HomeMy WebLinkAboutGREENBROOK BLK 1 LT 1
Hea,, 1 and Environmental Proteq ']on
~ ' '. "~'~ Fourth Floor West ~ .....
' 825 L Street
Anchorage, Alaska 99501
264-4720
SE PTI C'TAN I'(,:
DISTANCE ~On~rn ~.-\9_O NUMBER OF
FROM WELL ......... MANUFAC]URER
INSIDE LENGTH__~I~ ...... INSIDL WIDllt ~[~._ LIQUID DEPTH ~'~ .... LIQUID C.APACII'YX?-.~O_ GALLONS.
TILE DRAIN FIELD:
~ov~m ~,,~ t ,~ TOTAL LENGTH I
DISTANCE FROIVl WE'LL N~.__FOUNDATION__~ NEAREST LOI L N[ /NOk_.
......... OF LINE ~q
E of Lines ~-~D-~--- DISTANCE BETWEEN LINES ._Q[A ...... 'FRENCH WIDTH~Q IN. TOTAL EFFECTIVE
ABSORPTION AREA __~ .... SQ. F'F. LENGFH OP EACH L. INE ._O~ ~
g~ ~ DEPTI, OF FILTFR
DFPllt: lOP 0~ TILL I0 t'INISII (lt/Al)E _ MA1ERIAI_ NENEAfIt 'fILE -- =_ _IN. ABOVE -II[.E .~__ IN.
SEEPAGE PIT:
Lo9 Crib Rings__
BUILDING FOLJNDATION
DIAMETER ..... OR WIDTH___. LENGTIt .... DEPTH ..........................
Crib Size: DIAMEIER ..... DEPTlt_ _DISTANCE FROM: WELL_
TOTAL EFFECTIVE
NEAREST LOT LINE ....... ABSORPTION AREA (WALL AREA) SQ. FT.
Well
Class: ~o Depth:
Well Distance To: Lot-Line
Bldg: Sewer Line:'__
Pipe M~terials:
# of Bedrooms:
Installer:
Remarks:
F'ERP'II T NO.
FIF'E'L I CFIN'r
L O F: R T I O N
LEGFIL
[:,[~F'R.F.t'TI"IEi'.,I'F C ...... .FIEFILTH R1..SE:, EN',,,' I F.:ONHE1..,I"FRI._ i .... )TECT I ON
.......... "' L" ST.F.:EE'F, RI'.,ICHOI~:FIGE, FIK.
."£~; E% t-.-~ tie F-: F" E F-: !""1 3'C -'IF'
F'H I L.L t F' L 3C:I-:::1.4OOI)
1--I fI...LS I~& i:~JN
L:I. E:::L GfeEENEF.'Z"_'k' SUE:
SRA BOX 7:1-!._
LOT SIZE:
5,4. E~¢_-'tE~ '5~7!I..IFIF::E FEET
Ix,. TF. EN~.H
TYF'E OF SOIL FIE:SOF..tE:TION =r...TEfl '-'
HR;'<]:HUH I'.,ILIHE:ER OF BE£,F.'OI3HS = L::: SOIL F.'~FITIt",!G ,'..'S6! FT,--"BF.'.)=: iSF3
THE I;:':EI;!LtlRE[:' SIZE OF 'THE SCIII_ HE,::,UF. FTI~N SYSTEf'I IS:
THE LENGTH [)Ii'"tENSION IS THE LE1.',IG' ~-44 FEEl'.'.', OF I'HE TI~:ENC:H I]']1'.~: [:,RFIINFIEL.[:,.
":, '""' 3F-. PIT IrE; .-TFFINCE BETt, JEEI'-,I THE SI_IF.':FEtCE OF THF-'
THE L E.F fH OF R TF.'.ENCH --' --
GF[:OUND Ri'.44D THE E:OTTOH OF I I3N ,:: tl'.4 FEET::,.
'THIEF-::E IS NO SET WIr:,TH
THE _~FP ,EL DEF'TH IS THE ±'"II GF..:Ft',,,'EI_ E:ETWEEN THE OIJTFF:iI_L. F'IF'E
R1..,ID THE E:OTTOH OF THE
STFILLE ""-' ...... '"'-
Et E'RC:F.:FIGE F'LRNT f'IEIY BE IN [:, AT THE FE.P..flI FTE. E _- OPTION SLIB.IEC:T TO THE
FOLLO1.4 ~NG F:OND I T I ONE;:
% EITHER R F:L. FISS I OR ]~' NSF AF'PE:O',,,'ED F'LFINT f'lE¢¢ E;E INSTRLLE[:,.
":-' R E:F~NTINUOUS HRINTENFINF:E RGF. tEEf'IENT IS F.:ELqLIIF,'ED. IF R HRINTENANCE
FIGREEf'IENT IS NOT KEF'T -.:~E'RENT YOU f'IFIY BE F.:EL-:!LIIF.:EE:, TO ENLF/F.:GE THE ..-.,UlL
RE S "_' RF'T I ON SYSTEf'I FIND/OR YFIU f'IRY BE '51 tE,' 3'EF:T 'FEi PF.' _- ':-.',E 2 _ T I 7. 1.'44.
'Ti.--li~Z~ ,:' Z ":, Z t'-41:5F'E-:E:-r' Z -- '-- F--:EZ ~.';:-~11_...[ Z
E, HUI-..F ILLII'.,IG OF FINY S','S'FEi'"I 1.SITHOLIT FINRL INSF'ECTIOI'.44 FII'.44D RF'F'RO',,,'FtL E'Y THIS
DEF'RF.'.THENT 1.4 1LL E;E ':~,UBJEIZ:T TO F'F'.E SE: _ T I '5 1'-44
HINIP'IUH DISTANCE BETWEEN FI NELL 8ND FINY ON-SITE SEbJFIGE DISPOSRL SYS'FEI',I tS
±E~£~ FEET FOR A P~'.I',,,'RTE t,-IELL OR 2¢8 FEET FOR R PUBLIC NELL.
OTHER RE(.:~UIREHENT':-'; 1.'tRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRI::II',IS RRE
R',./FIILRBLE 1'O INSURE F'ROPEF.: INSTRLLRTION.
I CERTIFY THRT
±: t Al,1 FRMILIAR klITH 'TFIE REL-qt.JIREMENTS FOR ON-SITE SEWERS It1',1[;, WELLS RS SET
FORTH BY THE i',IUNICIPRLITY OF RNCHORFiGE.
2: I WILL INSTRLL. THE SYSTEH tN RCCORDRNCE I,.IITH THE CO.F;,ES.
2:: I UNDERSTRND THRT ]'HE ON-SITE SE1.SER SYSTEH P1RY RE~;!UIRE ENLFtRGEf'IENT IF THE
F.:ESI[:,ENCE IS REI"IO[:,ELE[:, TO I1'.¢]:LU[;,E I"'IORE THFIN Z.':
I::IPF'I.. ]. E' :F'-]i'~rF F'H I L.L I P LOCK1.,4400[:l
....... .........
F)f~'PL ]' CFINT
L..OCFI-F .1~ ON
j ..k'.GF~L
L.:].. E:::L GF~:E~ESNE:F.'X:)OK SUE:
L 3T ~!!; i ZE
,.., ,,_ .... ,. . TF.'E'HCFI
i"¢F'E O1:: :::;O :i; L FIE:'9.;OF.:Eg" ;( Ot'.,i ::, 'r .:, rE 1 ]: E;: ...
I'iFt;:':;iHUH NLihlE:EI~: OF' E:E:DF.:OF¢IS =: 2::
SO i L F.:RT ]' NG i::"T/E:F;: ::, =-" :'L.'E":.;~)
'i'HF:: ~:E:X..:!I...i i P::EE:, 'E, t ZE OF 'THE:. :.:.T,O :[ L.. FtE:tSOF. tF'T t ON SYSTEH :[ 5;:
THE LE ,t.~tht C, :!: HE:N'.'S :[ C~N :[5; THE LENGTH ,'IN FEET::, OF i"HE "f'F:ENFH (.".if:
FFIiS C, EF'TH OF' Ft TRENCH 3R F' Z T i S THE E:,:[ S'FFiNE:E E;t t.,.![::.l:l.. "fide ': _ F:'FFICE f3F'
GF:-IOLiN[::, FIN[)THE BO'f'TOI"i 3F': THiS EXC:FI'v'RTZON ,::iN
'iHEF::P." ]:'-.':., NC SET I.,-i]:DTH FOR ~I~..E.i',I~.HE..:,.
THE L:ii;i:Ft',,,'E:L C, EF'TH if.:.; THF. t,'tINIHLiM E:,EF'TH OF ,Ii:E[EN THE
Fti--diE:, THIS f.30"t""f'OH Of:' 'THE: E:::.:;CFI',.,'F!Ti ON ,' i N
If.:-:" if=It ~Z::: t
Fi PFICKFIGE PI....FINT i'"iR"r' BE tNtSTRL. I..E[:'
FOi.[..(:)P.i :[ f.,tG COND :[ '1" .TONS:
% I.:ZI'THEF-". FI CL. FkF, S; t OR
Ft CONT ]' NUOtJS; FIFI .t
FIGt;..'.[.:..'E:f'iE:NT ]:L::'; NOT
FIE:S C'tF4:P"F i
PL.F!NT i"iFiY DE INS"i'RI_L. ED.
]"f' iS REf.:.!LiZF::EE:,. :FF' Fi i'dFiiN"FENRNC:E
i'lR'-/ DE: REX;:¢JiREI) 'i-O E:Ni_FIi:~'X::iE: "Fi--lEi :SOil.
BE 5tjB,.TE:CT TO PRO.'F.;E:C;LiTi CHq.
"'tF' B..!i ,:L-, ,:: ;~:i".
DF:If:':i<:F i [.L.. :( NG OF FINg'
i)EF'FIF.:"FHE:NT H~'I..L.. E:E
i N'.E;PE:E:T ~. O '.4 FIN[) F:tF'F'F.': Z VI:::i EP-r' 'FH Z :5
E :' _ -f T i:'iN
i',i ]: N :!: HUH i:::, :i: S;TFtNC:E E'~.F:"f'HEEN Fi
:]j:_-~;~i FEET FOF.". Fi F'F::l"v'fiTF: P.lrELL.. Of;::
O'f'HE:t;::' F:'.[%)iJ I F.'.Ef"tENT:~; PIFIY IqPPL."r'.
F~VgiL..FIEd...E TO iN'2, UF.'[:.: PROPEl::,: tNSTRLLRTION.
F" !~:~: F~: il""',~ % "-Ii'" E ;:-=;', if=`' % if~'.' E: E~; E:::" E: ~: ~: ~.'-ii ~ E:% F~:
NJ::' RN"/ f.:IN-S :[ TE :E;E.t,.IRGE F' i :SF'I3:SFti._ .::, T .: ' :[
FEET FOR Fi F'I...IBi_]:C i-,-!F:l...L
:E;F'EC ~'[ F' [ Z:FtT :[ ON:~ FiNC, 'Cf31'.iSTF' ,. ~ 'i" ri. ~':~f'4 i':I t FiGF:tFiPtE;
Z ..bF.t IF'r 'f'HFi'T
J.' I .:::Ii'/ FFii"ilL]:FIP:: FILTH THE REX;!.i. jI~:EPiENTS FrOF:': r'N.--SZTE S:;EP.IEF.:L:i:; RF~E:, H[:':LLS F:l:F, S;iE'T
i:-" '
FORTH :,'r 'THE:
:2: .t: I.,.l:[l.J.. ;[N:E;TFII...I.. "FHE z,,.:.IE_~I IN
:~:: I UNE:,EF;:'.F;TFINC, 'TI...IFtT THE L3N-'_"-;ITE :.::.;bS!.,.llT£F..' ::, .r .., I Eri t'lFl'-? · ........... t.-~k:
F~:E'.'-;i[)EI',!CE: Z~S; F-::EHCIDELEF~-'J ].'N~U[::,E h'IOP.':[.C THFIN 3: E~[EE:,I;-':CtCFI"I:TS.
: .... ':: .....
Performed For Les Pace
Legal ~escriDtion: Lot 1
This form Renorts Soils Lo~
/
~_,F '~i.
2204 Cleveland Anchorage, Alaska 99503
Date Performed
Block 1 Subdivision
yes
~enth
Feet Soil Characteristics
Topsoil__ ~
· Coarse Gravel (GP)
Silty Sand (SM-ML)
8~25/76
Percolation Test
8 Fine Gravel (GP)
10
~ Sand (SP)
Silt (ML)
14-- Sand (SP)
18 .
20
Bo%tom of Test Hole
Was Ground Water.Encountered? No
I~ Yes, At what Denth? __
No bedrock encountered
Readinq
Date
Grnss Time
Net Time
Depth to H20
Percolation Rate ~inute
Prnposed inst~l~ation: Seepage Pit Drain Field
Deoth of Inlet DeD~H~'T~ Bottom Of Pit Or Trench
C~U?ENTS: 150 @qua.re feet drainage a~_e~'re__o~ire~_per bedr~QD~l.
~et Dron[
Test. Performed BY_~7~_~~ MackJT'~/~'~'~'~-~'-
Data Certified BY: CONSTRUCTION TDSt
Bat~.' 8/25/76 ~ - I~~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# -~ ~") ~_~-~ ."~j-_~L~ HAA#
1. GENERAL INFORMATION
Complete legal description
Lot I; Block I; Gr~enbrook Subdivision;
Location (site address or directions) 13191 Von Sch6ben
Property owner
Mailing address
Lending agency
Mailing address_
G~rald Grilly
Day phone
2107 Sorbu~ Way Anchorage, Ak. 99508
Day phone
Agent Carol Bennett FORTUNE PROPERTIES
' 3000 A Str~t Suit~ #101
Address Ane~n~g~.~ AZas~ 9950.~
Unless otherwise requested, HAA will be held for pickup.
3 ,~
NUMBER OF BEDROOMS:
Day phone 562-7653
TYPE OF WATER SUPPLY:
Individual well
community well
NOTE:
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
PubliC sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein, lfurtherverifythatbased 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
Address
Engineer's signature
$ & S ENGJNEERING
17034 Eagle River Loop Road No. 204
~agJe ~iver, AJaska 995//
Phone
Date ~ -"2.-z~¢-¢1 'z.._
DHHS SIGNATURE
Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: Date
I1111
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS 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. 1/91) 8ack MOA #21
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary Seal (Y/N)
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
I,, /~( I[ ~'R~_~l~l~Ic % Parcel I.D.
If~ B, or C, attach ADEC letter.
'"///3r Date completed
/u//A Cased to
ADEC water system nUmber
b///] Driller
/f~///~ Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WE/LL LOG
Absorption field on lot
Public sewer main
Sewer service line
L
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~00 ~L
g.p.m.
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout /~
Petroleum tank ~/,'~
Date of sample:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (~'N)
High water alarm (Y/I~
Date of pumping
Tank size /~,~0 (>/t4.. Compartments
Foundation cleanout ~/N) ,I/E..~ Depression (Y/~)
Alarm tested (Y/I~ /",J/,4
'~ I ~ ~ } ~,,h..''' Pumper //~+- /~tE
SEPARATION DISTANCES FROM SEPTIC/~G TANK TO:
Well(s) on lot ¢'J/]~' On adjacent lots
To property line o3,,6 ~ .p
Surface water/drainage
Absorption field
lO0'e
Foundation J~' ¢
Water main/service line ~0 ~-/-
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Vent (Y/N) "Pump~"b'rCLJ~evel at .--"~¢Pump off" level at
High water alarm level~ --~'~Cycles tested
Meets MOA electrica~ codes (Y/N) ~
SV~:Ao~::It~O N~STA.-TI O N TO"adjacent lots ~
D. ABSORPTION FIELD DATA
Date installed
Length Width
Soil rating /~O S'c-,~fL System type
Gravel thickness -~ ~
Total depth
Total absorption area Cleanouts present ~N) y/EZ' -
Depression over field (Y/I~ /%50 Date of adequacy test
Results ((_~/fail) ~PtS,~% "" for -~
Peroxide treatment (past 12 months)(Y/~) /]J0'¢ ~uo~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot /%J/,'~ On adjacent lots (:-~O0 ¢-F Propertyline (--~. 0
To building foundation c~ ' To existing or abandoned system on lot
On adjacent lots /00 ~' Cutbank J~J0/v'E- Water main/service line
Surface water /00 ~+- Driveway, parking/vehicle storage area
Curtain drain ~'0 ~JE~
bedrooms
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
$ & S Et~JGINEERING
703, ,:a[ile r~ivm' Loop Roac] No. 204
d~,cjle Pdver, Alaska 99577
Engineer's Name
Date ~ - ¢-/¥- ~L'2.-~
HAA Fee $ /'~, ~
Date of Payment ~ / ~'/CZ
Receipt Number qO~ t~,.b~ ~
72-028 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION ·
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99503
WALTER J. HICKEL, GOVERNOR
(907) 349-7755
March 24, 1992
FOR: S & S Engineering
PWSID Cf 21O346
My review of the records on file in this office reveals that the Greenbrook Subdivision
Class "A" Public Water System, is in compliance with the routine coliform bacteria
sampling requirements listed in Table C, and with the inorganic sampling requirements
listed in Table B of 18 AAC 80.200.
Sincerely,
Byron Roys
Environmental Engineer II
BR/cf
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~ 117, ~-~' Telephone: Home
Applicant Address ~ ~o¢~
(c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain);
(d) Lending Institution ~/"~/-~,/, ~-,¢ , Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family,~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] 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 [~ 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.
Page I of 2 72-025 (11/84)
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.
Nameof Firm /~-/&cc/~-~lar~- ~ ~- Telephone .~-7 I)
Address 7 / ~ -~ L/~ ,~ He ~/ ~'
Date (~ ,/'~ ,/c~ ~'
WATER WELL~OTE:/.-T~his Heal/tb/Authority~p~oval i~p~tion
cert~j.e~ thaCthe sub~dt water ~1 produce~150 galJ~ns per
~resen~ colif~ bacteri~ a sample~that w~ No ~¢ntee
or~tirioat~6 is exp~ed or imbed concer~ng the rang term
ad6quacy or ~afety of t~ water supply.
ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority ~prOval
inspection merely certifies that the subject on-site sewage disposal
system accepted at least 150 gallons of water per bedroom per day
as determined by methods approved by the Municipality of Anchorage
Department of Health and Human Services. No warantee or
certification is expressed or implied concerning the long term
adequacy of the on-site sewage disposal system. Construction data
reported on buried system components is from MOA files and was
not verified during this inspection.
DHEP APPROVAL
Approved edrooms
Approved ~!~'"~ Disapproved
Terms of Conditional Approval
Conditional
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 federal and state requirements. Employees of DHEP 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.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA~?
HEALTH AUTHORITY APPROVAL (HAA)
NIUNiClPALITY OF ANCHOI~AGE CHECKLIST - FEBRUARY 1984
Di~PT, OF HEALTH &
ENVIRONMENTAL PROTECTIO~
RECEIVED
264-4720
Legal Description:
Well Classification ~,·'~,~2'/-/,4/;~'~/' I '~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 Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot'~¢,~
To Nearest Edge of Absorption Field on Lot ,~ · '"
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments /~)--'~ ~,, ~/'~, ~'~.~;/¢ f'~-~)~
; On Adjoining Lots
On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed /",~) ' ~
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ?~¢" ¢
To Property Line ~,~::) · ~'
To Water Main/Service Line ~/¢-
Course
Comments
Size ~~o.'~o~Compartments
Air-tight Caps (Y/N) l/~..~ Foundation Cleanout (Y/N)
Date Last Pumped ¢ '~'~/-~--¢
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field ~'
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(1~/84)
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /-,.~:;~
Width of Field ~'~:~
Square Feet of Absorption Area
Depression over Field (Y/N) ,4/,0
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ,~'~
To Building Foundation ~ ~'
Lot .~CCZI~L
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
.~x¢/.).'¢,~ j Type of System Design
Length of Field ,~,~ '" v'
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N) ~/~--,$
Date of Last Adequacy Test ~ ~-¢-~'~
To Property Line ~'¢ * ¢
To Existing or Abandoned System on
; On Adjoining Lots /,~1~''¢'
To Cutbank (if present) ,ff//,¢4
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request
I certify t ha~__l~.av~, c~/§O/veri/f,]/cd, or conformed to all MOA and HAA guideli nas in effect on the date of this inspection.
Signed ~_./~../'~'~-~',,./~.~ Date ~'./ ~-~ /~
Company ,/~_~,]?h~r-!~. ,'¢ MOA No.
Receipt No. ~fi
Date of Payment
CE ~ 4369 .." ,'?.'/;¢
Page 2 of 2 .. ;'.':.',,'
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA gg501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
/ /
TO Whom it May Concern:
According to records on file in this office the ~'~e~-~ ~,u~ ~/~
Water System is in compliance with the State Drinking
Water Regulations
Sincerely,