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Home My WebLink AboutCAMPBELL HEIGHTS BLK 2 LT 3A2 GP(~ TER ANCHORAGE AREA BOROrI'.~H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 NAME ~ /~/' LOCATION INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ADDRESS PHONE LEGAL DESCR'PT'ON '¢/4 2 SEPTIC TANK: DISTANCE FROM WELl. LIQUID CAPACITY. MATERIAL ~ NUMBER OF .COMPARTMENTS. ~ ~./~'*'t,,~ ./~ '7 (~ LIQUID ,GALLONS. INSIDE LENGTH INSIDE WIDTH DEPIH__ SEEPAGE SYSTEM: NUMBER OF PITS LINING MATERIAl NEAREST LOT LINE SEEPAGE PIT: OUTSIDE DIAMETER OR WIDTH / '2_' . LENGTH / ~ ' i DEPTH ~'cr~/...~ , DISTANCE FROM WELL. /'//0 · , BUILDING FOUNDATION. '~OTAL EFFECDVE ABSORPTION AREA (WALL AREA) ~:~1~ ~ SQ. FT. TILE DRAIN FIELD: DEPTH: TOP OF TILE TO FINISH GRADE .DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE ~/~/'e ~ DISTANCE FROM ~0· WATER WELL: TYPE . DEPTH ~ , BUILDING FOUNDATION. SAMPLE ~ , NEAREST NEAREST SEPTIC ~;~, SEEPAGE ///~l OTHER LOT LINE "--""- , SEWER LINE ~ , TANK , SYSTEM , CESSPOOL , SOURCES DISTANCES: DIAGRAM OF SYSTEM ~'^~-,:~-: GREATEI-',ANCHORAGE AREA m'OROUGH c..No. IIEALTil DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT ,AME OF APPUCA,T~'e~. ~'.e.. /C/. ?~ ,A~UNG AODRESS4///O J~/'Z'~ P,0NE RESIDENCE ADDRESS ~,,~,,~,K)?g'~LOCATION OF INSTALLATION ~':'. LEGAL DESCR,PT~0N Z,,, ~- 3 ~ ~z ~ ,~ ~ ~7~/',¢,:~ APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH~ PF=it~4~gl~ TEST RESULTS SEEPAGE PIT J,'"' , DRAIN FIELD , OTHER. TO BE INSTALLED BY ANTICIPATED DATE OF COMPLETION ~//~' BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT TH,S ,s To SERVE AS/]//. '-~f~'-~Y -~"'~ ,~"' , PERMIT TO INSTALL A AS DESCRIBED BELOW. SIZE OF UNIT TO ~E SERVED ~ ~' ~ /~I~ DIAGRAM OF SYSTEM I certify that 1 am familiar with the requirements of Greater Anchorage Area .Borough Orymance No. 28-68 and that the above described system is in accordance with said code. 327 EAGLE STRELT ANCHORAGE, ALASKA 99502 Performed For..~{{ ~n,n~ Legal Dcscription: Lot~._4~...~Aock .. This Form Re~orts a: Sozls Log CASE Date Performed Subdivision ..Percolation Test Depth Feet Was Ground Water Encountered?.. ~Fy If Yes, At What Depth_:7,~y~. ;~, ~,, Reading Date Gross Time Location Sketch Net Time Depth To H20 Net Drop Frcposed lnstal~Seepage Pit L~ ? Drain Field Depth Of Inlet ~'- ~' Depth To ~ottom O~ Pit Or Trenc~_~.~..__~ COMMENTS: Test Performed Data Certified MUNIClP~,LITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 34:3-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING HAA# ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot. block, subdivision, section, township, range) l-o 3,4 -z fl 6 tz _c/t) Location (address or directions) (b) Property owner /4 H F~' Mailing Address e/S, (c) Lending Institution Telephone: (home) Business SZ3o ~ ~ 5t.~ t~,~¢he, t~vq~ A~ Telephone Mailing Address (e) Mail the HAA to the following address: (or check here [3. if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family E! Number of bedrooms 3. 3 WATER SUPPLY Individual Well l~l Community cI Public n Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site n Public li~ Community cI Holding Tank [] Note: If community'well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certified by my seal affixed hereto and as of the validation date shown below, I verify that m~, investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein· I further verify that based on 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 IxJat'~l* 7'ec.A~;¢~! .C~r.,t'o,.~ Telephone Address /~/~c~ -~c~;~ '.C~;.. ~c~ot-~e' ~.~ Date ~ / I~ / ~ Engineer's Seal 6. DHHS APPROVAL Approved for '~ bedrooms by Approved ?~ ' Disapproved Terms of Conditional Approval 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 in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data befo re a ce rtificate is issued. The M unicipality of Anchorage is not responsible for erro rs or omissions in the professional engineer's work. 72-025(Re~.7/88) Back Page 2 of 2 MUNICIPALITY 0FANCHORAGE (MOA)', ~.' Health Authority Approval (H,~.) CHECKLIST- FEBRUARY 1984 343.4744 Legal Description: l-otc Well Log Present (Y/N) ~ C/Date Completed Pre - Total Depth _"~?~w Cased to~' ??' Depth of Grouting Static Water Level ~¢) ~ Pump Set At If A, B, C, D~E.C. Approved (Y/N) Yield ~. ¥ ~n,'~ Casing Height Above Ground I' Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of ~,bs~rption Field on LOt Sanitary Seal on Casing (Y/N) )" (~$/~ I/~,r~ Y/~o) Depression Around Wellhead (Y/N) N ; On Adjoining Lots H. ~. ~ O~'Adioinlng Lots N.~. To Nearest Public Sewer Line ~-~' To Nearest Public Sewer To Nearest Sewer Service Line on Lot .. ~' 'Z,5' ~ WaterSampleCollectedby fflnf/cy Fete ~uc~ ;Date Water Sample Test Resul~s ~c~y - ~ Cof,~ /(oo~ SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (WN) Depression over Tank (WN) No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: TO Water-Supply Well To Building Foundation To Property Line To Disposal Field To Water Main/Service Line ; for Temporary Holding Tank Permit (Y/H) To Stream. Pond. Lake or Major Drainage Course Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ',,Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results. of Last Adequacy'Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation To Water Main/Service Line ~ * * ' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area TyPe of system Design Length of Field Depth of Field ,Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test. To. Property Line To Existing or Abandoned System on ; On Adjoining Lots TO Cutback (if present) D. LIFT STATION /4, Date Installed "- size in~Gallo~s ' " '; ,,Pump On" Level at High Water' Alarm Level at' Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions ~' Manhole/Access (Y/N)' " ....'' ' "Pump'Off" Level at ' "" " ' "Vent (Y/N) · Pumping Cycles during Adeq{Jacy Test. Receipt NO. C~ Date of Payment Amount: * es in effect on the date of this *"Check Permitted Bedroom Ratir~ A~ainst HAA Request"" I certify that I have checked, ~erified, or conformed to all MOA inspection. ;, ~ . (Rev. 1~8) Back ........ · .... ~ "Receipt NO.' Waiver Fee: $ Date of Payment Page 2 of 2 Engineer's Seal .CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562.2343 ~'~ Collected ll~ 19 9~ I 12:50 ~ecelved MA~ 19 ~0 I 13:15 Pze~erve~ ulth :&S Client Acct [eq I Irmtzuct: 900511 [~b ~mpl ID; 3 ~t~tx: ~?g~ llto~able XD(O.IO) ~/l [PA 353.2 10 I ?eli! ~e~for~d See Special IrJtzuctlor~ Ab:~e UA-Un, variable MD. Mono Detected *' See Sample [ema~k~ Above DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) · Location (address or ~i.rections) Telephone: Home .~/~ 7, (~i ~.';A'j:)plicant is (checkone' ~' ' ' ...... :,,k. endmg Institution I-I; Owner/builder ; Buyer []; Other [] (explain); (d) . Lending Instauhon?*, Telephone : ' Address Business (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the Iollowing address: 2. TYPE OF RESIDENCE Multi-Family [] Other Number of Bedrooms 3. WATER SUPPLY - '-" ..; I~dividual Well ',Community [] Public Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. · 4.' SEWAGE DISPOSAL ;* ' ''.' :; Onsite r3 Pu lic Community [] Holding Tank [] .'/,: .. Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84l · 5. ENGINEERING FIRM PROVIDIt iNSPECTiONS, TESTS, FILE SEARCH, D.4~, AND INFORMATION .- 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 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. Na me of Firm ~'~ ' Telephone Date ~'7~ ' ' DHEP APPROVAL c~,~.~01'1"/o~./,4/-.. ~ ./~. "~,,-~,.t.,~ Date Approved for ..f.,h~- bedrooms by Ap~ed Disa~ved Conditional ~/"'''''~ Terms of Conditional Approval CAUTION The Muncipafity of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is Issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engif~eer's work. , Page 2 of 2 .' MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST o FEBRUARY 1984 264-4720 M'JNicIPAUTY OF ANCHoRAG~ DEPT. OF HE.,'J. TH & ENVIRO;'~d,~.NTAL PROTECTIoN Legal Description: WELL DATA Well Classification ~/~//'//~1''7~''' If A,~: C, D.E.C. Ap, proved (Y.~I) Well Log Present (Y~__ Date Completed ~//~-'~/d~.~/ (~g I~)Yield ~ Total Depth ~ ~Z% Cased ,o ~ ~; Depth of Grouting Static W~ter Level ~ ~/' , Pump ~t At C~sing Height Above Ground / S~nit~ ~1 on C~sing~N) Separation Distances from Well: .//~ To Septic/Holding T~nk on Lot ~ · ' ~ On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~/~ ; On Adjoining Lots To Nearest Public Sewer Line ~ ~ To Nearest Public ~wer CleanouVManhole /~ ~ To Nearest ~wer Sewice Line on Lot Water Sample Collected by ~ ~ ~' ~/[~ ; Date /-~'~ Water Sample Test Results Com nt, / SEPTIC/HOLDING TANK DATA Size No. of Compa~ments Air-tight Caps (Y/N) ~ ~ Foundation Cleanout (Y/N) ~ Date Last Pump~ ~ P~~~N) __~;for ~ Hold~ High-~er Alarm (Y/N) ~_ Tempora~ Holding Tank Permit (Y/N) Distances from Septic/Holding Ta~~ ' ~paration To Water-Supply Well ~ _ ~ F~ndation To Properly Line __ ~ T~p~~ To W;t~rr~ain/Se~ice ~ine ~ ~, Lake, or Major Drainage Comments ~'~ Page 1 of 2 72-026(11/S4) C. ABSORPTION FIELD DATA "'~ting in Absorption Strata Square Feet of Ab Depression over Field (Y/N) ~ Results of Last Adequacy Test ~.~ Separation Distance from Absorption Field: ~ To Water-Supply Well '"'~roperty Line To Building Foundation ...... ~ To Existing or Abandoned System on Lot ~ __ ;On Adjoining Lots ~ To Water Main/Service Line To Cutbank (if prese?~ Comments ~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test D. LIFT STATION "Pump On',, Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Check Permitted Bedroom Rating Against HAA Request ** I certify t hat I,,~ ch/~c k~d..~eri lied. or conformed to all MOA and HAA guidelines in effect on the date of this inspection· Signed __~'--'~ - ~t/z'"'~'" Date Company . /~ MOA No. Receipt No. '~ ~ J ~' Date of Payment ;;t-- Amount: $ /~' ~.~;~' Page 2 of 2 72-02~* (t t,84) unicipahtYof Anchorage P.O, BUX 196650 ANCHORAGE, ALASKA 99519-6650 (907) ~64-,4111 o TONY KNOWLES. MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES February 28, 1986 ' Alan Wten Alaska Environmental Control Services, Inc. 1200 West 33 Avenue, Suite B Anchorage, Alaska 99503 Subject: Lot 3A BLock 2 Campbell Heights Subdivision Waiver Request, WR86-024 D~ar Mr. Wien: I have re-evaluated your request for a waiver of the separation distance required between the well on the subject property and the sewer line in 67~venue. After reviewing the as-built for the sewer line it is evident that special construction was used to reduce the possibility of leakage from the pipe Joints. In light of this information,.a waiver has been granted to 28 feet in this case. This waiver removes the condition attached to the Health Authority Approval for this property dated February 26, 1986. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/lJw ALASKA I UIROIqI I TAL COFITROL SI RUICSS, linC. (~nqimrerin§ ~, ~nuironrnenlol Sluclie$ February 7, 1986 Municipality of Anchorage Department of Health & Human Services 825 L. Street Anchorage, Alaska 99501 Re: Lot 3A, Block 2, Campbell Heights MUI%'ICIPALITy OF ANCHoe,,~.,, DEPT. OF HEAL """~'; £NVIRO,'~,M~: .... TH & · "-~'~,'u. PROTECTION E B 181986. RECELV. ED The above referenced lot consists of a single family 3 bedroom residence with a private well and public sewage disposal. The well was drilled prior to 1970, according to inspection reports on file. No ~zell log exists for this well. The public sewer line ~ich services this lot was installed in 1976. It is located on the south property llne. On the north side of this lot, ~hich borders E. 67th Avenue, a sewer llne was installed under the street in 1979. This sewer main llne is approximately 28 feet from the subject properties yell. There is no publlc water available for this lot. Since the subject well was dril~and operating long before the public sewer was installed, we request that you grant a waiver of the separation distance from well to publlc sewer llne of 28 feet. If you have any questions, please contact this office at 561-5040. Sincerely, Alan Wlen Engineering Technician Approved by: 1200 LUest 33rci Auenu¢. Suite ~-/~nc~orage. Alasl~a 99503e(907) 5G1-5040 ALASKA eI/UIROIIllli ilTAL COllTROL SI RUICI S, IllC. ~nclinttrinq ~ EnuironmcnlaJ Sit'its DALE WADE 3646 E 67TH AVENUE ANCHORAGE ALAS KA 99502 SELLER-DALE ~ADE 02/07/86 DALE WADE 3646 E 67TH AVENUE ANCHORAGE ALASka. 99502 60042 LEGAL:CAHPSELL HEIGHTS BLOCK 2 LOT 3A FLOW TEST ON WELL WELL FLOW DATE-O1/30/86 A FLOW TEST WAS PERFORMED ON THE ~ELL. 330 GALLONS OF WATER WAS PUMPED AT A RATE OF 2.? GPM OVER A DURATION OF 2 HOURS. THE DRAWDOWN WAS 27.6 ' WITH A RECOVERY TIME OF 30 MINUTES AND THE STATIC WATER LEVEL WAS 65.1 FEET. THE WELL IS ADEQUATE FOR THIS 3 BEDROOM 1200 l.~¢$! 33r~ J~ucnue. SuiI¢ ~ ·/~nchoraq¢. J~Io$~a gcJ~03 * (~07) ~1-~040 ALASK~ ENVIRONIV~ENTAL CONTROL SERVIC" '~ INC. 1200 West ~3rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 ~" DATE RECEIVED INSPECTION APPOINTMENTS TIME TiME TIME DATE DATE :)ATE iNSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE ~UNIC1PALITY OF ANCHORAGE I~ DEPARTMENT OF HEALTH&ENVIRONMENTAL ENVmO,MENTACSAN TAT ONDW S ON OCT -t9 1 Tele~one ~4720 MAILING ADD~S~ 3. LENDING IN T TUTI N . PHONE STREET LODATION 6. TYPE OF RESIDENCE ~,~ SING LE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY ~,..~ INDIVIDUAL' COMMUNITY r-I PUBLIC UTILITY NUMBER O'F~SEDROOMS [] 0~*e [] Four [] [] Two [] Five ,r~ Three [] Six Other · ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that~date0 give well depth (attach log if available.) J~,,,/L,,~/ SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE·· .~_ PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SiDE FOR C~FFI~IAL USE ONLY 1. TYPE OF RESIDENCE NUMRER OF BEDROOMS ~__.SINGLE FAMILY r-I ONE ~ THREE [] FIVE [] OTHER f--I 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 I-'1 Holding Tank Size: If Tank is homemade SOILS RATING give d[menslons: TYPE OF TANK ~ MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/H°lding Tank IAbs°rpti°n Area ISewer Line INearest LOt Line Absorption Area to nearest Lot Line 5. COMMENTS ,~f PROVAL (letter m~st accompany certificate) . DATE 72.010(Rev, 6/79) L GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Time of Inspection Bate of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Maili.g Address: .Y. Pho.e: Mailing Address: No. of bedrooms B. Depth D. Bacterial Analysis ~ /f?o Installer 5. Type of facility to be inspected 6. Well Data:~ A. Type C. ConstPuction~~. 7. Sewage Disposal Systom:,?~x-. A. Znstalled /~ B. C. Septic Tank: 1. Size Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material Total length of lines 8. Distances: A. Well to: Septic tank , Absorption area , Sewer Lines , Nearest lot line _ , Other contamination B. Foundation to'septic tank , Absorption area C. Absorptfl~ar~ to nearest lot'itn~ EQ-034 (1/74) Page 1 of two pages 3330 GREATER ANCHORAGE AR:0, BOROUGH Department of Environmental Quality "C" St., Anchorage, Alaska 99503 274-4561 REQUEST FOR APPROVAL OF INDIVIDUAL SE~!ER & UATER FACILITIES l. Type of Inspection: CMRO VA ~X 2. Property Owner: Vernon G. Be1! Mailing Address :3646 East 67th Avenue 3. Name of Buyer: Thomas Payne Mailing Address: 8480 Jewell Lake Road 4. Name of. Lending Institution: Mailing Address: $23 W. 8th Ave. 5. [lame of Realtor or Agent: Bob York Mailing Address: 715' L Street 6. Legal Description: Location: FHA CONV Day Phone 344-4226 Day Phone Spokane ~fo~tgaBe Co. 349-2709 Phone 277-054:~ Phone 277-8669 dwelling 7. Type of Facility to be inspected: 8. }!ater Supply Type of Supply:' Public Utility If Individual, number of dwellings If Individual, depth of well 9. Sewage Disposal'System Type.of S~stem: Public Utility If Individual, date of installation No. Bdrms. $ Indi¥idual X presently .served 1 (tmknown) Individual ~on-site) X Dual Septic w/vent pipes 1971 P. age 2 of two p~ges'£ Re~.st for Approval of Individual ~er & Water Facilities L~egal Description Approved ~ Disapproved Date /'~d'..,.~ )proval tValid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DZAG~M OF SYSTEM I certify that the inf~nqna~ton contained in this request for approval to be a true and accurate represent~fon of the subJec[ sewer and water facilities and these facilities EQ-034 (1/74)