HomeMy WebLinkAboutSTOCKHAUSEN LT 16Stockhousen
Lot 16
#051-062-23
Municipality of Anchorage
U'
On -Site Water and Wastewater Program 907 343-7904 '~ V_/bl`
ON-SITE WASTEWATER INSPECTION REPORT =` Z"`%;
OCT,
Permit Number: OSP171080 PID Number: 051-062-23
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
ALLEN J. DUBORD
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
21340 Ginger Lee Chugiak, AK 99567
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
STOCKHAUSEN 16
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
--
Distance between lines
-- Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area 2
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft
--
-- Ft.
Well
100+
--
--
NA
__
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1 1250 Gal.
Surface Water
100'+
--
--
NA
Material
Steel
Number of compartments
2
Lot Line
5'+
__
__
NA
NA
Foundation
10'+
--
--
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
*NA
--
--
NA
Remarks *None known. New 1250 -gal S.T.
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Installed per code.
Pump make and model
Electrical Inspections performed by
Tank to
PIPE MATERIAL House to tank 3034 3034
Installer RPC
drainfield
Drainfield CO/MT 3034
Inspector ARCTERRA
BENCH MARK (Assumed elevation) 100 ft
Inspeection 1" 5/31/17 10/27/17
Location and description
2nd
ction
3`d 4d'
Side of Gas Meter
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engin
s OF AZ\
Conditional Approval: Date��`��'
`9�1,
® 4 91H 4
I�
�n KENNETH M. DUI �
�v
7116 �
I
Approved r A cIluj Date �� 31
ZIP
1 � P OF l~
cso= �
s
eer's Stamp
Inspection Report_9-1-12.doc
A -C= 37.0'
B -C= 27.5'
A -D= 37.0'
B -D= 34.5'
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit;❑SP171080
ST❑CKHAUSEN LOT 16 PID#051-062-23
2 CLEANDUTS 'r
f
0
�w
wa
Qo
oN NEW
J 1250 GAL
Zr m / TANK
SCALE, NTS
FINAL GRADE
EXISTING FIELD
PREPARED FOR,
ALLEN J. DUBORD
21340 GINGER LEE DR.
CHUGIAK, AK 99567
FIELD BOOKS
BOUNDARY: BOUNDAI
STAKING: STAKING
ASBUILT: JLS
DWG. FILE:
ACAD FILE: FILE
COMPUTED:
DRAWN: BMW
CHECKED: KM D
DATE: 10/28/17
GRID: NW1460
" No.: 17143
MONITOR
SCALE: 1' = 40'
VARIES
o""`"o. MUNICIPALITY OF ANCHORAGE ,t,,,,,,
\1 On-Site Water&Wastewater Program
PO Box 196650 4700 Elmore Road y r
Anchorage.Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite
clrir(Merit
On-Site Wastewater Disposal System Permit
Permit Number: OSP171080 Effective Date: 519/2017
Work Type: SepticTank Upgrade Expiration Date: 5/9/2018
Tax Code Number: 05106223000
Site Legal Address: STOCKHAUSEN LT 16 G:1460
Site Mailing Address: 21340 GINGER LEE DR, Chugiak
Owner: DUBORD ALLEN J Lot Size in Sq Ft: 92782
Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field D Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907)343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: ll Date: C—/&-- /7
Issued By: J y, LA,Z,u1 L' Date: /c1/1 7
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 051-062-23
Property owner(s) ALLEN J. DUBORD 441-5775
Day phone
Mailing address
PO BOX 672589, CHUGIAK, AK 99567
Site address 21340 GINGER LEE DRIVE, CHUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) STOCKHAUSEN LOT 16
Legal description (Township, Range & Section)
Lot Size 92782 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑
Single Family (SF) PI
(w/wo ADU)
Septic Tank [1 Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: �5 Waiver Fees:
Date of Payment: 3109' Date of Payment:
Receipt Number: 04,3$ Receipt Number:
Permit No. QS P/9-/GgO Waiver No.
Permit App_9-1-12.doc
., ts.ctcTERR,4 ,
,' il
ARC�X ERRA
c ,
4 - CONSULTING, INC
1, fi 212 E. 51's Ave,Anchorage,AK.99503
" +'� Office(907)868-3791, Fax(907)868-3793
,,,,
May 8, 2017
Municipality of Anchorage
Development Services Department
On-Site Water& Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Septic Tank Upgrade Permit- Stockhausen Lot 16
The owner has requested we proceed forward to obtain a septic permit to
upgrade the failed septic tank.
We propose to decommission the existing 1000-gallon septic tank per code and
install a new 1250-gallon tank in the same location with new service lines and
cleanouts to serve the existing 3-bedroom house.
The adjacent lots are served by private water. There is no surface water within
100' of the proposed tank. We do not expect there to be any adverse effect on
adjacent lots by the development / installation of this tank. If you have any
questions,please contact me at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
1111
Bre' + . Western
•, ,ner's Representative
Attachments: On-Site Sewer Application
On-Site Septic Tank Sketches With Notes
20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH (907)868-3791 • FAX(907)868-3793
I
' MUNICIPALITY OF ANCHORAGE
/0 f r'"' \ DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION
\:-..!..c. 4 ENVIRONMENTAL ENGINEERING DIVISION
826 L Street-Anchorage,Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME A.,#)�c /�`��,C/f /} 01)MAILING ADDRESS ` ( EYr/e,-",- M AND
f rr
l/ lad./ /7
LEGAL DESCRIPTION
61 6 ,c 4.1.4€4 f /c/ .
LOCA' *N/ NO.OF BEDR S
Well i ! Absorptio fa ZQ t PERM! '
Y j f D
UDISTANCE TO: A
wt Manufacturer r.terial / A No.of Cgrppartments
to~
Lig.capacity in gallons Inside length Width Liquid depth
/00 o IF HOMEMADE: .-_----
DISTANCE �_�- -- •welling PERMIT NO.
Z_Fa- M�yvf�cturer Material Liquid y in gallons
D Well / oundation Nearest lot tWe � PE' ' ,/
w= DISTANCE TO: lQ_5 (�� (� (/
u.2 No.of lines ! Length of eec / Total length limey Trench w'.h/ // Distance between lines
i-Z w / r lP inches
Q¢ Top of tile to finish grade Material beneath filo ��^[ Total affecst_i al3soopp/tion area
cc
cc ,702-inch
{ ches
Length t Dep2Fi"` PERMIT NO.
w
ctI- Type of crib __r.-Ertrdiemeter Crib depth " otal effective absorption area
w0- -- — -
.,--�'- Well Buildingfoundation Nearest I`o ' e
_c°_ DI • •CE TO:
J CI' f / Depth Driller Distance to lot line PERMIT NO.
w - ..Iv.
DISTANCE TO: Building foundfit,n? Sewer line Septic 7i 5 Absorption 7 110
rtw 7
PIPE MAT 2017 SEPTIC TANK UPGRADE: . 5"Mto
SOIL TEST Decommission existing septic tank y-L'
I NSTALLE
per code &install new 1250-gallon - - - -174.4' -
REMARK
tank maintaining 5'+ from ,
Llz oVi S - ,
foundation / existing field & �!D 6`r`6"�
�4Ta
,—__.. 100' + from private water wells. -r' /
'
I . b 303 q —•
45
APPROV D DATE LEGAL
ki.:-
/• - . /090i 1e.)/0 S-)-C•‘c "7 -sC/
72-013(Rev.3/781
REALTY V
I_OL�ht P'( 7=C=t'St-T�r F. y 70(6881238 +� - 09 i03911 P2
4111 W 694 :21: P.@2=02
• AlfJ- f #
r--
Y
N OO'QO'OC"E 25931' A IV
9(�3 VI
'4 "' .N .. 4i
,..x 6. I
(� 1e9e oX ~ a I
F.*
Nib t41.9 1 •
• OUST. NGS''-
1 s 18.0
1 027
o
to '
L.'cI(9N _
8 x �� CR
- � Z
`x
O
NOTES WELL 1 $
1. No wells on adjoining lots are g
ret
within 100' of proposed tank >K P� way to
placement. I �
2. No surface water noted within 4/
100' of proposed tank placement. 1
a 1
m
I� p Im
/ ^ D
_.
...., I _, v NI
.20 i 2017 SEPTIC TANK UPGRADE: '
Decommission existing septic tank perin g
ii
5 code& install new 1250-gallon septic $
tank and two post-tank cleanouts per .1 a
code, maintaining 5'+ from foundation & -I -4 07
existing field,and 10' + from water line.
8 70
�;
IV
400 001001 258.31' . 1"....,
cji
(31 t, ii i .
._ __ r ............ r
GINGER LEE DRIVE i
tA � ��a. e. • n � . �xz ca
d _q ;' 0 o •
iiiiitla > \
I— R-+ X t 1 >QMO >Ia nt 4
1
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 AND/OR WELL INSPECTION REPORT
LEGAL DESCRIPTI(
[~UPGRADE
NO. OF BEDR~.~S
DISTANCE TO:
Liq. capacity in gallons IF HOMEMADE: Inside I~ngt~..~h W dth ~ Liquid depth
Well
DISTANCE TO: /0S /
No. of lines / Length of eac}
Top of tile to finish grade
Length Width
Type of crib
Well
TO:
Total length(~li~e~ Trench w~h~ //
Material beneath the
Building foundation
Distance between lines
PERMIT NO, J
~iiii~S~eJ~ot'~lJ~tt~'i n e p~~E R M i Z N O.
Septic 7~f~~ Absorption ~'~ /,
Depth Driller
Sewer line
DISTANCE TO:
I OTHER
SOl L TEST RATING
P]PEMATERIALS D~0 ,.~ ~ /~/~7~
REMARKS
DATE
LEGAL
72-013 (Rev. 3/78)
_r;,[_:iPFiF?.THENT OF ltEFiLTN F:iI'.~E:, [:P,Pv'}TRON!"IElt",!TFIL
E~ ¢'-,,] -.-...'. TEE;; K -FET ?; [~.E ~.,,.~ EPiiP:;.~;: F:' i9S F;~;: P"~ I1 -F,"'
790567 }
FIF'[::'L. iil
.. i 'l FIT T C N
LFi[~F!t..
L (lIT '=i i' F F:
i"!F!::':;IHLtH !",tLtI'"IE;Ef:,: OF 13EE:,I-~:OCfi'"tS = 3
'.5(').IL RFfl'IN[3 ':':~ '~! FT,.';E:F:)=
'i",gE LENGTH D'[h'.FNS)'EN .T.'.::; THE L. Ei'.,IGTH ,'NN FEET) OF THE; TF:ENCH
]'HE DEF'TH OF FI TRENCH OF~: F'ZT iS THE E:, :I: :STFII'.,!E:E f3ETHEEN THE 'F _,q'FR-:F OF THE
LiiRCILft'.¢.D FII'4t2 THE E:O'T'TOh'I OF THE E:'::C:FI',/FIT ]1 ON ,:1 I N FEET 1:'.
"11--IEi::%~! IS i'-,tO SET !.,.I!DTH F'3F' 'i'RENE:H[ES.
T!qE GF~:FI',/EL DEPTH :[2:; THE i-,1N'.4IhilJH DEPTH r'F GI:~:I=i',/E(L. I-F:ETHF_-'EN THE: i .TFFIt. i. P;[F'E
FtHE:, THE E:OTTOJ"I (}F THE E::'::CFI',,,'FIT~TON ,' _TN F'EET::,.
.... ~. , ..... ,:= 5R;: El
~,qP'~E::'~"::"~ ~ "r ~:P2}iE/i:* 'SLT;'_¢.=EF"'F' iR ,_.: t ~ ~I~-,,, .... I1 -':E
h!LIHD, IEF: OF' RES!DEHCES THFIT THE HELl. HIL!.. SERVE.
TH ! S [::,EF'RF:.'THE:I'-,!T [)i...li~: t i'.,!G THE
!'N ]' Fi; ~"~" '"F'F
TM
.._ r-r~.._,.-'.:r': i'r FIN[) 'THF~
13i::I(3KF]iLL. IHG r'l::' Fff.2.? '"'"' ..... . ...............
=:,=,'lEft I.,J](TI-]CiIJT FI'NAL TH':;F'E'CT];CIN FII'.,![:, F.!F'F'~:~'-',/Fd.. B'¢
DEF'FIF::]'HENT HZL. L BE ':~ E)'E'"T 'FEi F'F'-'=E'i T'ZEI'..I
H I i'-4 ~ HI..Ii',! E, I ':;i"I::it'.JCI~: E:ETHEEi',I A I,.E;LL F:Ii",ID FIF,t'¢ Ul~-::,... f E 5EHFIGF_: E:'
;{.F3lil ~-[:.~.. FIiIF4: FI FI.I,i'..E I.,.!i:[LI...~ lil~'
.... I:" I.JE~,L ! ... !.,.fI.S I... L.
· . . F UE, I. J. ~. I_': EF'Ei'.,tE: _ r~ :3 F' qN THE T'.'r'F'E
tf5';3 'i-O ;.,.'HPi FE'=f' F'F:OH I':1 ..... HE]!. . 'T'll -
tFIr=** F:EG!I..IIF::Et"IENTS; I¥iFl"r' FIF'I='t.'?'. ':pE~TF]'CFIT)'"fl"!q f'tl",!C' qEN':-;TF'IICT~Eff',!
ff,,,'F:t i !..F:IE:L..~; TCI I i",ISI~.IRE F'r~:OF'FSR I !'.,ISTf:ILLFFi' I
i
i:
FOR'T'H B"/ THE i"IUNICIF'FILiT'¢ OF FtNCF'IORRGE.
2: ~ 14H.L :[N:"STRL_L THE S'?STEH ~;F,t RCE:ORDRt'4CE I-4'/.TH THE CODE'iF
]:: i IJiq[:,ERSTRIqD 'i'H6FF THE ON-SITE L=.,EHEF'. S'-/':6TEH I'"IFT'¢ F..'.'EG!U:¢F.:E EN1....RRC'iEHf:£NT
RESiE:,EI",iC~]' !; . ,e.'(I"IOE:,ELED Tf' I I",!Cp" E"THOI~:E THI:"IH. 3: BEE:,F:OOi'IS.
..,=F ~ ~ TI-IRT
] FII"I FI=ti"IILIFII-:~:
:(F THE
~ CONSTRUCTION TEST LAB
"One Test is worth a Thousand Opinions"
2204 Cleveland Anchorage, Alaska 99503 277-0231
Performed for ~acke¥ Construction (Larry's)
Legal Description: Lot 16 'Block
This Foden reports: SOILS TEST Yes
Date ~erformed 9./24/99
Subdivision Stockhauser Subdivision
PERCOLATION TEST
Depth
Feet
2' Peat
Soil Characteristics
Brown Sandy Gravel
(GW-GP)
Bottom of Test Hole
Was Ground Water Encountered
If YES, What depth?
No
! ~ ! i Depth to H20 Net Drainage
Reading i Date ~ Gross T~ue Net TLme I
Percolation Rate
Proposed Installation:
Depth of Inlet
CO~C4ENTS: 1~0 sq. ft. drs~msg~
Minute
SEEPAGE PIT D~AIN FIELD
Depth to Bottom of Pit or Trench
Test Performed by
Data Certified By: CONSTRUCTION TEST LAB
Date : 9~/~9
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.oi.anchorage.ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Expiration Date:
GENERAL INFORMATION
Complete legal description ~/~/' ~H~E~ ~/~
Location (site address or directions) ~/~ ~ ~/~ ~ ~./~~V~.
Current Prope~yowner(s) ~¢ ¢ ~W ~I~¢ Dayphone
Mailing address ~E
Lending agency
Day phone
Mailing address
Real Estate Agent d/C,~C'/_//v'~' ~/-~,~_/Y'E) Day phone
Mailing Address ~. ~2~o3r ~'~ / ~'~1 ~__/¢rX ~I~-~, //¢,~- '¢~¢2,~ ,7~
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding Tank
[] Community On-site
[] Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent
professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are
required for the transfer of title (except between spouses) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
Certificates of Health Authority 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 less than 30 days old. 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.
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 Health Authority Approval Guidelines for the Health Authority Approval
application show 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 applicable Municipal and State
codes, ordinances, '~¢~dSr~C!t~?~lS~ceffect at the time of installation.
17034,5~a~;le River Loop Road No. 204
Eagle River, Alaska 99577
Name of Firm
Phone ~ '¢'¢- Z¢~-'~' ....
/n/oo
Date
bedrooms, with the following stipulations.
Address
.
Engineer's Printed Name
DHHS SIGNATURE
I,~ Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Expiration Date:
Original Certificate Date: _
Reissue Date:
75 025 ~Rev O1 007
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WELL DATA
Well type
Log present (Y~ /MO
Health Authority Approval Checklist
/~/' ,~(.,~'/'"/2/~/?/(r~ ¢~) Parcel I.D.:
IfA, B, or C, attach ADEC letter. ADEC w, ater system number
Date completed
Total depth
Sanitary seal (~1)
Cased to '~/~--
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform -~ Nitrate
Date of Sample:
B. SEPTIC/HOLDiNG TANK DATA
Collected by:
Casing height (above ground)
Wires properly protectec~/N)'
AT INSPECTION
'~. ~ g.p.m.
Other bacteria -(~/'
17034 Eagle River Loop Roa,4 No. 2~
Eagle River, Alaska ~577
Date installed /~ /~ Tanksize /~ Number of Compa~ments Z Cleanouts~N)~X
FoundationcleanoutCN) ~ Depression.(Y~. ~0 High water alarm (WN) ~/~
Date of Pu mPJl~g' ~:~?/~/~ Pumper ~'~
C, ~BSoRPTION ~I~L~ ~ATA "' .~'.
DateinCtalled /1~) ~ :- Soilrating (g.p.d./ft~orfF/bdrm) Systemtype
LenCh .~;~ widih- '? ~ '~
Gravel thickness below pipe ~ ! Total depth
Effectiv~ absorption area ~'/~, /~ Monitoring Tube presenf~N)~__ Depression over field (Y/N) /'~-~
Date of adeqUacY test '~/,/~-/~) Results(Pass/Fail)P/cF2",-( For "~'-"/-/'-¢-'~--~-- bedrooms
Fluid depth in absorption field before test (in.); -'~ Immediately after~-/~ gal. water added (in.): //'////
Fluid depth //~/~# (ins) Minutes later: ~ ~- Absorption rate = ¢ ¢~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) -"/~/¢/¥¢2/~I/'&'~/A,/If yes, give date
72-026 (Rev. 3/96)*
D, LIFT STATION
Date installed Size in g~
Manhole/Access (Y/N) !~ ~ ~el~ at'* "Pump off" level at*
High water alarm level at~.,~"-""~ *Datum
Cycles tested ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line ~.~-
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
/
Foundation /5/' Property line 5~
Water main/service line t/O ~ Surface water/drainage t/F/~
Absorption field
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /~) /''~ Building foundation /~ /~
Curtain drain
Water main/service line / ¢) /~'-
Surface water //~)(~ ',-/~ Driveway, parking/vehicle storage area
Wells on adjacent lots /~"~
F. ENGINEER'S CERTIFICATION
' certify that l have determined thru fie/d inspections and review of Municipal records~O/4~?~t~,ems are
in conformance with MO.A HAA guidelines in effect on this date.
Signatur
Engineer s Name ~ ~
/o0 -
HAAFee $ (,'~'~,
Dateof Payment
72-026 (Rev, 3~96)*
Waiver Fee $
Date of Payment
Receipt Number
INSPECTION APPOINTMENTS
TIME TIME TIME
INSPECTOR ~ NSPECTOR INSPECTOR
DEPT. OF HEALTH &
~UNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 LStreet-Anchorage, Aiaska99501 OCT 2 6 1979
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL ~ATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
MAI LING AD DR ESS
PROPERTY RESIDENT (If different from above} PHONE
PHONE
4, REALTOR/AGENT ~ _
MAILING ADDRESS
STREET LOCATION
S. TYPEOF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four [] Other__
I~ SINGLE FAMILY [~ Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
WATERRSLJPS PLY
B~ INDIVIDUAL* * ATTACH WELL LOG. A weft log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8, SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON-SITE**~III~ /9'7 ~' YEAR ON-SiTE SYSTEM WAS INSTALLED.
[] PUBL(C UTI LITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) I J
THIS SIDE FOR OFFICIAL USE ONLY ~
.j
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 UTILITY (/ ~ ~ '~ ?
Connection Verified
INSTALLER
[~Septic Tank or [] Holding Tank ' ,,~"~ ~D~)~'
Size: /¢'~¢ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ,.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72 010 (Rev. 6/79)