HomeMy WebLinkAboutELMORE #1 BLK 6 LT 4Imo e
lock
4
018-172
-10
Municipality of Anchorage
Development Services Department !:~
Building Safety Division
On-Site Water and Wastewater Program, 4700 Elmore St. ~
P.O. Box 196650 Anchorage, AK 99519-6650 Page
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: O<~l0 [!11 (cz.... RID Number: (_~ --- {~ ~ /~
Name:
~ ~0~ ~ ~f¢,'~ Wastewater System: ~ New ~Upgrade
Address:
~ ~ ~ ~~ ~ ABSORPTION FIELD
Phone: Number of Bedrooms: ~ Deep Trench ~ Shal~owTrench ~ Bed ~ Mound ~ Othe~
LEGAL DESCRIPTION Soil Rating: Total Depth from~
GPD/Ft2 Ft.
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gr~neath pipe:
Township: Range: Section: Fill added above origina~ grade: ~avel Length:
Well:~ New ~ Upgrade G~av~ width: Number of lines: Distance between lines:
orpt~ Ft. Ft.
Classification (Private, A, B, C):Total Depth: ~ Total aba Pipe Material:
Ft. Ft2
Driller: ~d~ Static Water Level:I : Date Installed:
~ GPM Pump ~et at: Uasing b 9ig~t Above Ground:
~t. ,,. TANK
SEPARATION DISTANCES D Septic B Holding ~ S.T.E.P. ~ Other:
TF~ Septic Absorption Lift Holding ~rivate Iv~nuf~c~urer: C~packy:
Tank Field Station Tank Sewer Line Gal.
Wel, '~ ''0 '~ ~ ~ ~~ Material:/ NumDer ct ~ompartments:
SuffaceWater [~'~ [¢~W LIFT STATION
~o~ ~,~ ~o t~ ~ o ~ , ~,~. ,v,~..~,~ .....
Foundation ~0 ~¢ ~0 I+ 'Fump on level at: wump oft ,eve, at: in. "iOn water alarm at:
~ ,n.~ Z~" ~ in.
Curtain Drain ~/~ ~/~ ~ ..~0 Pump Make & M°del '~ Electrical [nspecti°ns P ed°r m ed bY:
Remarks:
BENCH MARK
Locallon aha MescnptlOm
' Eo~Stamp
Inspections performed by: ~m~, Dates: 1st / ~%~~)X
Conditional Approval Date: t · ·, · · · ~, · ~..4 ·.
....
Reviewed and approved by: [ ~ Date: ~ ") 8'-'/i ~,T~ p;~;:~~
EXISTING 20' X 32' BED--n · .... // N ATA R 0 N A '~,"V E
......... /
/
I
~ ~ ~ ~M// '., ".: '"'", ' ".1 ' BLOCK 6 LOT 4
r-/,~ .... ~-~/~ / ,' '.. . .....~ ' ~ I
I
~ISTING LI~ ~ATION TO BE ~, / :, - ~ ' '{
I
I
ABANONED PER MOA CODE~ '~ ~ )"' ~ ' - -
~ ~ ~ ~ I., '~' .' I ~ I I
N~ 1,250~LLON~ ~',~ t. '~"~:'.' 7
~EP TANK x(~ '.':'.. '"" EX.NO HOUSE [
~ · . · ...... . . . ~ ~.
".., s,,, :.'.':.. 7'. :'.'""-./ "'
~ ~. · ....... ~ / _ ~ I
~ '~ "' ..... ' .... "'~ ~:/ ~ ' : I
_~ ~ :~ .....: ... ~ST~NC TANK TO eE PUaPED, ,l ~
:~ ~ ~ ' ' '.' C~USHED AND F~9 PE~ I~, ~ I ~:I
~. ~ ~, .,.:,. ...... .., ,, ~ ~ I ~,~ ~
I . ". , · ' " '
.; l
PROPER~ LINE~ ', 10' ~l~ ~EME~
~VAC~ LOT BLOCK 6, LOT ~
Septic Design Prepored for
~..""
ELMORE ~1 BLOCK 6, LOT 4 ~ / ~
~ ~ ~ TH
. 49__ ~
Anchorage, Alaska . ~~~
ANCHORAGE, ALASKA 99516 " ,,."~'~
Permit No. 0SPl11162 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 545-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 4, BLK 6 ELMORE S/D
PID No.' 018-172-10
V~ARK
F"'~O- --
C01
C02
TC01
®
TC01 TCO!~__ ¥~ ' ~ -~&/W
T~ ~'
DOUBLE CO ~.
/~ -' ~.L~.~ ~"--TANK WAS PUMPED AND CRUSHED
g..
ASBUILT
4~..." 49 T~H
MICHAEL N. ANDERSON.'"
SEPTIC SECTION
N.T.S.
Municipality of Anchorage
Community Development Department - Development Services Division
P.O. Box 196650 - Anchorage, Alaska 99519-6650- 4700 Elmore Road
Info and Help: (907) 343-$211
INSPECTION: Voice: (907) 343-8300 Fax (907) 249-7777
Inspection Report- ElecFin
E11-1596
Permit Type: Electrical
APPLICATION NO.
Master/Standalone Permit
NOtes:[his dUSton%r wanted a Phone Call before, but h'e'dbesnt leave a phone'numbe~ or '
name!! Requested by: NONE GIVEN NONE GIVEN stullergj@muni.org
Address Of prOjeCt:'
'4750 NATRONA AVE
Alteration
SChedule` Date~07/26/2011
Preference:AM
Inspection #: 139793
Parcel! ' 01817210000
Legal~ ' ELMOR'E #'1 BLK' 6 ET 4 G!3036
Des~:ription Of Work:' 'NO FOLDER: RUN CONDUIT UNDERGRO~JND FOR ELECTRIC'WIRING TO LIFT STATION
(JINNY ROSE DAY)
Contacts
CohtrJ~'~;(0r (907)360-9369 PROGRESSIVE ELECTRIC, LLC 1147 E DOWLING RD
Owner FARRIS GEORGE J & NANCY A
Inspector Comments:
j/
nspector: ., _~ z¢7,~-~
Permit Number:
Tax Code Number:
Work Type:
Permit Effective Dates:
Design Engineer:
Subdivision:
Site Legal Address:
Owner/Address:
On-Site Wastewater Disposal System Permit
OSP111162
01817210000
Septic
July 14, 2011
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Upgrade
to July 13, 2012
ANDERSON CONSTRUCTION & ENG'G
ELMORE #1
ELMORE#1 BLK 6 LT 4 G:3036
FARRIS GEORGE J & NANCY A
PO BOX 110292 ANCHORAGE AK 995110292
Site Mailing Address: 4750 NATRONA AVE, Anchorage Lot Size in Sq Ft: 36405
Total Bedrooms: 3
This permit is for the construction of:
N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
UNICIPAL]TY
Community Development Department !<~
Development Services Division ~
On-Site Water & Wastewater Program
Mayor Dan Sullivan
OF ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
Parcel I.D.
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Day phone
Number of Bedrooms
Property owner(s) L~.~O~¢~
Mailing address~
Site address
Legal description (Sub'd., Block & Lot) ,E:: I,.~. 0,-~
Legal description (Township, Range & Section)
Lot Size /~¢ ,,~D Sq. Ft.
THIS APPLICATION IS FOR: THIS APPLICATION IS AN:
([~ all that apply)
Absorption Field [] Initial []
Septic Tank ¢ Upgrade ~
Holding Tank [] Renewal []
Privy []
Private Well []
Water Storage []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
Permit No.
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11 )
Michael N. Anderson, P.E.
Civil/Structural Engineering & Construction
4661 Natrona Avenue
Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
July 11, 2011
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Elmore #1 Subd. Blk 6, Lot 4
To Whom it may concern:
This is a request for a tank replacement permit on the above referenced lot. The attached site plan has the
existing layout for the installation of a new STEP tank. The existing tank has started to fail and needs
replacing quickly. None of the neighboring properties will be impacted by this upgrade.
Please call me if you have any questions.
S inCer~~
Michael N. Anderson, P.E.
TANK DESIGN CRITERIA:
,:3 BDRM, 1000 GALLONS + STEP TANK = 1250 GALLONS
-SHOSHONI AVE-
--~-- ~--B------~,~RAB IT CREEK ..... d [, '' ' i I' '
/ l/ -- ~ . I F I I III
', · I ',,...-~ ii , .
\\ /
~' ~---~\,3 I[ ~ ,
I~ROI~ER'fY UNE . ,
/ \
- NAT R 0 NA__AVE- ,, -/-- ~
I \ / ~
r-~ / ~ I , tL~EXISTtNg HOUSE "
__ L___
- - '~1 ~- .....
EXISTINg TANK / II ~ <
m vaCAm ~OT [ II
""~ I
~ VACANT LOT ~\ I ]
-'---"- \".,I ..J J- '
- RIVE RTO N /AVE- ~ ' ---~ '
/ \
II ~ ·L-I:I-[/,~ II I
\\ II I I
I ' ~ _,~q II I ' I
II I I
........... ~,--- iL_ .....
J ........... __ .... J
-q ' ~ .... I
Septic Design Prepared for
GEORGE FARRIS ~,..~ ~- ...........
ELMORE #1 BLOCK 6, LOT 4 ." ~...-"
Anchorage, Alaska =...~;,.....~.~....~...:.: ........
Michael N. Anderson P.E DATE: 7/13/2011 EL N. ANDERSON:"~-
;~.Y'r~: No. CE 94~69
4~1 NAT~ONA AV~ D~AWN: D,~ ',;~.,¢~¢/ ...'"~_;~
345-3377 / FAX: 345-1391 SCALE: 1"=200' jj,.V%FEb~\
I
/
/ L~_
I ' EXISTtNg HOUSE
x
/ \ EXlSTIN W~:
~ i DIUS
L.___
,.
EXISTINg TANK // J
TO REI~IAIN VACANT LOT [ I
VACANT LOI
~, 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
PermitNumber: 'SL',/C~lOI2~ PIDNumber: 01~172.10
Name:
DouC, L,4 <J ~ R, A~ Wastewater System: D New ~ Upgrade
EO. SOX II~[o~j A~C~ A~, ~EII ABSORPTION FIELD
Phone:
3~-~ ~No, ofu~er~s: ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
LEGAL DESCRIPTIO N so. Rating: T~al Depth from original grade:
0.~ GPD/Sq ri. I To ~To~ oF ~a~.
Townshlp:]~ ~II Range: ~ ~II ~Uon~ Fill edd~ above ortginal~ grade: Ft Gravel length:~ FI.
WELL: ~I~T B New D Upgrade Gravel~ep;h: O.~E Fl Num~rof lines:~~lDi't"~"i~:~
Clarification (Private. A.B,C): Tolal Depth; ~s~ TO: Total absorplion area: Pi~ material:
Yield: I Pump Se~ at: I ~sing ~,ghl A~ Gr~M:
~PM, ' Ft., ,~. TANK EXISTIN~
SEPARATION DISTANCES ~sap~ ~ Ho~ ~ S.T.E.P.
Well ~ ~ J O I 12 O -- ~1 Material~o NC ~ E TE Numar of Compa.ments:
Sudace
w,~., ~1oo ~/o~ ~/oo -- ~/oo LIFT STATION
Line ~O 11 ~O -- ~ 720I ~REEE
"Pump on' level at: ~ 'Pump off' ~vel at: ~ High water atari
Foundation ~ ~ ~ -- O ~7" ~;t~ ToPI IIO" 8EZo~ ~PI ~BEZe~
mp Make & M~el ~ Electrical IM~tions ~o~ed by:
Remarks: ~v~l ~ = ~; ~" m~-~ BENCH MARK
/ / ~////~ /~- /, ~.~..........~,~4
Revtewed and approved by: · / / C Date: ~/~/
~ermitNo. 5tV q10125
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
LegalDescription: L u'*: B~ ELFtoRE S/b
.~..-~.attS~ Technical Services
~ermltNo...~k/~[OJ~.S' i"'"". 14530 Echo Street Page qT '
~fichorage, Alaska 99516
Municipality of Anchorage
of 3
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: ~. ~ I~ (o I::LMORE' -<;/D PID No.: OrE 172.1o
11¸
Ce
T24)13 A (2~1) MOA 25
ktFT
ql.O'
.............. ,U'_ -IOO.O~ ....
~o~trta~
COVER MATERIAL
IBo'rTc,~ oF ~.T. IF&~3, '
:
DIST. PiPE
~:E T,~E R ~RAvEI.
FILTER L4Nb
PAGE
1 OF
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 (UPGRADE) PERMIT
PERMIT NUMBER:SW910128
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:GRAY DOUGLAS F &
OWNER ADDRESS:P.O. BOX 113204
ANCHORAGE, ALASKA 99511
DATE ISSUED: 6/04/91
EXPIRATION DATE: 6/04/92
PARCEL ID:01817210
LEGAL DESCRIPTION: ELMORE #1 BLK 6 LT 4
LOT SIZE: 36405 (SQ. FT.)
NUMBER 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVEDBY:
ISSUED BY;:
DATE:
DATE:
TECHNICA. SERY:I. Efii
CIVIL & ENV~ONMENTAL ENGLNEER~NG * ENERGY CONSERVATION & ANALYSIS
TItEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-135S May 31, 1991
ANCHORAGE, ALASKA 99516 '
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to provide the required design narrative to accompany our permit
application to upgrade the wastewater disposal system on Lot s/,,, Block 6, Elmore S/D. Soils logs, a site
plan, design drawings and specifications are enclosed for your review.
During a recent adequacy test the existing lift station was found to be less than 100 feet from the.well
on this lot, and the soil absorption bed was found to be saturated with groundwater. The purpose of this
project is to relocate the lift station outside the 100 foot radius from the well and to construct a new
shallow bed with the proper separation from groundwater.
The soils tests conducted on May 21 showed groundwater to be at 7.5 feet in test hole #4, and the
percolation rate to be faster than I minute per inch. The design incorporates a two foot thick layer of filter
sand located between 1' and 3' in depth to provide a total vertical separation of 6 feet from the high water
table observed in late May. The size of the bed is based on 0.7 glXl/sq, ft., which for this 3 bedroom
residence requires (3 x 150)/0.7 = 643 square feet. This is best accomplished by a 20' x 33' soil
absorption bed as designed, which due to space considerations is preferable to a 15' wide bed.
The existing septic tank is a 1250 gallon single compaxu~ent concrete tank installed in 1968. It's
location 70 feet from the well was legal at the time of installation, and we propose to retain it in service,
after inspecting it's structural integrity at the time of the upgrade.
The existing lift station was Municipally approved at the time when it was installed in 1985, and it still
appears to be watertight and in good working condition. Because the lift station was improperly located at
the time of installation, we propose to relocate it outside the 100 foot radius from the well. At that time we
will .... have an opportunity to carefully inspect the condition of the tank and to verify that all components are
m good workln~ order.
The prese, nce.of a lift station enables us to use pressurized distribution of the septic tank effluent. The
proposed des:gn incorporates 32 3/16" dia holes in 1.25" diameter laterals which will pass .94 gpm each
with a residual pressure head of 5 feet for a total matching the pump output of 30 gpm. Two inch diameter
manifolds are used at each end of the laterals to ensure equal pressure throughout the distribution system.
The site plan identifies the locations of water and wastewater systems within 200 feet of the proposed
i~roject. The proposed project will have no impact on existing or proposed water supply and wastewater
disposal systems on adjoining lots, except for the requirement that new wells be 100 feet away. There will
be no known impact on reserved space/surface and subsurface, or on drainage patterns.
Sincerely,
Ted Moore, P.E.
31
LOT ~
NATRON A AVE'_
LoT '7
%4/E LL
4.'~4 r,.'
LOT 3
LOT u~ ~;L~
~BLoc~ G
3 BDRM
LOT 5'
Lc~T II
NOTE: 'I'B~: "[oPoCRArH'I OF 'tHIS LOT S'/.oPE~ 'TO THE
I~''~''....................d
· ¢ '~, ... ...
k"lattop Technlca] Bei'vlces
1453C~ Echo Street
· Anchorage, .Alaska 89516
LOT q. BLOCK
WELL t. SEPTIC SYSTEt4
~CALE: I ~-$O I NOTE. Tth$ IS riOT
2.~'
/
/
t~ Ab~ACE~T Ru~ /
PLAH
VIEW
PFC FRoPt
LIFT
SEC'r ~ o~! A- A
.T. 3
vER 4' ~
, I1,
}~lattop Technica! Seivlce~
14530 Echo Street
Anchorage, Alaska 99516
L~r, B~ EL~ORE -~/b
SDIL ABSORPTION BED
PLAN ¢ CRoss SECTioN
Flattop Technical Services
14530 Echo Street, Anchorage, AK 99516
Phone (907) 345-1355
Lot t'l, Block 6, Elmore S/D
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project includes relocation of an existing lift station outside the 100 foot radius
from the well and construction of shallow soil absorption bed system, together with all associated
plumbing.
1.2 Cons~xuction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All constzuction procedures and material specifications shall conform with Municipal and State
requirements.
1.3 All separation distances shall ~ in conformance with Municipal requirements, unless specifically
waived.
1.4 The contractor shall be responsible to obtain any necessary utility locates, and to work around ar~y
buried utilities.
2.0 Septic Tank:
2.1 The existing 1250 gallon single compartment concrete septic tank may be retained in service at it's
present location, provided it's structural integrity is verified by the engineer. If the tank is found to be
defective, it shall be properly abandoned and replaced with a new 1250 gallon two compartment tank
incorporating an integral lift station, to be located outside the 100 foot protective radius from the well.
2.2 A new septic tank, if required, shall be Municipally approved with two compartments, and shall
be set level on undisturbed soil. Each comprunnent shall be equipped with a watertight manhole cover and
a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial
type, rigid insulation.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste
line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. A
cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed
within 5 feet downstream of the septic tank. AIl waste lines shall be insulated with 2" rigid insulation
wherever buried less than 4 feet deep.
3.0 Lift station:
3.1 The existing municipally approved Greer lift station which is installed in a 42" dia CMP is to be
relocated outside the 100 foot setback from the well, at the approximate location shown on the site plan.
As the lift station is in the process of being relocated it shall be inspected by the engineer to verify it's
s .~.ctural integrity and watertight condition. In the event it is found to be defective, it shall be replaced
with a new Mumcipally approved "Orenco" lift station package.
,3:2 The. instalJ, er shal! verify fl)at the effluent pump and the on, off and alarm floats are in eood
wonang oroer ana operatmg as originally designed, and that all plumbing and wiring complie[wi~h code.
3.3 The hole resulting from the relocation of the lift station is to be filled with clean soil.
3.4 The pressure discharge line leading from the lift station to the soil absorption bed shall be 1.25"
diameter Schedule 40 PVC, sloped to drain back into the lift station between'pump cycles. The line shall
be .equipped with an appropriate, adaptor,,, to assure watertight inte..g~, ty' at the point of exit from the lift
stauon tank, and shall include a 1/4 diameter bleedback hole mszde the tank.
4.0 Soil absorption system:
4.1 The soil absorption system shall be constructed by excavating the peat and loam surficial soils to
create a 20' x 33' level bed surface in the native silty sandy gravel, at a depth of approximately 3 feet
below the original ground elevation in the vicinity of test hole/14.
4.2 A total of 2 feet of pit mn filter sand meeting Municipal specifications shall be placed in the
excavation to create a second level surface approximately 1' below original ground level.
4.3 Next a total of 9 inches of approved sewer gravel shall be placed on top of the filter sand. Sewer
gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve.
4.4 The 2" dia. manifolds and 1.25" dia. Schedule 40 PVC distribution pipes shall be buffed level in
the sewer gravel such that the pipe inverts are not less than 6" higher than the top of the filter sand. The
distribution laterals shall have 3/16" dikmeter holes drilled in the bottoms on 4' centers, with the hole
positions staggered by 2' in alternate rows.
4.5 Monitor tubes of 4" diameter shall be installed in the locations shown on the design drawings.
The portion of the monitor tube extending through the sewer gravel shall be perforated.
4.6 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches of rigid, burial type insulation is to be placed over the entire top surface of tile gravel, in
addition to the filter fabric. Fill slopes shall be no steeper than 3:1.
S.0 Inspections:
5.1 A total of at least 5 engineering inspections will be required during the course of the project: (1)
initial stakeout with the contractor to establish the location of the system and to discuss the plans,
.specifications and construction p.ro.c, edures, (2) after the native material has been excavated to expose the
infdtrative surface to ensure that tt is level and at the right elevation, and conforms with the soil test
information, O) after the sand filter material has been placed, (4) after the sewer gravel is in place and the
distribution pipes have been laid and connected up to the lift station, but prior to placement of insulation or
filter fabric, and (5) after final backfill and grading is complete. The septic tank requires one inspection
.afar it is exposed, and the lift station must be ins, .... pec ted beth after it is removed and after it is. re n os~__n__'rio ecl
In It s new location. These mspecuons may be incorporated wtth any of the above inspections.'
5.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
F/attop Technica! Services
14530 Echo Street
· ~.nchoracre, Alaslcc: 99516
MurdclpaTIt¥ o! Anchorage
DEPARTMENT OF H£AL.TH & HUMAN $£RV~CES
825 "L" Street. Anchorage. A~aska 99502-0650
SOILS LOG ~. PERCOLATION TEST
LEGALDE$CRIPTION: T R ~ Township, Range, Section: ~'C '~ "J"12/~ 1~=Jk/
SLOPE
I
4
5
6
7
8.
g-
10-
11
12
13
14
15-
16-
17-
18-
PT
St*4 REbl~tclt s~q~by LO4M
5M FINE SILTY S/il,lb
20.
II
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
D~i~th iD Water ~Jler_ ~. / /
~1or~ltorino? ..~.'7~'_ Dale: ,Yl3oFh
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER .
TEST RUN BETWEEN , FT AND . FT
COMMENTS
PEnFOR~EDBy: ~t~LA'ITOP TECl4. ~;V¢~ ,~?".~_~
ACCORDANCE WITH ALL IT*~TE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CtR.~V ~.A~ ~.iS TEST WAS PERFORMED ~N
Flattop Technlca! Services
· '*
Anchoraqe, Alaska 99516
Municipality ct Anchorage
825 "L" Street, Anchorane, Alaska 99502~n
~, ..... _ __~:_
ou~ Lu~ FERCOLATION TEST
LEGAL DESCRIPTION: 1' R S' Township, Range. Section: SE'C
pT SLOPE
II
III
IIII
IIII
Illl
I/I1
II
!11
.2, 4p
3-
4-
6
7 gao
8
9
10-
CLEAN SANb'I G~AVEt
CH, SILTY GR/tCEL
~N~ COBBLES
GP CL~N 5ANb~ ~RAV~L
WAS GROUND WATER
ENCOUNTERED~
IF YES. AT WHAT
DEPTH?
13-
14
'15
16
17'
18-
19-
20-
COMMENTS,
eeplhloWalerAfler_~, ~f I /
Monllorlng? ~ 7" Oale: ~
Reading Date Gross Net Depth to Net
Time Time Woter , Drop
q:ffz: 3o I~wv DRy
PERCOLATION RATE __ (mmules/inch)PERCHOLEDIAMETER , lO
TEST RUN BETWEEN . l~. ~- FT AND ~* FT
c£1111PY 1HA1 1HJS TEST WAS PERFORMED IN
ACC(~RDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; .-~ ~3'/ ~/'
72-008 (Rev. 4/85)
'Flaffop Technical Services
14530 Echo Street
Anchorac~e, Alaska 99518
Munlclpaqil¥ of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
DATE PERFORMED:
:_~121141
LEGAl. DESCRIPTION: T ~ ~' Township, Range, Section:
PT SLOPE
$~t R£bDIS~ $AN1>¥ LOA~
3~
5-
~E~ S~L~ P~C~Eb
PoC~ET~ or CLEA~ ~P
8 ~.U.
10,
11-
12-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
13-
14
15
16
17,
18-
19-
20-
COMMENTS
Oepth to Water After
taon[toring?
Reading Date Gross Nee Depth to Net
Time Time Water Drop
PERCOLATION RATE (m~nutes/inch) PERC HOLE DIAMETER .,.
TEST RUN BETWEEN _, FT AND FT
ecm'onu£oBy: FLATTop TOng, ~VC~ I--C-g-~ ~ CLIIllFY1HAl lHIS TEST WAS PERFORMED IN
ACCORD. ANCE WITH ALL STATE AND MUNICIPAL GUlDEL NES IN EFFECT ON THIS DATE.
72-008' (Rev. 4/85) DATE:
14530 Echo Street
Anchoracre, Alaska 99516
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
PERFORMED FOR: 5I~SEZ. BL~J~.NI~ /5~g~'J~y ~'J~/~y DATE PERFORMED:.
LEGALDE$CRIPTION: T ~ S' Township, Range, Section: ~E¢
SLOPE
3~
4
5
6
7
8
9-
10-
11
13
14
15
16
18-
19-
20-
COMMENTS .
PT
LoAM
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Oe~th Io Water AJier ~ ,q
Monitoring? ~ ~
P
E
Reading Date
~bb ~' 6~lt $/2~1qI
PERCOLATION RATE ~
TEST RUN BETWEEN . ~.-~
Gross
Time
Net
Time
Depth tO
Water
'20
t"/ vy
(m,nuteshnch) PERC HOLE DIAMETER .
FT AND · q FT
Net
Drop
P£n/~OBM£DDy: FLATTOp TE'/'R. ~/(~.~ I ~_~--~~_ CLII11FYIHAllHISTESTWASPERFORMEDiN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 {Rev. 4/85)
(~'N 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
NAME
MAILING ADDRESS
LOCATION
DISTANCE TO:
Manufacturer
Liq. capacity in gallons J IF HOMEMADE: Inside length
DISTANCE TO:I Well Dwelling
PHONE
Material
Width
NO. OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
PERMIT NO.
Manufacturer Material Liquid capacity in gallons
Well Foundation
DISTANCE TO: [ ~)!
No. of lines ~ ~ine Total length.o~ lines
Top of tile to finish grade ,, Material beneath ti.le,~
Length
Width Depth
inches
Oista~.~.~ b~tween lines
PERMIT NO.
Type of crib rib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
~tass Depth Driller Distance to lot line
Building foundation Septic tank
OTHER
DISTANCE TO:
PIPE MATERIALS
t
SOIL TEST RATING
)lion area
72-013 (Rev. 3178)
DATE LEGAL
PERM~IT NO:
DATE ISSUED:
APPLICANt:
ADDRESS:
CONTACT PHONE:
'MUN I C I P~--~L I TY OF ANCHORAGE
DEPARTMENT 0, HEALTH AND ENVIRONMENTAL I ~TECTION
825 L STREE~ ANCHORAGE~ AK 99501'
264-4720
ON--SITE SEWER
850509 ENGINEERED DESIGN
06/17/85
ARCTIC ENGINEERS JC/LOIS MORGAN
%1506 WEST 56 AVENUE
ANCHORAGEs.AK 99505
561-1545
LEGAL DESCRIP: SUBDIVISION: ELMORE LOT: 4 BLOCK:
SECTION: 54 TOWNSHIP: 12N RANGE: 5W
LOT SIZE: 56154 (SQ.FT. OR ACRES) ~
certify that:
1. I am familiar with the requirements for
2.
5.
on-site sewers and wells as set
forth 'by the Municipality of, Anchorage (MOA> and the StaGe of Alaska.
I will install the system in accordance with all MOA codes and regulations~
and in compliance with the design criteria of'this permit.
I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well~ wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot..
IF A
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE. OBTAINED;
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT;
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED ~J~/~ ................. DATE:
APPL I CANT~~ i~_A_i~~T-~----~ .....
LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
(2) AS-BUILTS
AND'(5) THE
ISSUED BY
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
PERCOLATION
TEST
DATE PERPORMED: 6 ' [ O ' % ~'
9 m
SLOPE
SITE PLAN
),.,.)
10-
11
13-
14-
15-
16
17
18
19
20
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES. AT WHAT
DEPTH?
P
E
Gross. ~ Net . Depth to Net
Reading Date Time (. k," ) Time C.'~.,~0 Water Drop
~ ,, ~.~ &O 16~s"
PERCOLATION RATE
TEST RUN BETWEEN
PERPORMED .¥:
72-008 (6/79)
O.-/tPAC, t"l"1' 06 OO-Ab',..,f-I rdc, D pi p6. '
· .~,..-~.,c,V'r'~.~,..I\ gq
iU
~)LAN VI
GO_AN ~
C- Ross.
~ (],oLT "~tH2 0
"
PYC.
AD^f'ToO.,
G.H A 11'4
c.V
Depth:
t~le
WELL:
lot ltne~'O~, nearest sewe~ line .
cesspool.. , other sou~'ces
' ' INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
Name ~D~DON 8E~- Mailing Add~ess
SEPTIC T~K: Dlstance from well Mate=tal
SEEPAGE SYSTEM: SeepaEe Pit: Nu~e~ of pits ~Outside dia~te~
width, . len~h , depth . lining ~te~ial ~ Dist~ce f~m
wen/ ' , ui di. fo= a tm. . nearesz
~sorption a~a (wall a~a) ~ sq.
TILE DRAIN FIELD: Distance f~om well . fo~dation ,, . hearst lot line
Total len~h of lines Numbe~ of lines Distance between lines T~nch
width Sn. Total effective ~so~ption a~ea sq.
Top of tile to finish ~ade Depth of filte~ ~te~ial beneath
in. ~ove tile
~~, ~epth./~', d[st~ce ~om bu[ld[n~ fo~da~[on~, aea~st . ~ segt[c tank.
DIAGRAM OF SYSTEM
DISTANCES:
DATE:
APPROVED~.
Health Authority
•
so. Bc,
•` .� •
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904 S A ZTYT
Certificate of On-Site Systems Approval
Parcel I.D. 018-172-10 Expiration Date: IF 7-
1. GENERAL INFORMATION
Complete legal description ELMORE#1 BLOCK 6 LOT 4 • .
Location (site address) 4750 NATRONA
RACHEL NOGACKIphone 296-8448
Current Property owner(s) Day
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community El
Public Water System ❑ Public Sewer ❑
WaiverNariance request for:
NONE Distance:
Receive,. by: Date:
C/57 (S/
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ -% Waiver Fee $
Date of Payment / t -lD /g Date of Payment
Receipt Number 2 z-5 i -- Receipt Number
COSA# (:) ._- ' ? %' 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.
Name of Firm C&M ENGINEERING Phone 854-5559
Address 20182 Tulwar
Engineer's Printed Name Charles Balzarini Date 7/22/18
:5;
6. DSD SIGNATURE 'Ai
4 9TH 00;
System#1 Approved for .3 bedrooms
,/•j' en.
System#2 Approved for bedrooms P' S ten.
r
Disapproved $��c�sf06:772'C3�-fs' • �
Conditional approval for bedrooms, with the following "�k. EEss�a�� �
•
c \`5,1 or
ae
ON-SITE SG)
WATER AND stt
WASTEWATER
PROGRAM `o:
s � p
By: �'�
Original Certificate Date: �1 7-
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 blue sheet r - .
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Elmore #1 Block 6 Lot 4 Parcel ID:018-172-10
A. WELL DATA
Well type private If A, B, or C provide PWSID# Well Log (Y/N) no
Date completed unk. Sanitary seal (Y/N) yes Wires properly protected (YIN)Yes
Total depth -1 q6 ft. Cased to +40 ft. Casing height(above ground) 18 in.
FROM WELL LOG AT INSPECTION
Date of test unk 7/16/2018
Static water level unk ft. 58 ft.
Well production unk g.p.m. +5.7 g.p.m.
WATER SAMPLE RESULTS:
Coliform Aia.
colonies/100 mL Nitrate I .)-mg/L
Arsenic ni'✓ ug/L Date of sample: 7/26/2018 Collected by: Charles Balzarini
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material step / steel Date installed 7/16/11
Tank size 1250 gal. Number of Compartments 3 Cleanouts (YIN) yes
Foundation cleanout(Y/N) Yes Depression over tank(Y/N) no High water alarm (Y/N) yes
Date of pumping 7i,,viq Pumper itawev1 T{-t (t.-9C Pczm f Th✓14-
C. ABSORPTION FIELD DATA
Date installed 6/19/91 Soil rating (g.p.d./ft2 or-ftlibdffn) 0.7 System type bed
Length 33 ft. Width 20 ft. Gravel below pipe 0.5 ft.
Total depth 4 ft. Eff. absorption area 660 ft2 Monitoring tube yes Depression over field no
Date of adequacy test 7/16/18 Results (Pass/Fail)PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 0 in.
Elapsed Time: 5 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date NA
D. LIFT STATION
Date installed 7/16/1i Size in gallons 1250 Manhole/Access (Y/N) yes
"Pump on" level at 30 in. "Pump off" level at 24 in. High water alarm level at 36 in.
Datum bottom Cycles tested 3 Meets alarm&circuit requirements?yes
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot +100 On adjacent lots +100
Absorption field on lot +100 On adjacent lots +100
Public sewer main+100 Public sewer manhole/cleanout +100
Sewer/septic service line +25 Holding tank +100
Animal containment areas +100 Manure/animal excrete storage areas +100
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation +10' Property line +5' Absorption field +5'
Water main +10' Water service line +10' Surface water +100'
Wells on adjacent lots+100'
ABSORPTION FIELD ON LOT TO:
Property line +10' Building foundation +10' Water main +10'
Water Service line+10' Surface water +100' Driveway, parking/vehicle storage +5'
Curtain drain +50' Wells on adjacent lots +100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION -16`~``\\
I certify that I have determined through field inspections and Aiiir�Q`\• ••• 1,
review of Municipal records that the above systems are in /c--).• .9 A
conformance with MOA COSA guidelines in effect on this date. * • TH ••
� • • • • • • •
Engineer's Printed Name Charles Balzarinl - /
Date 7/25/2018 1 • •
frl
CHARLES G BALZARINI
P • •
s'.• C - 3854�6//••• �`�cr/
Aar
lk\;PROFEssok�-�
COSA canary sheet_2-6-15.doc
MUNICIPALITY OF ANCHORAGE
Development Services Department �\ ' ' _ Phone: 90
On-Site Water 8,Wastewater Section - Fax: 90
Lift Station/Pump Vault
Maintenance Log
Owner Z�Gi� 41 c2 qct Si Street Address 'l 7 61-0 4��`�/ Y o Na.
Septic Tank:
-Sludge level C' inches -Pumping: required yes (o-
.� -Pumping completed
Lift station:
•Pump basket cleaned 6 o n• -Effluent filter cleaned 3 no
-Control floats cleaned et • -Proper float settings confirmed no
•Operation satisfactory ' no
Alarm System:
•Dedicated electrical alarm circuit yes no •Audible and visual alarm inside dwelling (
-Alarm system operation(satisfactory jnot satisfactory
Manhole Riser
•Ground water intrusion at riser to tank connection yes(no)
•Ground water intrusion around pipe penetrations yes(np.) -Weep hole functional
•Manhole lid: Functional(ye no Insulated (yes no Properly Secured(ye .
Other
•All manufacturer required inspections and maintenance completed no
Comments:
Qualified Maintenance Provider;
Technician e./(,r 2t l)/ Date of maintenance_
_
Company /2i T C- 41/2/-41g
2
Municipality of Anchorage
Development Services Department~'~UJ~'l
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
~.m uni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS 'APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. ~/5)/.`.--.
GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
COSA # / /
Expiration Date:
Day phone
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless othbrwise requeste~t,"COSA will be held by DSD for pickup.
NUMBER O.F 'BED~ooMS~i':
TYPE OF WATER'SUPPLY: Individual Well
Individual wate~ Storage []
Community Class __ Well []
Public Water System [] ·
TYPE OF WASTEWATER DISPOSAL:
IndiVidual On-site
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an' independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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. (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 Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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.
Name of Firm /~41 ~&-~/~
Address
Engineer's Printed Name
bedrooms.
DSD SIGNATURE
'~v'''''~ Approved for '~
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
(Rev. 11/05)
Municipality of Anchorage
:Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 995'19-6650
www.muni.org/onSite
(907) 343:7904
CERTI'FICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type _~~
Date completed { ~(P~/~
Total depth /~0 f.
If A, B, or C provide PWSID # _,.,.
Sanitary seal (Y/N) ~/
Cased to ~, ~ ff.
Well Log (Y/N)
Wires properly protected (Y/N) ~'
Casing height (above ground') /'~ in.
CJ
FROM WELL LOG
Date of test
Static water level / ft.
Well production / g.p.m.
WATER 8AMPLE RESULTS:
Coliform colonies/lO0 mL Nitrate I,~ mg/L
Arsenic: ug/L date of sample:
SEPTIC/HOLDING TANK DATA
Tank Type/Material
AT INSPECTION
ft-
~',t) ~- g.p.m.
Collected by: ~/~,
Date installed'
Cleanouts (Y/N)
High water alarm (Y/N) ~/'
Tank size, :/'~'gal., '" Number of Compartments
Fou.n,a~ation cleanout (Y/N~ ,~', Depression over tank (Y/N)
D~o ?'PumP!ng ._~~,~..~ Pumper ~(.
Total depth [ '~'li.~ '~ Eft. absorption area .O.~ Mo~itodr~tube
Fluid depth in absorption field before test ~) in. Water added
Elapsed Time: ~'t~t~0nin. Final fluid depth _~ in.
Any reiuvenation tmatn'~nt (pa~t '12 mo.) (Y/N 8, tyl~)
System type ~r'~C:~,
Grovel below pipe
Depression over field/V
For ~ bedrooms
New depth & in.
I
Absorption rate >= /~¢2'to' g.p.d.
If yes, give date
D. LIFT STATION ~
Date installed
"Pump on" level at ~ ~ in.
Datum .~' ~ ~
:E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at
Cycles tested
Manhole/Access (Y/N) ~/
High water alarm level at '~(.~
Meets alarm & cirCuit requirements?
in,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tar~k/lift station on lot
Absorption field on lot (
Public sewer main ~ ~/'/~
Sewer/septic service line
Animal containment areas ~'~O
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/Ht~I~NG TANK ON LOT TO:
Building foundation &'/~ { ~
Water main /~/,,'~,~= .
Wells on adjacent lots. ,/t~P ~'/'
Property line ~ ~
Water service line
Absorption field
Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line [~ f
Water Service line ~'~Pe I~L-
Curtain drain /k/./,~
Building foundation
Surface water / d
Wells on adjacent lots
Water main
Driveway, parking/vehicle storage.
· F; COMMENTS
~,.~,.~.,s c~..,.c^.,o. !, ._.-.~.~..o.t.~!.~,
I ced~ that I have dete~i~ ~r~gh field inspections and ~ .' .... ~ '~ ~I.
review of Municipal records that the above systems are in ~,~.: 4~~ ~ ~ C
~o~fo~ w, th MOA COSA ~/d~//~ ~ e~e~ o~ th~ d~t~. ~ '~~~~ ~
._ _ ,, ~.r~<~~~. ~
Engin~r's Print~ Name ~[I ~a ~J~ere~ ~,~ Mi~~"SON::~ ~
cos,. ~ee S ~ ~ ~ ~ ~ ~ ~. ~ e~ ~ w~e~ F~ S ~...
Date of Payment
Receipt Number
Date of Payment
ReceiPt Number
(Rev.~10)
Aarow Pump & Well Service LLC
(907)346-9355
Inspection Report
I ran a camera 56' down the well at 4750 Natrona Ave and did not find
any holes/cracks in the casing or leaking around the pitless.
~Beau Ma~~~
I
LOT 8
BLK 4
NATRONA AVENUE
LOT
BLK
5
6
i,i
._------ x-
SEPTIC
· VENT
(typ)
i
X
X
I,I
DJ
LL
:>_
Pr'
:fY
O
Q_
DJ
I-
x
/
X
BASIS
N89'46'50"E
~X--X X-
LOT 4
BLK 6
MH~'
SEPTIC
VENT
(typ)
OF BEARING
203.54' (203.71' R)
~X
/
GRAVEL
D/W
25.0'
X -X X--X
WOOD FENCE
55.5'
2,4-.5' EXISTING .~
HOUSE o.
36.0'
TEMP OR,AR~Y xF_ENCxE--~x~X~ X~ x%
10' UTILITY EASEMENT
WELL
ANCHORAGE RECORDING DISTRICT, ALASKA
ADD NO. 1
AS-BUILT OF:
ELMORE SUBDIVISION
LOT 4 BLK 6 PLAT P-635A
SURVEY CERTIFICATION: I, John L. Schuller, have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated thereon are within the property lines and no
enchroachments exist other that noted.
54.2'
52.8'
EXCLUSION NOTES: It is the owners responsibility to determine the
existence of any easements, covenants, or restrictions which do not
appear on the recorded subdivision plat. Under no circumstance should
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
WORK ORDER NUMBER: DATE: ISCA[E: E-MAIL:
JULY 20, 2011 / 1"=30'
1 1 -- 027 D.A~. BY: CHECKED BYt GRID NUMBER: BOOK/PAGE:
JLS / 3036 1101PEG
x x
LOT 5
BLK 6
NS9°46'30"E 203.54-' (203.71' R)
LOT 11
BLK 6
(~ = FND REBAR
O = FND IRON PIPE
~83~ Tat~ee~a S~ee~
A~cbora~e, Atas~a 99508
(90?) 227-~55 office
(90?) ~?~-~992 tax
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska g9619-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ('~\~ -- ~"'~ ~ ~\('~ HAA#
1. GENERAL INFORMATION
Completelegaldescription /--~,. ~ ~//'~'"~ '~'/'D
Location (site address or directions) /Y 7S0 Iq~z ~ron~.
e
Property owner p~,~ t'~r~ crr~ ~_~'~y Day phone ~ Yb'''gTa ?
Mailingaddress ?.0. Go~ 1l,~2o¥ ~ /~nc~or~,~. /~fi
Lending agency G-~/4 ¢ Day phone
.Mailingaddress ~/u/O I.z/. ~'~<~/or Rc~ ;. /qnc~e~,,9,~.
Agent ~'~(r¢/ ~'.~,'W'/~*'~ ~ F{'~/'/~< ?/-o/~ Dayphone ~?o"-~-?~'/
Address ~00 Col'c-logo,- -q/., ~*~or~v?~ 9~'0 ~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: I! community wastewater system, provide written confirmation from State ADEO
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that y
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system "o ~.,~ · .... · · - ·
· , '" ~,~, ~u~c[Iona! an(~ aoequate 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 Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection·
DHHS SIGNATURE
.~(.. Approved for
- Disapproved·
bedrooms.
Conditional approval for .
Additional Comments
bedrooms, with the following stipulations:
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.
Legal Descripti,on: /,P~ ~ 6[~'c~ b~/ ~/mo~ -,~ 'f Parcel I.D.
Municipality of Anchorage .
Department of Health & Human,,Servlces "
HEALTH AUTHORITy APPROVAL CHECKLIST ~w~ON
A. WELL DATA
Well type J~rl,~ ¢t~-¢
Log present (Y/N) I~
Total depth (OO ~
Sanitary seal (Y/N)
If A, B0 or C, attach ADEC letter. ADEC water system number
Date completed ~ l? o'~= Driller
Casedto. ~ ;oo' Caslngheight 15'"
Wires properly protected (Y/N)
FROM WELL LOG
RECEIVED
Date of test :
Static water level
Well flow -
Pump level
g.p.m.
SEPARATION DISTANCES FROM WELL T,.Oj
Septic/holdfng tank on lot
Absorption field on lot I~,1 ~
Public sewer main ~' ~' ~,
Public sewer service line /q' ~.
WATER SAMPLE
Coliform
Date of sample:
AT INSPECTION
~'/7/~/ ....
~' ~'; ~ g.p.m.
; On adjacent lots
; On adjacent lots
· Pul~lic sewer manhole/cleanout
( ~' ~"') Petroleum tank
Nitrate
~,.~ ,/'~' Other bacteri;~
Collected by: ~'/~.F/o~, ~"~"r~
SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alar .m (WN)
Dateofl~umping', ~/' ~? I~1 ·
SEPARATION DISTANCES FROM SEPTIC/~ ~C, LDlh~G TANK TO:
Tank size 12.,~¢~ ~1 Compartments
Foundation cleanout (Y/N) ~' Depression (Y/N)
Alarm t~ted (Y/N) ' -' A/. ,~.'
Well(s) on lot ~',,1' '
To property line
Surface water/drainage
Onadjacentlots '~' Ic`o' Foundation J) ~
Absorptionfield I~'2~ Watermain/serviceline ~' ~J"'
'~' (OOI /;';F ,'.'v'~' ~'.
'/2-O2~ (Re~. 3~91) Fm~t MOA 21
CONTINUED ON BACK PAGE
C. LIFT STATION
Installed 7 '
,.Date ~'
Size in gallons ..
Vent (Y/N)
High water a arm level
Well on lot 120
D. ABSORPTION FIELD DATA
Manhole/Access (Y/N)
"Pump on" level at ??" 0¢/o~, -/~/~ 2Pump off" level at
~, ~ ~/t Cycles tested
Meets MOA electrical codes (Y/N) )" '
SEPARATION DIS .T.A. NCE FROM LIFT STATION TO:
On adjacent lots . ~' too'
Date installed ~' ( Zo / ~ /
Length ~,.3 Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment !past 12 months)
Surface water
Soil rating O. ? ,.,~/p~'/~f ~- . System type EEC.(
. Gravel thickness O. 75' ' Total depth
Cleanouts present (Y/N)
Date of adequacy test /~.,4.
for
I "~"; ~lf yes,'give date ....
On adjacent lots ~. ('oo ' Pr0Pertyline
To existing ,or abandon~ed systerp on lot
Cutbank N,,4· Water main/service line
IIi
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot t o I
To building found.ati~n ..
On adjacent lots
Surface water ;> too '
Curtain drain
E. ENGINEER'S CERTIFICATION
bedrooms
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA a~nd HAA guidelines in effect,~ai,~ this inspection.
,
- ~......,...~.~.~
'.. '; , ~z~.: .. A ·
Signature ~1~ ~ '/~ ~= ~ ~? ~9~ f'~ ~e, ~.
Engineers Name ~ ~, ~ ~oo~
Date 5/~/~/ ~% c~ ~ ~ ~
· 1;~.~/,'... ...-
HM Fee $ ! :~ (~
Date of Payment ~) '~-~
Reoe ptNumber ·
72-02~ (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPAUTY OF ANCHORAGE
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
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot. block, subdivision, section, township, range)
Lot 4 Block 6 Elmor~ Subdivision
Location (address or directions)
/~750 Natrona Drive
Applicant Name J.C. HorKan Telephone: Home 345-162~, Business 263-6836
Applicant Address 4750 Natrona Drive, Anchorage
(b)
(c)
Applicant is (check one): Lending Institution 1"3; Owner/builder ~]; Buyer I-I; Other I'"1 (explain);
274-2551
(d) Lending Institution Alaska Hutual Telephone
Address 601 W 5th Ave, Anchorage
(e) Real Estate Company and Agent Fnr~-,,n- 'P~-npnr~-t~,..
Address 3000 A. Street, Anchora~;e
Telephone
(f) Mail the HAA to the following address:
Call Sue Dvorak-Fortune Proporteis, Will P/U
562-7653
TYPE OF RESIDENCE
Single-Family []~ Multi-Familyr'l
Number of Bedrooms (3) Three
Other
WATER SUPPLY
Individual Well [~( Community r-I Public r-I
Note: If community weII system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ Public I-I Community I'-I Holding Tank I-I
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
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As ce~a fled by my ~ eft, xed hereto a nd as of the validation date shown below, I verify that my investigation of this Health
Au,J'~cr~ A;prov'~ sbo~$ ~'.a! It',e on-si~e water supply and/or wastewater disposal system is safe, functional and adequate
fo~ lhe numbe~ of I:.e~;ccms and type of structure indicated herein. I further verify that based on the information obtained
from ~ Y, uruc~paSdl of Amchorage files and from my investigation and inspection, the on-site water supply and/or
waste.we*.er d~.po~.aJ ~fslem/s in compfianco with ell Municipal and State codes, ordinances, and regulations in effect on
t/ale of F~rm Telephone
This Department has the original
Engineers Seal on file.
Engineer's Seal
This office has received written confirmation from the engineer (Arctic Engineers Inc)
t~mt the conditions of July 1, 1985 have been met. Therefore, this property meets
Y~A require=ents.
' Ap~rc~,~ fcr ~:edrooms by Date
A~:~'ove~ .XX Die,pried Conditional
7/22/85
CAUTION
TI,e W2. uncif, aht/c~ ~-r,c~o~a;e Depadment of Health and Environmental Protection (DHEP) issues Health Authority
Ai~¢~aJ ce~f~ca'..e~ I:~,..e~ so~ely upon the representations given in paragraph 5 above by an independent professional
en$ir,~er re~,-.;e~ec ir, t~' e 5~a~e cf Ala~l,a The DHEP does this as a courtesy to purchasers of homes and their lending
in~u~or S in CrCt~' t5 Sa~S!! cert~,n fe~,:ral and state requirements. Employees of DHEP do not conduct inspections or
ama.'~'ze Cate bef~e a '~-~.~f,cafe is ,ssue~.. %he Municipality of Anchorage is not responsible for errors or omissions in the
Page 2 et 2
MUNICIPALITY OF ANCHORAGE
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
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ._~'.(~. ~'~'~,41~%,? Telephone: Home .~'¢'Y'.~''/~'~-- ~ Business ~
Applicant Address ¢-/?.~'_/~ /~/.,~?-~/,J~ ~'.'~/'~/'//~' /
(c) Applicant is (check one): Lending Institution r-I; Owner/builder~; Buyer n; Other I-I (explain);
Lending Institution
(d) Address
(e) Real Estate Company and Agent
Telephone
· (f) Mail t~e HAA to the roll.lng address'
TYPE OF RESIDENCE
Single-Family~ Multi-Familyl-I Ot~r¢.~
Number of Bedrooms ~ -* ~
WATER SUPPLY
Well~ Community r'l Public FI
Individual
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite/~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservabon
attesting to the legality and status,
Page I of 2 72-0~5 (ti 84~
the date of this inspection.
Name of Firm ~0~.
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORM/(TiON : *:
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
~,~/,-.J~"~"l~; /~...,~_ Telephone ,~'O"/'/RE~,.~-~
6, DHEP Appianu~:" . -
rovedfor ~'~ O) bedrooms by ~ (.0~'~-°ate
Approved Disapproved Conditional
Terms of Conditional Approval ~:::.~.~z e ~ l~-c..c.~r~.. ;T-~,~. ,,~--~) .~/4. 7'~ ~; 7-,
CAUTION
The Muncipality 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 engineer's work.
Page 2 of 2
A. WELL DATA
,~UNtCIPAUTY OF ANO''~ORAG~'
DEPT. OE HEALTH &
MUNICIPALITY OF ANCHORAGE (MO~iI~NVIRON~ENTAL pRoTECTION
HEALTH AUTHORITY APPROVAL (HAA) ~)~ ,~ r/ ~'
CHECKLIST - FEBRUARY 1984
:.-.:o E C t V £D
Legal Description: ~~1
Well Classification I ~z3 t Vt ~r) AL- If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) N Date Completed ,'., I q ~ ~ Yield
Total Depth t~(') · Cased to I t~) '
Static Water Level (~ ~ ·
Casing Height Above Ground I"~.
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Depth of Grouting ~t.
Pump Set At /'" qO
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) N
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line t,,,t./A
Cleanout/ManhoIe _~)./,~
Water Sample Collected by t.~3 ~"{
Water Sample Test Results ~; · ~-
"70'
; On Adjoining Lots
! O~) / ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
[,~ ~, (.~ -- .(~ t" A,'~ ;Date t_~.
Comments
SEPTIC/HOLDING TANK ~ ~ J~-
DATA
Date Installed I(~ ~ ~, Size ~ No. of Compartments
Standpipes (Y/N) ~ Air-tight%lCaps (Y/N) "~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~,~ Date Last Pumped -'~ '--"- __~; ~.~....~,_.~__..t./_~-
Pumping/Maintenance Contract on File (Y/N) ~/'*~,, ; for
Holding Tank High-Water Alarm (Y/N) Iq ~.~',- Temporary Holding Tank Permit (WN)
Separation Distances from Septic/Holding Tank:.~ ~,. 2-
To Water-Supply Well ~) ' ~ ' ~ *l TO Building Foundation
TO Property Line ¢'~ 0/'(' TO Disposal Field ~.-~
To Water Main/Service Line ~<:~0 ~'~- To Stream, Pond, Lake, or Major Drainage
Course I'A
comments .,~k.t"3c='-,,'.30,~C_w' "T' {~.-'"c~.-t' M 'I'A/,J~E' t~L)VV[ (31~) [,~- I,'t,- ~;~..._~-
Page I of 2
72-026{1t/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed tq (3 ¢~
Width of Field (/,~J ~/~,.J
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
TO Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway. Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ,.~ ~ ~
~plh of Field ' ~ '~
Grav~ ~ Thickn~ ~t ~
Standpi~ Print (WN)
Date of L~t Ad~uacy T~t
To Property Line [
TO Existing or Abandoned System on
; On Adjoining Lots ~"'O
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify t h~..e .~ ~, v/~d, or conformed Io all MOA and HAA guidelines in effect on the dale of this inspection.
compa.y MO^ No.
Date of Payment
Amount: $ ~
e
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3500 Tudor Road, Anchorage, Alaska 99507 279-8686
Date Received
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SFNER & WATER FACILITIES
FOR
· T~e of Facility to be Inspected, _ ~..,]
Number of Bedrooms~
'Bacterial Analysis
D. ~eepage Pit~ 1.
E. Disposal Field=
Total. Length of Lines ',~//,~
Distances:
A. Well To: Septic Tank ~t)~ , Absorption
Area /~9 9&, Sewer Lines
· ' '
B. Foundation to Sept1E tank/~'~ "~'Abso~tion A~a
C, Absorption Area to Nearest Lot Line ~ /
,~e~pJe.-t for Approval of ]~tdual Sewer & Water Facil[tte'~ Two
A~nroved ~ , approved Date
Approval Valid for One Year Fro~ Date Signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSI~',
I cert[fy that the Information contained tn this request for approval to be a t~ue
and accurate representation of the sub.tact sewer and water facilities located
Signed Date
2,
3.
u,.
5o
lla~. of person requesting approval
Numbe~.:of 3~edrooms In house
Waten ~nalysls:
b. Dete~£ent_ "' '
Well data:
b. Depth ./{gO
c. Castn[ Size
de
Distance from well to closest existing or proposed
1, ~ewer line
2, Septic tank__ ~! .
3. Seepage Area./~Z9" .
Cesspool'
5. Property Line. .~-~9/.
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainaEe ditch, etc.
Sewage disposal system.
a. Age of syste~ /~bY
b. Septic tank capacity in gallons ~_ff__~_~.
c. Name of septic tank manufactum~r ~/~.~.;¢~'--!
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type ~ _.~_~,f~~
1. Distance ,o p=ope~y line ,~0 ' to house fo~dation ~3/.
-e. ?erc~at Jo~ Test
f. Percolation Test performed by
Use the r~verse.side of this form to show diasram. Dia~ra~ should Jnclude
'.the foJ.l~o~ZnE infot-mation: ~operty lines;.well location, house location,
~i,t{c tank location, disposal area location, location of percolation test,
az~ d~ection of Ground slope.
9. Tf, e i,J.~,mt[on, on %his form Is true and correct to the best of my knowledEe.
Signature of Applicant Date SiGned
\
TO BE FILLED OUT BY HEALTH DEPART~.IENT PERSONNEL
~e above described sanitary facilities are hereby approved, sub)eot to the
..... ~llowin~ cond~Z~ons~
Conditions: ....
The above described sanitary facilities are disapproved rom the followinE
· Sz ~f &:~ '~ 3. . Date ~.[.[, ,'~1
CPJ: cw
