HomeMy WebLinkAboutWILLIAMSON #2 BLK 3 LT 3will*amson #2
Block 3
Lot 3
#015-074-03
Municipality of Anchorage Page _hof?
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 9 Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: — SLA) 9fe o l85 PID Number: _
Name: Wastewater System: ❑ New L2Upgrade
Atldreaa:if 2LID .ir�,ts E_ no(, ICL
ABSORPTION FIELD
No. of Bedrooms:
Phone: - -Z8045' .3 CJ Deep Trench Y Shallow Trench ❑Bed El Mound ❑Other
,��„e�—.�—�•���--
Soil Baling:
Total Depth from original grade:
LEGAL DESCRIPTION z GPD/Sq, Ft.
Subdivision; �-
Lot: — Block: Depth to pipe bottom from original grade: Gravel depth beneath pipe
3 3 writ o sa . � z, Li Ft. _ o. T. FI.
Township: Range: Section Fill adtled above original grade: Gravel length: .7s Ft
Gravel width: Number of lines: Distance between tines:
❑ New ❑Upgrade S Ft, I � Ft
Classification (PrivateF; C): Total Depth: Cased To: Total absorption area: Pipe material: 45TFJ p303"1
FI. Ft. 3r"�__ SD. Ft. f' 8/0 7q'vT --
Driller: � i`Drlllad: Sialic Water Level: Installer: ,r Date installed: 19G
d installed
r.lieI. I1-12 r
Yield: Pump Set at, Casing F e bove Ground:
Ft.
TANK
_ GPM __
SEPARATION DISTANCES
—.__------
❑Holding ❑S.T.E.P.
'-- Capacity in gallons:
Manufacturer: ��yK /r Ob®
r7/trsa,•
TO
Septic
Tank
Absorption
Field
Lill
station
Holding
an
Public/Private
Sewer Linos
�-
Materiel:
$f G_G/ �.
Number of Compartments:
- z' ��
Well-
ZeCKea
•W
„_
_.
surface
100
_•
�•-.� LIFT STATION
rFoundation
1S
1�
__
�,
Size in gallons:
Man firer:
—
---
"Pump on" level al: Pump oft' leve High water alarm al:
_.
zLl S3 `' -` •—
—
—_.
Pump Make A Model Electrical Inspections performed by:
ns®�"•—s'—��
—
Remarks, Or' ' J-cr_b -t--
---
BENCH MARK
Location and Description:
Assumed Elevation: /DD
i�or� ' �O✓/sc'a,L 'by kLJ 9/13�96
4 TO
Inspections performed by: 1ir��%' _Dates: 1st u��
2nd J, KEVIN WHITE: .'x
Pjts' GE 8828 yw
Department of Hethand u ervices approval d N
Reviewed and approved by7 Date:
96 9'�0i�,
72-013 T ay. 9/911 MOA 25
Permit No. SW 96eO I 8S —
Page _— Z_ — of _Z
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 u Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:�R 3 96LK 3 LJ_1111a sc>�_-- PID No.: 015 'NOS
2" RIGID
STI
N NEW 1000
GAL. S.T.
..f
GRADE=97.
NIT=
ION Y --Y SECTION X—X N4
NTS NTS VynMr 10
Aw (9i
/
/
/
/ I
LOT 3
BK 3
DRAIN FIELD
X = COMMUNITY WATER
K. & P. ENGINEERING
726 O Place #105
Anchorage, Alaska 99501
(907) 274-2493
72-013 A (2/91) MOA 25
1,D00 GA4 SEPTIC TANK
--0*— APPROX 2% SLOPE
SYSTEM DESIGN
W.O. # 96--06-02
Location: Lot 3 Block 3
Williamson Sub.
Date: September 4, 1996
Scale: 1"=50' —
iallp
2
A
B
FCO
4'
ST1
4
ST2
30.8'
54'
C01
35'
58'
CO2
39'
CO3
MT
100'
113'
C04
127
139
STI
N NEW 1000
GAL. S.T.
..f
GRADE=97.
NIT=
ION Y --Y SECTION X—X N4
NTS NTS VynMr 10
Aw (9i
/
/
/
/ I
LOT 3
BK 3
DRAIN FIELD
X = COMMUNITY WATER
K. & P. ENGINEERING
726 O Place #105
Anchorage, Alaska 99501
(907) 274-2493
72-013 A (2/91) MOA 25
1,D00 GA4 SEPTIC TANK
--0*— APPROX 2% SLOPE
SYSTEM DESIGN
W.O. # 96--06-02
Location: Lot 3 Block 3
Williamson Sub.
Date: September 4, 1996
Scale: 1"=50' —
iallp
2
/Lull COW
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE �Dpn--�
DEPARTMENT OF HEALTH AND HUMAN SERVICES -)- wgLo
P.O. BOX 196650, 825 "L" STREET, ROOM 502 V-.Dp
ANCHORAGE ALASKA 99519 6650
^)- k-lA-`1k6
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT nn LL\_k.ILh
PERMIT NUMBER:SW960185
DESIGN ENGINEER:K & P ENGINEERING
OWNER NAME:STARK BOBBIE S
OWNER ADDRESS:11240 TRAILS END RD.
ANCHORAGE, ALASKA 99516
PARCEL ID:01507403
LEGAL DESCRIPTION:
WILLIAMSON #2 BLK 3 LT 3
LOT SIZE: 17521 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 7/1.1/96
EXPIRATION DATE: 7/11/97
1. THE ATTACHED APPROVED DESIGN.
2. ALL, REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE: ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICAT:LON BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ARANDCIN F.XTRTTT\IQ CFPPTC TANK
RECEIVED B
ISSUED BY:
DATE:.pp'7/`
DATE:
to Septic Tank
2" insulatl
2" gravel
above pip
4" perfor
lateral
Frerrt.f.-tm-9ve"--below--ariginaF-greund-surf«
General Notes: Do not exceed 3'below existing ground surface.
1,94a 0" S br\ow qr'
This system design is based on a 3 -bedroom home. The lot is served
by a community well and distribution system.
Impact on adjacent lots: There are no private wells within 100'
of this proposed system and no public wells within 200`. The proposed
system has no impacts upon any adjacent lots as shown on the
attached site diagram. No major drainages were observed
within 100' of this proposed system.
Absorption area calculations: RECEIVED
3 bedrooms X 150 gallons/bedrooms = 450 gol.
Sail rating = 1.2 gpd / sf JUL 11 1996
Absorption area = 450 gpd = 375 sf
1.2 gpd/sf Municipality of Anchor€
Assume no side drainage. Dept. Health & FlUman Ser
Trench length = 375 sf
5 ft = 75 ft D. .... o..... ,>�.
SYSTEM DESIGN "Engineer
W.O. 96-06-02 ��' •••!�(eQO�
K. & P. ENGINEERING # < �Q,•.•' �+ e�
726 0 Place /105 Location: Lot 3 Block 3 d�`�' •;fa
Anchorage, Alaska 99501 Williamson Sub. STV •iia 7
(907) 274-2493 Date: June 25, 1996 V• . . . • •
Scale:— N.T.S. J, KEVIN WITTE
N
I I
1
10' EASEMENT 1 1 I LOT 5
BLOCK 3
I I II
1
0
Spring Hill Est. II LOT 4
RECEIVED
ipalltyt Anchorage
pith & V1man Services
y
BE OCK 3 �pPE
I I PIP EXIST . LOG
❑XIST.TAN
TRENCH (TYPE. I I I/�
1 �E/
I I ITP EW WIDE BRAN FIELD PROPC
F \�Q
5
O
'FO BE
LOT 3
BLOCK 3
1,000 GAL
LOT 14 I `
BLOCK 1 APPROX 2% SLOPE
LOT 1 LOT 2
BLOCK 3 BLOCK 3
I I 1 ❑]
IIS ❑ 0
I `I ❑
111 /
I /
E 90th Dr.
100'*-
scale ��
F = COMMUNITY WATER
SLOPES LESS THAN 2% AT NEW DRAINFIELD
SYSTEM DESIGN Engineer ligIt P f�P /,�g�j�a
K. & P. ENGINEERING W.O. # 96-06-02 ���.°°' �P�
72G 0 Place #105Location: Lot 3 Block 3 y�4(
Anchorage, Alaska 99501 Williamson Sub.
(907) 274-2493 Dote: June 25, 1996 �" �'" " " .. " • • ' • • /°
J. MIN WFUE
Scale: As Noted �yG✓e• ne nnnn f�
�r Municipality of Anchorage
�. DEPARTMENT OF HEALTH R HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
�f l Y .1
s A J. KEVIN WHIT
PERFORMED FOR: �o%�/ T0.[k DATE PERFORMED.0iiZ'b
4✓i((laMSen SiJ
LEGAL DESCRIPTION: f_f 3G 3 Township, Range, Section:
DEPTH p SLOPE
SITE PP-L�AN-'r-�--
�0rl
1 MLC L
2_
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
SP
Sid
WAS GROUND WATER A/O
ENCOUNTERED?
S
IF YES, AT WHAT I_
O
DEPTH? N 'q P
I:
geplh to Water Alter '7/(7/9
mer
Monitoring? lygale: —
Reading Date Gross
Time
Not
Time
Depth to Net
Water Drop
•ita_kr"n
Z
S
20 /
PERCOLATION RATE _ � � (minutes/inch) PERC HOLE DIAMETER
y�� TEST RUN BETWEEN _ — FT AND .FT '/
COMMENTS �L'�codJQf�1�CRL._9,b33C. 1Y�c�(>:1. /. *� �. Steen 0.h`l1CxNLi _
PERFORMED BY: _JS.fVv�� I _ CERTIFY THAT THIS
- TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: fUT 9/
`C
72-008 (Rev. 4/85) (/
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RECEIVED
JUL 11 1996
e th'& HOt uAnchorage
an SeYyica,
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O
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0
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Q 1.J
GREv ER ANCHORAGE AREA BOF UGH
UGH
OGDepartment of Environmental Quality
i _ 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME(i'-G &ye— 6/ 'IfnD y(h _ MAILING ADDRESS � 60;2'2 -It PHONE
�[�3 ,/���CC �% />
LOCATION_ G& — LEGAL DESCRIPTION !/� �50� S l07 3� L5 /k 3
SEPTIC TANK:
DISTANCE M//.50 9 3 NUMBER OF
FROM WELL_6JAYL"�MANUFACTURER St�FL �� MATERIAL 77CcL COMPARTMENTS—
INSIDE
OMPARTMENTS/
INSIDE LENGTH INSIDE WIDTH —LIQUID DEPTH LIQUID CAPACITY/000 GALLONS.
SEEPAGE PIT: Iq 20
NUMBER 01= PITS — DIAMETER OR WIDTH—, LENGTH_., DEPTFI —.
4
qP
LINING MATERIAL L2/CR18SIZE:g xG7DIAM ETER__DEPTH_�_ i DISTANCE FROM: -WAELL,�O
�� � TOTAL EFFECTIVE
BUILDING F-OUNDATION 3-5, NEAREST LOT LINE L . ABSORPTION AREA (WALL AREA) I _SQ. FT.
ADDITIONAL ABSORPTION
WELL: d RCClivl'4—
TYPE V CONSTRUCTION__
BUILDING NEAREST
FOUNDATION LOT LINE ,
NEAREST
SEWER LINE
DEPTH
SEPTIC
TANK_
¢1111'e— a -F -7
DISTANCE FROM:
SEEPAGE
SYSTEM _
CESSPOOL OTHER SOURCES _.
APPROVED-- DISAPPROVED — REMARKS
DISTANCES: y /1A/'- iC_Cr �G C'% DIAGRAM OF SYSTEM
INSTALLED BY:
tAIb
JW
35'1
PIPE MATERIAL:
77,
LOT SLOPE: 6,-1 .-
16,
REMARKS: �
DATES-u�tUPyc9-
G.A.A.B.
Form No. EQ -031
rf-,,aA ER ANCHORAGE AREA BOROUGH
\\uIIIIIVVIIIILI DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
3
Y 330 "C" STREET ANCHORAGE, ALASKA 99509
f TELEPHONE 274-4561 ( F-70 60 - /sT-
o
SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT
--vCaEvrz-C7C GCrL/ZA T/ 30y �� _ST Sccrrea1i 299-7T3
NAME OF APPLICANT __nn//'�r — MAILING ADDRESS -- PHONE
�j
INSTALLATION LOCATION �r _J b --
LEGAL DESCRIPTION _ -O 3/ A� E -n e=,�, 3
6�
INSTALLATION OF: SEPTIC TANK t/ SEEPAGE PIT__- DRAIN FIELD OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED �U /wE%J
FINANCED THROUGH -_ -- - TO BE INSTALLED BY
�,2EA 7L -T7-22-00/ �`
SOIL TEST RESULT,NOTEI TFy1�1�S PIG�jMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
�b"0-7% 9C,
SEPTIC TANK TANK SILE ` TYPE SEEPAGE AREA SIZE _ _ TYPE _—_-—
MINIMUM DISTANCES. REQUIREMENTS (,Q/L.-f"- A. -J
c" /
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT so / DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL -
SEPTIC TANK -S / , SEEPAGE PIT 6 / -. DRAIN FIELD
TO NEAREST LOT LINE.
WELL '1'0 SEPTIC TANK
DRAIN FIELD.
WATER MAIN TO SEPTIC TANK 1
DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
/
_-. SEEPAGE PIT _ /(J -
SEPTIC TANK, / —, SEEPAGE PIT _, DRAIN FIELD
TO RIVER, LAKE. STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANI< AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE. CAPS.
GRAVEL BACKFILL
CONFORM 'r0 BOROUGH REGULATIONS REGARDING INSTALLATION.
G.A.A.B.
OR
LICENSED DESIGNER
DIAGRAM OF SYSTEM
TIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
ABED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
5 1 /9 3 APPLICANT'S SIGNATURE
O. MO -01 6
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL. QUALITY Case 11
3330 "C" Street
ANCHORAGE, ALASKA 99503
Performed For rcarPo l -blloutll___ Dated Performed Jul -,._,If, ,Lgj3
Legal Description: Lot 3 Block 3 Suciclivision Ill-Il9.amtion�
---r--AimVlca-.:!—
This Form Reports Soils Loq_ _ _ _ V_ — Percolation Test
- Soil Test Must Be Logged To 4' Below Proposed Seepage System -
Depth
Feet __— Soil_ Characteristicq ;V /%'L.
,
j vo <;o:+i Hox,-.zon
3-
4--
5--
6—.--5--
6—.
43;'`/ .-._w.._..-. 7 y r r3c i 7 r rc.E C'.
II— Gravel. raid an
9—
10—
II -
12—
13—
14—
16' ----
Water Encountered? Id'o
If Yes, At What Depth?
Jai
Reading Date Gross Time I Net Time
--- - —
I
Depth to H2O I Net Drnp
rercoiation Kate f4inii -
Proposed Installe.ticn: Se(,p,aq'; Pit !_ Drain Field
Depth of Inlet_ Ocpth to Gottom of Pit }r 1'rencF__ —
.P _
C0MMENTS:Ab .-r�obl-ernn rurticiputoA; vrrr� _lxlcd co1.-1'--
Test Performed BY "r• '` l 'r1c,Yl 3 i,_oAi_le,--Date (ci tified RY:
Da.1:e:
)?C:
L,S
Municipality of Anchorage
Development Services Department
..� a _� -
Building Safety Division
On -Site Water and Wastewater Program :
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519.6650,x,
www.muni.org/onsite
I i����
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. COSA# Oq D�
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Uii 1 Ii ams.., 02 Lo+ 3 61ar- 3
4 Location (site address) r
it.
Current Property owner'(s) 1101011e slcl k Day phone 3q6- 2005
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
9
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ,SpuRHAni C%1iAe2rinq Phone 2'79'3916
Address 203 W. 15tti SF, 203. AncVtora4P. AK 99501
Engineer's Printed Name
5. DSD SIGNATURE
I� Approved for _,? bedrooms.
Disapproved.
Date 15 0
r. 1
10
LASS E. SFL'RKLAND..' jlitFESS
Conditional approval for bedrooms, with the following stipulations:
`�� VYAICn new
• WASTEWATER
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: (N • lffo- Original Certificate Date:_ %' J5-- 0 z
0� X41 If
(R". IIMS)
Municipality of Anchorage
• Development Services Department
Building Safety Division `
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Wi ili ayo5on $0Z Block 3 G13 Parcel ID: 0 /S- 0 % 1f —03
A. WELL DATA Comwtuni% UWeti. -SYSIern
Well type = If A, B, or C provide PWSID # — Well Log (Y/N)
Date completed _—
Total
Total depth — ft.
Date of test
Static water level
Well production
Sanitary seal (YIN)=
Cased to ft.
FROM WELL LOG
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate — mg/L
Arsenic: ug/L date of sample: =
B. SEPTICIHOLDING TANK DATA f
Tank Type/Material An cv�rTame, / S le P-1
Tank size 1000_ gal. Number of Compartments Z
Wires properly protected (YIN)
Casing height (above ground) in.
AT INSPECTION
ft.
g.p.m.
Other bacteria — colonies/100 mL
Collected by:
Date installed 7L,11%
Cleanouts (YIN) Y
Foundation cleanout (Y/N) it Depression over tank (Y/N) � High water alarm (Y/N) /V
Date of pumping 14 1910'+ 0'+ Pumper 1&41" �Arnpjnq .Service
C. ABSORPTION FIELD DATA
Date installed 1111ci /O Soil rating (.p.d. orft2/bdrm) 1,2 System type Slx11aa Trehc�
Length 15 ft. Width 5 ft. Gravel below pipe O, 5 ft.
Total depth q,� ft. Eff. absorption area 315 ft' Monitoring tube Depression over field W
Date of adequacy test _(011510(,p Results (Pass/Fail) N55 For 3 bedrooms
Fluid depth in absorption field before lest O in. Water added 980 gal. New depth O in.
Elapsed Time: =min. Final fluid depth O in. Absorption rate >= 450 t g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) None WOW Y1 If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' ley _ in. "Pump oft" le _ in. High water alarm le in.
Dat Cycl ested Meets al circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: Commr ni ly W ca Sys+ern
Septic lank/lift station on lot
Absorption field on lot
Public sewer main
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer /septic service line — Holding tank "—
Animal containment areas — Manure/animal excrete storage areas —
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
r
Building foundation 514• Property line S 1+ Absorption field S +
'
Water main 10 4. Water service line
Wells on adjacent lots 100' 1-
1o14 Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation tor+ Water main
toot
tor+
Water Service line 1014- Surface water 100+ Driveway, parking/vehicle storage
Curtain drain Nw+e obsecWells on adjacent lots loo 1+
F. COMMENTS
1014
G. ENGINEER'S CERTIFICATION OF
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in i 9TH W
conformance with MOA COSA guidelines in effect on this date.
r ••..� ..
Engineer's Printed Name a S SUof RI at\A %/ �':L/;RS E.}'..S�. ,F'qk;,, 'ct,
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
�U(ti�
Rc'�6g
Waiver Fee $
Date of Payment
Receipt Number
-P
----------------------------------------------------
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MUNICIPALITY OF ANCHORAK
~ ; 1 DFPARTME1 OF HEALTH AND FNVI RO J , PROTECTION
825 L Street., Anchorage Aka 93501
270,251.1, ex-. 7.7 r 1.25
� 1�I) � m-P��D�
Ikl: Time
Date
Insp
I
v Da _cc i July 8, 1.977 ------
Date
-.�_ao-%1.-h.CtPS.�
P _,h)1ael1 7u 3.. _ I isp _ZSUr Awls,
e �
REQUEST FOR APPROVAL OF INDIVTDUAT EWER AND WATER FACILITIES
1.. Lending
Institution Request:
Alaska
Pacific
BAnk % Sue
Benson
Mailing
Address: Post Office
Box 420
99510
Phone:
276-3110/40
Jan Koslosky 274-2671
2. Property Owner:. _-- - --- -- Phone;
Mailing Address:
3. Legal Description: Lot 3 Block 3 Williamson Subdivision
4: Single Family Residence: (xk Number of Bedrooms: three- ---_-
Mult.i_ple Family Residence: { ) Number of Bedrooms
5. Well System: individual Well &&. Community/Public: System 1")
Permit 4 - Depth of Well - Well Log on File ( )
Construction --- � - -. Bacterial Analysis
6. Sewage Disposal System: on-site System (xA Public 'Ut i.l.i.ty ( )
Permit it Installed Ini:aller
Septic Tank Sire Manufacturer
Absorption Area :foils Rate Material
7. Distances: Well to Septic Tank. to 1lbsorpLion Area
to Sewer. Line Nearest Lot line Absorption Areri
to Nearest Lot. Line
Page Two
Ueparf.ntenL of Health and EnvironnienL-al. Prot a ion
Request for Approval of individual Scwtix and Waf.et: ] aCJ-IA(-i(3:;
Legal. Description: LoL 3 Block 3 Williamson Subdivision
COmIll4:!ntu:
--.-----.-
YY
Attached: ( )
Letter Attached ( )
Approved � (1�2��- Da.tec
Disapproved: Da.ic:
Department Worksheet:�
N#7c--.• Syo7c. /ROYA- CWIC607-11 ,
�SOs�.r 0' '2�7,fEe) DcIr, ?'p
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL. PROTECTION
�•` l: IC -IC
825 L Street, Anchorage, A:Laska 99501
7.79--251-1, ext. 22.4, 2.25
- REO.UE.ST FOR APPROVAL. OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection:
2. Property Owner: -- Jan Koslosky
------------------------------------
Mailing Address: -.-------------------------- —_---Day Phone:—274 2671-_— --
Q
3
5.
6.
Name of Buyer: ---David and Sherry Shibata
Mailing Address:1702 McKinley
Name of Lendhing stitution:Alaska Pacific Bank
P. Mailing Address:P0. Box 420
Name of Realtor or Agent: _._ none
Mailing
L3 B3 Williamson SD
Legal
East 90th Dr.
Location:
Day Phone
276 1265 or 2762611
99510 276 3110 x-40
—--Phone:— --------
Anchorage
7. Type of Facility to be Inspected:--------.---
8.
nspected:_—_--SF
-8. Water Supply
Type of Supply: Public Utility___—
If Individual, number of dwellings presently served
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public, Utility—_
If Individual, date of installation._ _
72003(3/76)
Phone:
8drms. 3
ndividual__ xx
Individual (on-site)— xx
Sue Benson
Alaska Pacific Bank
276 3110 x 40
July 1, 1.977
o��cxoxa[t earn
�o
4LC
GREATER ANCHORAGE AREA BOROUGH
.
Department of Environmental Quality
g •„,„�,,,
'` 3330 "C”
Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Inspection
Date Inspection
of _O //Z
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1 .
f
Approval requested by: (7/ct A f 71C 2 / � %�f ✓ �C�� Y >x 1—I
Mailing Address: �^
— Phone:
2.
Property Owner:
���`/_ c � /Phone:
�
Mailing Address:
3.
Legal Description:
D / ®
4.
Location:
5.
DDD ,,,
Type of facility to be inspected x c w Via_-� No. of bedrooms
D
6.
Well Data:
A. Type (la �a u, ,a
C �,— B. Depth
C. Construction _---_
D. Bacterial Analysis
7.
Sewage Disposal System:
A. Installed ' /iy�%3 _—_ B. Installer
C. Septic Tank: 1.
Size /000 2. Manufacturer Ve_dp d_4 173-o
D. Seepage Pit: 1.
D.
Absorption Area flubC-5 2. Material /occ�ilvr!_
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank�1 I Absorption area O�, Sewer Lines
Nearest lot line �`_, Other contamination
B. Foundation to septic tank / o Absorption area
C. Absorption area to nearest lot line
EQ••034 (1/74) Page 1 of two pages
Page 2 of two pages - Req_..st for Approval of Individual S, 2r & Water Facilities
n
Legal Description/, -
Comments �Pc. k'.i `r.,t�,.,:,�✓ ------ ---
Appro
sapproved
Date./G�i�%2//y%
Approval Valid for one year from clate signed
reater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to oe a true ana
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date