HomeMy WebLinkAboutROLLING HILLS ESTATES BLK D LT 12I olling Hill
Estates
Block b
Lot 12
#011-072-36
MUNICIPALITY OF ANCHORAGE
. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name / DISTANCES
'i~--.Ol\j ~OLi~. J~/'/NI2,~ff._ m-~l,,Jl~. ,~F ~ Tn SEPTIC ABSORPTION
AddressFROM~ TANK FIELD WELL
Phone(si Permit No. No, o~ Bedrooms / j p /~
~- '~i7~ ~g°~O~sc.,..,o.J ~ LOT LINE
~¢~L/N~ /¢ /~ FOUNDATION
Township, Range, Section
AS-BUiLT DIAGRAM (Show location of well, septic system, property hnes, foundahon,
~ ~ ~N, ~ ¢ ~ , -¢ ~ ~ Orweway, water bodies, etc.)
TAhKS IN
Material NO of Compadments
I
TY~ O~ ~Y~T~
I
~ TRENCH ~ BED '~ W. DRAIN ~ OTHER J · I
~pth to p~pe bottom from ~otal depth from odginal grade
FHI aO0eO a~ove od~mal ~ra0e Grail Oepth beneath p~pe
' FT ~ FT
Gravel length Gravel ~dth ~
Total abs~r~hon area Dist ..... bet .... lines ~ J A~I ( I
I
I
Instal,er ~ X ~ ~ ~ '~ R ~ Date Installed~ I I
WELLS ?
[1
Scale= ~"~
~ ~ /~J~ ~ Inspections PedormeO by:
/
Municipal and State guidelines in eflecl on this dat~ ~ ~
Hea Ih Depadmenl Approva . , ~ Date:
M Lt N I C .1; P A L.. ): T ¥ O F A tq C H 0 R A '.':~ E
De!:~aPtmerrl:. of Hea].tl"~ &. Humar"~ Servic(.~,s
:~,~, 1 ...... ~1.. I (t:~(~;.t ~, Ar'H:::hc)r' age ~ A l aska 9c~5() :1. ;]!;Zl.:3.....47;~:.R~
LIt:) (]] r' ade
Enq (neet' Des:[.gned
ANCHORAGE, AK 99~'~ "2
D a y F'h OWl e:
248 '"" :3 '.1, '7 8
l::'ar ,:::e 1 I d: 0 1 .t, ,,.-07.2.-3~,:~
l,,..ot, i ~::B,~:I,~ Subd:i.v:Lsior'~: ROI_L. ING F.IiLL.'S ES"FAT'IE l._ot,",
Sect ion: 3 ]'c.~v~nsh.1, p: I~,;:'.N RarH~:le: 4W
l....o'L S:Lze Z5080 (sq. {t,.. (::~r~
?,h,,..:-~ B~.,-,d r' oc)ms ~ Th :L s P e~" m :i. t: 3 'Tot, a 1 Cap ac i t. y: 3
Bl(3(::k~ D
L.~ ::? .. J":av6,:, a'l: ]. ea%'L "/:: comp~u" Lm6, r]ts. [)ep'l:,h 'Lo '1:.o1::) o f' s(::?l::F[',, i c:: 'l:.aFi k ( .::: 4.
"':tu:L ...... i'(, :i~ i:'i...,!i, i.i'~!:>~ ~.::t'l:,:ior~ cJV(:,,;,?P taFl[:: (c~),
INt:::OF:U'I D.H,,H,,S,, I:::'F~IOF:~ 'I'D 1S'I' & 2ND INSPECT':f. OIqS BY ENG:I:IqEIER~ IF'
:q.':ll.::J,~ '~,.~; ~ '~L~t,.!RS~ CAL.]..,, :543,-,.-q.~81 AND LEAVE A MESSAI}})E,
C.i:)NS'I'I::UJCT i::'ER IEt',JGINEERS A'T"I"ACHIED APPt::~OVED DE:SIGN,,
i'iI[[~::~ ~'J;,~d'd]:I iEXF:'IRES :[2/::]~;1/88 AND VAL. ID FOR A SIIqGL.,.E~ F'AM]:t....Y HOME,
:t.,, :[ am faro:(.liar~ NJ. th the r'equ:Lremen'Ls for on-..,.si'Le ~ewer's and wells as set
;(..~ Lh by -l:,he Muriic::[p¢~.].~'l:..y of Aric:horage (MC)A) al'id 'Lhe St. ate of AZaska~
2. I ~.~:L'f] insCa.1, i 'Lhe system in ac:c:(:r'.danc:e with all MOA code~ and Pegulat:i. ons,
.t¢'~::l ir't comp],iarlce with the des.1, gr'~ c:p;Ltepia of th:i.s per'm:(,(,,
:;!;,, I ~.,~:i,:l.]. adher'e to all MOA and State of Alaska r, equirement, s far' the set l:~ac:t,,:
¢!:;?L,:,.~ces f'rc)m any ex:kst, ir~g well, vgastewaCep disposat sy~t. em oP pub].ic
4, :1: under'stand 'l:.hat thSs permit is valLd f'of a max:i, mLtm
also undePst, ar'~d that 'Lhe capac:i'Ly (::)f 'Lhe to'Lal sys'Lem is B bedrooms anti
ar'w' enlar'ctemer'vL will r. equ:i,r'.e
S
Tobben Spurkland P.E.
IN
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
I0
11
12
13
14
15
16
17
18
19-
20-
COMMENTS
( EN (~! ~ _E,~E~'~S SEAL)
Municipality of Anchorage ,~;- ~ ~ · ~
DEPARTMENT OF HEALTH & HUMAN SERVICES -
SOILS LOG -- PERCOLATION TEST
LO r J~, ¢~ ~]~$ Township, Range, Section: ~ ¢~,p~ ~C 3
SLOPE SITE PLAN
~ILT
]~OTTO ¢4 ~ F-
L4oL
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth lo Water Alter
Monitoring?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE //~ (minutes/inch) PERC HOLE DIAMETER
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE:
GRE ?' R ANCHORAGE AREA BORf IGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99§03
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME /O/,.~ ,A/~.g..-(O/~v
LOCATION
MAILING ADDRESS "~'¢'~/'~ ~ ,~7..~/~¢Y/Z'~'/~/~:~ ¢''''' PHONE
/
LEGAL DESCRIPTION /~/¢'2, ~:'/,~.p /~g~//~/)/~,- /'~//~ ~---~'~'~"'~ r
SEPTIC TANK,
DISTANCE
FROM WELL ~4'4::2~-~- MANUFACTURER
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAP~N$.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES ~.
ABSORPTION AREA ~//~'~'
TOTAL LEN~.TH
FOUNDATION /~) -/- NEAREST LOT LINE /~ / OF LIN
DISTANCE BETWEEN LINES /~//~ TRENCH WIDTH~IN. fOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE ~'~ ~ ~"~¥
,,. DEPTH OF FILTER //
TOP OF TILE TO FINISH GRADE // MATERIAL BENEATH TILE~___IN. ABOVE TILE L~ IN.
DEPTH:
WELL:
TYPE~~))~'//~'j''~ CONSTRUCTION ~_P~I~)~0' DEPTH
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION__ LOT LINE__, SEWER LINE TANK , SYSTEM
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED__ REMARKS
DISTANCE FROM:
DISTANCES:
INSTALLED BY: ~'~/~'7':. ~7~
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
DIAGRAM OF SYSTEM
GREATER ANCHORAGE ArEA Borough
3330 "C" TELEPHON .~774'4561 ~,'~ 99503
STREET A N CHO/,~G E; 'A~.,~KA
SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT
PERMIT NO..
INSTALLATION LOCATION
INSTALLATION OF: SEPTIC TANK SEEPAGE PIT.- , DRAIN FIELD --, OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED ~ ~/~_/~ //~ ~//}/~--/~* _ ~ ~l /~
.... NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUB.JECT TO PROSECUTION.
SEPTIC TAN K S IZ E /J)//~7~ TYPE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDAT,ON TO SEEPAGE P,T E~P~~
AREA SIZE .- T,YPE
DIAGRAM OF SYSTEM
_, DRAIN FIELD
S EPTICTANK T O SE EPA GE PIT WALL
SEPTIC TANK .~/~, SEEPAGE PIT
WATER MAIN TO SEPTIC TANK/ /~
SEEPAGE P~T /g)~ /
ALSO CONSIDER Area WELLS.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRib CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT rEMOVABLE CAPS.
GRAVEL BACKPlLL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
Municipality of Anchorage
Development Services Department
Budding S~fe~y Div~lon
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak.us
(~o~) ~3-7~o4
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D.
011-072-36
1. GENERAL INFORMATION
Expiration Date:
Completelegaldescdption LOT 12, BLOCK D ROLLING HILLS ESTATES
· Location (site address or directions) 5219 STRAWBERRY RD ..
cun'ent Propan'y OWner(s)
Malli
*' Lending agency['
Mailing address
Real Estate Agent
Mailing address
MARK &: DAWN ERNST
'* 5219 5]RAWBERRY RD.
"Day phone
245-8001
Day phone-
ERICH HEINRICH,/PRUDENTLAL
4241 "B' ST. ANcHoRAGE~ AK 99503
Dayphone 273-7337
Unless otherWiSe requested, IlAR wfll be held by DSD for pickup. '- -
2. NUMBER OF BEDROOMS:
3..TYPE OF WATER SUPPLY:
Individual Well ........
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Communlty On-sita
Public Sewer
The Municipality of,anchorage DevelOPment Services Department (DSD) Issues Cerlificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an Independent pmfassional civil
engineer registered In the State of AJaska. Certificates of Health Authority Approval are required for the Vansfer
of rifle (except between spouses) for pmparUes sewed by a slngle family on-sita wastawater disposal and/or
water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the data of Issue for properties served by a private or Class C wall and may
be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a paflod 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 enors or omisslons In the
pr~fasslonal engineer's work.
Note: Alaska Water and Wastewater Consultants, In~. shali be paid $f~%033.33 ,at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed bereto and as of the validation date shown below, I vedfy that my
Invesligation, based on procedures outlined In the Health Authorliy Approval Guidelines for this applicalion,
shows that tho on-site water supply and/or wastewater disposal system Is(ere) safe, functional and adequate
for the number of bedronms and ~l~e of $tructum lndicated herein. I further verffy that besed on the
information obtained from the Munidpality of Anchoraga files and from my Investigation and Inspecffon, the
on-site water supply and/or wastewater disposal system Is(are) In compliance with all applicable Munldpal
and State codes, ordinances, and reguIsffons In effect at the time of Installation.
NameofFirm ALASKA WATER &: WASTE'WATER CONSULTANTS. INC. Phone, ,357-6179
Address 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE:. AK 99504 '' '
Engineer's P~nted Name JEFFREY A. OARNESS. P.E. Date
- Englneer's Comments: ~'" '* *'
In conducing Ih~ evaluaUon, AWWC, ~ a~tom~tod to pnwk~ a ffx~mugh, ~ ..
DSD Gulde#nes & RegulaUons. The mported results d,.,~,~d ff~e ~ of ~he
dlstances measured to reacflty ldenffflable features. The operatlonal lff~ of all wells and
oU~er person or pazly ls not auff~o~zed, nor w#l lt confer any legal right whatsoever.
~ Approved for . '~ bedrooms.
Disapproved.
Conditional approval for __
-' ' ~ =. WASTEWATER :'
bedrooms, with the fllowing stipulatiofl~_,: *. PROGRAM ·
·
--.~.,~ .......
'"',~,/),1)) ) ) ) ) ) )P~
Attachments:
HAA Checklist
SeptJc System Advisory
Well Flow Advtso~y
ManItenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date: .~- -~~- ~) I
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater I~:~'am
p.o. BOx 196850 Alldllxage. AK 99519-6650
HEALTH AUTHORITY APPROVAL CHECKLIST
LOT 12~ BLOCK D ROLLING H!LI~ ESTATES ParcellD: 011-072-36
If A, B. or C provide PWSlD~ N/A Well Log (Y/N) NO
1973 ? Sanfimy seal (Y/N) YES Wires properly protected (Y/N). YES
Date oftest
Stefi~ water level
Well production
WATER ~M~IPLE RESULTS:
Co~foml ~) c~o~es/100 mi.
Date of sample: 4/13/01 ac 4/20/01
B. SEP1~C/tlOLDINO TANK DATA
Tank 'r~rlal GREER//STEEL
Nitrate 0.500 mgJt.,
Tankslze 1250 gal. Number of Comperlmente 2
Foundation deanout (Y/N) YES* Depre~__._~n over tank (Y/N) NO
Date of pumping 3/30//01 Pumper
C. ABSORPTION FIELD DATA PBELOW GP~D~ o a~
Date Installed lO/11/~8 Soil rating ~ ~/t)dm~) 1 ;30
Length 46' lt. ~ 5 lt.
Total depth ~2' ea. It. Eft. ebs~pfion ama 396 It" Mo~lt~g ~be YES
Date of adequacy test 4-15-01 Results(Pass/Fell) PASS
Fluid depth In ebso~on field before test 19.5 In, Water added 564 gal.
Elapsed Time: 137 min. Final fiuld deplh 30 In. Abeo~on rote >-
Ally reJuv~tatJoll ~nt (past 12 mo.) (y/N & type) NONE KNOWN
** O DRAINPIPE LATERAL
Other becteda 0 colonies/100
AWWCt INC.
* IN LAUNDRY ROOM
Date Installed 10-11-88
High water alarm (Y/N) N/A
DENAU
System type SHAU.OW TRENCH
Gravel below pipe 3.0' fL
Depression over field NO
For 3 bedrooms
New del~ 31 ~5In.
450+ g.p.d.
ff y~s. gNe date -
Ca,ting height (above ground)
AT INSPECTION
4.-13-01
91 It.
4.56 g.p.m,
12'+ In.
A. WELL DATA
Well type
Date completed
Total depth 160 It,
Casecllo 40+ It.
FROM WELL LOG
O. UFT STATION
Date In~talied. Size In gallone ~a~(~NT~ _
'Pump on" level et In. 'Pump . High water elsnn level ~t In.
~ ~ Cy~se tested. Meets eZarm & drcuit requlrements'~
SEPARATION DISTANCES
SE.,pARATION DISTANCES FROM W;; I ON LOT TO:
Septic link/lift station on lot
AbeerptJon field on lot
Public sewer main
Sewer/septic sendce line
100'+
100'+
N/^
25'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots. 100'+
On adjacent lots. 100'+
Public sewer manhole/dsenout
Hoeing tank N/^
Building foundation 20'
Water main N/A
Wells on adjacent lots 100'+
SEPARATION OISTANCE FROM ABSORPTION RELD ON LOT TO:
Property line 40%
Water sewlce line 10'+
Bulldlng foundation 25'+
Surface water 100'+
Wells on edjecent lots. 100'+
N/A
Abeo~p~on field 10'+
Surface water 1 oo'+
50'+
Property line 10'+
Water service line 25'+
CutliIn drain NONE KNOWN
COMMENI~
Water main N/A
Driveway, parldng/vehlde storage
SYSTEM MUST BE FILLED TO 100~ IN ORDER TO ACHIEVE ABSORPTION RATE FOR 3 BEDROOMS
ENGINEER'S CERTIRCATION
I cerUfy that I have determined through field InspecUons end
review of Municipal records that the ebove systems are In
conformence with MOA HAA guidelines In effect on this date.
Englnee~ Prlntsd N/ame _JEFFREY A. GARNESS
Date ~
H~Fee$ %0~. O0
Dali of Payment 5' P- 0 I
Receipt Number S '7~
Waiver Fee $
Date of Payment
Receipt Number.
09:57 pAX 007 D62 648S
//
SUS¥~¥GBLL~EBIIEICAIIOff LEGGND
! Lot CornePs
200 Wes~ 34th~
Anchorage, Alaska 99503 (907) 274-7611
project J ~J~ J Date. IO'~-~
$caJe J" · ~' Drawn by
04-19-01 10:07 FROI4-CTE ENVIRONI,~NTAt. 5015501 T-480 P.02/03 F-588
~'~K. Environmental ~ervJces Inc.
CT&E
CT&E Ret. It
Client Name
Project Name~
Client Sample ID
Matrix
Ordered By
PWSID
Sample
1011821001
AK Water & Wastewatcr Consultants Inc.
Rollin~ Hills Est.
5219 .qtrawbeny Rd/LI2 BD
D'tinking Water
Client
Printed Date/Time 04/18/2001 10:34
Collected Date/Time 04/13/2001 9:38
Receh, ed DatUTlme 04/13/2001 13:30
Released
Waters Depar tm~nt=
Nitrate-N 0.500 U
PQL
Uniu Mcthud
Prep An~y~'is
Dnt~ Date Init
0.500 mg/L EPA 300.0 I 0 max 04/I 3/0l
SCL
H/.c~'obi ologzr Laborat:ozy
Total Coliform TNTC OB
col/I O0~L SMI8 9222B
04/13/01 KAP
04-Z4-01 18:06 FROI~-CTE ENVIRONMENTAL
.M~kK CTIE Environmental Services Inc,
5615301
T-$53 P.02/03 F-829
CT&E RtL#
Client Name
i'roJea Name/~
Client Sample ID
Matriz
Ordered By
PWSID
Sample P~mai'ks:
1011942001
AK Water & Wastewatcr Consultants lnc,
Rol]~o Hill Est
LI2 Blk D Roiling Hills Est
Drinking Watcr
Client PO~
Printed Date/'rlme 04,r24.r2001 11:13
Collected Dnte~Tlme 04/19/2001 16:00
Received Date.rrlme 04/19/2001 16:30
Technical Director Stephen C, Ede
Re~ul~
AOowable P~ep Aml~is
PQL Units M~ Limits I:hte Da~e Init
Nih-ate-N
0.500 U 0.500 mg/L EPA 300.0 10 max 04119/01
SCL
l/icz'obiolowff Laboz'atoz'y
Total Coliform 0
0 col/100mL SMI89222B
04119101 SKW
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
H~(~/) -~7~ ~,.~L~ NAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, to~,..,j~,~n~.., i ~r nge)
Location (address or directions)
(b) Property owner ~-.¢,,"vl ~..~[~.-
Mailing Address
(c) Lending Institution
Mailing Address
Telephone: (home) ~'"~ ~-'317ffBusiness
Telephone
(d) Real Estate Company and Agent
Address
Telephone ,~ ~ q "' ~..,(~-0 f
(e) Mail the HAA to the following address: (or check here~ if hold for pick up.)
List contact person and day phone number beloW: ,I' ·
2. TYPE OF RESIDENCE
Single-Family ~. Number of bedrooms -z~
3. WATER SUPPLY
Individual Well ~;~ Community
Public
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On'site,S' Public [] Community [] Holding Tank []
Note: It' community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that 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 ail Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm '~. ~ Telephone ~- '~ ~ ~/~
Address
Engineer's Seal
6. DHHS APPROVAL
Approved for ~
Approved ~
bedrooms by
Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88)Back Page 2 of 2
· ~, O~ (~_"~,~ Health Authority Approval (HAA) /~
r\~ ~ ~m;i~,Tj~ CHECKLIST - FEBRUARY 1984
~ ,' ~ 343-4744
. WELL DATA~ '
Well Classification ~ ~
Well Log Present (Y/N) N Date Completed
Total Depth ~(_e.O Cased to ~ Depth of Grouting
Static Water Level ~ ~--
Casing Height Above Gr~)und
Electrical Wiring in Conduit (Y/N) /
SEPARATION DISTANCES FROM'WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C, Approved (Y/N) _
~ Yield
Pump Set At ~' g~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) ~/'
; On Adjoining Lots /i~4~) '~
; On Adjoining Lots /t,)-~ '~'
To Nearest Public Sewer Line '/'"//~ TO Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ / ~
Water Sample Collected by ~ ..-,¢> ; Date '
Water Sample Test Results /' ? ~---- ~:~ ~.-/.,,, NJ)
Comments
B. SEPTIC/HOLDING TANK DATA
Datelnstalled lO/lo/~ Size ~O No: of Compartments 7'-'1,~,~
Standpipes(Y/N) "/"t~ ~ Air-tightCaps(Y/N) %// Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~%/ /Date Last Pumped
Pumping/Maintenance Contact on F e (Y/N) ~'/A- ;for /~//~
Holding Tank High-Water Alarm (Y/N) /~/~¥ Temporary Holding Tank Permit (Y/.N) ~(//'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments ,
///'~::) "~ To Building Foundation ~.O '
To Disposal Field
72-020 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorptio~ St~'ata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
TO Water-Supply Well
To Building Foundation
Lot ~' ~)
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway; Parking Area, or Vehicle Storage Area
Type of System Design ~
Length of Field ~/~
Depth of Field ~' ~ ~
Gravel Bed Thickness .~
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existin,cj. or Abandoned System on
50
; On Adjoining Lots
To Cutback (if present)
Comments
D. LIFT STATION ~ 0 ~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/IN)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date
MOA No.
Receipt NO.
Date of Payment
Amount: $
72-026 (Rev, 7/88) Back
Receipt No. ., ,
Waiver Fee: $
Date of Payment
Engineer's Seal
Page 2 of 2
DATE RECEIVED
¢.- *' INSPECTION APPOINTMENTS
TIME TIME TIME
~UNICIPAU~ CE ANCHORAGb
~UNIClPALITY OF ANCHORAGE DEPT. OF I:';ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~NVIRONMEN~,:.L
825 L Street - Anchorage, Alaska 99501
1 9 1980
ENVlRONBENTAb IANI~ATION DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on pege 1. Incomplete requests ~Jll not b~ processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER ~ I PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above} ' PHONE
MAILING ADDRESS
,3. LENDING IN~UT~g
5. LEGAL DESCRIPTION
TR EET LOCATI ON
6. TYPE OF RESIDENCE / NUMBER OF~BEDROOMS
~ One ~ Four
~'~ SINGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available,)
8. SEWAGE DISPOSAL SYSTEM
,J~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL ~A~e
4, DISTANCES Septic/Holding Tank wer Line Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
~APPROVEDFOR _,~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accomp~icate)
#1: Time
Date
Insp
,~--ZUNICIPALITY OF ANCHORAGE
DEPARTMEN', 3F HEALTH AND ENVIRONMENTA~ PROTECTION
825 'nL~ Street, Anchorage,
Alaska~
99501
~~^~j 264-4720
~ ~ ~ Date Received: October 7
1977
11:00 a.m. #2: Time #3: Time
10-12-77 Wednesday Date Date
Willis Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: First Federal Savings and Loan
Mailing Address: 803 West Northern Lights Blvd. Phone:274-6561
2. Property Owner: Bernard A./Loise E. Larson
Mailing Address: 5219 West Strawberry Road
Phone:264-6757/her work
3. Legal Description: Lot 12 Block D Rolling Hills Estates Subdivision
4: Single Family Residence: '(x)
Multiple Family Residence: ( )
Number of Bedrooms: Two
Number of Bedrooms:
Well System:
Permit ~
Construction
Individual well (x) Community/Public System ( )
Depth of Well 167' Well Log on File
~\~ .6L~P~ Bacterial Analysis
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System (x) Public Utility ( )
Installed~'--~f/~7~ Inet. tiler
~-q~- Soils Rate ~ gO~ .Material '~~
7. Distances: Well to Septic Tank
to Absorption Area
to Sewer Line
Nearest Lot line
Absorption Area
to Nearest Lot Line
,Page ~wo
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 12 Block D Rolling Hills Estates Subdivision
Affadavit Attached:
Approved: ~'~
Disapproved:
(¸)
Letter Attached: ( )
Date:
Date:
Department Worksheet:
1
2.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street, Anchorage, Alaska 99503 - 274-4561
REOUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
Type of Inspection: CMRO VA FHA CONV ~'
Property Owner: .'_~/7;~,~'.,~r. ~/'~-~J~ ~'~-
Mailing Address: ~/~ ~. ~t~.~1~~ Day Phone >~
Name of Buyer: ~/~ ~
Mailing Address:
4. Name of Lending Institution:
Mailing Address:
5. Name of Realtor or Agent:
Mailing Address:
Day Phone
/
Phone
Legal Description:
Location:
7. Type of Facility to be inspected:
8. Water Supply
Type of Supply:
Public Utility
No. Bdrms.
Individual
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System:
Public Utility
If Individual, date of installation
Individual (on-site)
EQ-037 (1/74)
. __~.~ Gk. ATER ANCHORAGE AREA BOROUG,.
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA
279-8686
99507
DATE RECEIVED:,x~<'~
INSPECT:
TIME:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
ADDRESS:
PHONE:
z. PROPERTY OWNER:~O~y~/ 0~'~5 'P.ONE:
4. TYPE FACILITY TO BE INSPECTED: ~,~~ ,STREET:
WELL DATA:
J
B. DEPTH /~ 7'
C. SIZE .~:/z
D.
CONSTRUCTION
E. BACTERIAL ANALYSIS~'~Cfo"Ir~_
SEWAGE DISPOSAL SYSTEM:
A. SEPTIC TAN-K (IF HOMEMADE, SHOW DIAGRAM ON BACK)
1. SIZE
2. AGE /
3. "ANUFACTURER
4. INSTALLER
APPROVAL REQUE_ FOR SEWER & WATER FACILIi S
PAGE TWO
B. SEEPAGE PIT
1. SIZE
2. LINING
C. DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B.
C.
D.
E.
F.
G. FOUNDATION TO SEEPAGE PIT.
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
WELL TO SEEPAGE PIT
WELL TO SEWER LINE
WELL TO PROPERTY LINE
WELL TO OTHER POSSIBLE CONTAMINATION
FOUNDATION TO SEPTIC TANK
DA,E: .. __
APPROVAL LVALID FOR ONE YEAR FRO" DATE SI.GNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
G~ATER ANCHORAGE AREA BOROUG~
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
INSPECT: ~-~Sg:r~" ~
TIME: ~'~0
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER AND WATER FACILITIES
FOR
APPROVAL REQUESTED BY:
ADDRESS:
PHONE:
,)c' ~',,'' /?.
PROPERTY OWNER: ,
LEGAL DESCRIPTION: ,:,,?;'-/%
TYPE FACILITY TO BE INSPECTED: x.-'/'O//~, . ,wm~:4~"' '
NUMBER OF BEDROOMS: -.)
5. WELL DATA:
' A. TYPE
B. DEPTH
C. SIZE
D. CONSTRUCTION
STREET:"''
.W1 ''~ :.
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM:
A. SEPTIC TAN~ (I~ ~OMEMADE, SHO~ DIAGRAM ON ~AC~)
~. SiZE
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL REQUEST FOR SEWER & WATER FACILITIk~
PAGE TWO
B. SEEPAGE PIT
1, SIZE
2. LINING
C. DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
7. REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
Bo
C.
D.
E.
F.
G.
H.
8. COMMENTS:
WELL TO SEEPAGE PIT
WELL TO SEWER LINE
WELL TO PROPERTY LINE
WELL TO OTHER POSSIBLE CONTAMINATION
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT
SEEPAGE PIT TO PROPERTY LINE
APPROVED: DISAPPROVED:
DATE: DATE:
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
KASSLER/WEST MORTGAGE CORPORATION
604 EAST SIXTH AVENUE'ANCHORAGE, ALASKA 99501e 212-9501
DATE: February 16, 1972
GREA'¥ER ANCIiORAGE AREA I301/Ott(;1t
Dept. of Environmental. Ileaith
Pouch 6-650
Anchorage, Alaska 99502
RE: JONES, Royal M.
Legal: Lot 12, Block,, D,
ROLLINGS S/D
-(-F~iA) (VA) Case # VA
Gentlemen:
Per the attached form, we hereby request inspection for }lealth
Authority Approval.
Please send your findings to either the FHA offices or the VA Office
as noted above for the "Case Number'! Also, please send an exact
copy of the report to our office.
Your swiftness in expediting this request would be most appreciated.
Sincere ly,
KASSLER /WES'[ MORTGAGE CORP.
PoS.
--fY, Fl~ Proce~-.~lng DepagStmenr
If you wish to make an appointment before inspect].on, please call
Mr. Geo. Johnson of A. C. Davis - 279-2491
~RLA~ER ANc~ORAG~ AREA BoROUG~
Februery ~9~ lg7~
A. C. Davis Realty
Sub:Jec~: Lo: 12, Btoc~ ~, Rolling HtJls Subdivision.
of the well on t~)e ~ubJect property. Before this Depart-
~nt's anoroval can he given for th~ sewer system, we
aill need a signed diagram shoatng ~hat the se~er syste~
consist) of. The dtaqra~ ~ill need to be signed by som~-
on~ a~o ~nows ahat the ~yste~ is.
The water sa~le take~ at th~ tt~ o~ th~ t~spectton ~roved
Sincerely,
E~vtromnental Specialist
cc: Vetera~ ^d~intstrat{on
Ka~sler & Company