~#~-- ~ ~
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99503 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~'I~EW
LEGAL DESCRIPTION
[~UPGRADE
Liq. capacity in gallons Absorption area
.,STANCETO: ""
IF HOMEMADE:Dwelling Inside length
DISTANCE TO:
Manufacturer
DISTANCE TO:
Well
NO. Of lines line Tota/le~.gtj'J of lines
W dth
Material
NO. OF BEDROOMS
PERMIT NO.
No. of c~artments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Distance between lines
Top of tile to finish grade
Width
Material beneath tile
Type of crib Crib diameter Crib depth
Well foundation
DISTANCE TO:
Class
Depth
Building foundation Sewer line
DISTANCE TO:
Total effective absorption area
inches
PERMIT NO.
Total effective absorption area
Nearest lot line
Septic tank
Distance to lot line
OTHER
SOl L TEST RATING
REMARKS
DATE LEGAL
72-013 (Rev. 3/78)
F'F!']:;~:F'II T NO,
4F I-t_ I ~. I,ff
..0 C:F-FF* I ON
_EiGRL
LO-I'
4 ......... 5;ii;:! L.! Ft E'. E F:'EE'F
Fl"iiE; RIEg!I..III;;:E[:' oI¢.E OF THE :,uIL PE,:,LI.FTI-N :',,c ...... I5;:
THE L._ENGTH DIi"IENS;IOI".I I5:; THE I..ENEiTH ':lIN FEET) OF THE T!~:EI",tCH OR [:'RFf!I"*tF!EI.B'.
THE DEF'TH OF R "I"RENCH OR PIT IS THE [:,IS"I'RI'qCE BE'f'I.,IEEN THE :II;IJRF:'FICE Of::' 'I'HE
GROUND RND THE BOTTOM OF THE EXCR'v'RTZON (lt',l F'EE'I').
TFqERE I5 NO SET I.,JID]'I4 FOR 'Tt:~:ENCtqE:S.
'THE GRFIVEL [:,EF'TH IS THE MINIMUM DEPTH OF GRF~'v'E:I_ E:ETr'P.IEEN THE OUTFFILI.. PIPE
FiND THE E:OTTOM OF' THE E',:<CR',/RTION <IN FEET).
I::'EF;~:t"[ I 'F' I:::IPPL I CFINT HFIS THE RES;F'ONS I E: I L I 'f'"r' -F() ! NFORM TH 15; [:,EF'FIF;iiTFiiEl",l'F' [)LIR 111NG 1-HE
I II....LL_ IzlE:,.ifFICENT TO TH I E; F f. JF EF. I FINE:' THE
]' N5 TFILL R"F' l (iiN ' ~'=':* -' - ':: :' '= -; - ;" "'
I I ,.. ~ E. _. I t ,,. [ I.. OF FINtr'
..,L L. ¢[
NUMBER OF RE:~;ZDENCE~; TI'-If~T THE WELL 14ZLL. :::'; :
................... "T' ~....9 EZn <:" ;:2~. 1:' ~; ~ 'ql .:-::. F-' E::._ L.- If ~. L.." ~ ,..ii ,:.,.. F:P F;~: EZ
~r,_l I....~.1J...H RND
E:RCF::]:rlL. L. ING 13]::;' FIN'.r~ ...._.IE.I'I !.4ITHOUT F~[Ni::IL ~
[:,E]Z'FIR'T'MEN]" kliil L.L. E:E '5 1 IF:.TEr":T TO P};' '~- ':5 E ]:tFl' I ON.
i'"l I N I MUM D I 5-FRNCE BE'F'klEEN R .klELL. FIN[) F:li'.,IY ON-'-"-ii:; I'T'E E;EHFIGE [) ! E;PO:E;FIL. 5iPT'SII:'i'EM :[ 5
:'[.Eu21 F:'EET FOR R F:>RI'v'FFT'E 14EL. L.; OR
%50 TO 20'0 FEET F:ROM R PUBL.tC PFELL. DEPENDING UPON THE T'T'PE OF F:'LIE:L_IC WEii[.I
OTILEFR FREg!UIREhiiENii":5 I"1R'¢ FIF'F'L."r'. SF:'ECIFIC:I::FFIONS; RNF) CON'.E;TRUCTiON E:,IFIIGI';~:RMS FIRE
FI'v'FIILFIIE',LE TO IN'_:'~;URE PROF'ER Ir.,ISTRLLRTIOI'.,I.
I CER"r'IF%.' THFIT
:J..: ! FIl"l FFIP'iIL.!FII:4: N ITH THE REg!UIREi'qENT5 FOR ON..-.:E;ITE :E;EI.,.IER% FIh!D P.IIELL..E; F:iiS; 5E'F
F()RTH E:"r' ]'HE MUNICIF:'RLIT'¢ OF FlNCHORFIGE.
2: ! NILL. INSTFILL THE 5"/?I'Ef'I IN FICCEg4'.F)FINCE 1.4ITH THE E:ODEE;.
ii:: i LINDEF;,:STRN[:, THFFF' THE ON"SITE ':'SEP.IER ?r'STEM MFI"? REQUIRE ENL. F:IF~'.GF::]'qENT IF:: THE
RESIE:,ENCE IS REF4ODELED TO INCLU[:,E MORE 7'HF:IN ]: BEDRE~OMS.
°,%/
DATE SIGNED
Redi,~rm'- ® SEND PARTS 1 AND 3 WITH CARBON INTACT -
4S 469
pART :3 WILl. BE RETURNED WITH REPLY
r)FTACH AINII~ FIIF FOR FOLLOW-UP
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-B50, Anchorage, Alaska 99502 276-2221
SOILS LOG - PERCOLATION TEST
/z~clc.~v¢'~.~ DATE PERFORMED:
8
~' SOILS LOG
PERCOLATION
TEST
.h /7w
SITE PLAN
j7
10
11
13-
14-
15-
16
17-
18-
19-
20-
WAS GROUND WATER
ENCOUNTERED?
DEPTH7 IF YES, AT WHAT
/6 ' 7'o't,,./ O~.pt'A
Gross Net Depth to Net
Reading Date Time Time Water Drop
' ' ti. -/g o S
~/ ~.~///y~ ~o ~.',. lO ,.,,....
PERCOLATION RATE ~. 7- ,/~,','~ (minutes/inch)
TEST RUN BETWEEN ~ FT AND '7 FT
COMMENTS
MOENihiG-GREY &
PERFORMED BY: ~-- .~- ~¢--~'~
//× / - ·
CERTIFIED BY: ASSOCIATES, INC. ,
72 008 (7/76)
May 3, 1978
Mr. Richard W. Thornton
P.O. Box 4-2461
Anchorage, AK 99509
Subject:
Dear Mr.
Lot 1, Block 2,
Valley View Terrace S/D
Thornton:
Based on the April 27, 1978 recommendations from the Department
of Health and Environmental Protection this office has no objec-
tion to the locations of a septic tank and lift station within
50 feet of the
stream with the seepage area to be located at
Sincerely,
least 100 feet away.
cc.'~Les Buchholz
Anchorage Muncipality
Dept. Health & Environmental Protection
Supervisor
GL
0 0 0 0 0 0 rD 0 0 0 0
[~ 0 0 0 0 0 0 0 0 0 0 '%
i)ay
B 1 oc:k,~ 2
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[..,[)C:~Vi i C)N CHAIH[:)i!i: ]: S NIEZCESEiPffRY .. ):) I SF'OS I TI C)lq (]F E: X ]: ST :1: IqD NE'.I-I-
.815: DI::JI'EI:;:MIIqE:D I..-',/l'll:!i:l".l ixlEN NIEL,I... IKIEi!'F:'&..L, IiED. NcYr.[F:Y DHI-.IEi C)I:::
NIE).,[.~; D ]: SPC,','..ii I T ]: Otq :1: N WF? 11' ): BIB N,HIEN NELl.. I.,.CIG i ~ ,~FiLIM ]: T"I'tE D,.
l'I'! :t: ~!i F>l!]::dq :I; 'I I ,"ii I BSI.JI.tI:~iD l='[ll::i 'TIqE E[ X I ST I Iq(3 :5 BDI::/M. El I Iqi'iH...E I;::~::~l~l :t: I,...Y
]: C;i'.FII'II:¥ !HAili
]: l,',l:i ], ] .~c~i:JhC:,H*C~ Lc:I al,
cl'i.s'L~ncess~. {r',:)m any ~+(ist.'i. ng
any (;~,lq:iaPCje)mix,[i'~'., wJ:[ :!.
?
/
/
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(ger fie Drdlmg
by
DOC Co. dba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99667 · TELEPHONE 688-2769
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE - Started ; ,
PERMIT NUMBER
Ended ' /' ~
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
:/' ,y .-.
GALS. PER HR
KIND OF CASING
KIND OF FORMATION:
From Ft. to :' Ft.
From ~ Ft. to ,' / Ft.
From Ft. to ~ , ;" Ft.
From Ft. to ' /~ Ft.
From ' '~ Ft. to :~, Ft.
From Ft. to Ft.
From Ft. to Ft.
From -~ Ft. to Ft.
From__ Ft. to Ft,
From - ~ Ft. to Ft.
From , , Ft. to ' ' Ft.
From ' · Ft. to ':" Ft.
From · ~ Ft. to ,- Ft,
From .Ft. to Ft,
From Ft. to_ Ft
From Ft. to Ft._
From Ft. to Ft._
From --
From
From
From
~; - ~"' ~ From
From_
From
Ft. to--Ft,
Ft. t~__Ft.
Ft. to Ft.
Ft. to Ft~
Ft. to Ft
Ft. to Ft.
Ft. to.__ Ft.
.Ft. to Ft,
Ft. to __Ft._
Ft. to Ft._
Ft. to__FL
.Ft. to Ft
Ft. to Ft.
Ft. to Ft
Ft. to Ft.
Ft. to MUNicipFAtL. ii¥ Or ANchOrAGE.
DE~, OF rlEALTH &
Ft. to ENVIRO~I~ENTAL PROIECIION
MISCL. INFORMATION:
SEP P, 4 1980
RECEIVED
DRILLER'S NAME
F'EF:HZT NO,
DEPFtRTMENT i,~'~ HERLTH FIND
EN"/ I RONMENTFIL
i'OTECTI ON
"''".--'--' . ~TREET' FINCHORRGE BK.
264-4720
~ELL PERI~I ][ T
"80045? )
RF'PL I F:RNT
LI]CRT 1 ON
LE ~]L
4,..,~,0~-.::~ SQUFIRE FEET
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS
100 FEET FOR R PRIVRTE NELL OR t50 TO 200 FEET FROM B PUBLIC NELL DEPENDING
UPON THE TYPE OF PUBLIC HELL
MINIMUM DISTRNCE FROM R PRIVRTE NELL TO B PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMMUNITY' SEWER LINE IS 75 FEET.
NELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE NELL COMPLETION.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
13VRILRBLE TO INSURE PROPER INSTRLLBTION.
PEF-':]'-I I: T E::--:P I ]~:ES g.E,]Er-IBER 2-:--1..
I CERTIF'¢ THR:i"
1: I RM FRi'IILIRR NITN THE REL-:UIREMENT- FOR ON -ITE 5EI-4ER_, RN[:' .WELLS H.:, -ET
FORTH 8Y THE i'IUNIuIFPILITt OF HNE-HERH~E.
2: I HILL INz, TRLL THE _",_TEM IN RCCOR[:'RNCE WITH THE E. uDE-,.
RPPLICFINT RICHFtRD & MFIF.:TH THORNTON .
I :..:: L,E[.' B"r .......... =-_ TE ....
'v'4. 0
MUNICIPALITY OF ANCHORAGE
Department'of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
HAA# /1 ? o1 l
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot I; Bloc 2; Valley View Terrace Subdivision
Location (address or directions)
NHN Lower Terrace Street
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
4'~ ¢ ¢~771 Telephone:(home)
5?0 E~ 34~h Ave,ua, ~n¢~orage, z~-Gha
Telephone
(d) RealEstate Company and Agent JACK WHITE COMPANY ATTN: Lo~c,~ Crowder
Address ~0928 Eagle Rive& Road. E~le River. Alaska 99577
Telephone 694-5500
(e) Mail the HAA to the following address: (or check here ~,x, if hold for pick up.)
List contact person and day phone number below:
Business
S & $ ENGINEERING
]7034 Eagie River Lo~p Rued ~'~o. ;ziOn,
EaBle River, Alaska 99577
2. TYPE OF RESIDENCE ,.
Single-Family,El Number of bedrooms
3. WATER SUPPLY _/./
Individual Well ~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~ / Public [] Community [] Holding Tank [] ,_
Note: if community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 {Rev, 7/88) Page 1 of 2
5, ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm Telephone
Address
Date
S & S ENGINEERING
Eagle Ri','er, Alaska ~577
6, DHHS APPROVAL
Approved for ~ bedrooms
Approved ~ Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent,professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72 025 (Rev. 7/88) 8ack Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
; Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description:
Well Classification .~'~/~''~ 7-,~- IfA, B, C. D.E.C. Approved (Y/N)
WellLogPresen~.(Y/~N)~ ' Date~COmpleted _~'/'~,.,~/~'0 Yield
-, ' .--,, /' /
Total Depth/-"//0 Cased to '/~ Depth of Grouting
!
Static Water Level / ~/7
Casing Height Above Ground
Electrical Wiring in ConduitS)
SEPARATION DISTANCES FROM WELL:
To Septic/F~c:!d!n,~-Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~'~
Pump Set At ~ _.~ ~
Sanitary Seal on Casing/[Y)N)
Depression Around Wellhead""" (Y~).
f
; On Adjoining Lots ,/~ '/
; On Adjoining Lots ,,/'/~ !
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by,,~"t~ '~
Water Sample Test Results ~'7~f'c~ '~-¢' -~ ~'~/
SEPT C/.O'D .G D^*A
Date Installed _~,/~/~'~Size~,~~:~ o NO. of Compartments
Standpipes(~(N~ I/V~/ Air-tight Cap (,~N) /~ Foundation
Depression ~ver Tan~'r~ ~ Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) ~ ; for
Holding Tank High-Water Alarm (Y/N) ,/,-J/.~F Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Building Foundation
To Disposal Field
To Water-Supply Well ~Z'(:~ o
To Property Line ~..,o
To Water Main/Service Line
To Stream. Pond, Lake or Major Drainage Course
Comments
72102~ (REV. 7/'88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (YN~j
Results of Last Adequacy Test
Type of System Design
Length of Field ¢~'~
Depth of Field /'Z. !
/' Gravel Bed Thickness '~--'- ~_.
Statndpipes Present )
Date of Last Adequacy Test ~' -- ~:~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundat~/
Lot ,¢¢~'
To Water Main/Service Line
/O o
/o ./-
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area .
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots .~¢ z.~
~/'
To Cutback (if present)
D. LIFT ~
Date Installed -_ ----..
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
Pu m ping Cycle-~'~s '~Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed s & $ EN,GINEENIN~
Loop
Company ~£
MOA No.
Date of Pa;merit '~- ~/-f
Amount: $ //~¢ ~
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA
, INC.
~,.?~.,.~ FEDERAL TAX ID# 92-0040440/ ~j'~-
AiIA~YSi.~ P, EPO~'£ BY 8?d4PLg for ?fork Ordez ~ 20d47
Dllsnt Sample ID:LI; B2 VALLEY VIEW
?~SID :UA
Col]sct~d ~2R 15 90 ~ i0:30 hr~,
~eceive~ H~R t6 90 0 15:30 l~s.
P~e~erYed with :AS REQUIRED
Client Na~o : 3 & ~ gNGR
~oq ~
Ordered By ; BOB 3~FZg
Ch9mlah hoe ¢: 900~99 5ab ~mpl ID: I ~at~lx: WATZ~
Allowable
~ara~ncter ~ested ~ult Uilit~ ~ethod Lli~it~
IIiTRATE-~ IlD(O.iO) ~/1 EPA 353,2 I0
Sample ROU?ilI~ 3AMFLE
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
.DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # (~,~_("'h - '~ ' ~ .
~,-~ - :~3~. '"~ NAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT I; Block 2; VALLEY VIEW TERRACE
Location (address or directions)
(b) Property owner AHFC #¢4771 Telephone: (home)
520 East 34th Avenue Anchorage, Ak 99503
Mailing Address
Business
(c) Lending Institution
Mailing Address
Telephone
(d) RealEstate Company and Agent JACK mH?Y Cr)~p4&ly ATT~U ro~( ¢~e,-de~
Address 10928 Eagle £~ve~ ~o~ Eaqle River, Alaska 99577
Telephone 694-5500
(e) Mail the HAA to the following address: (or check here ~,if hold for pick up.)
List contact person and day phone number below:
$ & $ ENGINEERING
17034 Eagle RN,~¢ L~p Rea8 No. 204
Ea!lle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family [~X Number of bedrooms 3
3. WATER SUPPLY
Individual Well t2~X Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~X Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72*025 (Rev. 7/88) Page 1 of 2
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A. WELL i,~/j~'
Well Classification ~ ~ ~ ]~::)~/t L.,~,~ If A, B, C, DiE.C. Approved (Y/N)
Well Log Present(~'N) y Date Completed'
Total Depth
Cased to '7~::~ Depth of Grouting
Static Water Level c~'~ ~
Casing Height Above Ground /
Electrical Wiring in Conduit~'N) y'
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /
To Nearest Edge of Absorption Field on Lot '
Pump Set At
Sanitary Seal on Casing(~N) ~'
Depression Around Wellhead (Y~,
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
~['J'~/~ To Nearest Public Sewer Cleanout/Manhole
B. SEPTIC/HOLDING TANK DATA
Date Installed ~>-;~.-~-~E> Size
StandpipesE[~/N) y '
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)/
Holding Tank High-Waier Alarm (Y/N)
Air-tight Caps CN)
No; of Compartments
~' Foundation Cleanout ~[:~N) y
/,[//~._ate Last Pumped ~o '-'
; for '----
Temporary Holding Tank Permit (Y/N)
~EPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ,/~ If-
To Property Line /~ 1¢"
To Water Main/Service Line
To Building Foundation
To Disposal Field
To Stream, Pond; Lake or Major Drainage Course /OC~ I
Comments _~--- "~
72-026 (Rev. 7/88)Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y¢..~
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present4~C~/N)
Date of Last Adequacy Test
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
SEPARATION DISTANCE FROM ABSORPTION FIELD:
TO Water-Supply Well ~' / ¢~ ~'' To Property Line
To Building Foundatiqn/ ./~'- /s-- To Existing or Abandoned System on
Lot j,4//~ ' On Adjoining Lots ,..~c~
/
To Water Main/S~rvice Line ·/.4) I'¢'~
To Cutback (if present)
I
! Co .
D. LIFT STATION
Date Installed
Dimensions
Size in~
"Pump On" Level at %
High Water Alarm Level at ~
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
inspection.
S & S ENGINEERING
Signed ......... ,~,..~ ~ ,,,,~, r,,..., ~ .....
Company Eaole Rlye~AI,a~ka 99577
Date
MOA No.
'late of this
~eal
Receipt No, ~,.
Date of Payment
Amount: $
72-026 (Rev. 7~88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
FEDERAL TAX ID # 92-0040440
ANALYSIR REPORT BY 8AMPLE for Work O~dez ~ ~2LE7
Date Repair Printed: NAR 17 89 @ 14:22
Client Sample ID:L1, E2, VALLEY VIEW TERRACE Client Name : $ & S ENGR
PWBID :UA , i Client Acer : 9NSENGP
Collected NAR 15 89 @ ll':O0 h~s. P.O.~ tlOHg REC'D
Preserved with :AS REQUIRED O:dered By : RJS
Analysis 'Com~e~: :i~R)?~89~'' i. Send Repo~ts to:
Laborate=g Super,viso~ :STEPHEN C. EDE lis ~ S ENGR
Special
In~tzuet:
Chemlab gaf $: 4549 Lab Smpl ID: 3 Matzix: WATER
Allowable
Pa~ametee Tested Result/Unit~ ~ethod Limits
NITRATE-N ND(O.iO) mE/1 EPA 353.2 10
Sample ROUTINE SAMPLE.
Remarks: SAHPLE COLLECTED BY RJS.
1 Tests Pe~for~ned See Special Instructions Above UA=Unavailable
DD= Done Detected *' See Sample 8ermrk~ ~bove
NA- Dot Analyzed LT=Lese Than, GT=Gzeate~ Than
" DATE RECEIVED
- iNSPECTiON APPOINTMENTS
TIME
DATE DATE , DATE
MUNICIPALI~ OF
~UNICIPALITY OF A~CHORAGE BEPT, O~ HEALTH &
E~VlRON~ENTAL SANITATIO~ DIVlSIO~ JUL 9 1981
Telephone 264-4720 ~$ C
REaUEST EOB APPROVAL OF INDIVIDUAL ~ATEB AND sE~ER
MAI~I~G ~DDRESS
PROPERTY RESIDENT (If different from abeve~ ' PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION PHONE
I
MAILINGADDRESS ' /
B. LE~A~ DESCmPT~ON
J~f / E/j./
STCI~ET LO~ATION
B. TYPE OE .ES,OE.C~
[~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[] Two [] Five
I~ Three [] Six
[] Other
7. WATER~PPLY
INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON-SITE** ? c~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTI LITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY [] ONE [~]'~-THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[~]'~INDIVIDU^L DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVEO
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~NDIvIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY -7 ~
Connection Verified INSTALLER
[~]Septic Tank or [] Holding Tank v--
Size: / /;'' u C) If Tank is homemade SOILS RATING ~ ~_ ~_~'
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. .GOMMEN~S , / ,-~7
~./.
ti,
[~APPROV ED FOR ,.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72 010 (Rev. 6/79)