HomeMy WebLinkAboutELMORE #1 BLK 3 LT 18Onsite File Elmore #1 Block 3 Lot 18 #018-171-52 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211083 PID Number: 018-171-52 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Eric Bacon ABSORPTION FIELD Site Address ❑ ❑ Bed Deep Trench ©Wide Trench El Mound 14201 Elmore Road ❑ Other Phone Number of Bedrooms Soil Rating ITotal depth from original grade 4 1.2 GPD/SF 8.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot 4.0 Ft. 4.0 Ft. t ' Fill added above original grade Gravel length Township Range Section Ft. 50 Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES 5.0 Ft. N/A N/A Ft. Tol Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line 500 Ftz 1 N/A Ft. Well 104.5 109.3 I NA NA 25'+ TANK ®X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100'+ 100'+ ( NA NA GREER 1500 Gal. Material Number of compartments Lot Line 62.0 45.7 NA NA NA HDPE 2 Foundation 40.8 31.8 NA NA LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank Tank to Installer 3034 drainfield 3034 A+ Home Serivices Drainfield 3034 co/MT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation) 100 ft Inspection ection vt 12/3/2021 2 e 12/6/2021 Location and description 31a 12/7/2021 4th Corner of Concrete Entrance Pad ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date 4F Al .s TH -� •• v Steven �. Pannore Septic System ' `E- 81,t9 Approved Date Note: this approval does not include well permit requirements.��`'� rRPv nsrr»ii Rl DESIGN PARAMETERS �\ \vV \N PRIMARY/ RESERVE SEPTIC SYSTEM �. APPROXIMATE LOCATION iM N0. BEDROOM: 4(600 gpd) OF EXISTING DRAIN FIELD TANK SIZE: 1500g SERC RATE: <1 MPI SOIL RATING: 1.2 GPD/SF DECOMMISSIONED EXISTING 1250g SEPTIC TANK \ PER CODE AREA ROD: 500 SF INSTALLED NEW 1500g SEPTIC TANK PER CODE _ SYS. TYPE: WIDE TRENCH 4.0.0' ED WITH DCO AND DV MIN LENGTH: 50 LF "'� 10' TILITY EASEMENT USED: 50LFx5.0'Wx4.0' E.D., 8.0' TD TOTAL AREA: 500 SFELL (E) 3;j p RIVEWg1, \ I \�' ABBREVIATIONS � BS TH TEST HOLE o ` T1 (P) PROPOSED �' ren �V T2 A 4BR w (E) EXISTING ,�, C 1 \ DCO HOUSE CO CLEAN OUT N0. a o \ mi ss� (E) cn MT MONITOR TUBE NO. 1 "� \ \ M2 ``' TYP TYPICALLUT 18 } N t� To 2� B ' 96 0 I ? \ THS o — NEW UPGRADE DRAINFIELD 50LF x 5'W x 4.0'ED x 8.O'TDtt INSTALL CO AND MT AT EACH END \ \ NATRONA AVENU1 00 A B T1 50.1 72.7 T2 53.0 73.4 DCO 53.6 73.6 DV 54.8 73.9 C 1 68.0 79.1 M 1 65.5 76.5 C2 53.7 42.5 M2 1 54.9 41.0 NEW UPGRADE DRAINFIELD 50LF x 5'W x 4.0'ED x 8.O'TDtt INSTALL CO AND MT AT EACH END \ \ NATRONA AVENU1 00 W W Z o Wo Z Z m OD m �� 0 Z CONCRETE PAD O � W o9 o wZ Zw BS: 100.0 r � � U 101.fl'-fl-98.9 97 96.3-," 96.1 94. 90. 4.9 0.9 GP/GM 79.3 DRY 12/3/2021 NOTES: nA�+T(� (j LLC j (� oro`® RECORD DRAWING ONE EN V v C, LLC \h Date P.O. BOX 100217 ANCHORAGE, AK 99510 �cE °F A�'�s'11 12/17/2021 PHONE (907) 272-8218 FAX (907) 272-8211 /.,q�y�� Scale DRAWN BY:; 4 �r 1"=50' DRM �/ ......... ... .. r P.I.D. NO ERIC BACON ® ® B-171-52 v Steven R. Pannone ELMORE #1, BLOCK 3, LOT 18 ® PERMIT NO. 14201 ELMORE ROAD d�j•, CE 8149 coo OSP211083 PLAN ANCHORAGE, AK ���1�� pFESS10 � � Sheet 2 �,ata� O m AFA 2 C) ?E rn o o is: EMIORF --------- MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http:/Avww.muni.org/0nsite Permit Number: OSP211083 Work Type: Septic Upgrade Tax Code Number: 01817152000 Site Legal Address: ELMORE #1 BLK 3 LT 18 G:3036 Site Mailing Address: 14201 ELMORE RD, Anchorage Owner: BACON ERIC D & CAROL DALLEY Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 3/26/2021 3/26/2022 37299 1i Disposal Field R1 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 4 Co -A I - add yyA, -J-. fexv-y,�-�. — t"V� 1012G/21 Received By: Date: Issued By: Date: 3/2 4 .2D,2 9 MUNICIPALITY OF ANCHORAGE n. x i��r Community Development Department `" Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 018-171-52 Property owner(s) BACON ERIC & CAROL DALLEY Day phone Mailing address 5898 Raven Roost, Anchorage, AK 99516 Site address 14201 Elmore Road Legal description (Sub'd., Block & Lot) Elmore #1, Block 3, Lot 18 Legal description (Township, Range & Section) Lot Size 37299 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X Septic Tank ❑X Cels-ece�c h�s�u�lc 0S(oatto�r3- U a e Q (w/wo ADU) Duplex(D) ElElHolding Tank Renewal ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: fW 5 t 3 7 0 Waiver Fees: Date of Payment: 3�a5 a `� le251,�6-')( Date of Payment: Receipt Number: 657 qq6 4 6 Sga q6 Receipt Number: Permit No. d SPa 1108 3 Waiver No. Permit App_-'-'- Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com October 20, 2021 Subject: Elmore #1, Block 3, Lot 18 Septic System Upgrade Permit Request Design Narrative This is a design narrative for a permit to install an upgrade septic system to be issued for this property. The proposed system will serve an existing four bedroom (4) bedroom house. A diverter valve will be installed to facilitate the re -use of the existing field. This lot and the surrounding developed lots are served by private wells. Required separation distances to wells will be maintained. 1. Soils. One test hole was performed on the lot by PES and groundwater monitoring was performed in October of 2021. Groundwater was observed at a depth of 14.5' and bedrock was not encountered. Based on the results of the percolation tests and overall soils appearance; an application rate of 1.2 gallon/day/square feet was used for a conventional wastewater system in the area of the test hole. 2. Soil Absorption System Design. a. See Sheet 1 of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The lot slopes generally from northeast to southwest at approximately 5%-15%, with a slope of approximately 25%-25% downhill of the upgrade area. There are no steep slopes in the vicinity. 5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that the review is complete and that there are no further comments is received from MoA On -Site Department, the note will be removed and "Issued for Construction" drawings will be issued. The proposed installation will not affect the future development of this or the surrounding lots. Steven R. Pannone, P.E. Anchorage Mailing: P.O. Box 100217, Anchorage, AI( 99510-0217 Palmer 1\4ailing,: P.C. Box 1807, Palmer, AK 99045 Telephone: (107) 745-8200 FAX: (907) 745-5201 DESIGN PARAMETERS PRIMARY/ RESERVE SEPTIC SYSTEM �' 1 NO. BEDROOM: 4(600 gpd) I TANK SIZE: 1500g ' q I PERC RATE: <1 MPI SOIL RATING: 1.2 GPD/SF -,AREA RQD: 500 SF i \ SYS. TYPE: WIDE TRENCH 4.0.0' ED I \ 'MIN LENGTH: 50 LF I USE: 50LFx5.0 Wx4.0 E.D., 10.0' TD TOTAL AREA: 500 SF ABBREVIATIONS \ \ � \ APPROXIMATE LOCATION TH TEST HOLE OF EXISTING DRAIN FIELD I (P) PROPOSED z", \ (E) EXISTING \ DECOMMISSION EXISTING 1250g SEPTIC TANK\ -CO CLEAN OUT NO. PER CODE \ 2� SMT MONITOR TUBE NO. INSTALL 1500g SEPTIC TANK (P) PER CODE \ Z TYP TYPICAL WITH DCO AND DV �� 10' PTILITY EASEMENT -77 ~ "DR/vCW ),, WELL (E) \ biWI b \w 4BR~ HOUSE z �Z N HOESE � / () (a I s� \`\ w \ \ �\ LOT 18 \ TH_ 1 9 ,00 \z, I I \ UPGRADE DRAINFIELD (P) 50LF x 5'W x 4.0'ED x 10.0'TD -IW \ INSTALL CO AND MT AT EACH END \ � NATRONA AVE'NUE--:— � - WELL (E) Dote FOR CONSTRUCTION PAMOPC EMG SVC, LLCb�QF AL®�,1� P.O. BOX 100217 ANCHORAGE, AK 99510 fy 0/25/2021 PHONE (907) 272-8218 FAX (907) 272-8211 +�1 Scale DRAWN BY: DRM .... .. .... ... .... P_I.D. NO ERIC BACON . . oe8-ne-52 ELMORE 1, BLOCK 3, LOT 18 5'teven 'R: 'Ponnone' • 0 PERMIT N0. 14201 ELMORE ROAD �d�1iT CE 8149 \ / OSPXXXXXX PLAN. ANCHORAGE, AKk�FOPROfES510N��� 1 ShetOF 3 SPECIAL PROVISIONS TO SPECIFICATIONS 1. SCOPE AND SPECIFICATIONS: 1.1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MOA COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON-SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 1.2. CONTRACTED WORK WILL BE IN COMPLIANCE WITH MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) DIVISION 10 & DIVISION 20 AS APPROPRIATE. 1.3. SCOPE OF WORK: INSTALL NEW 1500g SEPTIC TANK, AND SOIL ABSORPTION SYSTEM. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 14.5 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SURROUNDING SOIL TEST HOLES. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 14.5 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY. 1.4. STRUCTURES DEPICTED ON THE SITE PLAN ARE BASED UPON ONE OF THE FOLLOWING: CONCEPTUAL PLOT PLAN DEVELOPED BY OWNER; A PLOT PLAN DEVELOPED BY RLS; OR A SURVEY AS -BUILT. 2. CONSTRUCTION SPECIFICATIONS: 2.1. ALL EXCAVATION DEPTHS ARE ADVISORY. THEY ARE TO BE VERIFIED AND MAY BE MODIFIED BY THE ENGINEER IF ACTUAL FIELD CONDITIONS VARY FROM THOSE USED TO PREPARE THE DESIGN 2.2. EXCAVATE THE DRAIN FIELD. BOTTOM OF EXCAVATION SHALL BE LEVEL AND SCARIFIED. RECORD ELEVATIONS AT BEGINNING, MIDDLE AND END OF TRENCH BOTTOM. CONSTRUCTION EQUIPMENT SHALL NOT OPERATE ON THE FLOOR OF THE EXCAVATION. ANY MATERIAL COMPACTED BY THE OPERATION OF THE CONSTRUCTION EQUIPMENT SHALL BE REMOVED AND REPLACED WITH UNCOMPACTED MATERIAL. 2.3. PLACE THE SEWER ROCK TO THE SPECIFIED DEPTHS. DO NOT CONTAMINATE SEWER ROCK WITH NATIVE MATERIAL OR SPOILS FROM EXCAVATION. LEVEL ROCK SURFACE TO 41" PRIOR TO INSTALLING THE PERFORATED PIPE. 2.4. ALL PIPE SHALL BE PVC CONFORMING TO ASTM D3034 OR ENGINEER APPROVED EQUAL. MINIMUM SOIL COVER SHALL BE 3 FEET OVER THE PIPE AND 4 FEET OVER THE SEPTIC TANK. ONE INCH OF INSULATION MAY BE SUBSTITUTED FOR 1 FOOT OF SOIL COVER. 2.5. ALL INSULATION SHALL BE 2" THICK DOW HI -40 INSULBOARD OR ENGINEER APPROVED EQUAL. CENTER INSULBOARD WIDTH OVER SEPTIC TANK OR LINES. 2.6. GEOTEXTILE SHALL BE MIRAFI 1405 OR ENGINEER APPROVED EQUAL. LAP ALL JOINTS 2 FEET MINIMUM. 2.7. COVER THE DISTRIBUTION PIPE WITH A MINIMUM OF 2" OF SEWER ROCK AND COVER WITH GEOTEXTILE BEFORE PLACING INSULATION AND BACKFILL. 2.8. MATERIAL USED AS FILL SHALL BE CLEAN AND FREE OF ORGANICS, TRASH AND CONSTRUCTION DEBRIS. 2.9. SLOPE ALL FILL MATERIAL TO DRAIN AT 2% MINIMUM SLOPE AND 3:1 MAXIMUM SLOPE AND IN SUCH A MANNER THAT PONDING AT OR NEAR THE DRAIN FIELD DOES NOT OCCUR. THE FILL SHALL BE LEFT AT 6" HIGHER THAN SHOWN TO ALLOW FOR SETTLEMENT. SEED SURFACE AFTER COMPLETING INSTALLATION AS PER MOA CODE. 2.10. RECORD THE FINISH GROUND ELEVATION OVER THE BEGINNING, MIDDLE AND END OF SYSTEM. 2.11. MAINTAIN 5' SEPARATION BETWEEN PERCOLATION HOLE AND THE DRAIN FIELD TRENCH. 2.12. EXPOSE. PUMP AND FILL LOG DISPOSAL CRIB OR CONCRETE TANK WITH SOIL TO ABANDON IAW WITH MOA CODE IF NEEDED. 3. CONTRACTOR RESPONSIBILITIES: 3.1. THE CONTRACTOR SHALL FAMILIARIZE THEMSELVES WITH THE SITE CONDITIONS AND LOCATIONS OF ALL LOT LINES, EASEMENTS, WELLS (E & P), SEPTIC SYSTEMS (E & P) AND SHALL MEET MINIMUM SEPARATION DISTANCES OR AS NOTED. 3.2. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 3.3. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED. ` 3.4. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES. 3.5. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. 3.6. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 3.7. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED -LINE AS -BUILT DRAWINGS TO THE ENGINEER. THE RED -LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND TANK ELEVATIONS. 3.8. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE WITH CLEAN -OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 4. THE CONTRACTOR SHALL SIGN THE FOLLOWING: I CERTIFY THAT ALL WORK WILL BE PERFORMED IN ACCORDANCE WITH THE APPROVED PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS -BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. CONTRACTOR: BY: TITLE: DATE: NOTES: FOR CONSTRUCTION DRAWN BY: DRM PLAN PATONE ENG SVC, LLC P.O. BOX 100217 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 ERIC BACON ELMORE #1, BLOCK 3, LOT 14201 ELMORE ROAD ANCHORAGE, AK of A/-gskk 18"Steven R. .Pannone' CE 8149 s 0FESSl�� Date 10/25/2021 Scale NTS P.I.D. NO TT9-171-52 PERMIT NO. DSPXXXXXX Sheet 2OF3 TEST HOLE 1 1 — 2 — 3 — 4 — 5 — 6 — 7 — 8 — 9 — 10 — 11 — 12 13 14 15 16 17 18 19 — 2.0 — ORGANICS AND ORGANIC SILTS POORLY GRADED GRAVEL WITH SAND AND SOME SILT DATE PERFORMED: 09/29/2021 SOILS LOG - PERCOLATION TEST SLOPE X TH i SITE PLAN \ I a \ \ THS_ 1 a �'co LOT 18 WAS GROUND WATER SLOPE ENCOUNTERED? N IF YES, AT WHAT TH DEPTH? -DRY x DEPTH TO WATER AFTER MONITORING? -14.5' DATE: 10/07/2021 COMMENTS: Test hole excavated by A+ HOME SERVICES PEROLATION RATE <1 (min/inch) PERC HOLE DIAMETER 6 inches TEST RUN BETWEEN 5 FT AND 6 FT PERFORMED BY: PES, I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. FOR CONSTRUCTION PAM0NE ENG SVC, C� LLC � '�pF q�00� Date P.O. BOX 100217 ANCHORAGE, AK 99510 �� qs�l� o/2s/2o2i PHONE (907) 272-8218 FAX (907) 272-8211 J Scole DRADW M BY: ...... ... .. .... �d� P.I.D.TNO ERIC BACON / e+8-171-52 ELMORE 1, BLOCK 3, LOT 18 Steven R: Pannon. e•0 0 PERMIT NO. �� CE 8149�fs� 14201 ELMORE ROAD ¢ c OSPXXXXXX SOILS LOG ANCHORAGE, AK�®�SS�ONP�E� sheet 3 OF 3 CLOCK WATER READING DATE TIME NET TIME LEVEL NET DROP READING i 8/29/202 2 TOO FAST TO ACCURATELY 3 MEASURE 4 5 6 PEROLATION RATE <1 (min/inch) PERC HOLE DIAMETER 6 inches TEST RUN BETWEEN 5 FT AND 6 FT PERFORMED BY: PES, I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. FOR CONSTRUCTION PAM0NE ENG SVC, C� LLC � '�pF q�00� Date P.O. BOX 100217 ANCHORAGE, AK 99510 �� qs�l� o/2s/2o2i PHONE (907) 272-8218 FAX (907) 272-8211 J Scole DRADW M BY: ...... ... .. .... �d� P.I.D.TNO ERIC BACON / e+8-171-52 ELMORE 1, BLOCK 3, LOT 18 Steven R: Pannon. e•0 0 PERMIT NO. �� CE 8149�fs� 14201 ELMORE ROAD ¢ c OSPXXXXXX SOILS LOG ANCHORAGE, AK�®�SS�ONP�E� sheet 3 OF 3 0=x0.002 Client: Pannone Engineering Services Project: Ellmore 41. Block 3, Lot 18 Date: October 4, 2021 Crow1herAssociates Particle Size Distribution Table (percent passing sieve size) Sample Source -- Sieve Size Percent Finer Percent Finer Percent Finer Percent Finer 3 inch 100 1-1/2 inch 100 3/4 inch 91 #4 72 #10 61 #40 25 #100 20 #200 20 0.02 mm Classification Silty Gravelly Sand (GM) Invoice 166 1632 Bellevue Circle l Anchorage. Alaska 99515 Telephone (907) 349-2195 / E mail: crowther@alaska. net \b— r NO co" o t .3i 0000 ROA D Department of Environmental Quality ' 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM L OCAT'DN L EGALDESCR,PT'ON SEPTIC TANK: DISTANCE INSIDE LENGTH MANUFACTURER INSIDE WIDTH MATERIAL LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID C APAC I T,Y~/~'.~'~-') GAL LON S. TILE DRAIN FIELD: D,STANCE FROM WELL /0~' FOUNDAT,ON--/--~ ~--NEAREST ~ TOTAL LENGTH LOT LINE/{~ OF LINES ABSORPTION AREA ~ ~) ~Q. FT, LEITH OF EACH LINE ~ I DEPTH: TOP OFTILE TO FINISH GRADE"~ / DEPTH OF FILTER MATERIAL BENEATH TILE ~ ~BOVE TILE ~ IN. TYP~>' ~ BUILDING FOUNDATION CESSPOOL APPROVED CONSTRUCTION NEAREST NEAREST LOT LINE , SEWER LINE , OTHER SOURCES DISAPPROVED REMARKS DEPTH . SEPTIC SEEPAGE , TANK , SYSTEM DISTANCE FROM: DISTANCES: SEWER LINE DEPTH: PIPE MATERIAL: ~ LOT SLOPE= REMARKS: DIAGRAM Of SYSTEM G.A.A.B. Fo~m EQ-032 WELL DRILLING P.O. BO~( 3442 ECB ANCHORAGE. Al( 99501 . PHONE 34'~-3792 NICIPALITY OF ANCI"IOI~AGE DEPT. OF HEALTH & ENVIRONMENTAL PCOTECTION MAR 2 5 1981 RECEIVED DR I LLER'S WELL L'OG SIZE ~, DEP'II"I /,4/~/ CA, SING DEFTH /~,z// GROUTING DEPITI A)/,,~" YIELD .-.,~.-*.,¢ STATIC HATER LEVEL ~7'..~. ' HON TESTED FORHATIONS ENCOUNTERED AND APPROPRIATE DEPTHS . / · To ~ ~ .~';,," ~ TOng'"' ~ / - / / // ~ , / -~'~'~ . TO . i -~ ......... DEF'RRTHEHT OF HEALTH FIND ENVIROI'~HENTFIL PROTECTION E:25 /'~' PERHIT WO, FIPPL I CFINT LOCFITION LEGAL 77216 LOT SIZE 42560 SQLIRRE FEET T"."F'E OF SOIL FiBSORBTIOfi S"r'STEH IS: TREfICH f'IA>4IHIJH HIJHF~ER OF BED'ROOHS =, 4 SOIL RATIHG (SQ FT,,"E:R)= 85 THE REQUIRED' SIZE OF THE SOIL RBSORPTIOhl S'.,'STEI'.I IS: 4 ---.-.~ G R Fi',.-' E L DEF'Tii= 4 [".,EPTI-i~--~,.-.c' LEFiI]TH~--~ ' --' THE LENGTH DIHENSIOfi IS THE LENGTH (Iii FEET> OF TilE TRENCH OR D,RAINFIELD. THE DEPTH OF A TREf,ICH OR PIT IS THE D'ISTFINCE BETWEEfi THE SURFFICE OF THE GROUHC, Fil.iD THE BOTTOH OF THE E>.~CAVATIOH (Iii FEET>. THERE IS rig SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE i'iINIHUH D,EPTH OF GRAVEL BETWEEhl THE OUTFALL PIPE FIN[:, THE BOTTOH OF THE E:,;CA'.,,'ATIOIi <Iii FEET>. REt;!I_I I ~:EB, 5EF'T 'r O TRI'iI--.' $ I ZE=., :1.25E" 6FiLLOI"-,I$ TI-4C~ < 2 > 'r I'-,ISF'EigT I 01'-4_c; RRE F-:EI2U T RED BACKFILLIHO OF FINY S"¢STEH WITHOIJT FINAL INSPECTION FIND APPROVAL B'¢ THIS DEPFIRTHENT WILL E;E SUB3ECT TO PROSECUTION. I'iltIIHUH DISTANCE _RETWEEN A WELL Ri'.iD Rf.l'¢ ON-SITE SEWAGE DISPOSFIL SYSTEH IS iF_JO FEET FOR Fi PRIVATE WELL OR 2EIFJ FEET FOR FI PUE:LIC WELL WELL LOGS FiRE REQUIRED FIND HUST BE RETURNED TO THE DEPFiRTHENT WITHIIq 20 DFI'¢S OF THE WELL COFIF'LETION. SPECIFICATIONS AND COHSTRUCTIOfi DIRGRFIl'IS FIRE FIVAILFIBLE TO INSURE PROPER I NSTALLAT I OiL F'ERI--i I T ',,-'RL I D I--'EiG: Oi'41-Z 'T'ERF~: FROI"I I $$1_1E I CERTIFY THHT f: I FIll FRHILIFIR WITH THE REQUIREHEfITS FOR ON-SITE SEWERS Ri'iD WELLS AS SET FORTH BY THE HUNICiPRLITY OF ANCHORAGE. 2: I WILL INSTRLL THE SN"STEfl If,m ACCORD, ANCE WITH THE CODES. 3.: I UNDERSTAN[:, THFIT THE ON-SITE SEWER SYSTEH HFIY REQUIRE ENLFIRGEHENT IF THE RESI[:,ENCE IS REHODELED TO IfiCLUDE I'iORE THAN 4 IBE[m.'ROOHS. FI/EcF~E I OFIHT J I ~."E:IJF1GRRTNER ,sS,,ED I~IUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO. TECTION Pouch 6-650, Am:hMege, Alaska 99502 276-222! SOILS LOG -- PERCOLATION TEST [] SOILS LOG I-1 PERCOLATION TEST DATE PERFORMED: ~v~Rf,! ~O IC~ O~O m,~ ~ SLOPE SITE PLAN ~ ;~ga( ~o~1 m 6 7' 8 9 10 11 12 13- ;O O Gross Net Depth to Net Reading Date Time Time Water Drop 15- 16- 17- 18- 19- 2O PERCOLATION RATE (m nuteslinch TEST RUN BETWEEN FT AND , FT CERTIFIED BY: /~en/;'~, -~rc'¥ E'/:~'b.Y..Z~DATE: M~ ~ 'D/~; '~"? MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 01817152000 1. GENERAL INFORMATION Complete legal description Elmore #1 B3 L18 Expiration Date: II �u�' Location (site address) 14201 Elmore Dr Current property owner(s) David Bacon Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) F-1 Duplex El Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well nX Private Septic n. Water Storage El Holding Tank E] Community Well 0 Community El Public Water System El Public Sewer n Waiver request for: Distance: mrs Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA# 05C U7 --C' Waiver 5. 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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 (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. Phone (907) 745-8200 Date 'Z.6 i2 /& 9F At 6. DSD SIGNATURE .... .. .. .... '......:.. System #1 Approved for bedrooms i� Leven . Pannone in CE 8149 System #2 Approved for bedrooms „ Disapproved Conditional approval for bedrooms, with the following stipulations: �g WATER A R z �� WA OG�\p,M J By: Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet o is Legal Description: Elmore #1 133 L18 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Judy 1977 Total depth 144 ft Cased to 144 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 12/712021 Static water level at beginning of test 98 ft. Comments B. TANK DATA Age of tank(s) new years Tank type/material HOPI/sep c Measured operating fluid level in septic tank new ❑ Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA Wide Trench Which system tested (date installed) 12/7/21 ❑ ALL standpipes present per record drawing Total measured depth from grade 8 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: new field COSA Checklist yellow sheet Parcel ID: 018-171-52 Structure served by this system 1 Well production at time of test 3.5 gpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes M No ❑ Coliform bacteria is Negative Nitrate 2.53 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by PES, LLC Date of Sample 12/7/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date new Results FV]Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 0 Yes Community Sewer Manhole/Cleanout > 100' Q Yes if No ft M Yes if No Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25' [D Yes if No Absorption Field on Lot > 100' M Yes if No ft Holding Tank > 100' F] Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' F71 Yes if No F71 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' [Z] Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F71 Yes if No ft Private Wells > 100' 0 Yes if No Water Main > 10' 0 Yes if No ft Community Wells > 200' n Yes if No Water Service Line > 10' [D Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' El Yes if No ft If absorption field is under driveway comment below Property Line > 10' n Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓V Yes if No ft Private Wells > 100' Water Service Line > 10' Q✓ Yes if No ft Community Wells > 200' Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 12/,�j COSA Checklist yellow sheet ft ft Yes if No ft �✓ Yes if No ft ,�� of ACS q fi LO ' v .(.'1 . ti Ste jen . Ponno c % CE 8149 ��- ' ' ' Application Date ' GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) · (a) Legal Description (include lot, block, subdivision, se~ction, township, range) ' Location (address or direct~ons)'.~':- ' MUNICIPALITY OF ANCHORAGE . 01 ~ ~ *~ ] ~'?~' ' DEPARTMENT OF HEALTH & HUMAN SERVICES . . ' DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL H~)'~- 4~:)c:~c~ g OF ON-SITE SEWER AND WATER FACILI~ ... (b) Prop ? Owne; ,~'~'-' /1~$/~'~ ": Telephone: Home (c) Lending Institution /~' ~ ~/~Z Telephone (d) Real ~tate Co~p;ny'~'~gent ' ~ '' Telephone Business (e) Mail the HAA to the followina address: or:. Check here Iffi. If hold for pick up. List contact person and day phone number below. , TYPE OF RESIDENCE Single-Family~J~ Number of Bedrooms WATER SUPPLY Individual Well~l~ Community 1'3 Public I-t Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ Public I-I Community f'l Holding Tank r'l Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 ~-o~s trey S~861 From ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal alfixed hereto and as of the validation date shown below, var fy that my nvest gat on 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. Name el Firm ~ Telephone ,~"~' Address /~D ~ ,~'~ /~"" ~T~ ~ ~ Date 6. DHHS APPROVAL ./(~)/__ '. / , Approved for bedroomsby Date7 ....... ~ p r'"~v'e~ ''~ I'"' 7 ~*~- Disap'~r;ve'~ ........... Conditio~'l'al ............................................. ; · Terms of Conditional Approval · : ..... CAUTION ..... = ': ............ · · .- The Municipality of Anchorage Deparlment of Health and Human Services (DHHS) issues Health Authority Approval.,. "' ' '~certificates based only upon the representations given in paragr~,ph $ abo~,e t~y an independent P~)fe~sional 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 satisf~ certain federal and state requirements. Employees of DHHS do not condUCt'inspections or anatyze data' ':~ before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. P.~ge 2 of, 2 ?2.~s may ~ e~ck I~UNNt~.NI'.kL' ~,~V~CE$ DIV~$1~I~UNICIPALITY OF ANCHORAGE' (MOA). HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Nnv ~ ? 't987 WELL DATA Well Classification 264-4744 Legal Description: If A, B, C, D.F-C. Approved (Y/N) Well Log Present{~N) Date Completed 7''/~]£?? Yield Total Depth /~4 Cased ,p /4~ Depth of Grouting ~/~ Static Water Level ~ ' ~O, ~ ' I Pump Set At ~ ~f~ Sanita~ ~at 0n'Casing ~) Depression Around Wellhead (Y~ ; On Adjoining Lots /~'$' ' ; On Adjoining Lots ,/4~"~ 7 To Nearest Public Sewer TO Nearest Sewer Service Line on Lot ~_, ~'ET}, ;Date Casing Height Above Ground Electrical Wiring in Conduit ~_.)N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ~'/)~E. -r" Comments (~ '/~- ~'" B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes~)N) Air-tight Caps ~)N) Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-SupPly Well ~ / TO Property,.Line , °,. '- -~ TO ~Vater Main/Service L~n~"_ :_. Course , ,~ Comments , _ ' : -. ~, .,.,. , .~,~, ." · . ~ ,' "- ~' .. ' ....'. :.. ~. ~;,,,,' .,~*' Page 1 of 2 ' ""a '"'° '~ ' Size /~'~'~ No. of Compartments Foundation Cleanout,A~N) Date Last Pumped /0'~'~'~<~ ;,or Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream. Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ' ~'~/~' To Water Main/Service Line Type of System Design Length of Field ,,%'""~-) Depth of Field ~ / Gravel Bed Thickness ,z/ I Standpipes Presentl~N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line ; On Adjoining Lots To Existing or Abandoned System on /0 !'~ TO Cutbank (if present) LIFT STATION ': ' ' ' Da~ ~'/~3- '"' "~ir~ensions ' ' ' Pump On Level at ~~,..,~'Pump Off" Level at . . High Water Alarm Level at ~_Vent (Y/N) _ . , Tested for .... P~ring AdeqUacy Test. Meets MOA Electrical Codes (Y/N), ' Comments *° Check Permitted Bedroom Rating Against HAA Request ** I certify that I have c~ecke~, veriflled, or conformed to all MOA and HAA guidelines n effect on the date of this inspection Signed ~/~-~ ,/,~'/,4~.---- Date Company J~'~"~'~'~<"" MOA No. Receipt No. c~- CT) 0 /. 0 ~,.,3,. ~ Date of Payment //'"/7 - 0C'7 Amount:$ / ~ d ~ Page 2 of 2 , ~, DATE RECEIVED ~*' · INSPECTION APPOINTMENTS 'liME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR,,, MUNICIPALITY OF ANCHORAGE ~RJNICIPALI';Y OF AN~O~GE {~ ENVIRONMENTAL. Tele~oneSANITATION~47~ DIVISION MAR 1 8 1981 Bi RECTIONS: Complete all pa~s o~ page I. Incomplete r~u~u will not be p~. ~ease allow ten {10) days for pr~sing. PROPERTY RESIDENT (11 different from ebon) PHONE 2. BUYER PHONE MAILING ADDRESS  PHONE MAILING ADDRESS 4. REALTOR/AGENT ~ PHONE 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OFRESIDENCE ~"~SING LE FAMILY NUMBER OF~BEDROOMS [] One [--I Four [] Two [] Five MULTIPLE FAMILY [~;]"-q'hree [] Six [] Other 7. WATER SUPPLY [~]'"~NDIVIDUAL' * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~"~DIVIDUAL/ON-SITE*° /~-~7 YEAR ON-SITE SYSTEM WAS INSTALLED. I-'1 PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Re~. 6/791 · ~-.- THiS SIDE FOR OFFICIAL USE ONLY - - 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS r-I SINGLE FAMILY I-'1 ONE I--] THREE I--1 FIVE [] OTHER I'-I MULTIPLE FAMILY [] TWO [] FOUR r-1 SIX 2. WATER SUPPLY ~ PERMIT NUMBER [] INDIVIDUAL *'* DEPTH OF WELL [] COMMUNITY . DATE DRILLED ... [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED . Connection Verified INSTALLER I--ISeptic Tank or [] Holding Tank Size: I ~_.~O If Tank is homemade SOILS RATING give dimensions: TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Sept,c/Hold,rig Tank IAbsorption Ace. ISewer Line J Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [~PAPPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79) Y Shnicipal[t-y Anchc rage 825 °'L" STREET ANCHORAGE, ALASKA 99501 (907) 264-4111 GEORGE M. SULLIVAN, ~IAYOR D£PAF, T~,fENT OF HEALTH AND ENVIRONMENTAL PROTECTION March 23, 1981 Kent Huey Star Route A Box 304-II Anchorage, Alaska 99507 Subject: Lot 18 Block 3 Elmore Subdivision Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: (3) (1) A well log submitted to this department for our review. The water analysis report needs to be delivered this office from the Chem Lab, 5633 B Street, for our review. to The septic tank pumped with a receipt submitted to this office. If there are any further questions, office at 264-4720. please call this Sincerely, Robert C. Pratt, R.S. Associate Specialist ncP/ljw cc: First National Bank of Anchorage % Jenny Hood Post Office Box 4-2090 Esther Bumgardner % Totem Realty 724 East 15th Avenue 99501 ~1: Time Date Insp ~,.MUHICIPALITY OF ANCHOrAGes, DJEPARTME: ~OF HEALTH AND ENVIRON,.1EN'~ ~. PROTECTION \ \f~ 82~'L Street, Anchorage, Alaska 99501 ~)\~ ~ ~%-/ 279-2511, ext. 224 or 225 ~ ~ Date Received: July 25,. 1977 Kennedy ~2: Time #3: Time Date Date Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: First National Bank of Anchorage Mailing Address: 811 36th Avenue 99503 Phone: 2. Property Owner: Jim Bumgardner Mailing Address: Star Route A Box 474-E 99507 PhoneR44-1933 3. Legal Description: Lot 18 Block 3 Elmore Subdivision 4: Single Family Residence: (x) Number of Bedrooms: Three Multiple Family Residence: ( ) Number of Bedrooms: Well System: Permit # Construction Individual well (x) Community/Public System ( ) Depth of Well Well Log on File Bacterial Analysis ( ) Se Sewage Disposal System: Permit # Septic Tank Size Absorption Area On-site System ~ Public Installed Installer Manufacturer Utility ( ) Soils Rate Material 7. Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line ti:o( ~'"~MUNICIPALITY OF ANCHORAGE~''~ :,.,~,,~:~,~y c,/.I.m.:~ .... Le Department of Health and Environmental ProtectiOn~L 825 L Street, Anchorage, Alaska 99501,',~°"" 279-2511, ext. 224, 225 ~quest for Approval of Individual Sewer and Water Facilities RECEIVED 1. Property Owner: ~ Mailing Address: ~O~/ ~/~ ~/ ~:~ ~. ~ Phone: ~ 2. Name of Buyer: '~12~'i7~ ~ ~ ~ ~-~ Mailing Address: ~~;-~ ~, Phone: Mailing Address: _~ -~ ~- ~-~ Phone: 4. Realtor/Agent: ~c~ ~ Mailing Address: Phone: 5.Legal Description: ~o+ / ~ /~~_ ~ Street Location: ~~' 6. Single Family Residence: (~'/Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: * Individual Well ~ Public/Community System ( ) If Individual Well, well depth If Community System, name of system 8. Sewage Disposal System: On-site System (~/' Public System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. 3/77 ~g~ ~o ~ Department of Itealth and Environmental Protection Request for Approval of Individual Sewer and Water Facilities i. Legal Description: Lot 18 Block 3 Elmore Subdivision Comments: Affadavit Attached: ( ) Letter Attached: ( ) Date: Department Worksheet: