HomeMy WebLinkAboutGLACIER VIEW HEIGHTS #4 BLK 1 LT 4OMI e a2' f r, std. IR `4 r l r Pia. WZI Municipality of Anchorage Community Development Department Page 1 of 2 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181108 PID Number: 050-491-54 ❑ New Q Upgrade Name: Robert & Mary Brody ABSORPTION FIELD ❑ Deep Trench ❑✓ Shallow Trench E] Bed E] Mound Address 22420 Columbia Glacier Loop ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 0.8GPD/SF 11.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 7.0 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Block Lot Glacier View Heights #4 1 4 Fill added above original grade 0.0 Ft. Gravel length 2@29 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines n/a Distance between lines n/aFt. SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding I Tank Sewer Line Total absorption area 580 Ft2 Number of trenches 2 Dist. between trenches 8.0+ Ft. Well 100+ TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100+ Gal. Material Number of compartments Lot Line 10+ NA Foundation 10+ LIFT STATION Manufacturer Capacity Curtain Drain 50+ Gal. Remarks Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank Tank to 3034 drainfield Jr's Septic Services Drainfield 3034 {CO/MT 3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 565.0 ft Inspection5, > / dates: 1 �/ t 2%� 2"1 7-f 12 3'd j��!` 4,h X61 Location and description Bottom house trim at house point A COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Conditional Approval: Date ,��G:O A[ ...... teven K� �onnone CE 8149 Approved Date 7 inspection Keport_1-1-1Z.00C -P BIW W N NIT � 1-0 n N n p "I'Q I I I WIcDIv1cDI�IWIm D (o 41 NO11" co co 1-i cll Cn LIT (VIWIImIm WILPICDImIJImI p m W p -A N IV -P N N N r r m U) C ;0 z K: 0 m zi m U) to P. c FOUNDATION CLEAN OUT(E) CLEAN CUT(E) CLEAN OUT(E) OCUSLE CLEAN OUT m m n -i p v '� _ Nc` -iO Tol mv-iM '{DOOrr*Tx N < aoV)ozzoxD N •D�OG7 rn 0-1 rn ` Cc m O Z o m Oz�DO m m> z 4` I-- m O U) ;D ;o > r () C m Lf)'-, ;AA- w— \ � / �/ / \\ ur Ncf)� 1 �r-> m X r ! / / % / F- P \N� �oo m \ i VALVE \ > . > / / SPUte' SPLITTER X M / / ! I S ` z O O 1 O o jo 0 CA il Ci -Tl m -i m -LEAN OUT \ /v y �/ m dCNROR TUBE I / 1 ` I cn W / F mm 1 IW ) ox / �� 1 ,> , [ONITOR TUBE I / O { / / / :LEAN OUT ttil I 0 /'C� /( PANNONE ENG SVC, LLC REVISIONSDAT P.O. BOX 1807 PALMER, AK 99645 1 7/22/2019 PHONE (907) 745-8200 FAX (907) 745-8201 i�P. ' A' `�'�t1 crnic NOTES: RECORD DRAWING I DRAWN I ACP I SITE PLAN GLACIER VIEW HEIGHTS #4 B1 L4 ROBERT & MARY BRODY 22420 COLUMBIA GLACIER LOOP EAGLE RIVER, AK 99577 "t'te'Ven'R. on orie' j OE 8149 �/ t��i``/"�6► 50' P.I.D. NO 050-491 -54 PERMIT NO. OSP181108 / SHEET OF 2 F- r / ;AA- w— \ � / �/ / \\ ur Ncf)� 1 �r-> m X r ! / / % / F- P \N� �oo m \ i VALVE \ > . > / / SPUte' SPLITTER X M / / ! I S ` z O O 1 O o jo 0 CA il Ci -Tl m -i m -LEAN OUT \ /v y �/ m dCNROR TUBE I / 1 ` I cn W / F mm 1 IW ) ox / �� 1 ,> , [ONITOR TUBE I / O { / / / :LEAN OUT ttil I 0 /'C� /( PANNONE ENG SVC, LLC REVISIONSDAT P.O. BOX 1807 PALMER, AK 99645 1 7/22/2019 PHONE (907) 745-8200 FAX (907) 745-8201 i�P. ' A' `�'�t1 crnic NOTES: RECORD DRAWING I DRAWN I ACP I SITE PLAN GLACIER VIEW HEIGHTS #4 B1 L4 ROBERT & MARY BRODY 22420 COLUMBIA GLACIER LOOP EAGLE RIVER, AK 99577 "t'te'Ven'R. on orie' j OE 8149 �/ t��i``/"�6► 50' P.I.D. NO 050-491 -54 PERMIT NO. OSP181108 SHEET OF 2 Q q n v z w a) m u LD u :P wU :39:v�v, Q Q © © 0 CD N LO O r II II of I_j U w .-a H N U Sz 0 CL U LO N W A .• �� i .-+ Q co co 0 3 i Z :D LIMa / / o j cuW / mW a 3 Xf N •%'. 'D1-• O H V C 0 ,PS 1tO �O o v o ^> �°, o s J' 3rO O U a> S N "C3 C �. ```\\\\\\\\Alit Np tilt y p 7�8 w O L l r >v +r `U �`� C •Cyd // � C7 N N i� ..0 O > > > .. M Q t'7S I _ (1) 00 GU i i : o � = ' � c� 3 CO o or of 0 co C) r- oo W \ �- o W aY sir ti W a CD Y U C 5 N co m J U > 0a ° 5 .o° 0.5 Nm t1J N Q ui Q D !` l� •U 4 L c to Cj 0 Z c� N U o 0 L-0 = 0 CO ca0)U) > -ago a) c� U (9 CD CL C7 p N Q Q MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program POBox 1g8OoO 47OOElmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 Permit Number: 0SP181108 Work Type: Septic Upgrade Tax Code Number: 05049154000 Site Legal Address: GLACIER VIEW HEIGHTS #4BLK 1 L 4 G:0059 Site Mailing Address: 2242OCOLUMBIA GLACIER LOOP, Eagle River Owner: BR(}DYROBERT C&MARY J Design Engineer: PANNONEENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: 6/6/2018 6/6/2019 2 Disposal Field 1771 Septic Tank 1771Holding Tank D Privy 11 Private Well 0 Water Storage All construction shall beinaccordance 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 (18AAC8O) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.G5.Provide notification bycalling (9O7)343-7SO4(24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall beeither: o. Opened and Closed onthe same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: C Date: Date: 3 E PI.MkNS 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. 050-491-54 Property owner(s) ROBERT & MARY BRODY Day phone Mailinq address 22420 COLUMBIA GLACIER LOOP, EAGLE RIVER, AK 99577 Site address 22420 COLUMBIA GLACIER LOOP Legal description (Sub'd., Block & Lot) GLACIER VIEW HEIGHTS #4 131 L4 Legal description (Township, Range & Section) Lot Size 43,560 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑ Upgrade 0 Duplex (D) ❑ Holding Tank ❑ Renewal El Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / 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: 6-61 Waiver Fees: Date of Payment: V23 % /q Date of Payment: Receipt Number: iii f40"-&(; Receipt Number: Permit No. 0 3P I M N Waiver No. Permit App_:-: ,_..:c: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181108, Rebecca Carroll, 06/06/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181108, Rebecca Carroll, 06/06/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181108, Rebecca Carroll, 06/06/18 W r.LL CAGtC- &LACIER Love S 3C;'- 18-40 C- " -Z-Z(-,7-3 — 1p0y+i1 esmT — — — 5 36 18-4o E 'Z53.18 hereby certify that a survey of Lot 4, Block 1 Glacier View Heights Subdivisi ddition #4 was made on August 1, 1993 and that the improvements situated thereon a ithin the property Lines and do not overlap or encroach on the property Lying adjace hereto, that no improvements on property Lying adjacent thereto encroach on t remises in question and that there are no roadways, transmission Lines or oth isibLe easements on said property except as shown hereon. It is the responsibility he owner to determine the existence of any easements, covenants or restrictions whi D not appear on the recorded subdivision plat. Under no circumstances should any da' ereon be used for construction or for establishing boundary or fence Lines. 9ted in Anchorage, AK, August 3, 1993 CONSTRUCTING ENGINEERS AS -BUILT SURVEY 9601 Buddy Werner Dr Anchorage, A1C, 99516 346-2000 694-9098 SCALE 1" = 401 69.5 11,0 GPAvt� b¢�v� / o0 �i 4'� s CD J PIN :•4rar� '�J eft a�t, c^� d7`U r�J z ;44 i R k SURVEYOR'S SEAL Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 $ Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: "SL,,.) c2:~OO~Po PID Number: 05'0 Name: f~o b~,,~ ~o~H WastewaterSyslem: ~New ~ Upgrade Address: ~o5~ ~ ~ ~¢~¢~ ; ~5o8 ABSORPTION FIELD Phone: No of Bedrooms: ~ ~ Deep Trench ~ Shallow Trench ~Bed ~ Mound ~Other LEGAL DESCRIPTION Soil Rating: Total Depth f[onl original grade: Lot: ~ Block: ~ ~1 ~([~SubdJwsi°n'~ Deplh to pipe bottom from~original grade: Ft. Gravel depth benea~ ¢ p~pe Ft. Town~l~ip: ~)~ Range: ~1~ Section:~)~ Fill added above origina~rade:,_ Ft. Gravel lengtl~__ / ~' Ft. WELL: ~New D Upgrade Gravel width: Number of lines: Dislance between lines: [ ~ ~ Ft. Classific~n {Private. AB.C): Total Depth: Cased To: Totat absorption area: Pipe material: ~¢~--rl(~W ~% FI Ft. ~ SQ. Ft. Driller: Date Drilled: Slatio Water Level: Installer: Date installed: Yield: GPM Pump Set at: Ft Casing Height~, Above GroundFt. TANK SEPARATION DISTANCES ~ s~¢~c ~ Ho~di.~ U S.T.~.., To Seplic Absorphon Lift Holding Public/Private Manuf~r~cturer: Capacity in gagons: Od O i Materiah ~1 Number °~°mpart ments: Well I ~ ' /~' I10 Surface / Water ~'lO0/ 4-~O0' ¢100 LIFT STATION~~' Lot Line ~1 4~/ ~, Size in gallons: Manufacturer: Foundation I~' ~, ¢ -- "Pump on" le~~bv¢ at: Curtain &ldo' ~ ldO' .kt~l~ ~p~Model J Electrical Inspections performed by: Drain Remarks: BENCH M~RK Location and Description: Assumed Elevation: ENGINEER'S SEAL Inspections performed by: ~s~ ~&~ DateS:2ndlSt ~-¢_a~ *~ ~":"'~'' Department ol He~nd HUm~ervices approval 'L";" Reviewed and approve Dat ~ 72 013 (Rev 9/91t MOA 25 PermitNo. %'t. AJ c~4/oI ~O Page of Municipality of Anchorage DEPARTMENT OF HEALTH AN[) HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: PID No.: 72-013 A (2/91)MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930048 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:BRODY ROBERT C 50% & OWNER ADDRESS:4057 EAST 20TH AVENUE #61 ANCHORAGE, ALASKA 99508 PARCEL ID:05049154 DATE ISSUED: 4/05/93 EXPIRATION DATE: 4/05/94 LEGAL DESCRIPTION: GLACIER VIEW HEIGHTS #4 BLK 1 LT 4 LOT SIZE: 43560 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST 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 (iSAACS0). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE: ~/d/~' Y DATE: ~ -~--f3 SITE PL~R-WATER AND WASTEWATER ABSORPTION SYSTEM SITE PLAN DETAILS PROPOSED WATER AND WASTEWATER ABSORPTION SYSTE~ LOT 4 BLOCK 1 GLACIER VIEW HTS ADD #4 SUB PREPARED FOR: MS. JEANNETTE: McCART 4057 E 20TH AVE, #61 ANCHORAGE, AK, 99508 SCALE: I" = I00' DRAWN BY CAL CONSTRUCTIN~ ENOINEERS 346-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 4-1-93 DRAWING // 93-S1-04-1 MODIFIED DESIGN FROM APPROVED PERMIT SW930048 ABSORPTION SYSTEM DESIGN DETAILS--BED SCOPE OF PROJECT: Original test hole was monitored on June 11, 1993 and found · to have water at 11' depth. Consequently, the bottom of the absorption field must be no lower than 7' below grade. The system is redesigned for a bed. ABSORPTION AREA CALCULATIONS: Minimum Required: 3 Bedrooms x 150gpd/bedroom = 450 gpd capacity Soils rating, proposed addition, 0.8 gpd/sf Minimum sizing: 450 gpd % 0.8 gpd/sf = 562.5 sf absorption area Use 15'W x 38'L x 0.5' D = 570 sf minimum for bed area Bed Bottom = 5' Below grade, w/ 4' cover IMPACT ON ADJACENT LOTS: There will be no additional impact to any lots by changing the design of the absorption system to a bed-design . MODIFIED DESIGN PROPOSED WASTEWATER ABSORPTION SYSTEM LOT & BLOCK I GLACIER VIEW HTS ADD #4 SUB PP~PARED FOR: MS. JE~NETTE McCART 4057 E 20TH AVE, #61 kNCHOP~AGE, AK, 99508 NOT TO SCALE DRAWN BY CAL CONSTRUCTING ENGINEERS346-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 M(N)IFIE~) 6-11-~ DRAWING # 93-S2-04-1 (14) ABSORPTION SYSTEM DESIGN DETAILS--STANDARD TRENCH ' ~oo ~:^~ I~ ~ --~ ~ ~~ D SCOPE OF PROJECT: New proposed absorption field is designed for a three (3) bedroom system. Lot is to be served by private well to be developed on site. ABSORPTION AREA CALCULATIONS: Minimum Required: 3 Bedrooms x 150gpd/bedroom = 450 gpd capacity Soils rating, proposed addition, 1.2 gpd/sf Minimum sizing: 450 gpd + 1.2 gpd/sf = 375 sf absorption area Use 3'W x 24'L x 8' D = 384 sf minimum for trench Trench depth: Bottom = 12' Below grade, w/ 4' cover IMPACT ON ADJACENT LOTS: There are no private wells within 100' of this proposed absorptJ, on system. The proposed absorption system has no adverse impact upon any adjacent lots as shown en attached site diagram. ENGINEER'S SEAL PROPOSED WATER AND WASTEWATER ABSORPTION SYSTEM LOT ~ BLOCK i GLACIER VIEW HTS ADD #4 SUB PREPARED FOR: MS. JEANNETTE McCART 4057 E 20TH AVE, #61 ANCHORAGE, AK, 99508 NOT TO SCALE CONSTRUCTING ENGINEERS3~6-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 DRAWN BY CAL 4-1-93 DRA~;ING # 93-S2-04-I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: tO' JO' ~'~ L. EGAL DESCRIPTION: L-..~r ~ I ~'"l.~..t._~ ~,~'t/~.%~ ~.~ ~ ~ Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? SLOPE SITE PLAN IF YES, ATWHAT ~ O DEPTH? p Dopti~ ~o Walor Altor Reading Date Gross Net Depth to Net Time Time Water Drop 4 ~-,~ ~ ~?,- ~ O',/~'/~~ ~'1~ PERCOLATION RATE TEST RUN BETWEEN . (mmutesllnch) PERC HOLE DIAMETER __ . FTAND 7,. J""~' ~ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ti [~ [ 9 !_.. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: ~r ¢ I ~"1=%,;..~ ~_~"~1~'~.) ~'~ ~t~- ~r Township, Rango, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15 16 17 18 19 2O COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? s IF YES, ATWHAT O DEPTH? p E Depth Io Waler Aller f",~ Monitoring? - Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN (minutes/tach} PERC HOLE DIAMETER · FT AND { F ' '. ~,~ ¢_pJ. ACCORDANCE STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: WITH ALL 72-008 (Rev. 4/85) SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759 OWNER OF LAND ADDRESS ~ : , LEGAL DESCRIPTION DATE - Started PERMIT NUMBER Ended DEl'TH OF ~,ELL ? ? / STATIC LEVEL OF W.\TER FI DR.kW DOWN Fq. GALS. PER HR , -~'- KIND OF FORMATION: From_~ Ft. to , Ft From~, Ft. to ;:! Ft, From ::~ Ft. to t~ Ft From ~ '(~ Ft. to J: ;~Ft. From__Ft. to.__Ft, From Ft. to Ft. From Ft. to__Ft. From Ft. to Ft. From__Ft. to. Ft. From Ft. to Ft From Ft. to_____Ft From Ft. to Ft From__Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From _Ft. to Ft. ~ ~ h (!, :, ~ ~:h::'.,. ~ From__ Ft. to __Ft .( :...; ; '~ .~ .,)' '~,i i~.;, ,: ' From__Ft. to__ Ft. .~ ,:,/: ~,':' /'//. , ,: ,'.5 / il'vt; ( 7 ' From.~_Ft. Io Fl, From~ Ft. to~ Ft. From~ Ft. to~Ft. From Ft. to Ft, From Ft. to Ft. From~Ft. to ~Ft, From ~ .Ft. to Ft From ~ Ft. to Ft From _~Ft. to Ft From ~Ft. to_ Ft From FL to Ft. From Ft. to Ft, From~Ft. to~ Ft MISCL. INFORMATION: DRILLER'S NAME ' 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 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone At Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 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: 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 ')lJOt~ sjeeu!Sue IBuo!sse~oJd eLI1 U! SUO!SS!LUO JO SJOJJe JOri elq!suodseJ ~ou s! eSe~oqouv ~o ,~!led!o!unlAl eqJ. 'p@nss! s! e~o!j!~Jeo e @~ojeq ~ep eZ~leU~ ~o suo!~oedsu! ~onpuoo ~,ou op SHHQ ;o see~old~U~] 's~u@~ue~!nbe~ @~,s pue I~epej u!8~eo ,~,s!~s o~ ~ep~o u! suoRm,!~su! I~u!puel ~!eq~, pue setuoq ~o sJeseqoJnd o~/~selJnoo e se s!q~ seop SHHQ eq.l. 'e~tSel¥ ~o e~S eq~ u! peJe~s!Be~ Je@u!bue leuo!sse~oJd luepuedepu! ue ,~q e^oqe .c qdeJSeJed u! ue^!6 suo!le~ueseJdeJ eql uodn ,~lUO peseq s@~eo!J!MeO le^o~ddv ~lpoqln¥ qlleeH sanss! (SHHQ) seoFde$ ueuJnH pue qlleeH ~o ~ue~ul~ede(] eBeJoqou¥ Jo ,~l!led!o!unR eq.L e~eQ S~UeLUUUOO I~UO!~!PP¥ :suollelndBs ~UIMOIIOJ eql LI:~IM '9LUOOJpeq 's~uoo~peq ~o~ le^o~dde leUO!~!puoo 'pe^o~ddes!(~ ~1¥N~15 SHHO '9 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo4F>I ~-~-~,¢,.- U//~ F-¥~ Parcel I.D. A. Well Data Well type ~¢¢\v ~-'u~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) )/ Date completed ~//.,9'5 Driller -'<~"-' V,4r~ Total depth I) ~, / " Cased to I l~, ~ Casing height Sanitary seal (Y/N) ¥ Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test ~- ?.¢ ~ Static water level ~ ~ Well flow 5' 0 g.p.m. "~ Pump level1 "- ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main .? '7_o©' Sewer service line g.p.m. ; On adjacent lots -hi oo' ; On adjacent lots -~-~oo' Public sewer manhole/cleanout -FZ~O' Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed :%'~11 19~.5 Cleanouts (Y/N) )' High water alarm (Y/N) Bate of pumping Nitrate ~ ~t)t_ Other bacteria Collected by: Tank size ~ooo Compartments Foundation cleanout (Y/N) ~' Depression (Y/N) F~ Alarm tested (Y/N) ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANI< TO: Well(s) on lot t-z.,% ' 'To property line (o%' Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line '70 72.026 (3/93)*Front CONTINUED ON BACK PAGE C. LIFT STATION ~ Date installed Manufacturer Size in gallons Manhole/A _ Vent (Y/N) "Pump on" level4/'at ~, ..~"Pump off" Level at Fligh water alarm level /~_.~...~es tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE_~ LIFT STATION TO: Wel~~ On adjacent lots Surface water D. ABSORPTION FIELD DATA [)ate installed ~-~-'/ Soil rating (GPD/Ft2) o. ~ System type Length S 8' Width Total absorption area [:)ate of adequacy test ~.o Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) ~ ~'~ Gravel thickness s"¢' Cleanout present (Y/N) "/ Results (pass/fail) --- for ~ ~-1 After test ~J R If yes, give date o ~ Total depth /4- 2 Depression over field (Y/N) Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation ~.z' On adjacent lots Sudace water Curtain drain On adjacent lots -~ I©o' Properly line .q-o' To existing or abandoned system on lot k~ fil Cutbank '~-~ °°~ Water main/service line + 70' Driveway, parking/vehicle storage area ~ 0 ' 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, HAA Fee $ ,//"7¢ Date of Payment ~-'--/~--- Receipt Number Waiver Fee $ Date of Payment Receipt Number