Loading...
HomeMy WebLinkAboutGROLL #1 BLK 1 LT 3BDroll #1 Block 1 Lot 3B #050-522-02 �\ MUNICIPALITY OF ANCHORAGE %® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM Q,ND/OR WELL INSPECTION REPORT � PHONE NAME NEW RR Imo 1.7 D � .. � ❑ UPGRADE MAILING ADD SS t - LEGAL DESCRIPTION / LOCATIOfNqq NO. OF BEDROOMS CC - Well � [ Absorpt�n area Dwelling t � DISTANCE TO: 1 ��j ��' •? . PERMIT NO. Ct, s- b- 7_ 7– uj Manufacturer �Material No. of compartments ILiqcapacity in gallons IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. 02< S _ b Manufacturer Material Liquid capacity in gallons Q J Well f Foundation f Nearest lot linw �._ PERMIT NO. DISTANCE TO: _ �>� �� I � ' cl �j J u f•Jo. of liars Length of eachAine Total length len th cj lines 7' Trench wi„ C_, 21ch _as Distance between lines a R. Top of the tp finish gra le j beneath t' 1e1 Total effec�tiv/e�absorpt�oil area _p � -.S U' � `` I /J � - lV Cc, --1, V 5r tj V �11�/-s•'v ��4..- inches Length Width Depth PERMIT NO. WA C7 F Type of crib Crib diameter Crib depth Total effective absorption area a ru °- Uj _ Well Building foundation Nearest lot line DISTANCE TO: J w Ce . Dep6V / Driller Distance to lot line PERMIT NO. � DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER � — PIPE MATERIALS RC- 1� SOILTESTRATING �l \ U INSTALLER !_ [ REMARKS iP — .:3.(jir1)'l 1 f! �� I,u s •:. ,. ,9. e.., . ,t.,., ailyyr.°4C1:,� -- "m .r -- -- --- a_, I vv •f APPROVED DATE LEGAL !a r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 `L�\ 264�4720 �.V�` � �� �5�U^� ����� � � PERMIT NO: 850051 DATE ISSUED: 02/06/85 APPLICANT: S & S ENGINEERING ADDRESS: SRB 1,960 EAGLE RIVER� AK 99577 -~- CONTACT PHONE: 694-2979 m�*^/ / LEGAL DESCRIP: SUBDIVISION: GROLL L�T:/S� B|OCK: 1 SECTION: 23 TOWNSHIP: 149 RANGE: In !v LOT SIZE: 2.601A (SQ,FT, OR ACRES) LOT LOCATION: PRUESS 8LVD. I certi[y that: 1" I am "amiliar with the requirements for on- site sewers and wells as set �orth by the Municipality o[ Anchora1d the State of Alaska. 2. I will install the system in accordance with all MOA codes and re��lations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State o[ Alaska requirements for the set back distances[rom any existing well, wastewater disposal system or public sewerage system on this or a:y adjacont or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES; THEN (1) AN ELECTRICAL PERMIT AND INSPECTION ISUST BE OBTAINED; (2) AS~BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED /�/~ APPLICANT: 13 & SkENGINEERING /y ' ISSUED BY DATE: C� IPUTATION SHEET DATE: -2-- 6S5 SHED / OF BY SUBJECT Z 5 -lo 's - Pit No, 14,57-C U w SUBJECT Ole Oil co 7"' C IPUTATION SHEET DATE: SHEET 2__PF Zi BY CKD It j, i7 A j.K., AAWV 4" �P�. t8 COMPUTATION SHEET SUBJECT: n DATE SHEL7 a OF -7 BY CKD l<J 1 'MUNICIPALITY OF ANCHO'l,AGE OEPARTM€:NT OF HEALTH AND ENVIRONMENTAL PROTECTION Un L. Stroot, Anchera0o, Alaska 09Ji01 26,1-4720 SOILS LOG -- PERCOLATION TEST 111 t_:> LVl_ I LI PLRCO LATION Fl sr PERFORMED POR:rc4�-!C/c [11.11112_-----------._- a lI- PERI ORMUo LEGAL DESCRIPTION:, I " DEI'l'H SLOPF SIP PLAN (r-EETZ_ (0cUrr+(14 lC I 1 Ir 2 gAry 51C� /„ �1\ s 0 v 10- f 11 12 13 - 14 - 15- %.no 1 in;Zw A 16 17 /� C S ftk+ai Ao 14 t- Depth to Water ._..,—__-._—__ C I' 18 DEPTH? .,-- ,_ �_Pzz Fes` �1 P� ego . Z qa r. WAS GnOUND WATEI'i /� C S ENCOUNTEREF)? t- Depth to Water ._..,—__-._—__ C I' IP YES, AT WHAT,,-__ DEPTH? .,-- ,_ �_Pzz Reading Datn-- - - --Gross- - Time Net Timc Depth to Water Net Drop if .,-- ,_ / t l f rr ✓' I r Cl? �o J`L a PERCOLATION RAT E o� •� • / � �©o°�'°�� Cii � TEST RUN f3rl"lV LN `--� f - .ND FT 6o a NiFS a�t� -a» �cl/%{_fes_-.-If>s'�.fiSYl2(�1'�liL�_iC. - -r3 yA d no e / g-- ._ ®. meq- -�:i. a 1-7 11N. c 72-008 (6/79) — '�j�C�cyC n� r (!�+' _`�.�/ - 15wa C I!'!e-e,?zi ! r � 7 GL7 f� ., LV Municipality of Africhorage MEMORANDUM DATE: August 12, 1985 TO: Laura Grow, Accounting FROM: Environmental Health Division SUBJECT: Request for Refunds s Account 11 2460 Please make arrangements for the following refunds. Most were due to over- payment or should not have even come to this office to begin with. Thank you. Jack White Company 3201. C Street, Suite 100 Anchorage, Alaska 99503 Receipt 11 349242 Amount $45.00 Account 11 2.460 U.S.S 113042. Lot 74 Wiz SEI -4 - Health authority approval which is a duplex and should have gone to State D.E.C. David Plunkett 200 West 34th Avenue Anchorage, Alaska. 99503 Receipt # 347121 Amount $45.00 Account 11 2460 Lot 6 Block 2 Lampert Estates Subdivision - Health authority approval which is a multifamily and should have gone to State D.E.C. Billy G. Andrews P.O. Box 100--560 Anchorage, Alaska 9951.0 Receipt 11 341204 Amount $145.00 Account 112460 Lot 9 Block 4 Rockhill_ Subdivision - Applicant paid for a MOA inspection, however, had a private engineer perform the necessary installation inspections. Only being charged for the permit fees of $30.00. S & S Engineering SR B 1.96•-X Eagle River, Alaska 99577 Receipt 11349351 Amount $45.00 Account 11 2460 Lot 2 Sleepy Acres Subdivision - Health authority approval as a conditional this appplication was to remove the conditional approval, and should have riot been charged a second fee. S & S Engineering SR B 196-X Eagle River, Alaska 99577 Receipt 11 346953 Amount $20.00 Account 11 2.460 Lot 7A Block A Timberlux Subdivision, Permit 11 850317 •- Applicant was charged for a permit, by mistake, that: did not belong to them. Laura Crow - Accounting August 12, 1985 Page Two Marvin Johnson 4300 Arctic Boulevard #46 Anchorage, Alaska 99503 Receipt # 332980 Amount $15.00 Account 11 2460 Lot 3B Groll Subdivision - Well permit 11850069, applicant obtained a well permit without realizing his engi.neer(S&S Engineering) had obtained it for him. Bill/Cheryl Tatom Receipt 11346901 1744 Bellevue Amount $15.00 Anchorage, Alaska 99515 Account # 2460 Lot 1 Block 2 Potter Heights Subdivision -- Well permit 118502.83, applicant obtained a duplicate well permit for the same property. He obtained an On-site Sewer/Well Permit on July 26, 1985 (11850450), therefore, this is a duplicate on the well. Laura J. Ward Office Associate LJW cc: Subdivision files attachments •n A O r. on W O O tr a r m Z O m r - •n •n O m •n m •n m m m m trn to I I I m m A cn r r O O O O O O O O O O O m (moi O a •a i -n t� :W :N O ;W ;O ;P, :0 O W :O ;N :Wco (D YET' to n p Z N .w :N :,1 -n -r7'•rr On 00000000000ITI Fo :00 co¢, p N :Ln :4 --to :� O :wO co V, SU zo 60 Zi ny i �7 W m w in J (n UJ im i a :�:j rj a ZD :n nn : A. Yt ta. ; f : O RO m rt (D n •n A O r. on W O O w tr v O n O O n trn .t cn r r p a •a i -n t� O :V (D YET' to n p w DEPARTMENT OF HEALTH AND ENVIRON�ENTAL PROTECTION 825 L STREET� 0NCKORAGE� AK 995O1 264�4720 85O069 03/18/85 BRADLEY K. BRENNON 204 TWENTY GRAND DR^ EAGLE RIVER, AK 99577 69 9549 SUBDIVISION: GROLL LOT: 3B SECTION: 23 TOWNSHIP: 14N RANGE: 1W 2A (SQ.FT, OR ACRES) � I certi[y that: 1" I am �amiliar with the requirements �or on~site sewers and wells as set �orth by the Municipality o� Anchorage<MOA) and the State o� Alaska. 2" I will install the sysiem in accordance with all MOA codes and reg:lations, and in compliance with the design criteria o. this permit. 3. I will adhere to all MOA and State o| Alaska roquirements [or Lhe set back disiances �rom any existin� mell, wastowater dis�osal system cr �ublic sewe system on t�is or any adjacent or nearby lot. �� c APPLICANT: ADL K" BRENNO�� v\�\ \\ ISSUED BY DATE: �� . \ , . C .T 0~ "\ v\� 0 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APP Parcell.D. 050-522-02 1. GENERAL INFORMATION Complete legal description GROLLM BLOCK 1, LOT 3B - n ttyl Expiration Date: Location (site address) 25508 CRYSTAL CREEK DRIVE, EAGLE RIVER AK 99577 Current Property owner(s) GLYNN & SHARON MACSURAK Day phone Mailing address Real Estate Agent 2. TYPE OF DWELLING: PO BOX 771265 EAGLE RIVER, AK 99577 ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ Day phone TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ WaiverNariance request for: t& e + / `,�'� `fie �-/?�na Distance: Cd "a Received Received by: oa Date: lea /S COSA to be released to the engineer, unless i ' e requested by the engineer. COSA Fee $ 5� Date of Payment_� �, 1) Receipt Number o COSA# 6c5L' 6 63 Waiver Fee $ 2155 Date of Payment j 5 Receipt Number Qa&3.02 6?0- Waiver 5. STATEMENT OF INSPECTION BY ENGINEER A*14ftl; by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, basedondures 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 ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 5111/15 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen�rr 0F' AL ` encroachments, deficiencies or discrepancies exist. / <<& / Q. — 6. DSD SIGNATURE L/' System #1 Approved for System #2 Approved for Disapproved. Conditional approval for S bedrooms. bedrooms. bedrooms, with the h� KENNETH N. DHE , 14 4Xi/1_ 1 SSE f (' Cj' By: ( Original Certificate Date: rP O C114 - 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 blue sreer_1aio-12.dw If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: GROLL #1 BLOCK 1, LOT 3B Parcel ID: 050.522.02 A. WELL DATA Well type PRVT If A, B, or C provide PWSID # Date completed 3/511985 Sanitary seal (Y/N) Y Total depth 145 ft. Cased to 145 ft. FROM WELL LOG Date of test 3.5.1985 Static water level 50 ft. Well production 80 9 - p.m - WATER SAMPLE RESULTS: Coliform NEG coloniW100 mL Nitrate ND mg/L Arsenic: ND ug/L Date of sample: 4.29.2015 B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC / STEEL Tank size 1500 gal. Number of Compartments 2 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 12+ in. AT INSPECTION 4.29.2015 102 ft. 2.5 9 - p.m - Collected by: ARCTERRA Date installed 6.22.1985 Cleanouts(Y/N) Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 4/28/15 Pumper JRs C. ABSORPTION FIELD DATA Date installed 6.22.1985 Soil rating (g.p.d./flz or ftp/bdrm) 287 System type SHALLOW DRAIN FIELD Length 288 ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth 3.8* ft. (Measured 4/29/15) Eft. absorption area 1440 fe Monitoring tube Y Depression over field N Date of adequacy test 4129115 Results (Pass/Fail) PASS For 5 bedrooms Fluid depth in absorption field before test 21510 in. Water added 750 gal. New depth 41611 in. Elapsed Time: 10 min. Final fluid depth 21510 in. Absorption rate >= 750+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off' level at _ in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 1001+ Absorption field on lot 1001+ Public sewer main 754 Sewer /septic service line 251+ Animal containment areas 504 SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots 1001+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 1004 Manure/animal excrete storage areas 1004 Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 1001+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line *3' Building foundation 10'+ Water main 10'+ Water Service line 104 Surface water 1001+ Driveway, parkingNehicle storage 10'+ Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 1001+ F. COMMENTS 'd LOT LINE TO FIELD WAIVER REQUESTED WITH THIS SUBMITTAL G. ENGINEER'S CERTIFICATION ! certify that ! have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. OF 4 " ` Engineer's Printed Name KENNETH M. DUFFUS K✓ � Date 611/2015 00�* 9 TH \ COSA canary sheet_2-6-15.doc NNM M. U 10 `>I�s�/ t'RgFEs5lo� .I in. 0*1""W Municipality of Anchora P.O. Box 196650 •4700 Elmore Road Anchorage, Alaska 99519-6650 0 (907) 343-7904 • Fax (907) 34 Q Ment S �+ Seppartmeknt 7997 ,N Development Services Division On -Site Water and Wastewater Proaram **** VARIANCEIWAIVER REVIEW **** Waiver#: OSV151048 COSA#:OSC161263 PID#: 050-522-02 Legal Description: Grail #1. Block 1. Lot 3B Engineer: ArcTerra Applicant: Glynn & Sharon Macsurak Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 0.0 feet. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ® The affected adjacent properly 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. .............................................................................. Waiver is Granted: X Waiver is not Granted: Date: ( l Approved by: Name of Reviewer Permit#: Q► cTERRq ARCTERRA CONSULTING, INC RF 212 E. 51" Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 June 1, 2015 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 RE: LOT LINE WAIVER — GROLL #1131, LOT 313 Per the recent attached as -built survey dated 5 / 15 / 15 by Mark Seward, LS -- the existing septic field is within the required 10' separation distance to the lot line. The measured distance is approximatelyp/I from property line and we are therefore requesting a waiver Al to lot line at this time. This system has been in operation since 1985 with no known issues and we do not expect there to be any adverse effect on the adjacent lot, which is vacant due to the location of this system. If you have any questions, please contact me at 868-3791 / FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus Attachments: As -Built Survey/ COSA v tea.. / A C01111 T -- 6hwAu & ASSOU.IATES LAND SURVEYING 694-0829 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCAL j��_ FOLLOWING DESCRIBED PROPERTY: Gao« saw AdG tid i L�ra� i DATE. �ti Q A�� AND THAT NO ENCROACHMENTS EXIST EXCEPT AS / �i� INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THC EXISTENCE OF ANY GRID= ' rn EASEMENTS, COVENANTS; OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI— f; O�anx Mtrk SaWar6 •' VISION PLAT UNDER NO CIRCUMSTANCES SHOULD Fs` ANY DATA HEREON BE USED FOR CONSTRUCTION ��'�ta�A�o • S �f OF FENCE LINES, OR FOR ESTABLISHING BOUND— �•wk 4a „ ARY LINES. DRAWN- '� ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH r(�b CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 1. GENERAL INFORMATION F. Application Date —%J (a) Legal Description (include lot, block, subdivision, section, township, range) 11 Location (address or directions) (h) Applicant Name 2vZL, � Telephone: Home — Business __- Applicant Address --- ---_-- _— _ __ (c) Applicant is (check one): Lending Institution EJ ; Owner/builder; Buyer 0 ; Other El (explain); (d) Lending Institution—__-____� rte_--- _-____� Telephone —_--_--—_—___ Address —— ----- -- — ----- — (e) Real Estate Company and Agent Address— Telephone--------_.---— — (f) Mail the HAA to the following address: {{ r��yztl7f tl �9Sy? d[,"7 _—__— TYPE OF RESIDENCE Single -Family', Multi -Family C] 5- Number of Bedrooms ___ _ _ 3. MATER SUPPLY Other Individual Well °" l Community El Public 0 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 17 Community 0 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 1 of 2 72-025(11,84) a 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 ver�`y that my jnvestigation 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 ti ie information obtained from the Municipality of Anchorage files and from my investigation and inspection, the or, -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 �sil1P3 �f7i�i': Address --- Date 6. f HIEP APPROVAL Approved for Approved VNI 690_2W19 j �•• bt r' A. Shaf_, ,Q bedrooms by _ ._______ ._ Date __ L c Disapproved ____ __ Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragroph 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 riot responsible for errors or omissions in the professional engineer's work. Page 2 of 2 a..,=, ., . fr.�o.onr E �� .� j �•• bt r' A. Shaf_, ,Q bedrooms by _ ._______ ._ Date __ L c Disapproved ____ __ Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragroph 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 riot responsible for errors or omissions in the professional engineer's work. Page 2 of 2 A. WELL DATA M MUNICIPALITY OI' ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL. (HAA) "'lly/ �p 41TY D NV fRpNMENTAI PR �fCOQ p�, N CHECKLIST- FEBRUARY 1984 2 if 264-4720 Rpr EDLegal Description: —�' ��3 � y Well Classification If A, B, C, D.E.C. Approved (Y/N) — Well Log Present C)/Nr--- Date Completed -3- T —(S Yield �1��� v� f� S ��'✓� Total Depth )-t;�_ Cased to y�{� Depth of Grouting Static Water Level Z"�>I _ Pump Set At Casing Height Above Ground —_ Electrical Wiring in Conduit 00'j—_ Sanitary Seal on Casing &NI Depression Around Wellhead.(-YQ Separation Distances from Well: To Septic/Holding Tank on Lot __—_j Zc� On Adjoining Lots To Nearest Edge of Absorption Field on Lot �.c0 %__ ; On Adjoining Lots _"Q o _ To Nearest Public Sewer Line _.�—� �e To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by Date Water Sample Test Results Comments SEPTIC/HOLDING TANK DATA Date Installed ��-Size /( � No. of Compartments _— Standpipesg4K_ Air -tight CapsOAN'r _ Foundation Cleanout/.Nj _ Depression over Tank,(Yd� Date Last Pumped Pumping/Maintenance Contract on File (Y/N). _ ; for Holding Tank High -Water Alarm (Y/N)�Temporary Holding Tank Permit Separation Distances from Septic/Holding Tank: To Water -Supply Well — I ��i t . To Building Foundation To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72nirt i 1 IPA %t t: To Disposal Field N1�'_ 3oI IZDD I To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata — Type of System Design Date Installed �� 11 �& Length of Field Width of Field Depth of Field Gravel Bed Thickness 11 S�6K";-N) � 'K.,..VCL- Standpipes Present Olw of Last Adequacy Test Norm/ Square Feet of Absorption Area Depression over Field (O — Results of Last Adequacy Test t--"/,4- Separation --"/,4 Separation Distance from Absorption Field: I h To Water -Supply Well `1 c» 1 I To Property Line z::) To Building Foundation 1.S Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Existing or Abandoned System on On Adjoining Lots 7S 14- /To Cutbank (if present) M �lOs- To Driveway, Parking Area, or Vehicle Storage Area Comments — D. LIFT STATION Date Installed - Dimensions Size in Gallons M nhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all ,M/OA and HAA guidelines in effect on the date of this inspection. Signed is V U1110INENRINt Date Comp tljN 01VER, ALASKA IND57: MOA No. / �� 0"0 3 Receipt No. Date of Payment IV \"5 - as �° � � .u. o o eae •eaai eat. •6gry Amount: $' .. 1•, 0..".r A. StiaMr ; Page 2 of 2 72-026 J 11/84)