HomeMy WebLinkAboutGLEN EAGLE BLK 3 LT 3 oGRE'" R ANCHORAGE AREA BO' Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAMEI~,Zi~,r~ "0,'c,(e.y MAILING ADDRESS b-)~ttm:~t ~O/IS7 LOCATION /-~(':/~ /)/[,,I~/Z ~?'~ LEGAL DESCRIPTION SEPTIC TANK: DISTANCE ~', NUMBER OF FROM WELL MANUFACTURER ~-~t~¢~ MATERIAL C~c~6- COMPARTMENTS '2~ INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY. / O¢¢ GALLONS. SEEPAGE PIT: NUMBER OF PiTS __ LINING MATERIAL BUILDING FOUNDATION DIAMETER I~l CRIB SIZE: _ DEPTH DISTANCE FROM: TOTAL EFFECTIVE NEAREST LOT LINE WELL ABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION TYPE CONSTRUCTION BUILDING NEAREST NEAREST FOUNDATION '~-?"l LOT LINE SEWER LINE CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK. SYSTEM DISTANCES: DIAGRAM OF SYSTEM INSTALLED BY: PIPE MATERIAL: LOT SLOPE: REMARKS: Form NO. EQ~031 DATE ~7t~ G,A.A.B. Performed For Legal Oescriotion: Lot 3 This ~orm Renort$ Soils Loq "O,e test is worth a thousa.d opinio.s" Klondike-Alaska Date Performed ~Block 3 Subdivision Glen Ea~le YES Zl/9/74 Percolation Test Depth Feet Soil Characteristics 1M OYerburden 3-- 4 7 .Silty Sandy Gravel G -223 Throughout depth of test hole /g' Bottom of Test Hole Was Ground Water Encountered? No I~ Yes, At what Deoth? I Readinq Date Gross Time Net Time Dent~ to H20 Net Dron Percolation Rate Minute Pronosed Installation: Seeoaoe Pit Yes Drain Field Depth of Inlet Depth To Bottom Of Pit Or Trench C~MFENTS: 22~ sq. ft. d~a~na~e area required per bedroom No be'dr~ck or water table encountered Test Performed By ~///~>~ r~f~-~- Data Certified B~:CONSTRUCTION TEST LAB P.O. BoxA t224 o 1310C Internalional Airport Road (907} 274-4[:,1 t ANCItORAGE, Al ASKA 99509 ORILLtlxIG Well Owner_ ............ :_: ..... 2 'iLr. '_Z'_~;"_ .................................... Use oJ! Location (address of: To,,vnship, Range, Section, if known; or distance main roacL .......... -%z~_~£ L: L:'_.:;LE_dzL'2_± L J ~D '"'~_ ~_ :?. _:'--'u.'x ~ ..................... ',?'~ ,/:,:'" D-f'4'" /,',.t ',~:' Size of casing E, Depth of Hole Z.:~; .... feet Cased to ...... '.~ ....... feet Static water level ,:'~ ft. (~d~U'~') (below land sLlrJ'ace. Finish of well (check one) open end ( ;[ ); Screen ( ); Perforated ( .;,'~ ). (r: .-. -r ;r'.',~' :~,, .'.~ ',' t;~:':'1 ~','.~ "" ~.., ..... ' .7 [(.., Describe perforation screen or Well pumping test at_ ~:9__gallons per' (h:o(f~') of drawdown from static level. ~ Date of completion Depth in feet from ground surface (minute) for_ //r, ,,-'? - .~ -~ 7 WF.I& LOG Give details of formations penetrated, size of material, color and hardnes.-~ .TO_ 27, ..... .TO. TO .TO .TO_ .TO ..... .7'0 ...... TO TO TO 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.# O~-O -~O/~/'~ NAA#. P 1. GENERAL INFORMATION -:,,.,. . :.. Complete legal description ~o~ 3; ~[ock 3; 'Glen ~agZe' P Location (site address or directions) NHN Sunny Glen Drive, Eaqle River Property owner Mailing address Lending agency Mailing address Agent Virgin.i=_ Kehfie!d Dave Doherty p. Q. Bow 775~9] . Day phone Bag'lc. River, AK 995?? Day phone 694-5023 Day phone 694-5023 Address 16600 Centerfield Drive, Eagle River, AK 99577 Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: XXXX 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 Public sewer NOTE: XXXX 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 o 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 type of structure indicated herein. I further vedfythat 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. Name of Firm s & $ ENGINEERING 17034 Eagle River Loop Road Address ~.~qJe Riv~. ~'~,.,I.. a,~e...,..~ Engineer's signature ~'"~ ~-~ Phone Date /0 / ~tCz// DHHS SIGNATURE Approved for v~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments f41ll[fll 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 DHHS 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-o25(Re~.1/91) Back MOA~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.~ ¢ Z ~,~ ~ /-~ cC ,,,/ ~-~_,- Parcel I.D. A. Well Data Well type ~¢-' Log present (~) / Total depth Sanitary seal 1~1) / FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~'~ / ~- 7,-S~ Driller _ ~'~- Cased to 70 ~ Casing height Wires properly protected ~N) / AT INSPECTION Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot // Public sewer main Sewer service line /,2_/I ¥ ; On adjacent lots ; On adjacent lots /b~ ~- ,/ Public sewer manhole/cleanout Petroleum tank /Oo WATER SAMPLE RESULTS: Coliform ~ Date of sample: Nitrate O, I ,~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ,3¢~ _ 7,.<-~ Tank size ,./~P(~ ~, Compartments ~ Cleanouts(~l) / Foundation cleanout (Y/~ /-.J Depression/('~-1~ High water alarm (.'~ /,--¢' Alarm tested (Y/N) /J[,4- Date of pumping ~ -¢~ 7 -~ ?'¢ Pumper ...,/"~,~. ~-¢-~',~ r,~d~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /o~ ~'~ To property line .20 /.z Sudace water/drainage On adjacent lots Absorption field /~ /~o ~¢"' Foundation /'¢ ' Water main/service line 72-026(3/g3)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N). "Pump on" level at "Pump off~j.ever~- High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARA~OM LIFT STATION TO: WeH-offlot On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed .~ -~ ~ ~ ~-<~ Length z/~j Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ Soil rating (GPD/Ft2) :;;z2_.,~-~ "~/~Z- .System type ~,,~,~.-- Width / z./ j Gravel thickness L, / Total depth / ~ / 7.2. L. ¢ Cleanout present4~N) '-/ Depression over field (Y~ / ~ v ,~ ~' _~ ~ Results (I;~fail) /~/r~5 for ..¢ Bedrooms .2 7" After test -~ ~" ~/~,J£ /~,,Jo~'~J If yes. give date ~J~//~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain ~0 I~ On adjacent lots / z~, / '~ Property line /o ' ' To existing or abandoned system on lot Cutbank /"/,//~ Water main/service line /.¢- Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I cern'fy that I have checked, verified, or conformed to all MOA and HAA Signature Engineets Name Date this inspection. HAA Fee $ ~' o/)¢ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 09/30/94 15:59 CT&E ENOIRONME~TAL LAB -~ER'JICEE; ~ 9~769412'11 xt3.7:35 C'I'~E Ret'.# Giant $~raple ID Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services LABORATORY ANALYSIS REPORT 94.4~39-J LT3 BLK3 (.iLI',~N EAGLIf SfD WATER Cli.ealt Nmnv S & S J!'NOINEERING WORK ()rder 82557 Ordered By R,J.S. Prinled Date 09/3(i/9z, (~). 15:05 hrs. Project Name Collected Date 09/26/94 d~) 13:30 llrs Project// Rccdved Date 09/26/94 PWSID UA Technical. I)irecJur 8TE}'HENC, 1;I)t! Remarks: ROLFflNE SAMPLII COLLECTI_'.D BY: RAY QC Allowable 'Ext. Anal Pm'amLtLr Resulls Qual t. Jniis M~.'0lod .[.hrtits Datc Date Init .................................... -o-.]~ ........... ~£ ..... Nitrate-N * See Special lnslrtlctions Above UA = II.navaiiable ** 8.c Sample ~nu~'ks ~eve ~ = Not ~dyzed U= th~tc~te& R~ofl~valtuis fl~e practical qmnfificalio~t limi(, LI'= lzss 'lhan D= 8~on&~y ~lution. or= ('h'eaLLr'ihan 5633 B Street, Anohorege, AK 99518-1500 - Tel: (907) 5(52-2343 Fox: (907) 561-5301 ............ ENVIRONMENTAL FACILITIES IN AU'~$KA, COLORADO, FLORIOA, ILLINOIS, MA¢;YLAND, NEW J6RSEY, ONIO, UTAH. WEST ViRGINiA 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 May 14~. 1986 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3; Block 3~ Glen Eagle Subdivision Location (address or directions) (b) Applicant Name EdZth Heyward Telephone: Home 69'¢-9~66 Business _2_17- '~_1_.1 Applicant Address 1602 Ea~Ll~_~_i?~._-'f. Roa~ Ec.,gle RiveJ[, Alaska 99577 (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer [-]; Other [] (explain); __ (d) Lending Institution __C_~¢ Mq~g¢_,.~¢ Telephone Address (e) Real Estate Company and Agent _~_J~ Address ~_E69~¢, Telephone _~ 594-5_5_0~ Hold (f) ~ theHAA to the lollowing address: _ __SLB 1 TYPE OF RESIDENCE Single-Family ~ MultFFamily [] Other Number of Bedrooms :3 (thee&) WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting Io the legalily and status. 4. SEWAGE DISPOSAl.. Onsite [] Pnblic [] Cornrnunity [] Holding Tank [] Note: If community well systom, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and stalus. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As cellified by my seal alfi×ed hereto and as of the validation date shown below, I verify that my investigation of this HeaJth Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for tire number of bedrooms and lype 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 aud/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspects0,, Name of Firm SI~ ll~-~-"~ ~' S ENGINEERING Telephone ~.2__ ,~/--/,-- ~-¢ '7 ,~ Address EAGLERIVERTAK99577 Date MAY I 9 1986 Approved for -~-~e--~-~oedrooms b --~t~_ Date Approved ~V 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 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. MUNICIPALITY OF ANCHORAGE (MOAI HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: WELL DATA Well Classification Well Log Present~/~ Total Depth Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot /Oo To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results If A, B, C, D.E.C. Approved (Y/N) Date Completed ~"- / ~ -- '7 ,.~- Yield '7o' Depth of Grouting Pump Set At Sanitary Seal on Casing f~/,N) Depression Around Wellhead ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~ ~ ~--~"/-¢'~, (~J ~//~L¢ ; Date Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~,'~O Standpipes ~.N) Depression over Tank 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 M~;,,/Service Line '~¢ ~' Size /¢) ,..~o No. of Compartments ~-' Air-tight Caps~/,l~ Foundation Cleanout,¢'¢'~ Date Last Pumped "--%'~ / ~¢"/ /'/'~'¢-' ' for '- ~ Temporary Holding Tank Permit (Y/N) ~ To Building Foundation To Disposal Field Course To Stream, Pond, Lake~ or Major Drainage Comments Page 1 of 2 72-026(11f84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design Length of Field Depth of Field Square Feet of Absorption Area Depression over Field,¢~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /Oo To Building Foundation ~'~ Lot Gravel Bed Thickness Standpipes Pr ese nt~CN') Date of Last Adequacy Test To Water ¢¢re~/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots ,~O ! ~ To Cutbank (if pres, ent) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) /%~//~'Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify th~ ~ ~,v~/~l~j~i~e8, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ..... Date __~V compan~,rn,~,rn ~n~=~ MOANo. Receipt No. ,~ L(q ~ Date of Payment ~ ~ Amount: $ L¢~, (~ E~ Page 2 of 2 72-026 (11/84) #1: Time ;'.~ Date /-~ Insp ~--~ DFPARTM~ 825 ,..N~CIPALITY OF ANCltORAGF EAGLE RIVER AREA OF HEALTH AND ENVIRONMEK . PROTECTION L Street, Anchorage, Alas~a 99501 264-4720 /fiD1 _ #2: Date Received: January 20, 197g k. Time .J~L~J ~, ~~ # 3~ %~.~me / REQUEST FOR APPROVAL OF INDIVIDUAL SEWER'IND WATER FACILITIES Lending Institution Request: Alaska Statebank Mailing Address: 310 East Northern Lights BlVd. Phone: Property Owner: Mailing Address: 279-7637 DOuglas Tweedie Sunny Glen Drive 99577 3 Legal Description: Lot 3 Block 3 Glen Eagle Subdivision'- 4: Single Family Residence: (x) Number of Bedrooms: Two Multiple Family Residence: ( ) 5. Well System: Individual well ~x) Community/Public System ( ) Permit Depth of Well Well Log on File ( ) Construction Bacterial Analysis Sewage Disposal System: Permit # Septic Tank Size Absorption Area On-site System (x) Public Utiliny Installed 1975 Installe~ I~©O Manufacturer __% ri (~- Soils Rate [.~} Material 7. Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line ,tUI, ~IPALiTY OF ANCHORAG[. Depat-Lment of Ilea!th and Environmental 'x '~-~e:Roques~ for Approval of I~kdJ.vidual Sc_wot and WaLor 3 o 4 o Properk?/ Owner: MaJ].Jng Address: Sunny Glen Drive, Eagle River ~ ~on~: Dr. William Sangster Ma~] Jng Address ?hon 94-43A Lending InstzJ. t:utLon: Alsska Statebank Mailing Address: 310 E. Northern Lights Blvd. Phone: 279-7637 Real%or/Agent: Marsha Tweedie Mai ].]ng Ad(h_eo. : Landmark RealAy ................ Phone 7 o 71 kre et Locak :ion: ..... _S_9_n.n~y G 1 en~ D_~r_j_v_.e_,_._E~atS_l_e_._R___SX e~r~A_l Single FamiJ.y Residence: ~ ) Number of Bedrooms: Multi. pie Family Resiclence: ( ) Number of Bedrooms. Water Supply: * Individual Wel. 1 (x) Public/Community System ( ) If Individual Well., well depth If Community System, name oi' system Sewage Disposal. System: *'~On-site System (X) Public System ( ) If On-site System, dake of inskaL]at;ion: _~1_9__7_~_ ...................... *NOTE: A well lo9 Js required on AL1, wells drJ_lled since 6/75. Lest :i.s required by this doparhmenh. : , A fee of $25.00 musi accompany oach request before p.rocessing can be iniLiaLed. · 3/77 Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 3 Block 3 Glen Eagle Subdivision comments: Affadavit Attached: Approved: _~~ D±aapproved: Letter Attached: ( ) Date: Department Worksheet: ..................... po.HnboJ roi oz~xv) A~3All3~ 'IVIOJdS PO~ .................... ~ ............ A1NO . 33SS3~I~QV 01 31¥a Bo REC~IP'i' FOR CERTWIED P~All,--,;]O.~ (plu~ ~E~T TO POSTMA~Ko~ DATE f~,O., S1AT~ AND ZIP CODE -~ 0~10~[ S ERYiCE~FO~[ ADDITIOII~ F~ ~TUR i sm~s i~w~O, and~atedelivered ~ D r~ r . . . . ......... [~ Wdh delivery ~o addressee only ............ R~CEIPT ~:~ 2 Shows to whom date and w ere do vered ~a~a~ 3~ [978 sE.vm,s ~- ' With delive'ry to addressee only ......... DELIVER TO AODRESSEE ONLY .................................................. 50d ~ SPECIAL PELIVERY (oxtro t~ ~ PS Form HO INSURANCE COVERAGE PROVIDED~ (See ephor Ap~, 1~'/1 3800 NOT FOI{ INTERNATIOHAL MAIL Alaska Statebank 310 East North~ Lights Boulevard ~horage ~ Alaska 99503 Subject: ~t 3 Block 3 Glen Eagle Subdivision Douglas/~4arsha T~eedie Property Be. for~ ~his department ~ay apI~;ove th~ request for sewer and ~ater fa¢ilities~ a percolation t~st must be perfex%ed to det~rmin~ if it is adequate for a two(2) bedroom r~side~oe. See a~ta~hed handout° If the syst~% fails '1:o meet the adequacy requirem~ent an upgrade will be r-~qu.tred b~fore this d~part.ment will send a final approval to the lendinq agency. Te)~%porary aI?pro~a! may he granted if monies are sscrowed for the upgrade. ~he u~jrade ~.~ust be, complete~ by Jun~ 1, 1978. If there are any further questions, plgase contact this "?' o~;i~ce at 264-4720. Sincerely, I~bert C. Pratt, Sanitarian z~cP/~]n cc: Mary Sangst~r % U.S. Fish and Wildlife 813 D Street 99501 Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 ~~ ~ Date Received~-~J~-~' ~ ~ Time of Inspection - 8[Q¢[S~ FOR gPPROV~k OF FOR i 2. Property O~ner: -_~r~ ~-,~, ~ ne: 4. 5. 6. Mailing Address: Legal Description:..~0 Location: Type of facility to be inspected ~ LJ Well Data: A. Type C. Construction Sewage Disposal System:/~i./~ A. Installed ~,'~'~' ~ ( ~]/~ . Installer No. of bedrooms B. Depth ~3 ~ ~ D. Bacterial Analysis C. Septic Tank: D. Seepage Pit: 1. Size //d(']¢'; 2. Manufacturer I~x, x ~ 1. Absorption Area-/]G~ 2. Material l~-',~ L] E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank C. Absorption area to nearest lot line EQ-034 (1/74) , Absorption area , Other contamination /7/ , Absorption area , Sewer Lines , Page 1 of two pages GREATER ANCHORAGE AP, L/, Department of Environm~.~ntc~i Ou,:lity 3330 'C" St,, Anci~orage, AIa~,'Ka 99503 R :- {l lI ii .', "F EqR ?,PP!',O'!AI F)F IHDIVii)U/',L SLWER ?, WI\TIP, i-ACILii'iES i. Type of Inspection: CMRO VA 2. Property Owner: ::it! ey, Mailing Address: ":!~A l;m: Mailing Address: /~/,] 1. ~,th Avo.~ 4. Name of Lending Institution: Nailing Address: Pm~ch 7-cia, 5. Name of Realtor or Agent: Mailing Address: i-tiA Da~/ Phone Phone Phone Phone 6. Legal Description: Lot Location: -:]!:? ,~;tmn¥ r'l,'p~ 7. Type of Facility to be inspected: 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well "' 9. Sewage Disposal' System Type ,of S~stem: Public Utility Individual If Individual, date of installation No. Bdrms. (on-site) Page 2 of two pages - Req~ 'or Approval of Individual S~ Water Facilities Legal Description Approved Disapproved Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74)