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HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 3Onsite File Zodiak Manor Alaska Block 5 Lot 3 #015-012-14 EP1AA/S MUNICIPALITY OF ANCHORAGE Development Services Department } Phone: 907-343-7904 On-Site Water & Wastewater Section � � Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 015-012-14 Expiration Date: Ci? _1 Z`l 1. GENERAL INFORMATION Complete legal description Zodiak Manor Alaska Block 5 Lot 3 Location (site address) 8525 Pluto Drive, Anchorage, AK Current property owner(s) Michael Shelton-Kelly Day phone 916-259-6715 Mailing address 8525 Pluto Drive, Anchorage, AK 99507 Real estate agent Jennye Schulenberg Day phone 907-229-4319 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex n Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic Water Storage n Holding Tank ❑ Community Well n Community ❑ Public Water System ❑ Public Sewer Waiver request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 675-6 Waiver Fee $ Date of Payment &P//q Date of Payment Receipt Number Q g6140D Receipt Number COSA# osa9/a/l Waiver# 5. 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. I acknowledge that On-Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone 907-522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date 5/31/19 ficls' * '1/4:is eott r ••I 6. DSD SIGNATURE • M'IV E"- ...•..• (` System •#1 Approved for 3 bedrooms •o inn,,MICHAEL E. ANDERSON =t�ir ♦`.-� . No. CE-4381 •f•ec'ii System #2 Approved for bedrooms t T.F •..• 05/31/19 ...• e Disapproved tt��;; �;���• Conditional approval for bedrooms, with the following stipulations: 14/47-p ►° I ' srp�q NO m -5,,A • ,AA4 ,111)))1 »») By: .----- k_ Original Certificate Date: G-1 Z -/a The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: Zodiak Manor Alaska Block 5 Lot 3 Parcel ID: 015-012-14 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test 7.1 gpm Date drilled 10/24/73 Water storage tank volume NA gallons Total depth 185 ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to 40+ ft ❑■ Coliform bacteria is Negative ❑■ Sanitary seal is functioning correctly Nitrate mg/L ❑■ Nitrate less than MRL (ND) ❑■ Wires are properly protected Arsenic 5.04 ug/L ❑ Arsenic less than MRL (ND) Casing height(above ground) >12 in. Collected by Forge Engineering Date of flow test for COSA 5/29/19 Date of Sample 5/22/19 Static water level at beginning of test 104 ft. Comments Well information taken from Municipal file. No well log available. B. TANK DATA C. LIFT STATION Age of tank(s) years ❑ Required maintenance completed Tank type/material PUBLIC SEWER Age of lift station years Measured operating fluid level in septic tank Lift station material ❑ Standpipes/foundation cleanout per record drawing Comments: N/A Date of pumping D. ABSORPTION FIELD DATA PUBLIC SEWER Which system tested (date installed) Adequacy test date ❑ ALL standpipes present per record drawing Results ❑Pass For bedrooms Total measured depth from grade ft (max) Fluid depth prior to test in Measured depth to pipe invert from grade ft(min) Water added gal ❑ N/A— pressurized field New depth in ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Elapsed time min ❑ Code-required soil cover over field Final fluid depth in El presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout> 100' ❑✓ Yes if No ft ❑✓ Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑Yes if No 22** ft Absorption Field on Lot > 100' ✓❑Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment> 50' ❑✓ Yes if No ft ✓❑Yes if No ft 47* Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' C1 Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water> 100' ❑Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' El Yes if No ft Water Main > 10' ❑ Yes if No ft Community Wells > 200' El Yes if No ft Water Service Line > 10' ❑Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water> 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS *Waiver on file (no waiver number given) **See attached waiver request G. ENGINEER'S CERTIFICATION ��4 ,�F ila tint � I certify that I have determined through field inspections and review ��' P••••' ••.qs �1. of Municipal records that the above systems are in conformance with .), �' ••, MOA COSA guidelines in effect on this date. 49th 4' 4 g MICHAEL E. ANDERSON I Li is �v •1C%'.• No. CE-4381 .#1/ rf so •.cc`,p'•..��..05/31/19 . ijir COSA Checklist yellow sheet ♦••4,IROFESS\,�4. Municipality P.O. Box 196650 i 4700 Elmore Road Anchorage Alaska 99519-6650 ! (907) 343-7904 0 Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program -7 E% �%MANOWAI Waiver#: OSV191040 COSA#:OSC191211 Permit#: PID#: 015-012-14 Legal Description: Zodiak Manor Alaska B 5 L 3 Engineer: Forge Applicant: Michael Shelton -Kelly trent Department Your request for a waiver of the required 25 feet horizontal separation from the Well to the sewer service line has been approved. The approved separation distance is 22 feet. This waiver approval applies to the Existing well only. Any future upgrade will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of non -objection have been received from the owner(s) of the affected adjacent property. ❑ Adjacent properties are not affected by this waiver. ■ a a a a a a a a a v a a a a a a a a a a v a a a a a a v a v a a a v a a a a a a a is a a a a v a a v a a a a a a v a v a a a a a a a a a a a a a a a a a I Waiver is Granted: X Waiver is not Granted: Date: t Approvedf - �--- _ Name f Reviewer a a a■ a all a a v a a a s a a a a a a 0 v a a a a a a a a v a a a a v a a a R a■ a a a a v a a a a a a In a v a a v a v N IN a a a a a a v a a t a a l ak S�c.r `� vte_ was ,� 2-5 2 05h PO BOX 240773 ANCHORAGE, AK 99524 GE 522-7773 677.7766 (FAX) ENGINEERING FORGECIVIL.COM VAN June 12, 2019 !4CqP111 MOA Development Services, On-Site Water& Wastewater Program j* TM * *r• � 4700 Elmore Rd •••• �� • ••• Anchorage, AK 99507 ••. ... .. ..... /� '• Benja ' chiller . 41, • ••. CE 12592 .•�`��/ 2/!?.. Subject: Zodiak Manor Alaska B5 L3 —8525 Pluto Rd ‘lll1PR\"l_" Foundation to Septic Tank Waiver Dear On-Site Services Engineer: This property has an existing well, but no septic system. During the COSA process, it was discovered that the well head is approximately 22' from the sewer cleanout. This is closer than the required 25' separation distance. However,this is a situation that has existed for 40 years at this point. The sewer connect card dates from 1973, and there is well information dated to 1978. In 1985 the lot was granted a waiver for the separation to the public sewer line, as it was within the 50' distance. In addition, there are four water samples in the file which show no bacterial contamination. Our recent water sample confirms no choliform present,and also shows no detectable nitrates. It is our opinion that the well is not being impacted by the sewer line. We request a waiver for the well to be within 22' of the private sewer line. There are no additional health risks associated with this waiver. Sincerely, Benjamin Schiller, PE P. a the r,-..lnunau.;tty ..t t`.'. uwni: ut b1UJdtr. prior to cunsiructiun, to vert:•: N 1>rop.):r-d building y.rnui• relative to fin • - ished grade xnd utility connections and to determine the existence of any ease- 7 ments, covenants, or restriction which its do not ayj�cnr on the recorded subdlvl- 1 / sloe plat. �rii� /4)(11 1 �' V \-c`‹ y1- \ \ \0 \ \`= \ Q-p / oN V1 J5� _p.19 '..1.... \ 4 va 53 -39. \ / 1 O Afl trio.� o - 29 s 1W"Z5 J -- SC.' 19 o _ \ ��� d • DoT 3 `� \ d N-4. . o_X -2. • ....---0, B LK. 5 t. \ ,v'.Zt. : -2 to 5 -A V • -7-;.'\o v to %.5s\ ` -- 1 \ 1. Pl\ foo9 ''' \ \ \ \\ W . \ O O z - g3. \ 1 \ 14— ----4. kt‘ . A-. ,,, , 04%.37., OFq3� /'` YCAi/-,„,,,_ ' sFe�ce over.-. - J �\ " ' p,� .!rte/:ei-j .Z/ e... --- , ; 7. �R�"rrJ�ED E L E VIONS ••••.• •• BLDG. GRAS��j g 'VA •: 4, 613-S f �p • LOWER j'.0 . EL. - BUILTo • ;`�(, �y�f �o' �UPI'- IF-LOOK E.L. - L` ! • •. !ST�arg- t SLAB EL.- 8/3//73 ��Q�o SuRVE'�ao - �EECE. T4/9/80 ��oano� REC�iLT //2.s/34LEGENO: LOT SURVEY CERTIFICATION 0 eon PiCpep Monument • Steel Pin Lot 3 , Block h ere2o Survey Hub jock 1Z,. !r rx,o �c S _ /-t 6-64 SEP I`F_!'FP_T 4/9/80 14/0F Anchorage Recording Precinct, Alaska As-atm.-7 REVISIONS DATE BY 'BP°red 8r:D/CK/NSON-OSI%4LD 8 PARTNERS Residence of: G t�t . -� N,) 800 Cordovo Street ph. 277-1685 Anchorage` Alosio ole: By: Sco/e: / " - - Wag' - F.B.. " Grid: r t 1-� r }f1 / — Jv Ie, / /Q .1�rD µ!o. X883 429-23 - • /2d7G - - . . (d) MUNICIPALITV OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN'rAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application [)ate C~'Z4 --~.~ - GFNERAL INFORMATION (a)Legal Descn'p'bon (include lot, block,_ subdivisiOn,V~ section, township, range) Location (address or directions) Applicant Name _~ J J~(~ -,,]~J~ Telephone ~ome 5~~ Business Applicant i8 (check one): Lending Institution ~; Owner/builcler~.; Buyer ~; Other ~ (expJain); (e) Lending Institution _ I~ E2A. r~ ~.,,,JC..,~"~ ~'-~p-~'hone Real Estate Company and Agent ~__..j~ i-j,~/~t~..~,' .~.,~,..(,[~.C) ._.~. Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDI=NCE Single,.Family~J~ Multi-Family [] Number of Bedrooms ',.,~') "q ¢~.~.~',,¢' Other WATER SUPPLY Individual Wellx Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [] ~ubiicx Community [] 14olding 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 n 1184) Page 1 of 2 ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TFSTS, FILE SEARCH, DA, ~ AND INFORMATION Aa certified by my seal affixed hereto and es 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 end sdequate 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 end inspection, the on-site water supply and/or wastewater disposal system ia in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~t,..~'j~k~l~ Address _ ~r~7 ~-'~ ~.~ .......... ; ,~ngineer's Seal DHEP APPROVAL Approved for Approved Terms of Conditional Approval bedrooms by l ~,/ nd~b nal Disapprove~_ . Co "o - CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain ledersl and state requirements. Employees of DHEP do not conduct inspections or analyze data before e certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 z2-025 (i 1/84) WELL DATA MUNiCiPALITY OF ANCHORAGE (MOA) HEAl. TH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Le~t§l Description: MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Well Classification ~"~1 V/~"Y~¢ If A, B, C, D,E,C. Approved (Y/N) Well Log Present (Y/N) . ~ Date Completed ~ Yield Total Depth /~,~'' _ Cased to ~ -~ Depth of Grouting Static Water Level /~ z Pump Set At Casing Height Above Ground ~ t Sanitary Seal on C~sing (Y/N) Electrical Wiring in Conduit (Y/N) ~ Depression Around Wellhead (Y/N) - Separation Distances from Well: To Septic/Holding Tank on Lot ~/~ ; On Adjoining Lots To Nearest Edge of Absorption Field · On Adjoining Lots Public Sewer Line ' = OTc Nearest Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Test Results 5~J~¢~ ~ ~PTIC/~OMiI~ T~ D~ Size No. of Compa~ments Standpipes (Y~ ~ Air-tight Caps (Y/N) ~~ Foundation Cleanout (~/ Depression o~ ~n~~ .... Date Last Pumped / Pumping/Main~nce Contra~t~File (Y/N) .... ~f~ Holding Tank High-Water Alarm (Y~ Tempor~9 Tank Permit (Y/N) Separation Distances from Septic/Holding Ta~~ a ~on To Water-Supply Well //¢ _~uilding Found t' ~~ To Property Line _ /// To ~eld .... To Water Main/Service Lin~/ ~, Pond, Lake, or Major Drainage Course ~/ Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA ngin Absorption Strata Type of System Design Date Inst~lt'l~.~,.__ Length of Field Width of Field ~. Depth of Field ~ Gravel Bed Thickness Square Feet of Absorption Area'~,..,~ Standpip~r see~t (Y/N) __ Separation Distance from Absorption Field: To Water-Supply Well _,/ To P~p~rty Line __ To Building Foundation ,/'"/ ' '~'~g or Abandoned System on Lot / ; On Adjoining Lots To Water Main/Service Line _ / To Stream/Pond/Lake/or. Drainage Course Tc~mDrimVeen~y, Pa~g"Area, or Vehicle Storage Area ¥ To Cutbank (if present) D. LIFT STATION Da~,, Dimensions Size in Gallons-'~'~'*---~....~ Manhole/Access (Y/N) "Pump On" Level at "~'~. "Pump Off" L High Water Alarm Level at Tested for ~.._~.._. '~'~---~--P~umping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) _ ~.-~/ Comments '~ /1 ** Check ,/R'~i'mitted Be/Broom Rating Against HAA Request L /. I certify tha~ [~aye chc~C~d verified or conformed to al MOA and HAA guidelines in effect on the date of this inspection. Signed ,"'/////J~/~-~..--.,~.~-. Date J ~" /'.-.. / CompA'n, ~//~g~--.-~,/~"L¢. MOA NO Receipt No. :~ ~ -¢-,;(', O I Date of Payment I - _~c, - 'o z~-- Amount: $ /;, Engineer's Seal Page 2 of 2 72-026 (11/84) FIELO PUMPING TEST OATA SHEET · LOCATION OF WELLS (Legal Description): ~O-f WELL DEPTH: Fl'. CASING: DATE DRILLING COHPLETED: STATIC WATER LEVEL (Top of Casfng): DATE OF TEST: F T SCREEH: DRILLER: FT -- Elapsea Time Sincel Clock Pumping Started/ Depth to Drawdm,m/ Pumping Remarks T|.~me Stopped, Him. ,Water, ft. Recovery Rate, ~PH I _ 0 /~ / (swl 0 0 Start I ~o ~ell zN · / I 20 /p4.,, ~ / I ~5 Ab-LC _ 35 1~4% 7% / 4o /h~,~ ./ .... 60 (l hour) I /44,~ / I _,, 180 (3 hours)~/~/~ / -- 24o (4 hours).~.¢.~,p / E" DEPT, OF HEAL u~AGE '~VIRo~,, TH & ~ 0 I .... c~TAL PROTeCTioN 15 I ~_ I 25 T '~" __J 35 I 45 50 55 -- _-- ~ ~n '(t hour) I_ MEMORANDUM DATE: TO: FROM: SUBJECT: October 7, 1985 Zodiak Manor File Stephen S. Morris, Civil Engineer, On-site Services Lot 3 Block 5 Zodiak Manor Subdivision - Waiver Request Review of waiver granted to 47 feet for distance between the well and public sewer line on Lot 3 Block 5 Zodiak Manor Subdivision. A waiver granted on February 2, 1984 was re-evaluated using the Alaska State walver procedures. Using thie procedure it was determined that the existing waiver should be honored. danuary 3L, i~N~ Anchorage, /~[( 99!30'? Approva] t<}r bhe individual sewer and water ~aci]it~es cannot be qFante¢l until the ][o] t©wing items have been completed: ° The top of the well. ca.%ing ~l-t(}uld I:)e seal. ed so that it water t~,jhto Nxl)osed elect~:Jcal wiF,os to tile wel]. head are in vi. elation conduit° meet [,l()A standards~ This distance is 22 feet; the a0prove,q distance is 7b l!eet~ Your are Jn vio]atiog PLoa:~e notify this Dopartment for a roinsoectJon when the noted <liscr'oparlckes lw~ve Doen corrected, iii there are any ~t~rther qtlestic)gs, [)].c¢age Ca],]. this of~fice at: As~'~ociat0 i,]nvj roamental spec:i,a ], ~ st /\ttachme{M: 150.5U q APPLIC FILLS ()UT UPPER HAL ONLY Property Owner Michael S~ge~Jones Phone Mailing Address 8525 ]~luto ~)2r~. ZipCode 99507 344-6691 Address Zip Code Phone [.ending institution Realty CO. & Agen( Address Zip Code 99502 Zip Code Legal Description Lot 3 Block 5 Zodlak Manor Street I..oca~io~ 8 5~-~P.~.J~-O-~'¢ · Type of Residence ~[ Single Family [] Multiple Family No. of Bedroomi"' (J Other Water Supply ~ Individual ATTACH WELL. LOG. A well Icg is required tor all weirs drilled since June 1975, I~ Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer Disposal Xr3 Individual Year Individual Installed; [] Public Utility When Connected to Public Utility: ~] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, Time Time Time Time Date Date Date Date Inspector Insp6ctor Insp6ctor Inspector Field Notes: ( ) APPROVED BEDROOMS ) DISAPPROVED )CONDITIONAL APPROVAL' DATE BY: 'CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank Well Log Received Septic Tank Size APPLIC NT FILLS OUT UPPER HA! ONLY r operty O,~,er /V~/~ I~/t I~ L '"' ~/~"~: ..... :;-~ ~'~i!~~ Phone Buyer ^ddress Zip Code Lending Institution PJ t;/I Realty Co. & Agent Address Zip Code Legal Description Phone Phone Type el Residence ~ Single Family ~ Multiple Family [~ Other Water Supply [] Community [] Public Utility Sewer Disposal bi Individual ~Public Utility Holding Tank ATTACH WELL LOG, A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available). Year Individual Installed:. When Connected to Public Utility: NOTE; THE iNSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN DE INITIATED. Inspector Inspector Inspector Insp6ctor EJeld Notes: ) CONDITIONAL APPROVAL* DATE ") "~'' ~' ~ Soils Rating Date Sewer InslalJed Well To Absorption Area Well to Tank Well Log Received Septic T&nk Size .....,fl DA'I~E RECEIVE'D INSPECTION APPOINTMENTS (I ' ' ~-~ ? ' TIME TIME~ INSPECTOR INSPECTOR [NSPECTO~. DEPT. OF IF',"XFiI & MUNICIPALITY OF ANCHORAGE ENVIRONMENr,q T,.,_'iLCTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEOTION 82~ L Street- Anchorage, AJask8 99501 J'~AY 1 5 Ig80 ~ ) ENVIRONMENTAL SANITATION DIVISION ~ Telephon0 264.4720 R E C E I V [ D BEQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES DIREOTIONS: OompJete all parts on page 1. In~ompl~te roqJl~Sts wilt not b~ processed. Please allow ten (10) days for processing. I. PROPERTVOWNER ~ PHONE MAILING ADDRESS ~OPERTY RESIDENT (If different from a~ove) PHONE ~ BUYER PHONE MAILING DDRES8 MAILING ADDRESS 4. R~ALTOR/A~NT . ~ J PHONE MAILING ADDRESS ~ LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE ~JUMBER OF~BEDROOMS [] ()ne ~ Four ~- SINGLE FAMILY [] Two ~ Five [] MULTIPLE FAMILY ~ Three ~ Six Other 7. WATER SLJPPLY ~ INDIVIDUAL= "ATTACH WELL LOG. A well log ~s reqmrea for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior m that date, g ye wel [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] NDIVIDUAL/ON-SITE*~ .YEAR ON-SITE SYSTEM WAS INSTALLED. i~.. ~UBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-O10 (Rev, 6/79)]'~J~;~ 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 [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED [] PUBLIC UTI LITY Connection Verified INSTALLER [~Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL ' Nearest Lot Line 4, DISTANCESwELL TO: Septic/Holding Tank Abserption Area Sewer Line Absorption Area to nearest Lot Line 5, COMMENTS ~A~PROVEDFOR __~ BEDROOMS [] CONDITIONAL APPROVAL (letter m [~] DISAPPROVED uT~pany certificate) 72-010 (Rev. 6/79) · ~1: Time Date Insp MUNICIPALITY OF ANCHORA' DEPARTM, ,' OF HEALTH AND ENVIRONMEI~ L PROTECTION 825 L Street, Anchoraa~, Alaska 99!501 264-4720 Date Received: February 8, 1978 1:30 p.m. ~2: Time tt3: Time 2-.9-78 Thursday Date Date Pratt Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Alaska Mutual Savings Bank Mailing Address: Post Office Box 1120 99510 Phone: 274-356] 2. Property Owner: Jack Morgan Phone: 344-84~4 Mailing Address: 8521~ p~u~o Drive 3. Legal Description: Lot 3 Block 5 Zodiak Manor 8525 Pluto Drive 4: Single Family Residence: (x) Number of Bedrooms: Three Multiple Family Residence: ( ) Number of Bedrooms: Well Sysnem: Permit = Construction Individual well (x) Community/Public System ( ) Depth of Well ].85' Well Log on File Bacterial Analyszs 6. Sewage Disposal Sysnem: On-site System ( ) Public Utility Permit ~ Installed Installer Septic Tank Size Manufacturer Absorption Area Soils Rate Material ( ) (x~ Disnances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area no Nearest Lot Line Page Two Deparnment of Request for Approval Health and Environmental Protection of Individual Sewer and Water Facilities Legal Description: Lot 3 Block 5 Zodiak Manor Subdivision Com~lenLs: Affadavit Attached~ ( ) Approved: {~.<, ~1~ Letter Attached: ) Date: Disapproved: Date: Department Worksheet: (oSe~sod Silld) ,)0~ ~IIVMI fJ3]~IA~]MO ~10:] l~dl~O~l MUNICIPALITY OF ANCHORAG. Department of Nealth and Environmental Protection 825 L Street, Anchorage, Alaska 99501 ~--~quest for Approval of Individual Sewer and Water Facilities Property Owner: Mailing Address: Name of Buyer: Mailing Address: Phone: Phone: Lending Institution: Mailing Address: Qf~ /~ ~'~' ~,0, /pO~I //~L~ Phone: Realtor/Agent: Mailing Address: Legal Description: Pc~q 3 Street Location: ~-5~5 Phone: (~F~ Number of Bedrooms: ~ ( ) Number of Bedrooms: 7. Water Supply: * Individual Well (~/-Public/Community System ( ) If Individual Well, well depth /~ / If Community System, name of system Single Family Residence: Multiple Family Residence: Sewage Disposal System: *~0n-site System ( ) Public System (L~) If On-site System, date of installation: *NOTE: A well. log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Road, Anchorage, Alaska 99507 279~8686 Date Received ~:Y 6/ Time of Inspection / Date of Inspection //7/?'// Aoprovel Requested Bv: Address: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES 2. Prooertv O~ner: 3. Legal Description: 4. Location: ~,3 5. Type of Facility to be Inspected: Number of Bedrooms: 6. Well Data: D. Sewage Dtsoosai System: Depth C. Septic Tank: 1o Size 2. Manufacturer D. Seepage Pit: 1. Size 2. Material Disposal Field: Total Length of Lines 8. Distances: A. Well To: Septic Tank -~ , Absorption Area ~- , Sewer Lines '- , Nearest Lot I,ir, e__~ ;'~ , Other Contamination Bo Foundation to e, ,. - .~.pt~c Tank ~--- ~ Absorption Area C. Absorption Araa to Nearest Lot Lino.~_ZL=~ : ,]mst for Aporoval of Individual Sower & Water Fao[htxos ?a.qe 'rrm Approval Valid for One Year From Date Signed Gre~ter Anchoraqle Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certtrv [..~at the information contained in this request :for approval to be a true and acc~ta repr'esentat~ ~n of the subject sower and water facilities located at: Si9ned Date