HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 7 LT 9Mountain PaPk
I sta
Block 7
Lot 9
#017-432
07
Municipality of Anchorage JUL 0 2 2018
Community Development Department Page 1 of 3
On-Site Water & 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. OSP171356 PID Number. 017-432-07 ❑ New N Upgrade
Name:
JOHN ROBBINS
ABSORPTION FIELD
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address:
12621 LUPINE ROAD *ANCHORAGE, AK 99516
■ Other
Phone: No. of Bedrooms:
Soil Rating:
Total Depth from original grade:
(907) 345-6791 4
**2.0 GPD/sq. Ft.
** F,.
LEGAL DESCRIPTION
Depth to pipe invert from original grade:
SEE DWG. FL
Gravel depth beneath pipe:
0.3 Ft.
Subdivision: Block: Lot:
MOUNTAIN PARK ESTATES #2 7 9
y
Fill added above original grade:
SEE DWG. FL
Gravel length:
30 Ft.
Owns Ip: anger a Ion:
- - -
Gravel width:
Beds Number of lines:
Distance between lines:
14 FL
5
2.5 Ft.
SEPARATION
DISTANCES
Total absorption area:
360+ SQ. Ft.
Number of trenches:
Dist. between trenches:
- F,.
To
From
Septic
Tank
Absorption
Field
Lift
Station
Holding
Tank
Public/Pnvate
Sewer Lines
Well
EXISTING
100'+
EXISTING
25'+
TANK ❑ Septic ❑ S.T.E.P. ❑Holding ❑ Ot
Manufacturer.
Capacity:
Surface Water
100'+
N/A
Gal.
Lot Line
10'+
Material:
Number of compartme
Foundation
10'+
LIFT STATION
Curtain Drain
NONE KNOWN
Co
Manufacturer. C\
Capacity:
Gal.
"Pump on" level at:
Pump off' level at:
High water alarm at:
Remarks: • THIS IS A BOTTOMLESS IDSF, EXISTING IDSF WAS REBUILT
IN PLACE AT A HIGHER ELEVATION. BOTTOM OF EXCAVATION INSPECTED BY MOAPump
Mak octal:
Electrical Inspections performed by:
ONSITE EMPLOYEE TIM ECKLUND ON 5/30/2018.
PIPE MATERIAL
House to tank EXISTING Tank to EXISTING
drainfield
Installer
A+ HOME SERVICES
Drainfield SCH403/4" CO/MT D3034
1N 'l 5 - G E. G
Inspector GEG, Ltd.
BENCH MARK (Assumed elevation)
99'88 Ft.
Inspection
Dates: 1 St 5/30/2018 2nd 5/30/2018
Location and Description:
3rd 5/30/2018 4th -
TOP OF MANHOLE LID ON STEP TANK
Community Development Department Approval
Conditional approval: Date:
ENGINEER'S SEAL
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Approved: / �.�/ l�i�/(�� frflt��rT� Date: 7/� 1
LICENSE4 professio��oo
#AECC884 ®0�0�000�
Inspection Report _1-1-12.doc
ARCEL ID
PNUMBER: RECORD DRAWING PO17-432-07 ER:
OS
P171356
0
O
ry I
wl
Z
0-
_j
1J 7
\ A B I C
\ \ MT1 53.7 22.6 43.1
\ MT2 62.7 33.5 54.1
\ MT3 56.4 42.7 68.0 MOUNTAIN PARK
MT4 44.7 34.0 59.3 I ESTATES #2,
\ \ I LOT 1,BLOCK 7
\ \ MOUNTAIN PARK ESTATES #2, \ \
\\ LOT 10, BLOCK 7
1DIUS
00' WELL U
I I U
F
1 100' WELL TRANSITION FROM UPPER TO
Rp,D1US I
/ LOWER PORTION OF HOUSE
�I FLUSHING VALVE
A /I I w
MT4 MT3 I w
<n
•.� j•• .i = �'.� : EXISTING 4 / w
�. BEDROOM
DRIVEWAY . �'•' \ HOUSE /
\ I / MT1 MT2 I o
/ EXISTING 1500 GALLON STEP 1
� 1
1100' WELL RADIUS
I
I
MOUNTAIN PARK ESTATES #2,
LOT 8, BLOCK 7 /
MOUNTAIN PARK
ESTATES #2,
BLOCK7,LOT2
W�
Q
U
NEW IDSF RE -BUILT IN-PLACE a
AT A HIGHER ELEVATION ��
I I
GARN ESS ENGINEERING GROUP, Ltd
CIVIL & ENVIRONMENTAL ENGINEERS_
3701 E. TUDOR ROAD. SUITE 101 *ANCHORAGE. AK 99507 -PHONE (907) 337-6179 • FAX (907) 33"246 • WEBSITE: vrvnv.gamessengineenng.cam
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
JOHN ROBBINS
345-6791
2 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
MOUNTAIN PARK ESTATES #2; BLOCK 7, LOT 9
L.K.B.
TYPE OF WORK:
DATE:
I,_ RECORD DRAWINGS
7/2/2018
MOUNTAIN PARK 1\,
ESTATES #2,
LOT 3,BLOCK 7
D
�N
Q
U
F-
t� N
SCALE:
1"=40'
► �G VI
P..V••; •..�..
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LICENSE44k%FE 5\S �•
#AECC884 /
PERMIT NUMBER: PARCEL ID NUMBER:
OSP' 71356 RECORD D RAW I N G 017-432-07
BOTTOM OF EXCAVATION =
99.90 -100.34
EXISTING AIRLINE
BOTTOM OF SYSTEM @
HIGHEST POINT PER MOA
RECORDS = 98.40
FINAL GRADE ELEVATIONS= 103.35 - 103.76
6" OF WASHED PEA GRAVEL
MT / I MT
14 FEET
1/8 INCH DIAMETER ORIFICES 24 INCHES APART
BOTTOM OF EXCAVATION INSPECTED BY MOA
ONSITE EMPLOYEE TIM ECKLUND ON 5/30/2018
PER CONTRACTOR, AN ALARM FOR THE AIR PUMP
WAS INSTALLED WITH A NEW PRESSURE GAUGE
AND THE AIR SYSTEM WAS CONFIRMED TO BE
OPERATING WITHIN NORMAL RANGE (2.0-4.5 PSI).
PER MOA REGULATION TOP OF SAND IS BELOW ORIGINAL
GRADE AND THEREFORE NOT A MOUND TYPE DRAINFIELD;
DRAINFIELD WAS NOT TOPSOILED AND SEEDED
FILTER FABRIC
2" INSULATION
INVERT OF DISTRIBUTION LINE = 100.94
EXCAVATED/REMOVED ALL CONTAMINATED
PEA GRAVEL AND SAND. IMPORTED NEW
SAND. TOP OF SAND = 100.64
(TOP ORIGINAL SAND FILTER =100.54)
GARNESS ENGINEERING GROUP, Ltd
- CIVIL & ENVIRONMENTAL ENGINEERS- - - - --- -- ----
3701 E. TUDOR ROAD. SUITE 101 'ANCHORAGE, AK 99507 ' PHONE (907) 337-6179 -FAX (907) 338-3246' WEBSITE:-gamessengineenng.com
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
JOHN ROBBINS
345-6791
3 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
MOUNTAIN PARK ESTATES #2; BLOCK 7, LOT 9
L.K.B.
TYPE OF WORK:
DATE:
� IDSF PROFILE
7/2/2018
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0��%� CE -7953
LICENSE'S 1;:"S`;
#AECC884
JN,C,PALs_ry MUNICIPALITY OF ANCHORAGE
\ 1 fir.
' \\ On-Site Water&Wastewater Program
• � � r � PO Box 196650 4700 Elmore Road J '
l I Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ;;
• http:llwww.muni.org/onsite
// I)ep ii tniynt
MCHONPG
On-Site Wastewater Disposal System Permit
Permit Number: OSP171356 Effective Date: 12/18/2017
Work Type: Septic Upgrade Expiration Date: 12/18/2018
Tax Code Number: 01743207000
Site Legal Address: MOUNTAIN PARK ESTATES#2 BLK 7 LT 9 G:2839
Site Mailing Address: 12621 LUPINE RD, Anchorage
Owner: ROBBINS JOHN M & Lot Size in Sq Ft: 19032
Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4
This permit is for the construction of:
D Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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: /Date: /2-`
Issued By: -Rut?t t`r+A Ccu ti Date: 12 g 2017
1111111M1 cc) 15 0,
"5--
NOV 1 7 2017
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On-Site Water & Wastewater Program
Mayor Dan Sullivan
On-Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 017-432-07
Property owner(s) JOHN ROBBINS Day phone 345-6791
Mailing address
Site address 12621 LUPINE ROAD*ANCHORAGE,AK 99516
Legal description (Sub'd, Block & Lot ) MOUNTAIN PARK ESTATES#2; BLOCK 7, LOT 9
Legal description (Township, Section & Range)
Lot Size Sq.Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DEWELLING:
(®all that apply) Initial ❑ Single Family (SF)
Absorption Field ® (w/wo ADU)
Septic Tank ❑ Upgrade Duplex (D) I
Renewal ❑
Holding Tank ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
N/A Distance: -
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: SCc•Q — Waiver Fees:
Date of Payment: 11-24—CI Date of Payment:
Receipt Number: 0`11 Ltif vl Receipt Number:
Permit No. e P 11 13 Waiver No.
(Rev.01/11)
manicy
GARNESS ENGINEERING GROUP, Ltd Advanced Treatment System
CIVIL&ENVIRONMENTAL ENGINEERS iimilu De ler
November 17, 2017
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Proposed Septic System Upgrade for Mountain Park Estates #2; Block 7, Lot 9
To whom it may concern:
The existing 4 bedroom house is served by a private well and septic system. The
bottomless IDSF is in a state of failure and needs to be upgraded. We are proposing to
re-utilize the existing 1 ,500 gallon STEP tank and re-build the IDSF. We are proposing
to excavate out all contaminated material, import MOA approved IDSF sand as needed,
and re-build the existing drainfield at a higher elevation. Comments regarding the
design are summarized as follows:
1. SOILS: See the attached 2001 logs which show the soil classifications, groundwater
monitoring, and the percolation test results.
2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications.
3. SURFACE WATERS: There are no surface water concerns.
4. TOPOGRAPHY: As can be seen in the attached design package, the average
topography around the proposed drainfield is relatively flat.
We are unaware of any adverse impacts this installation would have on adjacent wells
or septic systems. If you have any questions, please contact us at 337-6179. Thank
you for your assistance.
Sincer=ly, ho
Jeffre A. ar e -, P.E., M.S.
President
3701 East Tudor Road,Suite 101 .Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
ALL SURROUNDING WELL RADII SHOWN ARE APPROXIMATE
T12N,R3W,SECTION 26, T12N,R3W,SECTION 26,
W2W2NW4NE4NE4 PTN NW4NW4NW4NE4NE4 GARRETSON;LOT 7
VACANT VACANT
-"-------"""---------"T"---- -------
NORTHPARK DR.
e� ----- N♦ I I i i ♦\♦
MOUNTAIN PARK ESTATES#3,•-----/4--;<, MOUNTAIIO'RARK♦\ \
LOT 1,BLOCK 6 i� / /� �♦ ESTATES#2^♦ \ p � / MOUNTAIN PARK \
•
/ j �/ \LOT 10,BLOCK •
7\\ \\ ESTATES#2, \
r��� \ \ / LOT 1,BLOCK 7
LSEPTIC / �/ \ \ 1 0 € I
ARE 7p0 1 /pd w�CC'zip, \ IyI I 100'WELL RADIUS
I ; I /I MOUNTAIWPARK ♦♦ /
• f� ES #ES#2, _____ ♦ /
MOUNTAIN PARK ESTATES#2, ; ��` - - � 1 BLOZK 7,LOT 2 -- n
LOT 2, LOCK 6 ., \ \ �"�` ,• • ��♦ / / / \ �� ��(.1 / \
\,,e/ \/ ♦� `I/
I / �� \ 1
SEPTIC T \� A -, // \ I / - \\I
ARE \♦♦ / ♦ ` i \ -/� \4. I qp WELL RADIUS V
▪ / f 14, 1 ,J
CCL Rq•••L --- RAOI 1 I I \I /
` MOUNTAIN P14RK ESTATES#2,I I� fD i\ WELL Rp01US /
LOT 3 BLOCK 6 I CC ►v10UNTAIN PARK j '�' 1 100 j
1 ii
\ / ESTATES#2, / 1 \ MOUNTAIN PARK /
1 \• Z / LOT 8,BLOCK 7/ v \ ♦♦ ESTATES#2, i/
SEPTIC \\ \\ d \\ ♦!QT 3,BLOCK 7 _-� j
ARE ▪ \\\ \\� J / \\♦ CC i
♦ ♦ / i ♦ CC /
-- -- '--- -- O
Li_
MOUNTAINPARK ESTATES#2, MOUNTAIN PARK ESTATES#2,
MOUNTAIN PARK ESTATES#2, LOT 7,BLOCK 7 LOT 4,BLOCK 7
LOT 4,BLOCK 6
MOUNTAIN PARK ESTATES#2,
MOUNTAIN PARK ESTATES#2, MOUNTAIN PARK ESTATES#2, LOT 5,BLOCK 7
LOT 5,BLOCK 6 LOT 6,BLOCK 7
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GARNESS ENGINEERING GROUP, Lt ' .••"... =
CIVIL&ENVIRONMENTAL ENGINEERS
3701 E.TUDOR ROAD,SUITE 101'ANCHORAGE.AK 99507'PHONE(907)337.6179'FAX(907)338-3246•WEBSITE:www.gar ..nessengineering.com '\ .!'•' • ' "
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: i ' e r-y , a eSS::kki is
JOHN ROBBINS _ 345-6791 1 OF 3 ���.'. CE 795 sr
PROJECT/LEGAL DESCRIPTION: DRAWN BY: ♦�♦ �• •.••I I ���.�!•'"'''. 'r
MOUNTAIN PARK ESTATES#2; BLOCK 7, LOT 9 L.K.B.
��44 PROFESS\�r'4•�
40
TYPE OF WORK: DATE: LICENSE I11‘„`%4'
\DRAINFIELD SYSTEM DESING UPGRADE 11/17/2017 #AECC884 1
I / I \
/ GEG,Ltd.HAS A 8 PAGE SPECIFICATION
DESIGN CRITERIA: LETTER THAT PERTAINS TO THIS DESIGN.TO
NUMBER OF BEDROOMS:4 OBTAIN A COPY OF THE LETTER CONTACT
GALLONS PER DAY(GPD):600 GEG.BY PROCEEDING FORWARD WITH THIS NOTE:THE CONTRACTOR SHALL HAVE
PERCOLATION RATE/S:'9.6&<1 MINUTE/INCH INSTALLATION,THE ENGINEER,WELL DRILLER, THE NORTH AND EAST LOT LINES AND
/ PROPOSED APPLICATION RATE:"2.0 CONTRACTOR AND PROPERTY OWNER AGREE THE WELL RADII(FOR LOTS 8,9,&10)
/ MINIMUM DRAINFIELD SQ.FT.:300 FT2 THAT THEY HAVE READ THESE FLAGGED BY A REGISTERED LAND
'2001 T.H.#1 IN MOA RECORDS SPECIFICATIONS AND AGREE TO ACCEPT THE SURVEYOR PRIOR TO CONSTRUCTION.
"THIS IS A BOTTOMLESS ISF TERMS AND CONDITIONS OUTLINED. I I MOUNTAIN PARK
DRAINFIELD DESIGN: " \ ESTATES#2,
MAXIMUM DEPTH:LIMITED TO REMOVAL OF MOUNTAIN PARK \ \ LOT 1,BLOCK 7
CONTAMINATED MATERIAL ESTATES#2,
WIDTH:12 FEET LOT 10,BLOCK 7 \\ 11 D P
LENGTH:30 FEET
M.O.A.APPROVED SAND FILTER:AS NEEDED
EFFECTIVE:0.25 FEET 100'WELL RADIUS d
ACTUAL SOFT.:360 FT2 \1 1 �� ��
\
I 1 1 ,WELLRpDWS 1I
I li
4 A
I I EXISTING IDSF TO BE REBUILT
IN-PLACE AT A HIGHER ELEVATION
I —_ /I
__ MOUNTAIN PARK
_ i M.� EXISTING 4 ESTATES#2,
••4%4'•f BLOCK 7,LOT 2
/ •i. \ BEDROOM
/ 't•IDRIVEWAYI: ' \ HOUSE
/ IN 2001 GEG
/ / EXISTING AIR LINE TESTHOLE#1 /
C N I \ // TO BE RE-UTILIZED—\I I- U /
w E
/ /
\\\1 \ / ` _.� / w �� '
\ _ /
_— CONTRACTOR TO INSTALL NEW / U
PRESSURE GAUGE AND CONFIRM `�\ }
•\ I / ADEQUATE PRESSURE;IF NOT, �s_� ~
AIR PUMP IS TO BE REPLACED/ \ J
\ I / \`` / EXISTING 1500 GALLON STEP -- 1
/��� __��Y/ TANK TO REMAIN IN USE 1 1
__A
/
1100'WELL RADIUS
I I MOUNTAIN PARK \
ESTATES#2,
I LOT 3,BLOCK 7
I
O MOUNTAIN PARK ESTATES#2, / ii ),
CC / LOT 8,BLOCK 7 V
W i/ °
Z ii ty �� ()
/CT / /
J 1 /
� SCALE:
/ /
/ / 1'.40'
\ I / i I 1
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GARNESS ENGINEERING GROUP, � .
aAfgli*LalF"."R-2-- ' CIVIL&ENVIRONMENTAL ENGINEERSTa i
3701 E.TUDOR ROAD,SUITE 101•ANCHORAGE.AK 99507'PHONE(907)337-6179'FAX(907)336-3246'WEBSITE www.gamessengneering.com ,"�' I"' •
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: 0•ill;
1
AN ALARM FOR THE AIR PUMP MUST BE INSTALLED,
CONTRACTOR SHALL ALSO INSTALL A PRESSURE
GAUGE AND CONFIRM THE AIR SYSTEM IS
OPERATING WITHIN NORMAL RANGE(2.0-4.5 PSI).
BENCHMARK(TOP OF STEP TANK MANHOLE LID)=100.00
2'+OF COVER
6'OF WASHED PEA
GRAVEL MEETING
MOA IDSF SPECS
FILTER FABRIC
MT MT
_
2'INSULATION
Jr 3-1
3'4Dplc
20 ' `v!`t`x'%
11.11.
Anchorage Tank&Welding.Inc. Intermittent Sand Filter
SAND FILTER CONFIGURATIONS
•
r24" /' —�---
12' •. • C--4=0=•=••0•••• •C‘.••••00 ORIFICE 5MIELD
�^ .. • - • • - • • FLUSfMN6 VALVE BOX
( '."
�—.• O 0 O O 0 0=••••• 0®O l0Cc'
FROM STEP. +� CAP
SYSTEM C 1 .:p,
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• J12' IIININIIINISMININNIPOMNIMIP
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FROM AIR 3/4'PVC LATERA-
COMPRESSOR
-—•— • - • ---• • •--- • (w/I/8"9 ORIFICES)
• • • •
I-I/4'PVC MANIFOLD
TOP VIEW
12 x 30 SAND FILTER w/GRAVITY DISCHARGE
Page 37
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ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHORAGE
AND Z-(-4111' /4- ti n066./t S
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
°--)-Day of r'(e m r of 2014;by and between 30)n 1‘.A ("6, e ( 0006(7-5
herein the"OWNER,"and the Municipality of Anchorage,herein the
"MUNICIPALITY." In consideration of the mutual covenants contained herein,the
parties to this Maintenance and Repair Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS), described as
TrO$ F
located at(legal description).
/\AOw,\-a ;n P -V -- v L
2. Definitions.
Alteration. Any change to the design or function of an AWWTS that
includes the installation or removal of any parts,components or pieces not
included in the original construction permit and design.
Certificate of On-Site Systems Approval(COSA). An approval by the
Municipality of existing water and wastewater disposal systems given at
the time of property sale and title transfer in accordance with Anchorage
Municipal Code(hereinafter,"AMC") 15.65. These approvals certify that
the systems are adequate for the homes that they support and meet the
codes that were in place at the time of system construction.
Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
Maintenance and Repair. The scheduled and as needed replacement of
existing parts,components and pieces of an AWWTS that were included
in the original design which would allow the AWWTS to continue to
perform as designed.
Permit.An On-Site Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AWWTS.
3. Term. The term of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA,and shall continue while the AWWTS is in use or is operational or until the
property is sold or title is transferred by the owner and a new COSA is issued to the
new owner or transferee of the property.
4. Alterations.Installation and Removal of Additional Equipment. Prior to
performing any alterations to an AWWTS,the owner agrees to obtain an On-site
Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65.
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement,the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with an AWWTS
service and maintenance provider approved by the municipality and the
manufacturer of the AWWTS for the entire term of the AWWTS. In addition,it
shall be the responsibility of the Owner during the term of this Maintenance and
Repair Agreement,and any renewals thereof,at the owner's sole expense,to pay
for any and all: (1)repair(s),(2)maintenance,(3)adjustment(s),(4)replacement
costs,and(5)inspection costs.
B. Owner agrees to comply with all applicable ordinance,laws,regulations, rules
and orders for the AWWTS.
C. Upon request by the Municipality,the owner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor,the owner agrees to allow the Municipality access to this
information.
D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance,repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property will not occur
without a new Certificate of On-Site Systems Approval.
H. Owner agrees that the AWWTS installation and maintenance requirements as
provided by the AWWTS vendor/installer and approved by the Municipality are
the governing guidelines for the construction,maintenance and repair of the
Owner's AWWTS.
6. Nonwaiver. The failure of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions,nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof,or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended,modified or
changed by a writing,executed by authorized representatives of the parties,with
the same formality that this Maintenance and Repair Agreement was executed
with,and such writing shall be attached to this Maintenance and Repair
Agreement as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement,the only authorized representatives of the parties
are:
a. Owner: 30h✓1 2 G hw er I o OcN Beet S
b. Municipality: Director.Community Development or designated authority
C. Any attempt to amend,modify,or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance
and Repair Agreement shall be brought in the Superior Court for the Third Judicial
District of the State of Alaska at Anchorage. The laws of the State of Alaska shall
govern the rights and obligations of the parties under this Maintenance and Repair
Agreement.
9. Severability. Any provisions of this Maintenance and Repair Agreement decreed
invalid by a court of competent jurisdiction shall not invalidate the remaining
provisions of the Maintenance and Repair Agreement.
OWNER:
(signature) Date: /'� // l /
By: /��ed �� ( ig ) 7
,.‹:_1444,_ Dhiy (print name)
STATE OF ALASKA )
ss.
THIRD JUDICIAL DISTRICT )
The forego'.t instrument wage acknowledged before me this If day of
ke."..a/rde4,-,
20 f ,bY' / t� '
, -,' - STATE OF ALASKA
NOTA PUBLIC FOR ALASKA NOTARY PUBLIC
` :
M Commission expires: og'-O S• Suzan
L. Hartlieb
My Commission Exp rs;Aug 5,2019
MUNICIPALITY:
By: PUl t4 CA CCk9 (signature) Date: 12-/1 t/20(
R.Q)bQ.e Cg-Cro C (print name) Title:
Municipality of Anchorage ..,..,
Development Services Department -=. := ~.
On-Site Water & Wastewater Program. 4700 8curb Bragaw 8L
p.o. ~ ~,.~o ~, ~ ~,~o
www.cLanchorage.ak.us (gO7) 343-7g04 Page 1 of :S
On-~ite Wastewater Disposal Syetem end,or Well Inspection Report
Permit Number:. SWOIO2g:S PlO Number:. 017--432--07
Name:LArRY BETZEL WastewaterSy~tem: [] New · Upgrade
Addmae:
12621 LUPINE DRIW * ANCHORACE, A~ 9951e ABSORPTION FIELD
No. of ~edtoome: *
Phone: 1(508) 821--1907 4 rlDeep Trench rIShaIIo~ Trench ~Bed rlMound mother
LEGAL DESCRIPTION 2.o ~o/~. ~t *.2.:s4-:s.4:s ~
Lot: Block: Sub,Melon: ~:~"~.~ ~ I~e ~ ~ ~ ~ ~ ~ ~ ~
9 7 MOUNTAIN PARK'EST 0-1.0 ABOVE ~t 0.28
- - - SEE DWCL ~ :SO
WELL: [] New n Upgrade 12 ~t 5 2.4 et
,.....-/- e~ rt :S60 ~. ~ D 3054/ F-810/SCH 40 PVC
rt DENAE SEWER & DRAIN 8/22-27/01
SEPARATION DISTANCES ns.,~ 0.~., .S.T.~.,. O0~.r
~o s~,uc ~o~Uon t~t Ho~ng ,,~,~,,/n~ ANCHORAGE TANK 1500
we. 100'+ 100'+ - - 25% STEEL 2
su~o~o w.to, ~oo'. ~oo'. - - - LIFT STATION
Lot Un* 5% 10'+ -- -- - 1500I ANCHORAGE TANK / ORENCO SYSTEMS
F'a..doUon 5% 10'+ - - - TIMER TIMER 46"
Curta;n Om;n N(~NE KNOVI ~1 ' 20 051 05 HHF M.O.A.
~emarke: *BOTTOMLESS INTERNITTENT SAND FILER BENCH MARK
-EXISTING SEPTIC SYSTEM COMPLLit. LY BOTTOM OF WINDOW SILL ON EAST END OF HOUSE
ADANDONDED PER UPC.
· *PRIOR TO PLACEMENT OF ISF SAND 100.00
Inspections performed by: AWWC. INC. Dates: 1st 8/22/2001 ............ ~.~!..,~.. .........
2nd 8/23/2001 .~.~.,- J ..k.~ .........
3rd 8/27/2001 . '-..d~ff ,~,k. GaT-ness.:' 2
Department of Health and Human Services approval ~ht~" ~ .' ~ ~
y~D ~1;,o. .... ~,L ....
Raviewed and approved b ate: '~_q_.Z._~_~ -~[~x~:a r,'~°,~a~.~:-
pERMIT NUMBER: AS BUILT D:R.A~G P,'~RCI~.IO NUMBER:
SW01029~ - 017-452-07
~ ~ - 2s.8 ~8.5I ~ ~ ~ I I
% MH ~ ~7.2 2~=~ I ~
~ ~ 39.8 ~2.s 4~.5 ~ I <
I
~ ~ ~~ m~"~ - / qllllP
~ ~~.fi ~ ~ .~oo~/ ~ ~111111~
X ""~ .... -- ,/ MTn2 '
/ _ N~ ~5oo ~ON/ .
~ / / S.~. T~K J ~ N~ BOW~SS I.S.r. }
I I
I I
A B C
ST1 - 28.8 18.5
ST2 -- 35.2 27.0
MH -- 37.2 28.3
MT1 39.8 22.6 43.5
MT2 48.6 34.7 54.9
Mi'3 36.1 43.0 68.5
MT4 24.6 34.4 -
.../ I I
/ , / ~. , ,
~S~TER & ~STEWATER ~ ,~/t~,;.~ ~ ~,~
CONSULTANTS, INC.
PRD~De~I ~ ~' ~ m ' ~H~Er ~ ~5~ ' ~ ~?~?~P~ * ~ [~O?~Z~eFOR: ~ON[ ~BD:
~RRY 6~[L 1-505-82~-~907 2 OF
~OUNTAIN PARK [STAT[S S/~; LOT 9, BLOCK ?,
AS-BUILT OF S~PTIC SYSTE~ UPGRADE '~~
~=~ ~'~: AS-BUILT DRAWING
SW010293 017-432-07
: - /-- fief I~f fAI~,
fOF I~l~ fAkr, --~
X , - /
~I &SI~ ~TER & WASTEWATER c.J.o.
CONSULTA~S, INC.~
MOUNTAIN PARK ESTATES S/D; LOT 9, BLOCK 7,
PROFILE AS-BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
FR[~ -' 'Denall Sewer & Drain FHONE NO..' 90? 333 9776 Sep. ~5 21~! 1~4'-I~ P1
'
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(gO7) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Aug 02, 2001
Expiration Date: Aug 02, 2002
Permit Number: SW010293 Parcel ID: 017-432-07
Legal Description: MOUNTAIN PARK ESTATES #2 BLK 7 LT 9 :
Design Engineer: 0041 AK Water & Wastewater Consultant Site Address: 012621 LUPINE RD
Owner Name: Larry Betzel Lot Size: 7648 SQ. FT.
Owner Address: 1120 E. Huffman Rd. #676 Total Bedrooms: 4 Permit Bedrooms: 4
ANCHORAGE, AK 99515-0000
This permit Is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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 ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, seaIed, and heated to prevent freezing.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchomge.ak.us
(907) 343-7904
Parcel I.D.
ON-SITE SEWER/WELL PERHIT APPLICATION
FOR A SINGLE FAHILY DWELLING
017-432-o7
Permit Number
Propertyowne~s) LARRY BETZEL
Dayphone 245-5569
Mailing address (1) 1120 E. HUFFUAN ROAD ~/676
Mailing address (2) ANCHOEADI~. AK
~pCode 99515
Legal description (Lot, Block & Sub'd.) UOUNTNN PARK ESTATES ~2: LOT 9. BLOCK 7
Legal description (Section, Township & Range) N/^
Lot Size Acres/Sq. FL
Number of Bedrooms
4
THIS APPLICATION IS FOR:
Sewer Only 1~]
Sewer and Well
Sewer Upgrade ·
Well Only ~E]
water Storage
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Jacuzzi ~E]
Water softenlng unit
I certify that the above Information Is correct. I further certify that this application Is being made for e
Single Family Dwelling and is In accordance with applicable Municipal codes.
ALASKA WATER &: WASTE'WATER CONSULTANTSt INC.
Permit Fees: ~,.~O .~O
Date of Payment: '7'/~ LI[ Q I
Receipt Number:. /7'~:~ q ~
WaN'er Fees:
Date of Payment:
Receipt Number:.
ALASIG WATER & WASTEWATER
July 23, 2001
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, Alaska 99519-6650
Reft Septic System Upgrade for Lot 9, Block 7, Mountain Park Estates Subdivision/t2
(Bottomless Intermittent Sand Filter - ISF)
To whom it may concern:
The existing 4 bedroom house is served by a private well and septic system. The existing septic
system consists of a 1250 gallon septic tank and a trench type drainfield. The existing trench is
surcharged and must be upgraded. We are proposing that a 1500 gallon S.T.E.P. tank and a
Bottomless Intermittent Sand Filter (ISF) system be installed. Comments regarding the proposed
upgrade are summarized as follows:
1. GENERAL: A test hole was excavated on the property to determine an area suitable for a
septic system upgrade. Due to the topography (dictates use ora lift station), shallow ML at 5.5
feet, and the owner's desire to minimize the impact area, it is our opinion that a Bottomless ISF
system is the most viable option.
2. SOILS: Attached are logs which shows the soil classifications, groundwater monitoring, and
the percolation test results. It is ou_r opinion that due to the overall appearance of the soils, a
application rate of 2.0 gallons/day/ft2 should be used..
3. DRAINFIELD DESIGN: Bottomless Intermittent Sand Filter (ISF)
a. Percolation Rate: 9.6 & <1 minutes/inch
b. Allowable Application Rate for ISF: 2.0 gallons/day/ft2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 300 ft2
f. Effective Depth below pressure pipes: 3 inches
g. Width: 12 feet
h. Length: 30 feet.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
i. Effective absorption area-- 360 tt2
j. Air Supply: Thomas Industries, Model 5070, "Anchorage Tank".
k. Air Supply Line: "Wasteflow" emitterline, I/2 inch I.D, "Anchorage Tank".
1. Sand Material: In accordance with M.O.A. latest standards
m. Pea Gravel: 100% passing 3/8" sieve, less than 20% passing the 1/4" sieve, and
less than I% passing the #8 sieve.
We are proposing to excavate down to a depth of 3.5 feet (maximum - remove all organics),
place a minimum of 6 inches of sand, install the air supply line, and cover it with 1.5 feet of
sand. On top of the sand, we will place 6 inches of 3/8 inch pea gravel, with the pressure laterals
midway in the layer. We will use a conventional lift station (Anchorage Tank), equipped with a
programmable timer so that flow can be intermittently dosed to the ISF.
4. SURFACE WATERS: There is no surface water within a 100 foot of the proposed septic
system upgrade.
5. TOPOGRAPIlY: As can be seen on the attached topography site plan the area for the
proposed upgrade is generally flat with a slight slope from southeast to northwest; in short, there
are no slope concerns.
6. MATERIALS AND CONSTRUCTION PRACTICES: The materials used, and the
construction practices will comply with DHHS' "Intermittent Sand Filter Design, Installation &
Maintenance Manual". The contractor should read this document prior to construction. Copies
are available at the Municipal Onsite Services office (4700 South Bragaw St.).
7. CLOSING: I am open to any suggestions from your department, which would be an
improvement to the proposed design. I am unaware of any adverse impacts this installation
would have on adjacent wells or septic systems. If you have any questions, please contact me at
337-6179.
S'c~!
Pres
Th~ufor your assistance.
Lmess, P.E., M.S.
NOTE: ,4ttached is a site plan drawing, a design drawing, a topography site plan, 2 soils logs,
and a 7 page construction specification letter which are all part of the design package for this
septic system.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
I
J
~,~f~ ~*~.~ / (SEE PAGE
MOU~NN p~X~,' / I ~U~NN P~K ~g~ I m
L~ 1,/BL~K 6 ~11 %%~T 10, B~K ~ ~ ,
j ~ ~ I ._~1 Ii '
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,/ , 7/~/200
B.S.~.
, CONSULTANTS, INC. ~" -- 100'
~RRY aETZEL (907)545-5569 1 OF
MOUNTAIN PARK ESTATES SUBDIVISION ~2; LOT 9, BLOCK 7
SITE P~N
\ \1
~ 12 ~ LON~. ~ ~0 ~ ~D~ ~D ~' ~ ~
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~: ~ PRO~S~ N~ 1~
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~SI~WI'ER & ~STEW~I'ER ~~.s.o. ,?~?'z9,~, K s%~
~o.~,~.,~.,,~. ... .. ..... 7j~..., ...~ ........
6~Oi~B~.~,~H~G~.~5~e~(~OTB57~IY~eF~11~84~6 1" ~ ~0~ [ ~
~,~,,~o,: ~0~-.. c~ .~,~ ....-,~
,OU,TAm ,ArX [States SUmWS~O. ~2: LOt ,..UOC~ ~ ~.." ............. '[~
~ or wo,~: ~.o,...~o~~
DESIGN DRAWING FOR SEPTIC SYSTEM UPGRADE (BO~OMLESS ISF) '~A~
/~'"--~- X N Z__~~Y~~'
/~ ................. q --,
/ I~~~
/ k~ ................ ', ,
L,,,,,,~ ....... ~"~~~
~ f~ ~ ~ ~. (~ I/4 ~ ~ ~)
P~N VIEW
~AY ~ ~ ~ . ..-~ .. ,...,.-~ · · . ............ ,~.
,~~ PROFILE VIEW L
~ou,~,~, ~*~K [S~*~[S SU~mWS~O, ~: LOT e. ~LOC~
D~AIL O~ BO~OMLESS INTER~I~ENT SAN~ FILTER (ISF) '~~
.,ZkIL~Slr~,~. '~¥.A.TER & WASTEWATER '"
.... CONSULTANTS, INC.,
ISOIL LOG - PERCO~TION ~ESTI .... J/ ~ ..................
~?, ~ ·
~ DESCRI~ON: MOU~NN P~K [~A~S SUBD~SION ~2; LOT 9, eLOCK 7 ~ '.
PERFORMED FOR: ~ B~ DATE: 7/13/2001'~h~e I',,~ [-7953 ,,,,.'
(PACE 1 OF 2)
~ ~ ~ ~ ~ ~ SITE P~
:~. :.~ ~ GW ~::::: ORG / ' ~ ~ ~ J~"=mo'
~lGP ML ' " 'I
~n~l~]l~M ////z cc I'b · ~ ~ I
~ ~c ~ DC ,g ~ ~ ,'
..~... s~ ¢~2~c, .-[- ~~,~,,1' '
+. · ,:,
DEPTH TO nA = ~ __~ ~ JI I
J l tJl ll
· ~ J
~ u-/o, ' I , , l, ,I
~ v~vo, / / Il
9 ML - ~D 11 O' 7/20/01 ~ / / ' '
IIIIIIIIII DIGGING ' '
,o4111111~1 (~) ~ ,~ /
IIIIIIIIIIA~'~ ~ATE J~E~ Na CLOC~ NET T~ WATE~ LEVEL NET D~OP
'~111111111 ~ ~ , T~E (~N~ES) RE~Na aNCHES)
IIIIIIIIII ~ ~ ~/~/~oo~ ~ 3:~s - ~- -
~111111111 ~ ~ 2 3:4~ 3o ~ 3/4'
lillllllll ~ ~
~3~ ~;s~ ~ 3 3:45 - s- _
1~ J ~ I 5 4:15 - 6 . -
6 4:45 30 2 7/8 3 1/8"
16
17
18 ~ I
19 PERC0~TION ~TE 9.6 ,(~IN./INCH) PERC. H~E DIA. 6" (INCHES)
TEST R~ BETWEEN 2.5 FT, ~D 3.0 FT.
2
CO~ENTS: S01~ WERE PRESOAKED FOR 4+ HOURS PRIOR TO ~
PERFORMED BY A~ WATER ~ W~ATER m, JEFFR~ a. O~NESS, CERn~ ~T mis W~ ~RFORMED
IN ACCORD~CE W~ A~ ~ATE ~D MUNICIP~ GUIDEUNES IN E~ECT ON ~IS DATE:
DEPTH TO DATE
GROUNDWATER
O~ 7/13/Ol
DRY 7/16/01
11.o' 7/2O/Ol
XVA'I"EI{. & XVASTEWATER '...X
..... CONSULTANTS, INC. - ~ (.-..;., ..~,p~,pz;i1 ............
ISOIL LOG - PERCOL~IION IESII ..... :...
1-- (PAGE 2 OF 2)
2--
:~-"" GW----i0RG'
~ GP ~ ML
GM CL
4-- GC
~ SW NH
7-- ~ DEPTH TO DATE
~ GROUNDWATER
Z
8--
~ ,o~¢
o
1°-I DATE RE.lNG CLOCK NET TIME WATER LEVEL NET DROP
11 ' ~ TIHE (HINGES) RE. lNG (INCHES)
~ 7/16/2001
12~
o
14-- ~ PERK HOLE ABSORBED 5 GALLONS OF WATER
~ IN LESS THAN 4 MINUTES
15--
19-- PERCO~TION ~TE <1 (MIN./INCH) PERC. HOLE DIA. 6" (INCHES)
i TEST R~ BETWEEN 4.5 ~. ~D 5.0 FT.
20--~
COHHENTS:
PERFORMED ~ A~ WATER & W~AT~R I, J~FFR~ A. ~NESS, CER~ T~T THIS W~ERFORMED
IN ACCORD~CE Wl~ ~ ~A~ ~D MUNICIP~ GUIDEUNES IN E~CT ON ~IS DA~:
DEPTH TO DATE
GROUNDWATER
¢..~. t
PROPERTY OWNER MAINTENANCE AGREEMENT
ON-SITE WASTEWATER DISPOSAL SYSTEM
This agreement, dated ~.o ~ aZ ,200.[, is made between the Municipality of
Anchorage Depaxtment of Health and Human Services (DHHS) and the property owner(s) of
This agreement is made for the purpose of maintaining an on-site wastewater disposal system
on the subject property.
The property owner(s) agree to the following:
The property owner(s) will have an annual inspection of the system performed by a registered
professional engineer. This inspection shall verify that all effluent and air pumps, timers, and
alarms are functioning as designed. Any deficiencies shall be corrected and the engineer's
statement that the system is functioning as designed shall be filed annually with the DHHS.
- - eProperty Owner Property Owner Name
(Notarize Here)
~to set my hand ,nd
I'/ota~ Public (signature)
My ~s~on expkes:
NAME
I
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
PHONE
MAILING ADDRE~S~) ~- t L~
LEGAL DESCRIPTION
LQCATIQN
DISTANCE TO: I[-¢"r~)~ _v~ll t~)~_&:~ Absorption t~;:)area
Manufacturer I
~ ~ IF HOMEMADE:
Dwelling
DISTANCE TO:
Manufacturer
Well
DISTANCE TO:
No. of
Top of tile to finish grade
Width
Foundation
Depth
Type of crib Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
Driller
DISTANCE TO: Building foundation Sewer line
NO. OF BE~7~OOMS
No, of compartments
Liquid depth
PERMIT NO.
Material
~ot linel3
Trench wid~;d~
Liquid capacity in gallons
PERMIT NO' 0t~O 5C)~
Distance be~wl7 ~es
Total effecti've ~bs~prptio~ area
~.~,nches ~,,~'
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERM,T NO. ?¢05
Absorption area(s)
OTHER
PIPE MATERIALS
SOl L TEST RATI N~
INSTAI~LER
REMARK~
APPROVED
DATE LEGAL
I I I
*~.~ OF HERLTH RND Ef.I',,,'ZRONMENTRL PRO~
~PPL[C:RNT NEZL' R. ROS~ 7t1 W. ~'
LOCATION ~OF'~ NE RD
LEGAL L.S¢ B7 NOUNTRZN PK EST ~:' LOT SXZE t902:2 SQUARE FEET
T'¢PE OF SOXL flBSORE:TZON S~'STEM [5: TRENCH '
MR~'~IMUM:NUMBER OF:~BEE:,ROOMS = ..4 SOIL RATING
: THE RE~Z~UIRED SIZE OF THE SOIL ABSORPTION SYSTEM I~:
[:.EF'TFt= , 7 LEf-~]TH= 1,21 ~3F~R'-¢'EL [:.EF'TFt= ;~:.
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINF'IEI_D.
THE DEPTH :OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
TFIE GRAVEL DEPTH IS, THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F:Ef&:~I_I I RE[) SEF'T I C: TRf-I~:: S I
PERMIT APPLICANT HAS THE RESPONSIBILITV TO INFORM TNIS DEPARTMENT DURING THE
INSTRLL.RTION INSPECTIONS OF RN'¢ WELLS RD.J'RCENT TO THIS PROPERTV AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE,
E,H~.kFILLIiqU OF AN'T' S"r"STEM 14ITHOUT FINFIL IN_,FECTIUI'.,I FIND APFR~ ,HI_ THIS
[EFHR]MENT WILL BE SUBJECT TO F'RO~,ERIITION
MINIMUM DISTI~NCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL S'T'STEH IS
:LO~3 FEET FOR A PRIVFITE 1.4ELL.~ OF.:
:t,SC~ TO 2.F-.~E~ FEET FROM R pUBt_IC WELL DEPENDING UPON THE T'T'PE OF PLIBLIC WELL.
NELL LOGS ARE REC..!UIREr:, FINE:, MUST BE RETURNED TO THE DEPARTMENT WITHII'.,I LZ'O DA.'T"S
OF' THE WELL COMPLETION.
OTHER REC.!UIREMENTS i',lFl'¢ FIPPL'¢. SPECIFICFITIONS FINE:, CONSTRUCTION DIAGRFiMS FIRE
RVFITLFIBLE TO INSURE PROPER INSTALLATION.
t CER]'IFV THAT
±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS RS SET
FORTH 89 THE MUNICIPALIT'¢ OF RNCHORRGE.
2: I WILL INSTALL THE S'¢STEM IN 8CCORDRNCE WITH THE CODES.
3:: I UNDERSTAND THAT THE ON-SITE SEWER SVSTEM MR'¢ REQUIRE ENLARGEMENT IF THE
RESIDEN~:E~EMODELE[~TO INCLUDE MGRE'THAN 4 BEDROOMS.
RPPLIChI.ff' NElL FI. ROSS
,¢ '~ .
F'ERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Al~ka 99502 276-222'~
SOILS LOG- PERCOLATION TEST
t .o5,5' DATE PERFORMED:
~S~I LS LOG
[] PERCOLATION
TEST
2
3
4
8
9,
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS ~,~
SLOPE
WAS GROUND WATER
ENCOUNTERED.;'
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
"- TEST RUN BETWEEN
FT AND
(minutes/inch)
-- FT
CERTIFIED BY: ,/d/- ---~:'~ DATE:
72-008 (7/76)
\
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
Telephone 264-4720
PRE-INSPECTION CHECKSHEET -- TYPICAL TRENCH ON LEVEL TOPOGRAPHY
NIINIMUM WELL
DISTANCES:
INDIVIDUAL WELL
TO TANK 100'
TO TRENCH 100'
CLASS A~ B
PUBLIC -- OVER 25 SERVICE OR
MORE THAN 15 CONNECTS
TO TANK 200'
TO TRENCH 200'
PUBLIC WELLS MUST
ON THE S/D PLAT. ADEQUATE
MINIMUM 5'CASTIRON INTO UNDISTURBED SOIL (4"
PLASTIC PIPE ASTM D3034 M
IN PLACE OF THE CAST IR(;
BE USED
.CLASS C
PUBLIC - UNDER 25 SERVICE OR
LESS THAN 15 CONNECTS -
TO TANK 150'
TO TRENCH 15'0'
PROTECTIVE RADIUS RECORDED
.~ PLANS ARE REQUIRED.
[]4" CAST IRON CLEANOUT
WITH AIRTIGHT CAP
CLEANOUT WITH AIRTIGHT CAP
r-iALL CLEANOUTS MUST COME AT
LEAST TO GROUND LEVEL
[] PERFORATED PIPE INSTALLED LEVEL
E~]SEEPAGE TRENCH INSTALLED ACCORD-
ING TO S01L TEST
[]SEPTIC TANK MUNICIPALITY APPROVED
[] INLET AND OUTLET OF SEPTIC TANK
WATERTIGHT
[]TRENCH INSTALLED ACROSS SLOPE
[]PERFORATED PIPE LEVEL
[] LINE BETWEEN TANK AND HOUSE
2% TO 6% SLOPE
[~]BOTTOM
MINIM
AND
[] RAI
/ I REP
t4_ .,~-- SITE
MI
2X GRAVEL DEPTH
PERFORATED PIPE
(PERFORATIONS DOWN)
SOLID PIPE WITH CAP
ABOVE T-JOINT
PERFORATED PIPE
GE TRENCH 4'
TABLE
VE BEDROCK
EXCAVATION TO LOT LINE 10'
BEFI E INSTALLING GRAVEL
BUILDING PAPER
EARTH BACKFILL
MINIMUM 2"
PERFORATED
PIPE.I~
NOTE:
E~100'MINIMUM FROM TANK
AND TRENCH TO RIVER,
LAKE OR STREAM
SCREENED GRAVEL
%-2%"
DETAIL- SEEPAGE TRENCH
72-006 (Rev. 3/78)
PERMIT NO.
FIF'PL I CANT
LOCR'F 1 ON
LEGRL
DEP~RTMENT 'HEALTH AND ENVIRONMENTAL O~EC:TION
825 'L' STREET, ANCHORAGE, AK. 9950t
264-4?20
~qELL F'E~:~'qI l"
< ?80449 )
JOHN L. IJ.=,TER
LUPINE RD
L'.-'.~ B ? MT PRRK E_TMTE_, ~2
~22'~ W 69TH 99502
/ko
LOT =,IZE 190_-'-':2 SQUFIRE FEET
MINIMUM DISTANCE BETWEEN 8 WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR 8 PRIVATE WELL~ OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLV. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
8V~ILI~BLE TO INSURE PROPER INSTALLATION.
F' E F-." f-11 l' E~"-':F' I RES [)EL-:EZf"IBER 3:1.. 1'_-4;--'"8
I CERTIFY THAT
it: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: t WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
S t GNED: _~___~
A~-~ICANT JOHN CUSTER
V
','? 2
· -' WELL CONSTRUCTION LOG
., co.V'~rn~ gn I~,nq ~ ~n&-Dn~e%
Drilli
Well location: (address S legal description) ~'~
Static water level .~ ft. (~ below)land surface. Dateq-~'/-73
(open-end, screen, perforated,~ ether),
Finish
of
well:
Describs iatervals and sizs'
Wall yield tested by (pumping, bailing, air) at
for .hours with
USGS no.
Date welt completed ~
Nearest commun""~VIRONMENTAL
PROTECTION
gal/min.
ft. of drawdown from static level.
DRILLER'S MATERIAL LOG
RECEIVED
Depth below land
surface in feet
Give description of strata penetrated
(size of material, color, hardness of drilling, and water content)
t
~to
~t 0
__to
__to
to
to
--to
to
Municipality o.f Anchorage .:
Development Serv,ces Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-8650
L
www.cLanchorage.ak.us
(907') 343-7so4
CERTIFICATE OF HEALTH AUTHORITY AppRovAL
FOR .~ SINGLE FAMILY DWELLING
Parcel I.D. O17-452-07
1. GENERAL INFORMATION
Complete Ingoi description
Location (site address or directions)
.N~ /O/0~11
Expiration Date: / ~ ' ;7.. ~'"'- ~D /
MOUNTAIN PARK ESTATES SUBDMSION; LOT g, BLOCK 7
12621 LUPINE DRIVE~ ANCHORAGE, AK 99516
Current Property owner(s)
Mailing address
Lending agency
LARRY Btlz£L Day phone 345-5569
12621 LUPINE DRIVE, ANCHORAGE, AK 99516
Day phone
Mailing address
Real Estate Agent
Mailing address
MARC LITR.E Day phone 558-2482
INTEGRITY FIRST PROPERTIES, 8001 PIONEER DRIVE
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBERCF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individuai Well ~
Individual Water Storage
Community Class Well ~__.
Public Water System
TYPE OF WAS i e:WATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) 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) for properties served by a single family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for properties served by a pdvata or Class C well and may
be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
wells or a public water system. The Munldpaltty of Anchorage Is not responsible for errors or omissions In the
professional engineer's work.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1630.00 a~ or pdor
to closing for the enginsedng services pmvfded.
4. STATEMENT OF INSPECTION ny ENGINEER ..
"As ~ertified by my seal affixed hereto and as of the validation date shown below, I verify that my
.' ~nvasb~gati~n~besed~npmcedums~ulIinedintheHeeithAu~#lyAppmva~GuidelInesforthisapp~ication~
~ .-- 'shows that the on-site water supply and/or wastewater disposal system is(am) safe, functional and adequate
for the number of bedrooms and Jype of structure indicated heroin. I further vadfy that based on the
Infonwation obtained from the Municlpalily of Anchomge files and from my InvestigaEon and Inspeclion, the
on-site water supply and/or wastewater disposal system is(am) in compliance with al~ applicable Municipal
and State codes, ordinances, and regulations In effect at the time of installation.
NameofFirm .ALASKA WATER & WASTEWATER CONSULTANTS. INC.
Address 6901 DEBARR 'ROAD, SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name..JEFFREY: A. GARNESS, P.E.
Phone ,.337-6179
Engineer's Comments:
In conducing this evaluation, AWWC, Inc, atlernpted to provide a thorough,
conscientious engineering enat~is of the system In acco/dance with ADEC and MOA
DSD Guldal/nes & Regulations. The reported results desc#bed the per/om~ence of the
system under the condl~ons encountered at the time of the to~ end separetion
distances measured to readily identifiable fealures. The operational life of all wells and
septic sys~ms depend on the Iocal soSs condl~on, groundwater levels that may _
#uctuate during the ~ear, and the water usage of the fam#y being sen/ed by the sysfem.
These corm'ltions are outside the consol of gte evalualor of the sysfem. Salisfentc~y tost
results do not guarantee future perf~m2ence of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWWC, Inc, can therefore not ptovfde
any warranb/ or futura estimate of how long the sysfem will continue to meef the
opereEonal requirements of the ADEC or MOA DSD. The conlent of this repot Is for
~he sole benefit of the owner l/sisd ebova. Any reliance upon or use of this report by any
other person or parb/ Is not euthoSzed, nor will lt confer any legal right whatsoever.
5. DSD SIGNATURE
/./" proved
Disapproved.
Conditional approval for
.~'.' '.
~." ON-srI'E ".~__~'
bedrooms, with the fllow~ng supu~auons~ ~ WASTEW^TER; .
- Attachments:
HAA Checklist
Septic System Advisor/
Well Flow Advisory
Manltenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date: ~ ~'' '~''''' ~) /
Legal Description:
A. INELL DATA
Well type PmVAT~;
Date completed 9/27/78
Totaldepth 150 ft.
Municipality of Anchorage
Development Services Department
Building Eighty Olvl~on
4700 South Brlgaw sr.
P.O. ~ 1~ A~c:horage, AK 99519-~50
HEALTH AUTHORITY APPROVAL CHECKLIST
MOUNTAIN PARK ESTATES S/0; LOT 9, BLOCK 7 Parcel ID:
If A, B, or C provide PWSID# N/A
Sanitary seal (Y/N) YES
Cased to 60 fl.
FROM WELL LOG
Date of test 9/27/78
Static water level .12 .ft.
Well production 3 g.p.m.
WATER SAMPLE RESULTS:
Nlti'ate O. ~' mg./L
Collected by:
callfom~ ~ colonies/IiX) nd.
Date of sample: 9/15/2001
B. SEPTIC/HOLDING TANK DATA
Tank Type/Matedal $.T.E.P./STEEL
Tank size 1500 gal. Number of Gompmlmenta 2
Foundation cieanout (Y/N) YES
: Date of pumping NEW
C. ABSORPTION RELD DATA
Date Installed 8/27/2001
Length 30 It
Depression over tank (Y/N) NO
Pumper
$oll rating ~r ft'/berm) 2.0
Width 12 It.
Totaldepth .2.4-3.~ ,fi, Eff. absorption ama 360 fl~ Monltodngtube YES
Data of adequacy test NEW Results (Pass/Fall) PASS
Fluid depth in ebsorpfion field before test - In.
Elapsed Time: - min. Final fiuld depth -
Any rejuvenation treatment (past 12 mo.) (Y/N &
017-432-07
YES
YES
wen Log (Y/N).
Wires properly protected (Y/N)
casing height (above ground)
AT INSPECTION
7/13/2001
34 fL
.g.p.m.
1.9+
18+ .in.
Other bacteda ~ colonles/100 mi.
AWWC, INC.
Dateinstalled 8/22/2001
Cleanouts(Y/N) YES
Hlgh wateralarm(Y/N) YES
System type. I.S.F.
Gravel below pipe 0.28 It.
Depression over field NO
For 4 bedrooms
Water added - gal. Now depth - in.
In, Absorption rate >= g.p.d.
NONE KNOWN If yes, give date -
D. UFT STATIOH
Data installed 8/22/2001
"Pump on" level at TIMER in.
Datum ~OTTOM OF TANK
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons 1500
'Pump off' level at ..T. JJ~in.
Cycles tested NEW
Holding tank
Manhole/Access (Y/N) YES
High water alarm level at 46
Meets alarm & circuit requirements?. YES
Septic tank/lltt station on lot100'+
Absorption field on lot 100' +
Public sewer main N/A
Sewer/septic service line 25'+
· On adjacentlots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
N/A
Absorption field 5'+
Surface water 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water service line 10'+
Wells on adjacent lots I00'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10%
Water sen/ice line 10%
NONE KNOWN
Curtain drain
COMMENTS
Building foundation. 10'+ Water main N/A
Surface water 100'+ Driveway, partdng/vehlcle storage
Wells on adjacent lots 100'+
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections end
review of Municipal records that the above systems are in
conformence wfth MOA HAA guidelines in effect on this date.
Engineer's Printa~ N~F~e
Data
JEFFREY A, GARNESS
in.
Fee $ ; 00
Data of Payment ~(~) j
Receipt Number O ~-(
(~av. 12/oo)
Waiver Fee $.
Data of Payment
Receipt Number
Parcel I.D. # O 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
GENERAL INFORMATION
Complete legal description
LoTq; ~14 "/'
Location (site address or directions) I ~- (~ ;Z I
L-U P~N~- Df'Z~V~
Property owner
Mailing address
Day phone
Lending agency
Mailing address
Agent
Address
uay pnone
Day phone
Unless Ottierwise 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
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 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.
NameofFirm '~¢~b.~- ~u~t/.[~.'~¢ ~'~-~-- Phone ¢.'~1-;[¢///¢
Address ~0 % d/_/ /,~-¢--'fn ~ ~ -%
Engineer's signature
D~S SIGNATURE
Approved for
Disapproved.
Conditional approval for
~'., ,{ ~L~ bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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.
72-025 (Rev. 1/91) Back MOA ~1
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL -qERVICEI~ DIVRilON
Municipality of Anchorage ~
DEPARTMENT OF HEALTH & HUMAN SERVICES [10¥ ] ~,' ]Dg(~
Environmental Services Division
s~V'L" Street, ~oom $02 ' A,¢ho"age, A'aska ~@$0'1' (g0?) S4'S'*ZJ~ (~ E ! V E, []i~lLl~
Legal Description:
A. WELL DATA
Well type ~
Log present (Y/N) ~-/
Total depth I ~ 0 I
Sanitary seal (Y/N)
Date of test
Static water level
Well production
Health Authority Approval Checklist
LoJcq,BJ~"I' Mpi~ ~ z_ ParcelI.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to {~ O I
FROM WELL LOG
9. 7. 7e,
or'l- ,452- o-~
7e
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
WATER SAMPLE RESULTS:
Coliform ~5
Date of sample: IO[z-"z"J
Nitrate
(-'~. q "~ i ~ ~/J Other bacteria I'-!
Collected by: 'il
B. SEPTIC/HOLDING TANK DATA
Date installed [0/ze/7s- Tank size
Foundation cleanout (Y/N) 7 Depression (Y/N) l"4 High water alarm (Y/N)
Date of Pumping ~.~-4~ P~ umper ~_o ~-[.d~Lec 'v~ /~
C. ABSOR~ION F~LD DATA t
Date installed ~]zq]~ Soilrating ~or~2~dm) 1~O System~e
Jo~:O Number of Compartments o~ Cleanouts(Y/N)
!
Length I oQ--I Widm
Effective absorption area /~ O _.~
Date of adequacy test
Fluid depth in absorption field before test (in.);
tt
Fluid depth I~'~ (ins.) IvlAnu:~o
Peroxide treatment (past 12 months) (Y/N)
Gravel thickness below pipe oQ.5' Total depth ~5//11
Monitoring Tube present(Y/N) V Depression over field (Y/N) ~'~
Results (Pass/Fail). T For /q/ bedrooms
Immediately after ~OOgal. water added (in.): o~- ~
Absorption rate = ~> ~O-O g.p.d.
If yes, give date ¥'4
D. Lll~r STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump oW' 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 I I 011 '~' ; On adjacent lots
Absorption field on lot I"~01 -k ; On adjacent lots
Pablic sewer main lx[//~. Public sewer manhole/cleanout
Sewer/septic sen, ice line ~ ~,~ ,~ ~ Lift station
SEPARATION DISTANCES FROM SEPTIC, HOLDING TANK ON LOT TO:
Building foundation ] ~ t t ~+
Property line ~--0 Absorption field
Water main/service line ~,~ Surface water/drainage ~//~-N- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation '~0 t
Surface water
Curtain drain
ENGINEER'S CERTIFICATION
Water main/service line '~ a~ ~
Driveway, parking/vehicle storage area
Wells on adjacent lots "~ /O'-O Proper~ line
' .. ~ere'
HAAFee $ '~) t/J~
Receipt Nunlber ~-~
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
in col~formance with MOA H/lA guidelines in effect on this date.
Signature '-5-7 ~
Engineer's Nan, e ~o~ S~Or~
I certify that ! have determined thrufield inspections and review of JvIunicipal records that the above systems are
'
' ;;-:~:' Ap~ROVA~.~.~ FOR A SINGLE FAMILY DWELLING
'GENERAL'IN'~b~TioN- 7::'~_:?::::~:~:~":.'::. - _ ::" "~ '. -'~-;?-'.:
c~mpJe~e'i~g'~i'aesC~,btiO,'::'- ~'b~'q, ~ .~ "~ ~
Location (site address'or direct ons) .--' '" ~ -
,.: :" ...::.._. ~ai~i~8~res.~:~!~`~!!?~:~i;`.~:::)~;~i~-~;~):~..~.:~-.
. -_:. ' ... Lending:agency Day phone
'-~ ..... ~"'?:'~'t lnl~e~ 'nfh=~r~nn~ted'~H~ will be held for'nlckun
' . .,~ .... ' ......... · ................... ,,, ~-¢ ~ ,:=C -' . ' t., '- " '~ '~-~.~'<':','~-7¢::::':':'%' .......... '~ '-,%:.*-%~-~:;:~ ~:'~'
-- 3. ~PE OFWATER SUPPLY.._.~
........... Commumty well :,:.:,,._~.
.. ' - %:;;- '.' --:' - '. - Public water, z.:::.;~:: - .::~;?.--.~- .... ... : '~. - :-:~
. : -::. ::.:- .--'.~;' 'NOTE: :-~-::lf communi~'~w~/l'syStem; 'pro~/de~fi~enCOnfi~ation from
~: ::;..Individual on-site ............. "
72-025(Rev. 1/91) Front MOA~21
As Certified by'my seal affixed hereto and as of the validation date sh0w:n."13'~iow, I. ~eri
and/or wastewater disposal system is safe, functional and adequate for the number of b~rooms
an~ ~Po ~i stru~luro indicatod heroin. I fu~h~r V°ri~ that ~a~ed on th~ information o~taiaed from'
the Municipali~ Of Anchorage fil~ 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 r~ulations in effect on the date of this ~nspection. '
': :':':: :?:::?/~'~a~i:'.Ce'ftificate~'.ba~'Or~!Y:~l~b~ the"i"els~(i:nt~t!ons:giv~'~'ih':l~.~'pii'~ ~b'ove"b~i'an:ind~nd~t:;:?;:,~:;::·
.: ;;;:::Vi::::~,:~ p~of .e_ ~!?.~..a!,egg!neer regis~e.[e~ i~ !h.~ State of Alaska, The D H NS d°es this as a coi~to:l~J~cha~ers'of h0rneS':;~; :':'::
:: :';: '.: i;::i.:~!--! .a-n,d ~h.~i:!e .r~.;.ing !nstitutiOnSj~'b~'deri~satisfy ~er~ain federal aha state reqUi.r~ments: sml~ oy~ ~f~DH, FiS do n0{ ;.:: :~ :!::i::
:::,:?::::~c-0,n-db~-:ih§pectibns-~or analyze,'data': before a ,certificate:is.iSSUed..;:.TheMuhiCiPalitY,,Of~Ar{ch'~3-~16,'is:-not.:::.::.
:' ::: ::; /res~0nsible for errors or Omissions in tlie prOfeSSional engineer's WSrk.':?,:'~:-!,-?i':':: :.':':~:::!:i: ?': ::.":': ~': ::; :": '
72-025(Re~.1/~1) Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ~J~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~)','~-~1~ ?~ Driller \/~,~
Cased to ./~ cO Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
/~.).~ ~ Other bacteria
Collected by: ~'=', ~
B. SEPTIC/HOLDING TANK DATA
Date installed ~/?-'¢f / ? ~
Cleanouts (Y/N) '~,~ Foundation cleanout (Y/N)
High water alarm (Y/N) I~/~.
Date of pumping ~) ¢,.~ ~ ~, ~ t~
Tank size ?~ ~ ~ Compartments
~ Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ! i, ~¥ ~- On adjacent lots
To property line ~ ¢J '~ Absorption field
Sudace water/drainage p4 1 ~
Foundation )~
Water main/service line
7fi.026(3/93)OFro~t ~ , .CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Sudace water.
D. ABSORPTION FIELD DATA
Date installed ~/7~ / 7~ Soil rating (GPD/FF)
Length I~1 Width ,~ Gravelthickness ¢,~,,5 Totaldepth ~,,~ "'~11
Total absorption area ~ ¢),.~ Cleanout present (Y/N)
Date of adequacy test ~ ~ ~ '~ ~' ~ Results (pass/fail) '~' for ¢ Bedrooms
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N).
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~,~' I ~ Property line
~) '~' To existing or abandoned system on lot
Cutbank ~ ~ ~,1 ¢-~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I cerb'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect*Ob 'the d~te. of this inspect/on.
HA,& Fee $ -_~¢_/L~.
Date of Payment
Receipt Number ~/~' ('~~)
Waiver Fee $.
Date of Payment
Receipt Numar
72-026 (3/93)' Back
MUNICIPALITY OF ,~NCHORAGE
Department of Health & H~uman Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions)
Property owner ~,Y--~,~) ~'RT~.~,~-,~ Telephone: (home)_,~-5'-'~2~TBusiness
(c) Lending Institution TelePhone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here~, if hold for pick up.)
List conta, ct person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family~ Number of bedrooms ~/
3. WATER SUPPLY
Individual Well ~J, Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site,S, Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, 'rESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of thevalidation date shown below, Iverifythat my investigation of th is
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.
/
Approved for y .bedrooms by Date
Approved -Disapproved Conditional
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated 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 inordertosatisfycertain federal and state requirements. Employees of DHHSdo not conduct inspections
or analyze data before a certificate is issued. TheMunicipalityofAnchorageis not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back
Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA)
MU~__ ~' OF ANCHf~ Authority Approval (HAA)
£NVlR~ SERVICEs I~IE~KLIST . FE BR UARY 1984
v 343-4744
J[-J~J 2 ~- ]989 Legal Description: L~ ~-7' //~,~,~7/4,'.,~
RECEIVED ,,v,.z
A. WELL DATA
Well Classification /~u,. m//¢/t_.,)¢ ,¢ t/ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Y. Date Completed 9--27- 7(~' Yield')lf- 3
Total Depth~ /5~0 / Cased to'~[-- ~'~) ~' Depth of Grouting /¢'~ ,'~ ¢
Static Water Levelr -J~¢" ~'-/~,'J' 7'-~' $~-- Pump Set At ~/~/,4//~/,-.,-,~,,
Casing Height Above Ground ~" Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot / ~) ~ ; On Adjoining Lots / ~E3 '¢-'
To Nearest Edge of Absorption Field on Lot / ~¢ ¢' ; On Adjoining Lots
To Nearest Public Sewer Line /~' /¢ , To Nearest Public Sewer Cleanout/Manhole /~/,
/
To Nearest Sewer Service Line on Lot //~ :f
Water Sample Collected by //~ ~'*'~ Y Pc' 7~'$ ;Date
Water Sample Test Results ,~ ~/,Lr/.4¢_/¢,' y
Comments '::~ ;/-'-~,~n Dtt//$ l~-,w~ ,')..'~
B. SEPTIC/HOLDING TANK DATA
Date Installed31t~ ~/'7o~ Size ~' J ;2_~¢ No. of Compartments -~- ;2,
Standpipes (Y/N) 7 Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) /V
Depression over Tank (Y/N) ~ Date Last Pumped ~' '---~'~
Pumping/Maintenance Contact on File (Y/N) /~,/8/,, ;for /~/*/~,
Holding Tank High-Water Alarm (Y/N) N /¢, Temporary Holding Tank Permit (Y/N) /V.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well /(~ / 7~
· To Building Foundation //'-¢<"
To Property Line /~2" ~- To Disposal Field //~ /
To Water Main/Service Line -~¢
To Stream, Pond, Lake or Major Drainage Course
Comments ~-
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ ~/'7 ~
Width of Field ~ *.~ /
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test //-/~ c,¢ b,/)¢'¢',
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot /V'o/t., (
/
Length of Field
Depth of Field
.Gravel Bed Thickness ~ '-~"¢-- //
~)._~ Statndpipes Present (Y/N)
Date of Last Adequacy Test
Type of System Design'~ 7
/
To Property Line .~L /,.~
To Existing or Abandoned System on
; On Adjoining Lots
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ¢
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
To Cutback (if present)
Meets MOA Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have che~cked,,g)ar~f, i4~or conformed to all MOA and HAA guid~_s~'b~f,[ect on the date of this
inspection. ~/ // /~ ~
Signed · ~~ ~~
~, ;~o~
Receipt No. (> % ,~ / ,~ / ~ Receipt No.
Date of Payment (.O '- ~ / ' ~ Waiver Fee: $
Amount: $ /'~ ~-~ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
{907} ~49-64~1
WATER wR:r.r, TEST
LOCATION:
Client's Name:
Address:
Subdivision:
Lot:
Block:
7
Initial Reading on. Meter: ~.~'
D P4g'/ GAr.tONS ~A r ,r~Ns FI~r,n METER
DOWN TIME G~M ~ VOLUME TOTAL MONITOR LEVEL READING
,?
-~/' _~; -Y-Y 3, s" 3~ J~
Go" o~. a ~ ~7.7 .3_ ?
//9
,, .~ 3 't ~ ; ~ K -~ . ~ 0.3 ~ 7 ..,$
,_ ,~ 7 , x.~ ~ ~ 0
~ ~ G t~'V~ ~,.~ ~: ,' ,, 7 ,
~' I:~ 2.9 _~ .~ ~ o 7,S ~ y7o~ o
g~. 2:2o %0_ v~ 73 g
:'3
0.3c
0,~.7
Production Rate: GP."I 24-Hour CapaciT/ Gallcns
J
INVOICE
SEWER AN D DRAIN
"-"~ ~'~' '~'~,/-~-~ CLEANING SERVICE
RO. BOX 112688 PHONE 345-2513 ANCHORAGE, ALASKA 99511.2688
HRS. @
Job Address
D~T~ ~USTO~£~ 0~#
ROTC-ROOTER SERVICE CALL
PROBABLE CAUSE OF STOPPAGE?~r_. z~ _~.~x~_ ..~'~,,.,~.~..,,-~
~.. ~ ~~ ,-~~~ .........
WORK ACCEDED BY
:..::..:..-... .-.,. :-:.:..... .-- .:'. ~ _ :., '-
:-:-: ...... - .~,~_~: ', ~:.,.:='_ .-. _ . ...... -_.-, : :. ~::.....,.: .. .... :~.:~:_.~-_:--:::~. _.__.-
. .. .... . ...... _ . . _.. - ~...._..,_ . .--.'_~: .~:.
TRtP CHARGE H RS. @
OVERTIME CHARGE HRS. @
ADDITIONAL LABOR CHARGE HRS. @
/,,,,'~UMPINGSERVICE../.:_~',d~ (GAL.) HRS.
HYDRO-JET SERVICE HRS.
jim ATERtALS .
PROM' ,;,NVO,CE
TOTAL FOOTAGE CLEANED OR THAWED
BLADES USED__
STEAM THAWING HRS, @
NORTHERN TESTING LABORATORIES,
600 UNIVErSiTY PLAZA WEST SUITE A FAIRBA,"~F:S. ~LASK& $97C9
2505 FAIRBANKS STREET ANCHORAGE. 4LASK4 ~503
INC.
907-479-3115
907-277-8378
B.E.P.
2220 East 88th Avenue
Anchorage, AK. 99507
Attn: Mr. Ports
Source: Lg/B7 Mt. Park Estates
Sample ID#: A061689-12
Date Arrived:
Time Arrived:
Date Sampled:
Time Sampled:
Date Completed:
06/16/89
1200
06/16/89
1030
06/16/89
Parameter Unit Result ADEC MCC*
Nitrate-N mg/1 0.29/0.28 10
Reported By: ~"~ Date: 06//19/89
Francois R0digari, Anchorage Operations Manager
* MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIES,
600 UNIVERS!TY PLAZA ~,',rE,~T. SUITE A ~A~RBANKS, ALASKA 99709
2505 FAIRBANKS STREET '~'~CHORAGE. ALASKA 99503
iNC.
907-479-3115
907-277-8378
Quality Control Report
Client: B.E.p.
ID#: A061689-12
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample # Parameter Unit Result Acceptable Limit
EPA WS378-12 Nitrate-N mg/1 7.64 7.17 - 8.01
Reported By: ~ ~ Date: 06/19/89
Francois Rodigari, Anchorage Operation Manager
NORTHERN TESTING LABORATORIES, iNC.
600 UNIVERSrI"Y PLAZA WEST, SUITE A ~A R~ANKS, ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE ALASKA 99503 907-277-8378
Drinking Water Analysis Repod for Total Coliform Bacteria
TO 8E COMPLETED BY CLIENT
[] PUBMC WATER SYSTEM I.D. #
~X[ PRIVATE WATER SYSTEM
NAME
Mailing Address
City State Zip Code
SAMPLE DATE: ~ /~ ~c~ Phone I~c-/Z) ~'~'~'--~ /f~-'¢!
Mo. Day Year
Purchase Order No.
[] Treated Water
[] Untreated Water
)
Collected by
SAMPLE TYPE:
~. Routine
[] Special Purpose
[] Check Sample (for original contaminated
sample with lab reference no,
SamlHe Time
No. Loc~tion Collectm:l
L ~ [37 f/),~,~,~ /~,'_~o
Laborator~ Ref, No.
2
3
4
5
6
7
9
10
Signature of Representative
FOR LABORATORY USE ONLY
Direct
Count
TO BE COMPLETED BY. LABORATORY
Received at: [~].~nch. [] Fbks.
Time Received //~:~
Next Sample Due
COMMENTS:
SATISFACTORY
UNSATISFACTORY
RESAMPLE
OTHER BACTERIA
TOO NUMEROUS
TO COUNT
U
R
OB
TNTC
*No. of TT~ Colonies per 100 Chi5
Time
I',u~ 0252
AGREEMENT made this' I~_~ day of JG~J~ , 1980
by and between STEPHEN SO~NSEN, of Anchorage, Alaska, herein-
after referred to ~s Licensor. and NIBL ROSS Of Anchorage,
Alaska, hereinafter referred to as Licensee.
IN CONSIDERATION of the mutual promises herein con-
rained and good and valuable consideration in hand received,
the parties agree as follows:
I. GRANT OF RIGHTS
Description .of ~reml~s:
Licensor hereby gran~s to Licensee a license to occupy
· and 0se, subject to all the terms ~nd conditions hereof, the
following described premises:
The southwest corner o'f Lot Ten (10), Block
Seven (7), MOUNTAIN pARK ESTATES SUBDIVISION II,
upon which s water well has been located,
including the present pipzng system to Lot
Nine· (9), Block Seven (7), MOUNTAIN pARK
.ESTATE SUBDIVISION £I, according r~ the
.~ Records of the Anchorage Recording District,
Third Judicial District, State of Alaska,
as described .in Exhibit A attached hereto
and incorpora~e~ herein.
The premises may be Occupied and ~ed by Licensee
· ., .solely for the purpose of obtaining 'water from the presently
constructed and operating well; including the distribution pzpe
attached thereta located on the southwest corner of Lot Ten (10),
Block Seven (7)', MOUNTAIN PARK ESTATES SUBDIVISION II (herein-
after r~ferred to as encroachment) during the period commencing
' on //~.F/~Z¢~ , 1~, o~ which date ~ubject well con-
structed by the Licensee was placed ~n operation and until
terminated.
III · AGREEMENT
Licensee shall pay Licensor for this license Two
Hundred Fifty and NO/100 ~ollars ($250.00), the total amount
payable in advance, unless otherwise agreed to by Licensor.
IV. SURVEY
In addition to the payments above provided, Licensee
agrees to pay ong-half (1/2) of a survey by Bell Herring &
Associates of Lot Ten (10), Block Seven [7). Licensee agrees
Licensee agrees to pay for any and all' damage re-
well which is th~ ~ub]ect matter of t~is agreement. Licensee
agrees to provide an architectural ~over satisfactory to
pay any and all attorney's fees incurred as a result of the
the dare'of the s~gni~g ~f this agreement, or resulting from
tions in the past, or present, as to what quality, o~ the
the agreement'of the parties that Licensor shall 'not be respon-
sible in ~he past, 6r present, or future for the quality,
is Licensor responsible, in any manner for the continued supply
VIII. SUCCESSORS IN INTEREST
T~is license may be transferred to the assigns or
successors in interest of the parties an~ the terms herein shall
be binding on said assigns, or successor in interest.
IX. ENTIP~ETY OF AGREE~NT
This written agreemenc shall constitute'the entire
agreement of th~ parties and no representations, warranties or
statements of the parties shall survive this writing. This
agreement shall not be amended, modifi~ or changed without
written agreement executed by both parties before a notary
public of the. State of Alaska.
. IN WITNESS WHEREOF, the parties have executed this
License Agreemen~ at Anchorage, Alaska, the day and year first
above written.
LICENSOR:
STEPHEN SORENSEN
LICENSEE
NIEL ROSS
STATE OF ALASKA
THIRD JUDICIAL DISTRICT
-THIS IS TO CERTIFY that on this/~day of ~/~
1980, personally appeared before me, the undersigned, a Notary
Public in and for the State of Alaska, duly sworn and commis-
sioned as such, STEPHAN SORENSSN, to me known to be the
individual described in and who executed the within instrument,
and he acknowledged to me that he signed and sealed the same
as his own free and voluntary act and deed for the uses and
purposes therein mentioned.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal the day and year first hereinabOve written. -
5O4
mc£ D 2 5 5
STATE OF ALASKA
THIS IS TO CERTIFY that on this day ~f ,
1980, personally appeared before me, the Unddrsigned, ~Notary
P~blic in and for the State of Alaska, duly sworn an~ con~is-
individua 1 described in and who executed the within instr%u~ent,
and he acknowledged to me that he signed and sealed the same
purposes therei~ mentioned·
IN WITNESS WHEREOF, I have h~reunto set my haWd and
seal the day and year first hereinabove written.
OTA.qy
Notary Public in and for Alaska
My Commission Expir~s:./~./~-~'~
iVDt~ Tt/ ,oA f~ K
lOT IO -
' '"' ' . MUNICIPALITY OF ANCHOP. A~ '
· - DEPT. OF HEALTH &
' . .'' i '.."' ' ENVIRONMENTAL PROTECTION
'~ ° ~ DATE RECEIVED
TIME TIME - \ ~ /~"~-' rIME
~~ ~UNICIPALI~ OF ANCHORAGE
~UNIClPALITY OF ANCHORAGE ENVIRONMENTAL F; OTZCTION
DEPARTMENT OF HEALTH ~ ~VIBO~TAL P~OTEOTIO~
825 L Street-Anchorage. Alaska 99501 ['~AY 1 4 1980
ENVIRONMENTAL SANITATION DIVISION RECEIVE
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
1. PROPERTY OWNER ~ PHONE
MAI LInG ADDRESS
PROPERTY RESIDENT (If diffe~nt from above) PHONE
2. BUYE. , PHONE
~AILING ADD,E88
~, [EN~I~ 1~STIT~TIO~ ~HOBE
MAI LI'N~ ADDRESS
MAILING ADDRE~
5. LEGAL DESCRIPTION . ·
STREET LOCATION [ ,
18, TYPE OP RESIDENCE
[] One L~~ Four [] Other
~/ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
7. WATER SU~-Y
r~l" INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
[~'" INDIVI DUAL/ON-SITE**
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) [L~ Id.~
THIS SIDE FOR OFFICIAL USE ONLY ::
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 ~'~ ~
Size: / ~_5-o If Tank is homemade SOILS RATING
give dimensions: ~ ..~
TYPE OF TANK MANUFACTURER /~ ,,** .
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
EZ~APP ROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~ PT. OF HEALTH
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten {10) days for processing.
1. PROPER~ER .~ -- . ~ PHONE
........ -I
PROPERTY RESIDENT (If different from above)
MAILING ADD~
8, LENDING INSTITUTION
, ..
MAILING ADDRESS ~
MAILING ADDRESS
_~ PHONE
PHONE
PHONE
5. LEGAL DESCRIPTION
STREET LOC~TION
'~7~ OF RESIDENCE
NUMBER OF BEDROOMS
~ One ~ Four
~IJ~'l NG L E FAMILY [] Two [] Five
[] ' MULTIPLE FAMILY [_~ Three [] Six
: [] Other .....
7. WATER SUPPLY
._'~i~-qNDI VI DUAL'~
[] COMMUNITY
[] PUBLIC UTILITY
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.)
SEWAGE DISPOSAL SYSTEM
~IVIDUAL/ON~SITE**
[] PUBLIC UTILITY
'~*lf individual/on-site, give installation date_~
If system is over two (2) years old an adequacy test is required
by this Department.
72-01O(3/78)NOTE: THE INSPECTION FEE~ ~~MUST ...... ACCOMP flY EACH_ ,", REQUESTT.i~.,~ BEFORE~PROCESSING~. d_.bCAN BE INITIATED._
THIS SIDE F(_'~F', OFFICIAL. USE ONLY
INSPECTION APPOINTMENTS
'l'/Pi: OF RESIDI-:NCE
· SINGLE FAMILY [~ ONE i.~] THREE I'-] FIVE [~ OTHER
J MULTIPLE FAMILY [:~ TWO [-~ FOUR ~] SIX
PERMITNUMB[:R
WA i'[;1~ SUPPLY
I,~DIVIDUAL DEPTH OF WELL
" COMMUNITY DATE DRII_[ ED
; i:UBLIC LJTI LITY
(/:Oml(~Ction Ve- f ed ............ LOG RECEIVE[)
~EWAGE DISPOSAL SYSTEM PERMIT NUMBER
[iq[)IVIDI.IAL/ON -SITE 5'~E~S i'~LL -
Conmocdo~ V~ ified .............................................
'}::ep/Jc 'i anl< o~ [~] HoldiNg Ta~fl<
Yi'E OF i'ANK MANUFACTUREF~
~ O'r;~.!. ASSOI:~PTION AREA MATERh4L
[$ CC, iVIM ~i:: N TS
............................ ~ ..... ~.~ .........................................
CONDITIONAL APPF]OVAL (loit~r must ~ccompany certificate)
~ ~'i"-'¢C-'Ll'~i~''~'~' ~ .................................................
