HomeMy WebLinkAboutNORTH WOODS UNIT 3 BLK 14 LT 2Northwood Block 14 Lot 2 #051-732-30 ¢ Municipality of Anchorage Page of__ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: .~t ~c~ ~_\ {~ ~ ~_~ PlO Number: ~'~ - Name: ~ ~ ~.~ Wastewater System: ~ New ~pgrade Address: ~ ~,~ ~ ,~ ABSORPTION FIELD l No. of Bedrooms: ~eep Trench ~ Shallow Trench ~ Bed ~'Mound D Ot~er Phone: ~ ~_ ~ Total Depth from original grade: LEGAL DESCRIPTION SoilRating: . ~ GPD/Sq. Ft. ' ' ' · Depth to pipe bottom from ordinal grads: Gravel depth beneath pipe ~ ~ Ft. Township: ~ Range: Section: Fill added above original grade: Gravel length: ~.~ Number of lines: Distance between lines: WELL: C New ~ Upgrad~ Gravel width: ~ ~"~ Ft. ~ /~ Ft. Classification (Private, A,B,C): Total Dep~ ~ased To: Total absorption area: Pipe material: ~.~ Ft. Ft. //~ SQ. Ft. Driller: ~/~ '~te Drilled: Static Water Level:Ft, Installer:~¢~, ~ ~ Date~/installed:~ /~ , Yield: ...... t,Pd~p Set at: Casing ,~,~*~ov~ ~,ou..: TAN K ~.~'~'~-~'EPARATI O N DISTANCES ~eptic D Holding D S.T.E.P. To Septic Absorption LiE Holding ~ubllc/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~]~/~ ~ Number of Compa~ments: WaIF ~ ~ ~ ~ ~ Material: ~ SudaCewater ~/~ ~/~ ~h ~ '~ LIFT STATION Lot Size in gallons: Manufacturer: Location and Description:  Assumed Elevation: ENGINEER'S SEAL DePartment of Healt d Hum e ces approval - 72-013 (Rev. 9/91) MOA 25 Permit No. Page ( of :~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: /- ~-- ~'~'/z/ A/o,~-,-Ht,',/OOZ;, z./.,,//7-_7:z:~ PID No.: 72-013 A (1/93) * Permit No. Page ;~ .of ;~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: /-,~ ~'~'/~/A/~-~/oo~ ~,,~-~ ~ PID No.: 72-013 A (1/93) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT NUMBER:SW940124 DESIGN ENGINEER:DOUGLAS T. KENLEY, P.E. OWNER NAME:DAW ROY C & ELAINE S OWNER ADDRESS:23120 LIVE ALDER AVE CHUGIAK, AK 99567 PARCEL ID:05173230 PAGE 1 OF 1 (UPGRADE) PERMIT DATE ISSUED: 5/13/94 EXPIRATION DATE: 5/13/95 LEGAL DESCRIPTION: NORTH WOODS UNIT III BLK 14 L T 2 LOT SIZE: 26692 (SQ. FT.) NI/MBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: Douglas T. Kenley, P.E. HC01 Box 6034, Palmer, Alaska 99645 (907) 746-1073 April 27, 1994 Mr. Roy Daw 13120 Live Alder Road Chugiak, Alaska 99567 Lot 2, Block 14, Northwoods Subdivision III Chugiakr Alaska PERCOLATION TEST RESULTS AND GENERAL SITE INVESTIGATION REPORT On April 15, 1994, the above-referenced 26,689.5 square foot site was inspected in conjunction with soil perk tests being performed for application and approval for the installation of an on-site waste water disposal system. The site is located on Live Alder Road in Chugiak, Alaska. The system is being installed to replace an existing system serving a three-bedroom home. The existing 1,000 gallon septic tank will be re-used. The site is on the south side of Live Alder Road with a slope ranging from approximately 1% to 2% in the east-west direction and 1% to 2% in the south-north direction. The immediate area that has been selected for the waste water disposal system has an average slope of 1%. The failed bed system is in tile front yard. The proposed replacement site is behind the dwelling. It appears that there are no obstructions that would prevent surface water runoff. The property is served by a community well system. On-site observation and physical sllrvey show that there are no private or community water wells within a 100' radius of the proposed system. No surface water was observed at the time of the inspection. One percolation test was taken at the site to assess the adequacy of subsurface soils to accommodate the replacement on-site waste water disposal system. The results of this test are attached to this report. Mr. Roy Daw April 27, 1994 Page 2 Subsurface soils were found to be medium-dense, silty sand and gravel overlain by 12" of surface organics. The percolation rate for the test hole was found to be approximately 14 minutes per inch. If there should be any questions concerning the percolation rate or characteristics of the site~ please call me at (907) 746-1073. Sincerely, ~sg~a~q T. Ken~eY P~,E Permit No. Legal Description: Page '¥ of '/ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report /_ Z z~/~ /¥ /)Ja,e:T~v'oo,~,F ~/~,'V, PID No.: 72-013A(1/93) * 2'-0" MINIMUM MR. & MRS. ROY DAW Lot 2, BIk. 14 Northwood Subd~ Phase III Chuglak, Alaska PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST LEGAL DESCRIPTION: ~ ,~ 4;~/~' /x///V~,~r~-/¢c~.CTownship, Range, Section: ~,',~',~/ ~,,,v',,~ ¢'a~~' ~"...~ SLOPE 7 8 9 10 11 12 13 14 15 16 17- 18 19 2O SITE P LA N ~. / ~C+.~F- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE /-'//Z~ (minutes/inch) PERC HOLE DIAMETER ~ ~' TEST RUN BETWEEN ~$*~/ FT AND '~ FT PERFORMED SY: ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ~N T"iS D~. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DATE:  MUNICIPALITY OF ANCHORAGE /- `% DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE(~TION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME .... ~ UPGRADE MAI LING ADD~ ' -O~ LEGAL DESCRIPTION-- ,' ~ ~ Liq. cT~n gallons iF HOME.DE: inside leng~ Width Liquid depth ~ ~ DISTANCE TO; Well Dwelling ~ O ~ PERMIT NO. O Z ~ Manufacturer ~ --~ Material Liquid capacity in gallons No. of lines I Len,th linecz, Total length of ,i¢~8 TreBoh wiCh. ~ ~ ~ ~ Of each , Distance baleen lines ~ X ~' inches effec~e~b~r~n~ ~ ~ Top of tile to finish grade Material beneath tile ~ inches ~ Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area e Well DISTANOE TO: Building foundation Nearest lot line ~ Class Depth Driller Distance to lot line PERMIT ~ DISTANCE TO: Building foundation 8ewer line Septic tank Absorption area(s) OTHER iNSTALLER APPROVED DATE LEGAL i II Department of Health and Environmental Protection' 825 · ~" Street, Anchorage, AK. ~01 . 264-4720 Permit'S' ' ~©~ * HANDWRITTEN PERMIT * * * , !~k AND/OR ON-SITE SEWER PERMIT 7/3e~ '~' ~'-' ~'-- Mailing Address: Location: Phone Number: . .~,~ Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed.' ~ Holding Tank: Maximum Number of Bedrooms: <~ Soil Rating (sq. ft/br) The Requ~'red Size of the Soil Absorption System Is: DEPTH ,, , ~,~ LENGTH /7)~ ~-GRAVEL DEPTH ~o .'~' WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a 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. The gravel depth is the minimum depth of gravel between the outfall Pipe and the bottom of the excavation(in feet). · * REQUIRED SEPTIC(HOLDING) TANK SIZE = ,, /~3-~)~ GALLONS * * ?ermit applicant has the responsibility to inform this department during the Lnstallation inspections of any Wells adjacent to this property and the number )f residences that the well will serve. · * * TWO(2) INSPECTIONS ARE REQUIRED * * * ~ackfilling of any system without final inspection ~and approval by this departmeni ~ill be subject to prosecution. 4inimum distance between a well and any on-site sewage disposal system is 100 feel ~or a private well or 150 to 200 feet from a public well depending upon the type )f public well. Minimum distance from a private well to a private sewer line [s 25 feet and to a community sewer line is 75 feet. Well logs are required ~nd must be returned to this department within 30 days of the well completion. )ther requirements may apply. Specifications and construction diagrams are [vailable to insure proper installation. * * * PERMIT EXPIRES DECEMBER ~1~ 1 9 8 3 * * * I certify that: (!) I am familiar with the requirements for on-site sewers and wells as 'set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3,~rooms.~ S igne~: ,Al 0 ~ bi~, ~~ Is sued by: ,~C'~~~ Applic% ~/ Date: ~ -~,~ [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264~4720 SOILS LOG- PERCOLATION TEST PERFORMED FOR: -~--L~'/,~"/~/ L, ~'~<x.,~C~',.~ C~ DATE PERFORMED: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17, 18- 19 20 COMMENTS SLOPE SITE PLAN ~",~) ~'(~/~/--~,) WAS GROUND WATER S ENCOUNTERED? /~ L '0 P E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE J/* ~' (minutes/inch) TEST RUN BETWEEN "~"~ FT AND ~'~/~']'-' FT C ERTIFIEDBY: ~ /~ DATE: 72-008 (6/79) uepanmem et rfeattn and H uman.Se vices " . · -' ' ,'. Division of EnvironmentaIServices, :'..',' ..... ; On-Site Services Section 825 'L' Street Room 502 :: ,.,'. ~,,;;':.: · · '- " P.O. Box 196650 Anchorage. AK :99519-6650 ~ ~ , ,, · , :- . .... · · .,: : v ..:,- . ,'www.ci.anchorage.ak.us (907) 343-4744. ' .... 1. GENERAL INFORMATION Complete leg.~l desc~'i~)tidn ~f- 7_.. Location (site addres~s or directions) Current Property owner(s) Mailing address CERTIFICATE OF HEALTH AUTHORI r,.Y. APPROVAL,.; .... FOR A SINGLE: FAMILY,DWELLiNG . Expiration Date: tz'(~,r'Ch~l I/ ~."/ /~ ~ Dayphone Lending agency Mailing address Day phone Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class /~ Public Water System .Well TYPE OF WASTEWATER DISPOSAL: I"'1 Individual On-site [] Individual Holding Tank ~ Community On-site [] Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 01/00)' STATEMENT OF INSPECTION BY ENGINEER A~s certified by my seal affixed hereto and as'of the validati;3n' date shown below, I verify that my investigation based on procedures outlined in the Health At~thority Approval Guidelines for the Health Authority ~,pprova! .. application show that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my investigation and inspection, the on- site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address /-'//~'/'/0 Englneer's Printed Name P1,,-[.,.e ( ~-[, /n ~-¢,¢.~' DHHS SIGNATURE ~ Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: /1/- ' ~ $ ' ~"~'-- Original Certificate Date: Reissue Date: 75-025 (Rev. 01;00)° Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastawater Program 4700 South Bmgaw St. · P.O. Box 196650 Anchorage, AK 99519-6650 www.al.anchorage.ek.us (~07) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: /~4. ~- ~/~/ /~er4-h f&,/~L ~,//~ A. WELL DATA Well type Date completed Total depth ft. Data of test Static water level Well production J WATER ~P~-~ULTS: colonies/100 mi. Parcel ID:~ IfA, B, or C provide PWSID # ~ . Sanlta~, seal (Y/N) ..~ropedy protected (Y/N) Cased to ft. J Casinghalght (above ground) FROM WELL LOGJ AT INSPECTION J ft. ft. g.p.m, g.p.m. Nitrate mg./t. Other bacteria colonies/100 mi. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size ~ gal. Foundation deanout (Y/N) Data of pumping Number of C. ampartments ~ Depression over tank (Y/N) bJ Pumper 5 ~.. % Date installed Cleanouts (Y/N) High water alarm (Y/N) ~///,~ C. ABSORPTION FIELD DATA Data installed S-Z.4. -'% + Soil rating (g.p.d./ft2 or ~/bdrm) O, ~ Le.gth '7~f,O ft. ~ ~.V Systamtype [::).~co "~ ~'~-~.-~, ft. Gruel bel~ pipe ~ ~ ~ ff. Depression ever field ~ For ~ b~m~s N~ dep~ in. in. ~so~tion rata >=. ~D ff g.p.d. ~o Ify~, g~e date Totaldepth ~,0 ff. Eff. absorption area Itz4~ft2 Monitoring tube y Date of adequacy test ~/r,2 + iyo~ .Resutts (Pass/Fail) ... ~ a ~.. ~ I, u'+/, ,-/· .s-,~ Fluid depth in absorption field before test in. ~ , Water added gal. · V/o /,~'+. l,u' Elapsed Time: min. Final f~id dept~ Any rejuvenation treatment (past 12 mo.) (Y/N & type) 'Pump on" level at ~. ~. _ in. High water alarm level at. cymes teste · ' ? Septic tank/lift station on lit Absorption field on lot Public sewer main Sewer/septic service line E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: SEPARATION DISTANCES FRoM SEPTIC,~ TANK ON LOT TO: Building foundation Water main / Wells on adjacent lits Property line '~'~ Water service line /Do/-/- Absorption field ~ "~" Surface water /o c~ / -~ Building foundation /~ ~ Water main SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service line Curtain drain Surface water /P(2 ['~ Driveway, pafl(ing/vehicli storage Wells on adjacent lots ..~_c_IO° .'~ F. COMME~ITS G. ENGINEER'S CERTIFICATION I certify that I have determined through field IrrspectJons end review of Municipal records that the above systems em in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name HAA Fee $ Date of Payment Receipt Number (Rev. 12~00) Waiver Fee $ Data of Payment Receipt Number ~ )1~I /11:)~0 CESSPOOL~ ---'1 ~lJil t.1 PUMP~R~ PAGE DRIVER INVOICE DATE OF SERVICE TIME ~ Pump Septic Tank w/up to 3 Backwashes [-"1 Pump Holding Tank [--'1 Extra Time / Backwashes Required [-"] JR's recommends your next pumping in AUTO [] We will call or send a reminder at that time. · :,. ~ ,'t ~Standpipe(s),,,. needs repair; missing / crimped I broken / no caps ' "Ii ~ Only one standpipe on septic tank I'"-I Tank appears to be j'c"~? gallons I crib leach [] Last Pump # of gallons [] Other Quantity Description Amount "7.37,.) Gallons Pumped - Septic System $ cj Extra Time I Backwashes Other: Total Amount Due: $ ~..~'" Payment Terms: 30 days from invoice date - 1..-5% per month late fee $25 charge for all returned NSF checks MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage,'Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description -~'~ 7',2 Location (sit~'~ddreSS or directions) Property owner ~ ?, /.P~, ~:2 Day phone Mailing address .~.?/~ Lending agency Day phone Mailing address.. Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water" NOTE: 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 ';' ' o STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approva. I 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, Phone ~- ordinances, and regulations in effect on the date of this inspection. Name of Firm /P,~ ;, ~ -~ 7'- ~'P/~/'~),, Address //~'~'/ ~-~,~ -~,.~sf/', ~'~., ~/~ Engineer's signature ~ ~ ~c~7/ bedrooms. DHHS SIGNATURE ~ Approved for .~_ Disapproved. Conditional approval for Date ~-' Z~'7'~7/ bedrooms, with the following stipulations: Additional Comments Date 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 DH HS 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. 72-4Y25(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Parcel I.D. Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number /\./~ Date completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: al j~ /I Septic/holding tank on lot ,, AbsOrption field on lot ~ AT INSPECTJ~J~ MUNiCiPALiTY OF ANCHORAGE /// '"-ENVIRONMENTAL SERVICES DIVISION -~ 3 I 1994 .g.p.m. / R"I EIVED ; On adjacent lots ; On adjacent lots Public sewer main Sewer service line WATER SAM~LTS: Coliform Date of sample: Nitrate Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Cleanouts (Y/N) High water alarm (Y/N) .Tank size / Foundation cleanout (Y/N) /',~"$ Compartments Depression (Y/N) Alarm tested (Y/N) /t/./.~ Date of pumping /~..~., r- ~i/~/~Z Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot * On adjacent lots x, , , . Foundation TO pmpe~y line ~ ~ ' ~bsorption field / ~ ' Water main/se~ice line SuVaco wator/drainago 72-026 (3/93)°Front 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) f DIST~ LIFT STATION TO: SEPARATION Well on Io/t On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump ofl~.l-evel~af~ Sudace water D. ABSORPTION FIELD DATA Date inStalled ...~".,~.,z- ~¢/¢;¢¢/ Soil rating (GPD/FF) Length ~,~- Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width ~- / Gravel thickness //~/77~ ~: Cleanout present (Y/N) ~ ~/~.' Results (pass/fail) System type Total depth Depression over field (Y/N) for After test .~ If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots On adjacent lots ~//'/J Property line / ~/~ ~ To existing or abandoned system on lot Cutbank ,,c~/~ Water main/sen/ice line Surface water -'-1'¢*'--'~- Driveway, parking/vehicle storage area Curtain drain E. ENGINEER°S CERTIFICATION I cern'fy that I have checked, verified, or conformed to all MOA and HAA guideli~e:,~,in eff~f this inspection. H~ Fee $ ~0 ~ Waiver Fee $ Date of Payme~ ~-~/-~ Date of Payment Receipt Numar ~ 5~¢~ Receipt Number APPLIC " IT FILLS OUT UPPi R HAL/ ONi Y Property Owner. Baltic Builders ~, Phone Mailing Address P,0. BOX 4-a412 Ancho]~age~ Alaska zip Code ~500 688-2831 Buyer Address Zip Code Lending Institution Phone Address Zip Code Realty Co. & Agent Phone Address Zip Code Legal Description Lot 2 Block 14 Noz'thwoods, Phase Ill Street Location Live Alde~' Avenue Type of Residence [~ Single Family [] Multiple Family No. of Bedrooms ~ [] Other · Water Supply  Individual ATTACH WELL LOG. A w6tl log is required for all wells drilled since June 1975. Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utirity Sewer Disposal [~ Individual Year Individual Installed: 1¢)8~ [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: ~ . ~ b.._ MuNtcIPAL!TY et- /~,'~ ..... ~' ) APPROVED BEDROOM8 *GONDITIONg OF APPROVAL~ Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received ~ ~ ~ /~'-- / 7 ~ ~ Well to Tank Septic T~k Size ~'~ ~ ~ ALASKA el ull OFIlllerITAL COFITIqOL IF'lC. Noverrber 4, 1983 Nunicipality of Anchorage Department of Health &Environmental Protection 825 L. Street Anchorage, Ak. 99501 Re: Health Authority On October 31, 1983 our company inspected the sewer system located on Northwoods Phase III Block 14, Lot 2. All the standpipes are capped and protrude above ground level. The flnlshed grade looks good and surface dralnage is away from the septlc system. The well is a community well and did not require our inspection. According to Mr. Bruce Erickson of Alaska Department of Environmental Conservation, the community well ls up to standards at this date and no water sample ls required. MUNICIPALITY OF ANCFIORAGE F!EPT. OF ]//',LT!i $~ E NV l RO;'<M;:;"i] !',L FP, L~)T,~C HON RECEIVED 1200 LUcs! 33r~ Au¢nu¢, Suite ~ · Ancbrqe, Al~sb 99503 · {907) 276-1361