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MAJESTIC VALLEY ESTATES BLK 4 LT 7
Municipality of Anchorage " U �� a U,L" j -J`�, Wastewater Program • 343-7904 �LFoage On -Site Water and (907) lJ. L, ON-SITE WASTEWATER INSPECTION REPORT Nov J ,q 2 ®'9 OSP 191280 050-731-34 Permit Number: PID Number: Dwelling: 0 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ■❑ Upgrade Name: Lance Westhouse ABSORPTION FIELD ❑ Deep Trench ❑ Shallow Trench ❑ Bed [:]Mound Address 26202 Imperial Dr ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 887-6814 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Majestic Valley Estates 4 7 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well >100' N/A N/A N/A >25- . TANK ❑C Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1000 Gal. Surface Water >100' N/A N/A N/A Material Plastic Number of compartments 2 Lot Line >5' N/A N/A N/A NA Foundation >10' N/A N/A N/A LIFT STATION Manufacturer Capacity Gal. Curtain Drain None Noted RemarksTank is insulated. Pump on level at Pump off level at in. High water alarm at in. Tankonly permit. A 5 1 1 Iin. M %epee,) Pump make and model Electrical Inspections performed by S o �S C-0n�v`rneA PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Johns Excavating Drainfield D3034 CO/MT Inspector J. Mlllette BENCH MARK (Assumed elevation) 100 ft Inspection 151 7/15/19 nd Location and description 2 3rd 41h Bottom of siding @ point A. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp `�• 44"q Conditional Approval: Date ���p°°•°'' `°••°° �� CD. 49th 0 vvv... .vvs.q .........vv ..•v vv�.s.vV;� 0 Wp �•Y�n•;•a _ MICHAEL E,.............. ANDERSON �C�f'•e• No. CE -4381 #40 TF °°•° 11/18/19 Approved Date 5 0090 � ��0'ORpFE°SS\&O;P� Inspection Report_9-1-12.doc MAJESTIC VALLEY ESTATES, BLOCK 4 LOT 7 PERMIT # OSP191280 PID # 050-731-34 LOT E G ENGINEERING PLAN AS -BUILT 0 50 100 FEET 1 "=50' 1,000 GALLON ;TIC SEPTIC TANK ' MANWAY. LOT 8 A B 22.3 20.4 19.5 23.4 19.9 25.3 17.1 24.5 LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE MAJESTIC VALLEY ESTATES, BLOCK 4 LOT 7 PERMIT # OSP191280 PID # 050-731-34 * TANK REPLACEMENT ONLY PROFILE AS -BUILT (NO SCALE) VV.V INSULATION ASBUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY; tea 7 vG AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDf— VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND— ARY LINES. SE'WARD & ASSOCIATES LAD SURVEYING 694-0$d SCALE-. �� �, Q ��►� I o OF A DATE: �S 4 ,- r H r GRID: r...:./.�:'....... .-# 00, Duens AAerk Seward if FB- LS A018 DRAWN: D 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:llwww.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP191280 Work Type: SepticTank Upgrade Tax Code Number: 05073134000 Effective Date: Expiration Date: Site Legal Address: MAJESTIC VALLEY ESTATES BLK 4 LT 7 G:0363 Site Mailing Address: 26202 IMPERIAL DR, Eagle River Owner: WESTHOUSE LANCE MICHAEL Design Engineer: FORGE ENGINEERING This permit Is for the construction of: c Jr, I epa i'trnent r1pip- r 718/2020 Lot Size in Sq Ft: 64301 Total Bedrooms: 3 O Disposal Field Z 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 (2417). 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 Received By: d �x Y Issued By: Date: b C ell f % MUH OLS UTY OF AHCHORAGE 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. 050-731-34 Property owner(s) Lance Westhouse Mailing address 26202 Imperial Drive Eagle River, AK 99577 Site address Same Day phone 887-6814 Legal description (Sub'd., Block & Lot) Majestic Valley Estates, Block 4, Lot 7 Legal description (Township, Range & Section) Lot Size 64,301 Sq. Ft. Number of Bedrooms Three (3) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade ❑x Duplex (D) ElHolding Tank ❑ Renewal E]Multiple Dwellings ❑ Privy ❑ (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. 'V l'j'F, as� - (Signature of property owner or authorized agent) Permit/Rush Fees: 925. D D p� Date of Payment: T 431 m 1 Receipt Number: 0Q S� Permit No. © ell 199 d Waiver Fees: Date of Payment: Receipt Number: Waiver No. Permit App_::- : :'-:c *OFL&M PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) July 3, 2019 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Majestic Valley Estates, Block 4, Lot 7 – 26202 Imperial Drive Septic System Design Dear On-Site Services Engineer: The septic tank on the subject lot has failed and must be replaced. We are submitting this design and permit application for the construction and placement of a new 1,000-gallon septic tank. The attached site plan identifies the location of the home and the existing well and septic system along with the new tank location. No conflicts exist between this proposed tank and any other well or septic system, whether on this lot or adjacent lots. Wells on this and adjacent lots are shown. The new tank will be constructed a minimum of 100’ from the existing well on the lot. It will also be 100’ from all adjacent wells and surface water and more than 5’ from the existing absorption trench. Please refer to the attached plan sheet for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Michael E. Anderson, P.E. 7/3/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191280, Rebecca Carroll, 07/09/19 MH 10050 0 FEET 1"=50' 3-BDRM HOME DECOMMISSION EXISTING SEPTIC TANK PER MOA CODE. DECK REMOVAL MAY BE REQUIRED. NOTE: NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND MAJESTIC VALLEY ESTATES, BLOCK 4 LOT 7 IMPERIAL DRIVE 1/29/19 20' UTILITY EASEMENT 1,000 GALLON SEPTIC TANK w/20" MANWAY PLACED 5' FROM PROPERTY LINE & 5' FROM DECK SUPPORTS. EXISTING DECK EXISTING WELL EXISTING ABSORPTION TRENCH SV 2CO Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191280, Rebecca Carroll, 07/09/19 ( ~ 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 {'-1 UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION DISTANCE TO: I Well /,~ / Manufacturer ~,~ ~r~"~. tv in gallons ~) IF HOMEMADE: Wetl DISTANCE TO: Manufacturer DISTANCE TO: Length of eac_%l ne No. of lines _ / Top o! tile to finish grade Length Width Type of crib Well DISTANCE TO: C~as$ Depth DISTANCE TO: Building foundation I Absorpt~:~rea W dth In$idelength DweHing IMaterial Nearestlothn~¢~ / Trench width I ~d inches Total length of lines Material beneath tile Depth inches NO. OF BEDROOMS PERMIT NO. No. o! compartments Liquid depth PERMIT NO. Liquid capacity in gallons Distance betwe n lines Total effective absorption area Crib depth Building foundation PERMIT NO. Total effective absorption area Nearest lot line Septic tank OTHER PiPE MATERIALS $O~L TEST RATING INSTALLER REMARKS APPROVED . DATE 72~13 (Rev. 3178) LEGAL F'ERI'~T NO. ( 790168 Ft_PPJ~ZCRMT C. POGAflY LOCAT I ON LEGAL r'llJf,~ I C I P~_ I T'~ O,,F, A f,~O_.HOF:AGE ~~ DEPARTMENT 0F~!ALTH RND EH¢IRONr. IENTFIL PF.~CTION 825 'L~ STREET, RNCHORRGE, AK. ~501 264-472~ Rf4D Clf4--S I TE SEi,IEF4 PERt1 I T ) BOX 32~ E.R. 694-2~50 L? B4 MAJESTIC VALLEY EST. LOT SIZE 54000 SQUARE FEET TYPE OF SOIL RBSORBTIOH SYSTEM IS: TREHCH MR>.'.IMUM NurIBER OF BEDROOMS SOIL RRTIHG <SQ FT?BR>= THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH= 8 LE f41..-~ TH= - 6RR',,-'EL DEPTH= 5 'THE LEHGTH DIMENSION IS THE LENGTH <IN FEET> OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TREHCH OR PIT IS THE DISTAfICE BETWEEN THE SURFFICE OF THE GROUND FIND THE BOTTOM OF THE EXCRVATIOH <Ill FEET>. THERE IS NO SET HIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MIHIMUM DEPTH OF GRAVEL BETblEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET>. REt.~U I I~:ED SEPT I 6: TF-.H'-.I K S I ZE= 1£~00 GF4LLOI'-IS PERMIT APPLICANT HAS THE RESPOHSIBILITY TO IfIFORM THIS DEF'FIRTMEMT DURIMG THE INSTALLRTIOH IHSPECTIONS OF RHY HELLS ADJACENT TO THIS PROPERTY AND THE MUMBER OF RESIDENCES THAT THE HELL HILL SERVE. TI-IQ ( 2 ,', I f-.ISPEOT I Of-IS AF.'E REO. L: I RE[:., BRCKFILLIHG OF ANY SYSTEM HITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT HILL BE SUBJECT TO PROSECUTION. MII'IIMUr.1 DISTANCE E:ETHEEN R HELL FIND ANY ON-SITE SEHRGE DISPOSAL SYSTEM IS i00 FEET FOR R PRIVRTE HELL.: OR 15¢~ TO 200 FEET FROM R PUBLIC HELL DEPEMOING UPON THE TYPE OF PUBLIC I,IELL. WELL LOGS FIRE REQUIRED AMD MUST BE RETURNED TO THE DEPARTMENT I,IITHIH _~0 DAYS OF THE HELL COMPLETION. OTHER REQUIREMEflTS MAY FIPPLY. SPECIFICATIONS AMP COHSTRUCTION DIAGRAMS FIRE AVAILRBLE TO INSURE PROPER INSTALLATION. F"ERi'-I I T E~--':F' I RES 12. ECEr-IE:ER 2:-.-1. -1~79 I CERTIFY THAT l: I RI'I FRHILIRR HITH THE REQUIREMENTS FOR ON-SITE SEHERS AMD HELLS RS SET FORTH B'.r' THE HUNICIPALITY OF ANCHORAGE. 2: I HILL INSTALL THE SYSTEM 1N ACCORDANCE HITH THE CODES. ~: I UNDERSTRMD THRT THE ON-SITE SEHER SYSTEM MAY REQUIRE ENLRRGEMEHT IF THE RESIDENCE IS REMODELE[> TO INCLUDE MORE THRH ~ BEDROOMS. ISSUED By_~~~_DRTE .... V3. 2 OF "EALT" A"D EHYIRO,',, E,,T, L :PRO'TEOTIO,, ,' ;' 825 ~tL~ STREET; 8NCHORAGE~ AK. 9~501 ,, ,' PERfllT N0. ( , ~ ~ . "f' .~ , .'.. ,., , . . , LOC~TION ~ , ~' . , ,' '.' ~ "'~ " ' '" LEGAL ~ ~ LOT ' IhRE HRXIHLU1 HUHB~R OF BEDROOMS = I . S~IL (S FT/BR>=~ ' ',', ,'~ ~ ,I . ,I , *, , ~ ~ , THE REOUIRED SI~E OF THE, SOIL ABSORPTION SYSTEH IS:' ,~ '." DEF'TI~= CE~4GTH=,m , m3FJR'...'E ,' DE ~1~ TH~ LENGTH DIHEH~ION ~ THE L~NGTH (IN'FEET~ OF. THE', TRENCH OR TH~ DEPTH OF A TREHCH, OR F'IT'1~ THE DI~TRNCE BETI.J~H THE ~U~,~R~ GROUND AND THE BOTTOH, OF. THE 'EXC~VRTION' (IN FEET>.' ' ,I ' ', THERE IS NO SET WIDTH FOR. TRENCHES. ~ ~ , ',' THE GRAVEL DEPTH~I5',THE MIHIMUPI DEPTH ~)F GRAYEL E:ETf'JEEH THE"OUTFRLL' PIPE AN[) THE BOTTOM OF T~E,EXCBVRTION~(IN PEET). ' ) . '" ~ '' , , . ~:EL~LI I RED ~i T I C :Tl~r-Jt< hn' · I ZE= ' GRLLO F'ERHIT 8PPLICRNT HR5 THE RESF'ONSIBILITV TO INRORH THIS'DEF'RRTHENT,DURIHG THE INSTRLLRTION IHSPECTIONS OF AN~ HELLS RDJRCENT TO THIS F'ROF'ERT~ ',87D THE NUMBER OF RESIDEHCES ~HRT~ THE WELL NILL SERVE. E:RCKFILLING OF ANY SVS~EMmI~ITHOUT,,FINRL INSPECTION RND'RPPROVRL,',8'~ THIS "' DEP~RTHEHT WIL~'BE ~LIBJECT TO PROSECUTIOH. ~ . ItIHIHUM DIeT.rICE BETHEEN' lqELL AND ?Ny ON-SITE SEt,I~GE DISPOSAL 'SV. STEM lO0 FEET FOR ~ PRIVATE 'WELL; .OR ,, · ' , 150 TO ~00 FEET FROM R 'PUBLIC WELL DEPENDIHG UPON THE TYF'E OF PUBLIC WELL. HELL LOGS ARE REQUIRED 'AND MUST BE RETURHED TO THE DEPRRTI'IENT wITHIN ~D DAYS OF THE HELL COMPLETION.' i ,, . , , ., , , . O~HER REQUIREMENTS MAY 'RP~'LY.. SPECIFICATIONS AND CONSTRUCTION ~IR~RAr. IS ARE R~AILABLE TO IH~URE PROPER INSTALLATION ' ' F'ER%~ ~ ~ ~>~F' ~ ~'~ ~Er.I~:E~ ~.. ,~-- ~.,--~ I CERTIFY THAT , m ,, ..... , ~: I AP1 F~HILIBR NITH THE~REQUIREHENT~ FO~ ON-SITE ~EWER~ AND HELL~ R~'~ET FORTH B~ THE MUNICIF'A~ITY ~OF ANCHORAGE. ' .,, 2: I ~ILL IHSTAQL THE ~Y$~EH I~1 ACCORDANCE HITH THE CODE~.~ ~: I UNDERSTAND THAT THE 'ON-~ITE ~EHE~ ~TEf'I I~A~ ~EQLIIRE EHLR~OE~EHT ~E~IDEIlCE I~ REMODELED '~0 ~INC~UD~:IIORE THAN ~ BEDROOPI~. ,. . u , :// - V~.2 EVELO,' , ENT CO. O 6 E GEOTL..HNICAL 8 D Russell Oyster 694-2774 Soils ~ Foundations Performed for: Box 90, Davis St.. Eagle River, Alaska 99577 694-2774 or Earl Ellis SOIL LOG ~-22~o Land Development N~e: CiiA!LLk, S 8 [OSANY ,~F~CI. ~N. Natllng Address: ~ox 363 .~h.~le P~ver. Alaska Let 7. Block ~, M~Jestic Vallnv ~;states So11 ~h~racte~tst!cs Legal Description: Death (feet) Tel. No. 9qg77 0 1 EL - Silt topsoil ~%th roots and organics. 275 sq. ft./sr. 2 S~Jy Gr~vel with slight amount of silt. Cobbles to 6 inches. 140 sq. 5 6' 7' 8 9, 10 11 Silty $~n~y Gravel with cobbles to 12 inches. Percolation Hate = $.1~ inch~s / 60 minutes = 15 minutes / inch : 190 sq. ft. / ~r. Forcolaticn test run at 6 to ? foot level. Sandy Gravel 190 s,. 1C0 sq. ft./Lv. 12 15 16 GP--G.u. - Sandy Gravel. Fairly co~rse and slightly cem~ntei with silts. ~otto~ of pit Ground Water Encountered: Yes Proposed Installation: Seepage Pit No ~ If yes, what depth Drain Fte~d ~¥ Conlnents: Performed by: Date: CHUGIAK, ALASKA 688-3199 I 4 VJ I Lis 14,q A #001;RILLING CC WE SERVE ALL ALASKA POST OFFICE BOX 42 -CHUGIAK, 4LASKA 99567 -- L-�Lx OWNER OF LAND ..... ...... '� ......... ADDRESS ....... . .. . ... . ................. WELL- SITE .... ...... ................................. . .................. DATE- STARTED ....... ........................................................... DATE- ENDED ............ ............................................................ . . KIND OF FORMATION: FROM .............. 0 ...... FT. TO .............. B . ..... F T Z 0. r, I.. FROM .............. 9 ...... FT. TO .............. 0 ..... F`T.nal��= .. ............... . FROM .............. 9 ...... FT. TO ........... 1Z ..... FTSi;.-.4---z ... 0-r.;A-;L&L I FROM ........... L.3 ...... FT. TO ........... 1.0 ..... FTJ:�22 A cx .................... FROM ........... J.Zq ...... FT. TO ............ �4 ...... F T I .................. FROM........... 9 1 ...... FT. TO ............ 9.5 ..... FT -'a . .. .................... FROM............ 9--r ...... FT. TO ........ 11.6 ...... F T I ;;. r. d; -" Q .-L ................. FROM ........ ...... FT. TO ........ 11-6-L FT-L-'-QJ-d-Qr .................... FROM ........ FT. TO ......... Ul ...... 'I FT,"=w='-=4 ................. FROM ........ J.= ...... FT. TO ........ 12�1 ..... FTnal-ezl:Z ................. FROM ........ 1-210 ...... FT. TO ........ .'!.!i ..... Frj -ra= ................. FROM ........ ...... FT. TO ......... t2D ..... . .. ................. MISCLINFOR,MATION: Cased 146 ilt. set purmp 10 to 15 ft- off l,'Ot'D—,, KODIAK, ALASKA 4864826 DEPTHOF WELL ...... ......................................................................... STATIC LEVEL OF WATER FT . ..... �n=-- ......... ........ DRAW DOWN FT . ..... 6a .. ......... r.Al-q- PER FIR . ........ KINDOF CASING ...... U..XL ..... ;;-Q....142 .................................................. FROM ............ Un ... FT. TO ......... 121 ...... FT. -'"r-2-r-tu=ad .. Rzek FROM ..... . ..... 1.11 ... FT. TO ......... 1-9.5 ....... FT-�.,.�Zrzeic ............ :. FROM ...... ..... V9.5 ... FT. TO ......... 1,-9� ....... FT -t ur-cj Z - - .—". Qck FROM ............ FT. TO ........ Z. .3 a ....... ............ FROM ........... 2132 ... F -r. TO ........ 2aL ....... FT-Z--ac.+u- � ... �Dck FROM ............ 2.31 .... FT. TO ......... 2.7..; ....... FT-LZ��=Za .. ............. FROM . ......... .-.7..;L ... FT. TO ....... 2. .2 a ....... FT..."z ' .4 w. o 4 ... .�ock FROM ....... . . ... FT. TO ......... ;' 1 ........ ............. ,-7- FROM ........... -7- 1 ... FT. TO ......... 31" � ....... ... aock FROM ............. 3-7--_'� ... FF. TO ......... 3.;L-9; ....... FT. � ............. FROM FT. TO 3.;.r ...... FT - ck ........... ... ......... FROM ........... ... FT. TO ........ L= ....... FT-L'�I"-!-- ................. DRILLER'S NAME ......... . ....... .. . ................................................................. 0 Municipality of Anchorage On -Site Water and Wastewater Prb-9ram (907) 343-7904 2 A. -W 'C5RTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel (.D. 060-731-34 Expitaflon Date: an I. GENERAL INFORMATION Compleielle"g'a-I 8es'criptionMaLestic Valley Estates Block 4 Lot Location (site address).26202 Imperial Dr, Eagle River, Ak Current Property owner(s) _Lanee Westhouse Day phone Mailing address 26202 Imperial Dr Eagle Rilver, Ak Real Estate Agent Day phone' 2. TYPE OF -DW ' ELLING-' Slngfe-Famfow oADU) ❑ Duplex-, 11 Multiple 66el6ngs; (Single Family and/or Duplex) 3. NUMBER OF BEDRo,OMS. TYPE OF WASTE -WATER DISPOSAL: 4. TYPE OF WATER SUPPLY - Individual Well individual Water Sior ag a community Class _well Public Water System 0 ri Individual Holding Tank Community Public Sewer El WaiverNarianca,- request for. Distance, Received by. the� engine COSA to be releosed to thee englnear, unfess othe s U tedbytheenglineer. COSA Fee Receipt Number COSA4 QSCa.01 E5 Waiver Fee $ Date of Eaytrtenf Receipt Number Waiver# 7- 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 arld 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, ARCTERR,&'CONSULTING, INC. Phone 696=6111 Address 20441 PTARMIGAN BLVD .EAGLE RIVER. AIC 99577 Engineer's Printed Name KENNETH M.DUFFUS Date /a m7 Engineer's comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as.of the day tested. The now and absorption rates may change due to subsurface conditions that may ndt be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are sublectto these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, AfcTerra can not give any estiMate.of hdw.long a system will function satisfactory for current or future d��-��� occupants or can ArcTerra guarantee that no unseen (JV A_L�� encroachments, deficiencies or discrepancies exist.. ®�`� 6. DSD SIGNATURE J System #1 Approved for bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the 9 is xA u us po' Rkl T. c cwiral�ulafiort� Off' By: �1 Original Certificate Date:X R-. X02 6 The Municipalityof Anchorage -Dave fopment Services Division (DSD) issues Certificates of onsite 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 fasponstble for errors oromissions in the professional engineer's work. 1. ATTACHMENTS: COSA Checklist X� Septic System Advisory. Well Flow Advisory CCSAbImsheel i0-10.12.doc Nitrate Advisory Arsenic Advisory Other COSA Checklist Legal Description: Majestic Valley Est Block 4 Lot 7 If more than 1 septic system on lot: COSA Checklist # of _ A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 5/3/79 Total depth 490 ft Cased to 146 ft ® Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 32 in. Date of flow test for COSA 10/6/20 Static water level at beginning of test 183 ft. Comments B. TANK DATA Age of tank(s) i years Tank type/material Septic/Plastic Measured operating fluid level in septic tank 491' ❑■ Standpipes/foundation cleanout per record drawing Date of pumping 10/5/20 D. ABSORPTION FIELD DATA Parcel ID: 050-731-34 Structure served by this system Well production at time of test 1.3 qpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes E Nc ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by Arcterra Consulting Date of Sample 10/6/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station — years Lift station material Comments: Which system tested (date installed) 6/1/79 Adequacy test date 10/6/20 ® ALL standpipes present per record drawing Results ❑✓ Pass For 3 bedrooms Total measured depth from grade 9.2 ft (max) Fluid depth prior to test 52 in Measured depth to pipe invert from grade 3.7 ft (min) Water added 450 gal ❑ N/A – pressurized field 65 New depth in ® Monitor tubes go to bottom of effective. If not, state depth into effective Elapsed time 420 min — N Code -required soil cover over field Final fluid depth 52 in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) — date of test) Gallons introduced _gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet 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' Community Sewer Manhole/Cleanout > 100' ® Yes if No _ ft [21 Yes if No _ ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' Yes if No _ ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No _ ft Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft Yes if No _ ft _ Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No _ ft 0 Yes if No _ ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No _ ft Surface Water > 100' ® Yes if No _ ft Property Line > 5' ® Yes if No _ ft Wells on Adjacent Lots: Absorption Field> 5' ® Yes if No _ ft Private Wells > 100' 0 Yes if No _ ft Water Main > 10' ® Yes if No — ft Community Wells > 200' Yes if No _ ft Water Service Line > 10' ® 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' ❑ Yes if No 9* ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No _ ft Private Wells > 100' 0 Yes if No _ ft Water Service Line > 10' ® Yes if No _ ft Community Wells > 200' ® Yes if No _ ft Surface Water > 100' ® Yes if No _ ft F. ENGINEER'S COMMENTS *Per 6/1/79 IR G. ENGINEER'S CERTIFICATION I certify that I 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. COSA Checklist yellow sheet �,c) '1g710 C] V� • ., l r� ,-2OCT •1017 7 4 �t Municipality of Anchore ; _ -_ On-Site Water and Wastewater Program; ',2 (907) 343-7904 ; 4' s. f., E 3 i• Certificate of On-Site Systems Approval Parcel I.D. 050-731-34 Expiration Date: 2 1- I 1. GENERAL INFORMATION Complete legal description Majestic Valley Estates, Block 4, Lot)( Location (site address) 26202 Imperial Drive Current Property owner(s) Eric & Elizabeth Hanssen Day phone Mailing address . 26202 Imperial Drive, Eagle River, AK 99577-9628 Real Estate Agent Day phone 2. TYPE OF DWELLING: O 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 Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: it/ Date: ( /1//7- COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $526 Waiver Fee $ Date of Payment /O12/ i, Date of Payment Receipt Number D a‘p3M Receipt Number COSA# 0915/ 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 watepply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedroom ar type of structure indicated herein. I further verify that based on the information obtained from the Municipa 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 Crewdson Engineering, LLC Phone 907-280-9493 Address PO Box 671389, Chugiak, AK 99567 Engineer's Printed Name James Crewdson Date 10-28-2017 Note: as engineer of record, the information I have provided on this form satisfies MOA Cer fN.fskq-Site Systems Approval requirements only, and does not include any statements or guarantee•alagM ytlzftAl)<rp life and serviceability of the subject systems. _� 't�T",/.•.' • -'�99s�` l l 6. DSD SIGNATURE r h ' *• 44- x4 ;* Il System #1 Approved for 3 bedrooms ;f J� ' .. __ System #2 Approved for bedrooms / .�,2.1Jam* A.Crevrdson '•? Disapproved �� Esc!' 011527 =i Conditional approval for bedrooms, with the following stiptl jFESS\ -2- ti,n) i ----ri-t3iS S eighc '-k---1 ,K,1C I< 3 ,Ijeck,t4 0-eee " s �v o-� iP0 t` Z D 1 eco o ,�VWI'�' ;,,P �;�h, '',9, p,, y \ l ON-SITE +- WATER AND " WASTEWATER 6. \cc, PROGRAM . ,0 apt = 1 SERJ By: J -� Original Certificate Date: 11 ^ 7-I / The Municipality of Anchorage Development Services Department(DSD) issues a Certificate 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...I _, c If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: Majestic Valley Estates, Block 4, Lot 7 Parcel ID: 050-731-34 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (Y/N) '' Date completed 5-3-79 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 490 ft. Cased to 146 ft. Casing height (above ground) 18+ in. FROM WELL LOG AT INSPECTION Date of test 5-3-79 10-27-17 Static water level 300 ft. 194 ft. Well production 1 gpm 1.5+ g p m WATER SAMPLE RESHtTS: -- 1 - - - _ - Coliform _ colonies/100 mL Nitrate r�Ymg/L \Arsenic 4'0 ug/L Date of sample: (.i N '1'7 Collected by: (re d'\ ?„- s , B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 6-1-79 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y (IR approved with 1) Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 10-24-17 Pumper JR's C. ABSORPTION FIELD DATA Date installed 6-1-79 Soil rating (g.p.d./ft2 or ft2/bdrm) 190 SF/bdrm System type Trench Length _ 53 ft. Width 2.5 ft Gravel below pipe 5-8 ft. Total depth 9.2 ft. Eff. absorption area 689 ft2 Monitoring tube Y Depression over field N Date of adequacy test 10-27-17 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 49 in. Water added 450+ gal. New depth 69 in. Elapsed Time: 120 min. Final fluid depth 49 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? 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 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 75+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ 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 9 (per IR) Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain NONE KNOWN Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION ._ c .9/ A4q%, I certify that 1 have determined through field inspections and •y• • �� 9 review of Municipal records that the above systems are in 1A'•. 4•'•'j•� fk :'��/ conformance with MOA COSA guidelines in effect on this date. / .�. !�• . •,.__.:,, / / Engineer's Printed Name James Crewdson �p, • =mes A Crewdson; j Date 10-28-17 i G115 7 r Note. as the engineer of record, I have provided information on 1k��RpFESS100\"—° this form intended to satisfy MOA COSA requirements only, and '`V•VZtt` it does not include any statements or guarantee regarding the LLC 1 i ?- 71-C1future life and serviceability of the subject systems. �t COSA canary sheet_2-6-15_CE pdf Cin Engi ring,_LK ;...r James"Jay" Crewdson, P.E. Email:CELLC.1@outlook.com Cell/Text: (907) 280-9493 Fax: (907) 688-2295 'c ,. ovil&Environmental Engineering November 7, 2017 Municipality of Anchorage On-site Water&Wastewater Program 4700 Elmore Road Anchorage,AK 99519-6650 Attention: Tim Ecklund Reference: Majestic Valley Estates, Block 4, Lot 7 COSA Review Comment 2 Septic Tank Integrity Verification I completed the site inspection for a COSA on the subject property on October 27, 2017. During the inspection, I verified the integrity of the septic tank in accordance with the code by observing whether there was a depression in the surface of the soil cover over the tank and by measuring the liquid level in the tank. This was done prior to the addition of water into the septic system for the drainfield adequacy test to help ensure an accurate liquid level reading was obtained. The soil cover over the septic tank did not have a depression,which indicated the tank was structurally sound.The septic tank liquid level was found to be approximately 50 inches above the bottom of the tank, which is what would be expected for a tank of this type and configuration and indicated the tank was not leaking. Given the results of my septic tank inspection (shown above), I made the determination that the septic tank was adequate for its intended purpose and in accordance with the code. Please feel free to contact me if you have any questions or would like to discuss this further. Thanks, t� A!,..47‘‘k gyeaairet-/-----7Via,.• ,1� .� 1 Jam "Jay" Crewdson, P.E. % /�� ,:, T es A.Crewdson 6�) 011527 ..•mo i Lc_ I (a)' ALc ?c)( PO Box 671389 . 18368 Amonson Road • Chugiak,Alaska 99567 DATE: November 5,2017 FROM: Eric Hanssen SUBJECT: Request to Cancel Permit Application for Septic Tank Replacement,Block 4 Lot 7, Majestic Valley Estates Subdivision TO: Municipality of Anchorage On-Site Water and Wastewater Program I am providing this letter to request cancellation of a permit application for a septic tank replacement at my residence located at 26202 Imperial Drive, Eagle River or Block 4 Lot 7,Majestic Valley Estates Subdivision.The original intent of the permit application, submitted to the MOA On-Site Program in 2012,was to replace the original tank and install a larger capacity tank to enable possible expansion to a 4-bedroom sized septic system in the future. This permit was never formally approved by the MOA On- Site Program. Since the time of the original application,the existing system has continued to perform as designed without any issues,and our family has decided to not pursue replacement of the tank or expansion of the overall system. We are now seeking a Certificate of On-Site System Approval (COSA) in preparation for selling our property, and would like the 2012 permit application for tank replacement to be closed to enable the COSA process to proceed to completion. Thank you very much for your time, and please feel free to contact me at 907-845-6445 if you need any additional information. Sincerely, Eric C. Hanssen Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Sewices Section 825 'l.' Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 vn~v.ci.anchorage.ak.us (907) 343-4744 Legal Description: HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D.: A. WELL DATA Well type ~ t e Date completed _~ / _~ / 79 Total depth 4 9 0 ft FROM WELL LOG If A, B, or C provide PWSID it __ Sanitary seal ¥ Cased to /~ 0 + ft Well Log y Wires properly protected ¥ Casing height (above ground) 18 * AT INSPECTION in. Date of test ~ / ~ / 7 q Static water level 300 Well production 4/4/n~_ 179 fl ft 1.0 g.p.m o. 9 g.p.m WATER SAMPLE RESULTS: Coliform ~ colonies/100 ml~ . Nitrato~mg/I Otharbacteria ('~'2 c°l°nios/100 mi Date of sample:~ollected by: ~'~ ~, '_ / .... -'_! I SEPTIC/HOLDING TANK DATA Alask~ ~.~'J' TankType/Material SeDl:J.¢/ S1:e~1 Date installed 6/1L/79 Tanksize t000 gal NumborofCompertments Cleanouts y Foundation cleanout Date of pumping ~, / 2. / 0 2. ABSORPTION FIELD DATA Y Depression over tank Pumper J R ' .. High water alarm Date installed 6/1179 Soilrating (g.p.d./ft2orlt2./bdrm)lq(~ Length 5 3 ft Width _2,_._5~ft Gravel below pipe _~.~__ft Total depth 1 0. ~t Effective absorption area 6 8 9 fl2 Monitoring tube Y Date of adequacy test z./~,/02 Results (Pass/Fall) p~,,, Fluid depth in absorption field before test ~. ~_ in Water added ;; .~0 Elapsed Time: I ~ min Final fluid depth 6~. 5 in Any rejuvenation treatment (past 12 mo.) (WN & type) nnno ~cnn,~n Sy~emtype Depression over field N For t bedrooms gal. New depth 59..~ in. Absorption rate >= 4 ~ 0 g.p.d. If yes, give date. -- 72-026 (Rev. 01~00)' Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Water Well Advisory, Health Authority Approval # 010282 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 4, Lot 7 of Majestic Valley Estates subdivision, the well's productivity was determined to be 0.9 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3-bedroom residence is 0.3 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. I~Y-09-2002 694 1211 P o ~/~2 ASBUILT ~ & ~ FOCLOWIt4~ I)~l~rt'~ PROPERTY: , . Laboratory Division ~r~gfmamusw,~'~fwz~;~ 200 W. Po~or Driv~ · Tel: (907) 562-2343 Drin1~ag Water Analysis Report for Total Coliform Bacteria A,oho,,~*. AK , DE B£FOP-~ COLLE~I'iNGSAMPLE Fax: (90 561-5301 _. pUBLICWATERSYSTEMI'D'# [: I I' ~ I ~ pRIVATE WATER SysTEM · Da)' Year Month / ~. D Treated Water Foxed Anal)als shoWS this Water SAMPLE to be: ~ Satisfactory Unsa6sfacto~/ S~mplc over :30 hours old, ~ul~ ~y be un~li~lc Sample ~o Io~g i~ ~nsi~ s~mple should not be over~ou~ old at examina~o~ to indicate ~li~le ~sul~. Please sena ~me R~eivcd ~~ Anal~cal MathS: ~ M~brane Filt~ * N~ber of colonle~Z 00 mi- Result* Analyst '-' Client notified of uw~~results: []. .~ Phoned - Spoke with Fazed BACTERIOLOGICAL WATER ANALYSIS RECORD ~ Routine ~ . RepeatSami)le(forroullnesampln n Untreated Water with lab ref. no. · ) D Special Purpose Time Collected SAM PLE LOCATION Collected By MMO.MUG R~ult: Total Coliferm I~lem~rtne filter: Dirtd Count ~ Verification: LTB ,= BGB _ Fecal Collform Confirmation _ Final Membrane Filter Rc~lts ~ . ColoniedtO0 mi COLIFIRM ,. Coliform/lO0 mi ~Y-06-02 0~:5~P~ FROM-CT&E ENVIRONPENTAL SRV 9075615~01 T-684 P.01/82 F-974 ."T&£ R~t'.~t 1022049001 ~en! Name S & S Enginecdng pro]eel Name~ Maicstic V.Ucv Estates ."ltent Sample ID [x~t ? Block 4 dal~ix Dt-i-ldn~ Wat~ 'WSID 0 lample Re~lu All Dates/Times are Ara.alta Stand'i'd Time Printed Date/Time 04/22/2002 16:41 Colleeted Date/Time 04118/2002 13:40 Received Date/Time 04/18/2002 17.35 Units Method ~low~ble ~ A~l~is t.irnh~ Date D~ Init 0.200U 0.200 mF/L EPA 30Q.0 (<10) 04/19/02 .[DT ~icrobiology ~.abor&tory Coliform col/100mL SMI8 9232B (<!) 04118/02 SBH APPL""ANT FILLS OUT uPPER 'H~"'F ONLY ~rope:~ Ow.e~ ~ ~_t..%0~ Phone Mailing Addre. Zlp~e ~%~ ~ 694--3943 Addres~ Lending Insti~tion ~ Phone Address Zip ~e tegalOescript~n Lot 7 Block 4 'MajeStic Valley Es~tes Subdivision ~Slngle Family Water Supply mm~ity For wells ~illed prior to th~ date. give well depth (attach I~ II available). Sewer Disposal ~ Holding Tank NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. RECEIVED ( ~ ) APPROVED ~DROOMS 'CONDITIONS OF APPROVAL ( ) DISAP~OVED ( ) CONDI~NAL APPROVAL' DATE ~' ~ ~ BY: Soils Rating Date ~wer Instalt~ Well To ~sorption Area ~ ~ ~ WeTI LOG R~eiv~ ~ DATE RECEIVED ~. INSPECTION APPOINTMENTS TIME . ~. TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOJ~ ~UNICIPALITY OF ANCHORAGI~ MUNICIPALITY OF ANCHORAGE DEPT. OF HEALIH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~:~/IRONMENTAL p~,OT.CCTION 825 L Street - Anchorage, Alaska 99501 ) ENVIRONMENTAL SANITATION DIVISION MAR 2 7 1981 Telephone 2644720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWI~ I~A~I~LI~E~~' 1. PROPERTYOWNER I PHONE MAILING ADDR ES/~ · PROPERTY F[ESIDENT lit different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE MAILING ADDRES 4. REALTOR/AGENT ~/~ /t ~ ' PHONE 5. LEGAL DESCRIPTION TREET LOCATION - ' 6. TYPE O~ RESIDENCE i ~/ NUMBER O~BEDROOMS / [~SINGLE [] One I-'1 Four [-1 Other FAMILY [] Two [] Five [] MULTIPLE FAMILY [~""~hree [] Six 7. WATER SU Y ~DIVIDUAL* * ATI'ACH 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 UTILITY depth (attach log if available.) 8. SE~AG~ ~3~AL SYSTEM [~ INDIVIDUAL/ON-SITE'" /! YEAR ON-SITE SYSTEM WAS INSTALLED. - [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/7914~- .- THIS SIDE FOR OFFICIAL USE ONLY , 1. TYPE OFRESIDENCE I-'1 SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL r-'l COMMUNITY [] PUBLIC UTILITY Connection'Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE r--IPUBLIC UTILITY Connection Verified []Septic Tank or I-'lHolding Tank Sze: l[~C..~ IfTankishomemade g;ve dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELLTO: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE I--I OTHER r"] TWO [-I FOUR [] SiX PERMIT NUMEER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING Septic/Holding Tank Absorption Area JSewer Line INearest Lot Line 5. COMMENTS DATE [~/APPROVED FOR ~ BEDROOMS I-1 CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED /~~/~ 72-010 (Rev. 6/79) -'- · MUr~IL:IPALIT~ OF ANCHORAGE E/1UNICIPALITY OF ANCHORAGE DEPT. OF HF-'AI.TH & ~--~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTt~IRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 JUL 6 1979 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 R[C[IvgD ~EOUEST FO~ APPROVAL OF INDIVIDUAL WATER AND SEWER FAOILITI DIR[gTIONS: gompleJe all ports on pBge ~. Inoompl~to roqu~s~ will not b~ processed. Plesse allow ~en (J0) days for progessing. 1. PR~.E[RTY OWNER ~ PHONE MAILING ADDRESS / ' ' / ~ PR OPE RT~ R ESI'~ENT ~lf differen{ ~rom~ve) PHONE 2, BUY~ PRONE MAILING ADDRESS 3, LENDING INSTITUTION I PHONE MAILING ADDRESS ' ~ / 4. REALTOR/A~NT ' I PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATI D'N 6. TYPE OF RESIDENCE ~ SINGLE FAMILY ~ MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 7, WATER SUPPLY ,~ INDIVIDUAL* *ATTACH WELL LOG. A well Icg is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach Icg if available,} 8. SEWAGE DISPOSAL SYSTEM **If ~ INDIVIDUAL/ON-SITE** individual/on-site, give installation date ?h/7~ If system is over two (2) cears old an adequacy t~st is fe~ ~ired [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIA'DED, 72-010(3/78) ~ · ('"' ~' i ~'-'-' - ' THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSPECTO R DIRECTIONS: 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 [] I NDIVI DUAL/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 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR. ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) / ) LEGAL DESCRIPTION " 72-010 (Rev. 3/78)