HomeMy WebLinkAboutEAGLE CREST #1 TR B LT 36
~'~ /' MUNICIPALITY OF ANCHORAGE
. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
t ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage. Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE I ~NEW
LEGAL DESCRIPTION
- Material ~[~1 NO' of compartments
,[~ IF HOME.DE: ~ ~ ~ Liquid depth
~O~ DISTANCE TO: ~etl ff Dwelling PERMIT NO.
= I Foundatio~ Nearest lot hne PERMIT
~[= T. of tile to finish grede ~' 0" Material ~neath tile C ~~ inrhesinches Totaleff~ti. abso~tlonarea
~ DISTANCE
d ~ ~ Depth Driller Distance to lot line PERMIT NO.
Y
~ Building foundation S~r line Septic tank Absorption area(sD
~ DISTANCE TO:
OTHER
SOIL TEST RATING
DATE LEGAL
724313 (Rev. 3178)
PERMIT NO.
r,lUN I C I 5~'~L I T~' OF RNCH~'=',~RGE
DEPARTMENT f HEALTH AND EHVIRONMENTRL ]TECTION
825 ~L
264-4720
0~4--5 I TE . ~E~EE PERM I m
78~32 )
, APPLICANT MR. SRGRR KLONDIKE AK. IHC.
~ LOCATION CRESTVIEW
LEGRL L36 ~_..'~-- ~'~ ~"'~.~_(C~r.~ LOT SIZE
TYPE OF SOIL RBSORBTION SYSTEM IS: TREHOH
10600 SQUARE FEET
HRXIMUM NUMBER OF BEDROOMS
SOIL RATIHG
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= 'i 0 LEf-IGTH= 26 GRAVEL DEPTH= iS
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRIHFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTRHCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IH FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE HINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (Itl FEET).
REQU I RED SEPT I C: Tt:Ir-IK $ I :::'E= :1.000 GI::ILLOr-i~:
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RNV WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDEHCES THAT THE WELL WILL SERVE.
· TI-dO "~ 2 ~' I I',ISPECT IONS lire REOU I RED
BACKFILLING OF ANY SYSTEM WITHOUT FIWAL INSPECTIOM AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
~IIHIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL; OR
150 TO 200 FEET FROM R PUBLIC WELL DEPEHDIHG UPON THE TYPE OF PUBLIC WELL
OTHER REQUIREMENTS ~IAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERM I t EXP I RES DECEMBER ::~:::L~ :L~:~?8
I CERTIFY THAT
l: I RM FAMILIAR WITH THE REQUIREMEHTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL IWSTRLL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDEHCE I~ REM~SLSD T~ IHCLUDE ~ORE THAN 3 BEDROOMS.
2204 ~..eve3an8 7,nchorage~
~ ~'~" '[;r Sager
Perlormzo
;Lee~l ~escri~on: Lot 36 B]ocl: _
· This form Renort$ Soils Lon Yes
~9503'
Date Perfo'rmed 10-26-78
Percolation Test~o
~enth
Feet
4~
8~
~0~
So~1 Characteristics
Peat &'.Reddish S(lt
Brown Sandy Gravel
Brown Sandy Silt
Bottom of Test Hole
!18 ~
Ras Ground Rater Encountered?' ' No
Yes, At what. Depth?
t i
Read{nq
Date.
Fercolation Rate
Grnss T~me
U~nute
Net T~me
Depth to H20
Dra~n F~eld
/,'et Dror
Frn~osed lost~llat~o~: Seenaoe P~t
De.nth of 1n3et Depth 1o Bottom Of P~t O~ lrench _
CI~.p£NTS: 100 Sq.' Ft. drai.na e arep required per hed~nr~. ~m ~ 2' to 12' and 150 Sq. ft.
· drainage area re utr d ' . ~ ~
~ -- Data Certified E~': -.
Test Performed By_ David Paul '
-- Date: 10-26-78
L
( er fie Brilliug og
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
DATE- S~
PERMIT NUMBER
DEPTH OF WELL '=~ ~=~'
STATIC LEVEL OF WATER FT.
DRAW DOWN FT. /' '~
GALS. PER HR -~' ~' '~
KIND OF CASING ~"' ~:: ~'~ ~,s
./-:/
KIND OF FORMATION:
From ~" Ft. to
From Ft. to ~
From Ft. to
From / ''~ Ft. to ';'
From '~ · Ft. to '?
From ::"' Ft. to
Fr~ '-;:'" Ft. to "'~<~
F~ '" :~ Ft. to
Fmm ~':-? FI. to /
From / TM ~ FL lo ' *'~
Ft. C.~/'~ 7' From
Ft. , ,,~,/..'f2,"'.~,~'; ¢;- 1,.3~' ~.~'~,'-,rl~rom __
FI._ c:~. ~/ C~' ~'~'~, ,.:r'~ From__
Ft. I'/~:'/;'~/?~'J From __
Ft.__ '-?/~ ~' From __
Ft. <?':~-!~ ~' ?'//~"¥~'~/- From
From ' ? ~ ''/Ft. to
From '-" -: Ft. to -~ '~'~
From Ft. to Ft..
From ' ~ ~ Ft. to -'~
From ,"=~ Ft. to
From Ft. to Ft.
Ft..
From
From
From
From
From
From
Ft. to Ft.
.Ft. to Ft.
Ft. to___Ft.
Ft. to Ft,
Ft. to__.Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Fi. to Ft
Ft. to____Ft.
FI. to Ft.
FI. to Ft..
Ft. to=__Ft.
Ft. Io Ft,
MISCL. INFORMATION:
/ /
DRILLER'S NAME /"- '-'"~ ~'-'
PERMIT I"10.
DEPARTMEHT ,~'~HEALTH AND ENVIRONME~ITAL J~TECTION
825 'i STREET~ ANCHORAGE, AK.
264-4720
NELL PERFfl I T
APPLICANT MRRYRLVCE SAGER BOX 2347 ~5:L9 688 -~058
LOCATIOI, CRESTVIEW & 4ST AVE ~ L~O
LEGAL L~6 BLK B EAGLECREST S/DI~~. ~ ~IZE ll~7~ SQUARE FEET
HINIMUH DISTANCE BETWEEN R IdELL A~lD ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
l~O FEET FOR R PRIVATE WELL; OR
150 TO 2~0 FEET FROM A PUBLIC WELL DEPEtlDING UPON THE TYPE OF PUBLIC WELL.
tqELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 3~ DRY~
OF THE WELL COMPLETIO~I.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS Rt~D CONS]RUCTIO}I DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERrfiIT EXPIRES DECErfiBER ~, 1979
I CERTIFY THAT
1: I RM FA~IlLIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF AIICHORRGE.
V-~. 2
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
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 36, Tract B, Eaqle Crest
Location (address or directions)
(b) Property owner t'"'~'~A ~ I ~'~-, ~ t, ~: . Telephone: (home)
Mailing Address ~/_~?~,-,t ~../-,""~ \~.~,~,,-,,~,n,,-, ~-~'~l,.wO{'~.-F,
Business
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent C.~"~,.~'l~n~l l~,~lt'y-- t.c~l~ P~rl~qmn
Address ~!.~ n~ ~ ~- : ~glP ~i~mr, ~k. qq~77
Telephone 694-912~
(e) Mail the HAA to the following address: (or check here ~, if hold tor pick up.)
List contact person and day phone number below:
S & S ENGINEERING
170~4 R~E_le Rivm- Loop. Re~ He 91~2[
Eaele River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family ~] Number of bedrooms
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 ~] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
?~-o~ m~,. ~,~) Page I 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 all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
S & S ENGINEERING
Address 1703,~ p~_lq Rl,~er Loop Road No. 204
Eagle River, Alaska ~9577 ~
Date
6. DHHS APPROVAL
Approved for --~
Approved
Disapproved Conditional
Terms ef Conditional Approval
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 Mu nicipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work. · '
; 72-025(Rev. 7/88}l~ack Page 2 of 2
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
JUN 1 2 ]989
RECEIVED
Legal Description: !--~'f'
If A, B, C, D.E.C. App'r0ved (Y/N) I~/~
Well Log Present~/N) "/' ' Date Completed
Total Depth'Z~Z.-I ' Cased to '7-- ~"Z'~ Depth of Grouting
Static Water Level '~'''Z~
Casing Height Above Ground ~,,~_.11,~
Electrical Wiring 'n Condu't ~1)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot -,.,~;-T
Yield ~,~ ~.'~1-1 *-sr"
Pump Set At
Sanitary Seal on Casing~TN)
Depression Around Wellhead (Y~ r'~
; On Adjoining Lots
; On Adjoining Lots
TO Nearest Edge of Absorption Fiel~o~ Lot ~
To Nearest Public Sewer IT ne,, ,/~. To Nearest Pubii(~ sewer ~leanout/Manhole
To Nearest Sewer Service Line on Lot ~ IA_
Water Sample Collected by ~5 '~/~l~.~Gt ;Date
Water Sample Test Results '~,,~.~.~,~-.~-i~-.,~--"'"~=~__..~'~. ,.~
Comments 'Y'"
B. SEPTIC/HOLDING TANK DATA
· Date Installed !~-~"~E> Size ~c)c>~ Ne. of Compartments ~---
Standpipes ~TN) ' ~' ': Air;tight Caps~3F/N) "/ Foundation Cleanout ~1)
Depression over'lank (Y~N~ ~
Pumping/Maintenance Contact on File (Y/~
,oid~ng Tank High'Water Alarm'(WN) /'~/'~"
Y
',Date Last Pumped [-~- '~.
:for
Temporary Holding Tank Permit (Y/N) ' ~/~'
To Building Foundation
To Disposal Field : '['~'~'°'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Wafer-SuPply Well ¢~ I~I
Td Property Line' I ,o ..L
TO Water Main/Service Line
To Stream, ~ond,'Lake or Major Drainage Course I ~ t..~...
Comments \
Page I of 2
C. ABSORPTION FIELD DATA ' ·
Soils Rating in Absorption Strata
Date Installed
Width of Field ' ?-.-
Square Feet of Absortion Area
Del~ression over Field (Y~:~, _ )~ Date of Last Adequacy Test
Results of ~Last Adeq~aC¥ Test ~ .z~-~-'l., ~i~'~ - "~ ~:~1.._,
Type of System Design
Length of Field "~,:=' '
Depth of Field c~, ~
Gravel Bed Thickness ~ ~
"~'~c="~ Statndpipes Present~[~/N) .. ~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
TOLotBUilding Foundat~7~_
To Water Main/Service Line
.To Property Lin~ ...~. I
To Existing or Abandoned System on
; On Adjoining Lots '"~.--'7_~ '
TO Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Drivewayl Parking Area, or Vehicle Storage Area
Comments ~' ~::~::~-<~P'~-,'~r'~ ~ ,-~
Dir~er~Sions.
Manhole/Access '(WN)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
tailed
Size in
"Pump On"
High Water Alarm Level ~
Tested for
Meets MOA Electrical Codes (WN)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that ~[ ~.a~/~l~N~iified, or conforr~ed to all MOA and HAA guidelines in effect on the
inspection.' 17034 Eagle Ewer Lm)p Road No. 204 ' "
Signed r,~la ~,jyer~ Alaska ~5~ .
Company ~//Z7 '
Date
UOA No.
Receipt No. 0-~-~///~
Date of Payment
Amount: $ 7~'/'~'/~
. ~ . Page2of2
"~ ' Receipt No. ~
Waiver Fee: $ ") ~).
Date of Payment ~-~ - I,~ -~-,
SHT.
No. 1457-E
Eagle River, Alaska 99577
17034 Eagle River Loop Road
ROBERTA. SHAFER
CIVIL ENGINEEH
694-2979
PROJECT: ~,,,.~...,e,- '[:::~_~--.~.~ - ~-'1~{::~ DATE OF TEST;
LOCATIONOFWELL(LegalDescriptlon): ~ ~ ~ ~ ~ ~~
WELL DE.H: ~ ~ ~ H
~. CASING: ~[~ ~. SCREEN:
DATE DRILLING COMPLETED: ~ -~ t - ~ DRILLER: ~ ~
STATIC WATER LEVEL ~op of Casing): ~ ~ FT. DATE: ~ - ~ ~
ELAPSED TIME SINCE DEPTH TO :)RAWDOWNI PUMPING
CLOCK PUMPING STARTED/ WATER, FT. RECOVERY RATE, GPM REMARKS
TIME STOPPED, MIN.
!\?z.-c, o 'Z.-"z~ (sw~) o 0 start ~--~o~5
\ -.,~ 20 *?.:*z._"~ '
25
.="X.~'
30 F-'~ - · ...
40
180 (3 hours)
210
240 (4 hours) "Z-'.'~ "~ ' "~' "~-'"'~
RECOVERY
t 0 -"Z..~.'"'/ ~ 0
10
15
~0
gO
35
Flow is not Guaranteed
Subsequent Variations
Can Occur.
CAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID ~ 92~40440
P~SID
Collected JY~
Recetve~ ~ON 2 89 I 16:20 hzs.
Client Name :
Client Acct: $~$~P
P.O.I NONI
~eq I
Ocde~,d ~ :
Chemleb [ef l: 5558 [eb Smpl ID: 5 Matrix: NIT[I
lllouable
Paramete~ ~ested ~esult/Onltl Method LtMt~
NITRRT~-M 0.$0 r~/1 EPA S5~.2 10
Sample lO0~l~l SAMPLE.
Tettm Pezfozmed See Special Instzuctiorm Above UA-Unavailable
None Detected "See ~ample Remazks Above
Not Analyzed LT-Less Than, GT-Czeatez Than
uniCipahty of Anchorage
Department of Health and Human Services
825 "L" Street
Tom Fink,
Mayor P.O. BOX 196650 Anchorage, Alaska 99519-6650
343-4744
June 15, 1989
Robert Shafer, P.E.
S & S Engineering
17034 Eagle River Loop
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 36 Tract B Eagle Crest S/D
Waiver Request %WR890025, HAA% HA890211
PID % 050-291-14
Dear Mr. Shafer:
Your request for waiver of the required 100 foot separation of
a septic system to a private well has been approved. The
approved separation distance from well to septic tank is 90
feet; the. lot line waiver from west property line to septic
system is 5 feet.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services.
DJR/ljw#6
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
JUN 1 2 1989
RF. CF_iVED
ROBERTSHAFER, P.E.
ROGERSHAFER
CIVIL ENGINEI:H$
(907) 694-2979
Sc[ne JO, 1989 FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORT~
WELL INSPECTION
FLOW TEST
ROAD DESIGN
SOILTEET
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
M. nicipa~y o{ Anchorage
DEPARTMEMT OF HEALTH AND HUMAN SERVICES
P.O. Box 196650
Ancho~ge, At~k~ 99519-6650
REFERENCE: Lot ~6; Tra~ B; E~g~e C~t S~b~ui~ion ~1
Req~t ~o~ ~e the ~ched H~h A~ho~v Approv~ (HAA)
g~a~ .~ ~ue~. ~o~ ~he ~o~z~.. ~cpara~on ~nce ,b~en.
~ ~tance of 90 fe~. '~o requ~t Vou~ue.~'~u~ ~o~ the
[~cpa~on '-~tan~.~ b~'~"the-6~p~c'~6~t~nd the ~t
th~ ~ in :~V, 1979 th~ w~ d~er, ~ S~van, requited a
~uer fo~ the le~6~ ~epa~a~on ~nce f~om the ~u~V of
Ancho~ge (MOA). A ~uer to ~ ~tance o~ 94 {e~ ~6 giuen bY the
MOA bV ~ of ~ note on the ~ p~lt.
A ~k a~v~l~ ~ been p~o~ed and ~ app~ t~ no
A. A plot p~n ~ho~ng the r~ue ~tance b~een the
the ~ep~c ~rt~.
{Low te~t report ~or the referenced
E. A ~ log {or the referenced
F. The ~l pe~lt mith approva~ o{ a le6~er 6epa~a~lon dl6tance.
It l~ o,r opl~on the ho~zonta~
18AAC72.0~! Z6 ~aot required in t/~, c~6e.
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Lo: $6; T~e.t 8; E~gLe C¢e.6t $~bc~u~6~on #I
$~n¢ I0, 19~9
'' MUNICIPALITY OF ANCHORAGE DEPT. OF
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~~RONMENTAL
ENVIRONMENTAL ENGINEERING DIVISION
~[QU[ST FO~ ~P~OVAL OF INDIVIDUAL WATE~ AND SEWE~ FACILITIES
DIRECTIONS: Complete alt parts on page 1. Incom~le~ r~qu~ts will not be proee~d. PI~ allow t~ (10) ~s for
PROPERTY RESIDENT (If different from above)
2. BUYER! ~)[
JPHONE
PHONE
MAILING ADDRESS
I" LEGAL D ON3
J STREET LOC(~,/~ ~(,~ ~.~TION ~*
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUI~LY [~ IND~WDUAL*
[~] COMMUNITY
[] PUBLIC UTILITY
NUMBER OF BEDROOMS
One [] Four
Two [] Five
Three [] Six
[] Other
· ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.}
SEWAGE DIS(N)SAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTI LITY
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
724)10(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TiME TIME TIME
DATE ' DATE DATE
INSPECTOR ~ INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEORO~)M~
I--'1 SINGLE FAMILY I-'1 ONE [--I 'THREE I--I FIVE r--I OTHER
[] MULTIPLE FAMILY r--I TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON-SITE .~_-- DATE iNSTALLED
I-'IPUB LIC 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, DISTANCESwELL TO: Sept'c/H°ld'ng Tank IAbs°rpti°n Area ISewer LIne INearest LOt Line
5. COMMENTS
~APPROVED FOR B BEDROOMS
[] CONDITIONAL APPROVAL (letter must f~5~'com-'~ny certificate)
[] DISAPPROVED /
LEGAL DESCRIPTION
72-010 {Rev. 3/78)
MUNICIPALITY OF ANC"HOt~kGE
MUNICIPALITY OF ANCHORAGE DEPT. O:' I:':ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTrI~NMENTAL
825 L Itmet - Andtmi~I. AJIIka e9501
ENVIRONMENTAL ENGtNEERING DIVISION MA~ ! 3 1979
Telephone 264-4720
DIRECTION~: Complete ~dl pIrti o~ page t o Imm~l~leti ~ will nas be pmelIed. IqI~It II!~ tiff (10)
1. PROPERTY OWNER
IAI LING AODRESS
ROPERTY REEIDENT (If different from M)ove) I PHONE
MAILING AODRESS (~C~
~ R~LTO~AGENT I PHONE
~ILING ADDR~
LEGAl. DII:CRIIrrlON
STREET LOCATION
6. TYPE OF R~IDENCE NUMBER OF BEDROO~
~ One ~ Four
~ SINGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISFOSALSYSTEM
~' iNDiViDUAUON.SiTE*°
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A w~ll log is required for ail wells drilled
since June 1976. For wells drilled 9rior t~,that date, give well
depth (attach log if available.) / r~ ~
I
**If individual/on-site, give ir~stellatlon date ,/~ .
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~)10(3/78)
, THIS SIDE FOR OFFICIAL USE ONLY ·
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1o TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY I--I ONE ~ THREE I-'1 FIVE I-~ OTHER
[] MULTIPLE FAMILY i'-'l. TWO I-'] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
~ INDIVIDUAL DEPTH OF WELL
i'-I COMMUNITY
DATE DRILLED
I'--I PUBLIC UTILITY
Connection Verified LOG RECEIVED
3~ SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
'~ INDIVIDUAL/ON -SITE DATE ~NSTALLED
F-IPUBLIC UTILITY
Connection Verified I ~ J~ L~ -'~
INSTALLER
'~[~SepticTank or f-lHoldingTank I A '~{~ ~%rI
Size: tC~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA
MAT~L
S. COMMENTS
~"APPROVED FOR ,~'~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (T~fle) /' ~,'~
72-010 (Rev. 3/78)