HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 37MUNICIPALITY OF ANCHORAGE
Development Services DepartmentUqPhone: (907)343-7904
On-Site Water & Wastewater SectionFax: (907)343-7997
Parcel ID 050 -282-20
Certificate of On -Site Systems Approval
OSC241497
Expiration Date:
l
Legal description EAGLE RIVER HEIGHTS BLK 2 LT 37
site address 10132 CHANDALAR ST
Current property owner(s) DAVIS BRIAN & CANDIDA
The On-site system(s) is/are approved for bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By: i /� ��-- Original Certificate Date:
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
Ddvelopment Service Department (DSD) issues COSAs based upon representations provided by an
Mdependent professional engineer. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X
Absorption Field Advisory
Tank Age Advisory
Other
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section CDJ Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcell.D. 05028220000
Complete legal description Eagle River Heights L37 132
Location (site address) 10132 Chandalar Street
Jeremy Rawley/Mai Yee Thao
Current property owner(s) Day phone
2. ON-SITE SYSTEMS SIZED FOR -,')_BEDROOMS
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑■ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑■ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑N
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ q 14 � Waiver Fee $
Date of Payment
COSA # Q SC -2- y 11-1 q 7
Date of Payment
Waiver #
COSA Application—June 2022
COSA Checklist
51/
Legal Description: Eagle River Heights L7,'B3 Parcel ID: 05028220000
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
X Well log is filed with Onsite (or attached)
Date drilled 4-16-15 Total depth 111 ft
Cased to 111 ft
Sanitary seal is functioning correctly
Q Wires are properly protected
Casing height (above ground) 22 in.
Date of flow test for COSA 10-2-24
Static water level at beginning of test 67 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank _
Date of pumping
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Well production at time of test 4.9 gpm
Water storage tank volume 35 gallons
Well disinfected for coliform test? ❑ Yes F No
A Coliform bacteria is Negative
Nitrate 6.23 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L F Arsenic less than MRL (ND)
Collected by Tom Klebesadel
Date 10-3-24
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings)
Effective depth used in
Effective depth remaining in
Comments/Deficiencies: Residences on this property are served by a community/public wastewater system.
COSA Checklist June 2022
In
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
❑ Yes
Septic Tank/Lift Station on Lot> 100'
N/A
Surface Water> 100'
Community Sewer Manhole/Cleanout>
100'
❑Yes
if No_ft
_ it
Wells on Adjacent Lots:
Yes
if No ft
Neighboring Tank> 100' E] Yes
if No N/A
ft
Private Sewer/Septic Line> 25' E] Yes
if No N/A ft
Absorption Field on Lot> 100' ❑ Yes
if NoN�A
It
Holding Tank > 100' El Yes
if No N/A ft
Neighboring Absorption Fields > 100'
N/A
❑ Yes
Animal Containment > 50' E] Yes
if No N/A It
❑ Yes
if No _
ft
Community Sewer Main > 75' QYes
if No _
ft
Manure/Animal Excreta Storage >>1100'
Yes
N/A
if No ft
❑ N/A— Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations> 10'
❑ Yes
if No
_ It
Surface Water> 100'
❑ Yes if No _ It
Tank to Property Line > 5'
❑ Yes
if No
_ it
Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes
if No
_ It
Private Wells > 100'
❑ Yes if No _ ft
Water Main > 10'
❑ Yes
if No
_ It
Community Wells > 200'
❑ Yes if No _ ft
Water Service Line > 10'
❑ Yes
if No
_ it
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
NameofFirm PPA/n&w
Phone
907-863-2455
Engineer's Printed Name
Date
of: AfA-''Xi)
1
1
Ij
COSA Cheddbt_June 2022
w
CL
cu -Oo
U) m
W
Y N O N
E N Y V
�o 23-
(n T a
E E (n
o a) o
O Y a)
aa)) c U Z
0 o B F-
a a U
a
ca
LL
a) m
E (cn,
0
O
U
0
0 (n
T of
a)
LL
U
C
LO
LL
X
Qj N
E LNu
a
L'
0
U
a)
� w
a) 7
0
m
O
4
N
(D
N
U
J
J
C1
c
a)
C
0)
C
w
a`)
a)
C
O
WI
O
N
O
LO
N
0
ti
Y
O
0
n
in
>
�
c
o
w
o
ca
N
Q
O
U
C
>
a
U
m
L 2
Cl)
J 6
o
a) a)
r �
u)
E
a)
E 3
Oco
a�
a
w (n
o
Q
O
od
a)
j, LL
a)
m
06
a
a)
U) .�
v
_ a
N C
m
(n
O �
.0
N
N Z
O
aj
d U
> c
U
W m
o
Z
a
�>
U
O N
T N
E
`1
Q
(^O N
(h
O O
U
C
U
w�
w o
�
m
U
CN
OU)
(n
m U
a)
L�
a> a
.CL
0
0 m c
❑ J
0 Co
(E9
Z Q
C
0
o 0
N
u) N
Lu
0 >
Q) a�
E
-0
cn
O O
C
a
w
CO
m
U) (1)
'
N
U
ca
LL
a) m
E (cn,
0
O
U
0
0 (n
T of
a)
LL
U
C
LO
LL
X
Qj N
E LNu
a
L'
0
U
a)
� w
a) 7
0
m
O
4
N
(D
N
U
J
J
C1
c
a)
C
0)
C
w
a`)
a)
C
O
WI
om
0
n
in
>
w
—
oo
o
>
E
E
Y
Y
Y
U
0
c
U
U
U
U
U
U
w�
m
LU
U)
U) (1)
'
d
J
L
N
� al L
rn
6 L V
7 v
O F-
~
O
Q
o C
C�
a
as
0
O J
L
(D N
� 9 U
7 C
J N
J N
e
'
Q
C U
C
Aca
a
Y �
C CL
>
~ V N C5
J
�Wy
Y U O
o-
c cXa
) m :�
� F
E
CL
m
N
O
r
O
O
3
Lri
Lri
v�
�
v
0
L.
O
>
LO
n
(D
4)
O)
@
m
O
N
V
(O
>
F-
Q
c
O O ti
m E C
E =3 o
N
v
o
O O (U
C >
N
>N75
> >
J ^
� v
m w
OO
O
co
Lo
V
N
N
OM
m
m
m �
Cl)
(
o
LO
LO
O
LO
1-
M
O
N
LO
V
V
ca
LL
a) m
E (cn,
0
O
U
0
0 (n
T of
a)
LL
U
C
LO
LL
X
Qj N
E LNu
a
L'
0
U
a)
� w
a) 7
0
m
O
4
N
(D
N
U
J
J
C1
c
a)
C
0)
C
w
a`)
a)
C
O
WI
ENGINEER'S EVALUATION
ON-SITE DRINKING WATER &
WASTEWATER DISPOSAL SYSTEMS
Property Description (Legal): Lot 37 Block 2 of Eagle River Heights
Physical Address:
Owner's Name(s)
Owner's Address:
Serving:
No. of Bedrooms:
10132 Chandalar Street
Jeremy Rawley & Mai Yee Thao
1800 S Butternut Avenue
Broken Arrow. OK 74012-5920
Single Family Multi -Family (No. of Units
ON-SITE DRINKING WATER SYSTEM:
Property Served By:
Property is served by a Public Water System, approved by ADEC and currently in monitoring compliance.
BK Recent water samples have been tested by a certified ADEC laboratory. Sample results were found to meet
current ADEC drinking water standards for coliform bacteria levels.
Notes: Well produced an average flow rate of 4.9 gpm during testing with 6 feet of drawdown.
ON-SITE WASTEWATER DISPOSAL SYSTEM:
disposal system was installed by an ADEC Certified Installer and/or Registered Engineer.
This wastewater disp stem was tested in accordance with current ADEC policies and was found to
be operating adequately. The re dentifiable features of the system were observed and documented.
From visual site evidence and ADE entation on the system's installation it appears this
system was installed to meet 18 AAC 72 regulate d ADEC policies at the time of installation.
No documents are available for the design or construction of t 1 em. It appears the system
meets the separation requirements outlined in the current ADEC regulatio AC 72. It also
appears the system meets other ADEC policies that were in place at the time of insta
Notes: Septic system was not evaluated.
This report portrays the conditions found on the date the system(s) were testedlinspected and to any documents obtained from
ADEC or other agency. This report does not constitute a guarantee, explicit or implied, for the firture performance of this
water supply and/or wastewater disposal system.
Company Job No
Inspected By:
2024 -109 -RM
Thomas Klebesadel
Engineer Responsible: William Klebesadel, P.E.
Date: 10-6-24
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC241497
Subdivision: Eagle River Heights, Block: 2, Lot: 37
907-343-7904
Fax: 343-7997
A water sample revealed a nitrate concentration of 6.23 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
HUNIClPALITY OF AHCHORACE
DIVISION OF ENVIROI~iF-NTAL HEALTH
DEPARTHENT OF HEALTH AND ENVIRONHI~NTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. Ge.eral I.formation Applicatio. Da,e.. ~//~//~,~'-
(a) ~gal.o~ Description ~ F~/'~ (include ~,~ lot, H~. block, 7-/~ ~1/subdivision, ~.D ~c) section, .~¢c township,/l~, range)
Location (address or directions)
(b) Applicants Hame ~/~6,-,,~
(c) Applicant is (cheek one) Lendin~ I-stifu~io.
Buyer [--~; Other ~ (explain);
(d) Lendin~ Institu=ion ~! / ,~ Telephone
Address
(e) Real Estate Co. & Agent
Telepho.e ~'~/~
(f) Hail the HAA to the followin~ address:
2. Type of Reside.ce
$i.gle-Famlly..~...
Number of Bedrooms
Hulti-Family~--~
Other {describe)
3. Water Supply
I.dividual Well~
Note: If community well system, must have written confirmation from the State
Department of Eoviroumental Conservatio. attestin~ 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 Enviro~ental Conse~atlon attesti~ to the legality a~ status.
[Page 1 of 2]
Engineering Fir~ Providin~ lnspections~ Tests~ File Search~ Data and
As certified by my seal affixed hereto and as of the validation date sho~u below,
verify ~t my inves~i~a~ion of ~h~s Health ~thority Approval sho~ ~t the o~site
~ater supply a~/or ~s~e~ater disposal system Is safe, f~c~ion~ a~ ~equa~e for
~he number of bedrooms a~ ~pe of structure i~ica~ herein. I further verl~y
based on ~he info~ation ob~ain~ from ~he ~nicipality of ~chorage files
inves~iga~ion a~ inspection, ~he o~si~e ~er supply a~/or ~s~e~a~er d~s~sal
system is in compliance ~th ~I ~nicipal a~ State c~es, ordinances, a~ regula-
=ions in effect on 2he da~e of chis inspecCion,
Approved / Disa
Ter~s of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE I~PAR~iENT OF [~LTH AND EL"~IROL%~NTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON TUE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN ~uE STATE OF ALASKA, TH~ II/EP DOES THIS AS A COt~TESY TO PURCHASERS OF H0~ES AND
TREIR LENDING IR"3TITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
I~NTS, EHPLOYEES OF ~tEP DO NOT CONDUCT. INSPECTIOL~ OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED, THE ~7~NICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OHISSION~ LN T~ PROFESSIONAl, ENGINEER'S ~ORK,
(DHEP SEAL)
RR6/e~/D18
[Page 2 of 2]
7-19-84
D[~L OF H[,',LTII &
[ N',"J~O N,V, ENTAL F~L.,i..~TION
A. ~ELL
MUNICIPALITY OF ANCMORAGE (MO~)
HEALT~ AUTHORITY A~P~0VAL
CHECKLIST - FEBRUARY 1984
Legal, Description:
Well Classification ~/~ ~"
Well Log P~esent (Y/N)
Total Dspth k Cassd to
Static Weter Ls~sl ~
CasinG?s.ight.. Abo~ G~und ~
Electrical Wi~irg in Conduit ?Y/N)
Separation Distar~ss. f~cm Well: k
To Septic/HoldinG Tar~ cn Lot
To Nsaz~st Edge of Absorption Field ~ Lot
To Nsa~est Public Se~ Line k
Ware= Sample Collected By
Water Sample Tsst Sesults
1,1AR 1 4 'Lg85
.RECEIVED
If A, B, ~ C, D.E.C. A~(m~d(Y/N) Y~ W-~l~
D~te Cc~pleted Yield
Depth of G~outin~
Pu~ Set At
Sanits~y Seal on
De~ession A~ound Wsllhead (Y/N)
; On ~djoinin~ Lots
; On AdjoininG Lots,
To. Nsa~est Public Ss~r
To,Nsa~est Sewsr Servi~e Line on Lot
"x
Be
To Property Mne
To Water Main/Se~vine Line
Course
Dete Installed % Sizs No. of Compartments
Standpipss
Airtight Ca~ (Y/N> Foundation Cleanout ,(Y/N)
De~ession over Tank .(Y/N) ~te r~t Pumped
PumpinG/Maintensn~ Contract on Fi~ (Y/N) ; fo~
HoldinG Tank High-Wate~ Alarm (Y/N) X Tempc~a~y HoldinG Tank Permit (Y/N)
Separation Distances f~cm Septic/Holdi~ Tank:
To Water-Supply Wsll ko Building Foundation,
i~al Field
[Pa~ 1 of 21
Ce
Soils Rating in Abso~pticn Strata
Date Installed ~ '
Width of Field k
Square Feet of Absorption A~ea ~
Daix~ssion o~er Field (Y/N)
Rasults of Last ~isguacy ~sst \,
Separation Distance f~cm Abscmption
To 1~ate=-Supply I~11
To Building Foundation
Lot
To 1~ater Main/Se=vice ~.ine
TO St~eam~/L~ke/c~ Majo~ ~ainage Ccu~se
T~e o~ System Dasi~
Length of Field
Depth of Field
C~avel ~ed Thickness
Standpipes P~esent (Y/N)
Date of r~t ;~eguacy ~st
k, To l~o~erty Line
\,To Existing ~ Abandoned System
; On ~djoining Lots
~ ~(if ~nt)
To D~i~sway, Pa~kirg A~ea, c~ Vehicle Stc~age A~ea
C~nta - · k
De
Date Installed
Si~ in Dall~ns
'Pump On' Level at
High Water Alarm Level at
Tested fo~
Electrical Codes(Y/N)
Cce~enta
Dimensions
Manhole/A~cess (Y/N)
~%~mp Off" Level at
VeP. t (Y/N)
7~st. Meets MOA
** (~eck Pe~mftted Bed~o~a Rating l~ainst tIAA Raqusst
I ~tify that I have c~ecked, ve=ified, c~ oonfc~msd to all MOA HAA Guidelines in effeCc
on the date of this irspection.
K~/dS/s
[Page 2 of 2]
MOA No. J T
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
CONSTRUCTION AND OPERATION CERTIFICATE.
for
PUBLIC WATER SYSTEMS
APPROVAL TO CONSTRUCT
Plans for the oe,,~4e~mth3n or modification of
public water system located
, Alaska, submitted In accordance with 18 AAC 80.100
have been reviewed and are
[] approved.
Jconditionally approved (see attached conditions).
TITLE DATE
If construction has not start;d within two years of the approval date, this certificate Is void and new plans and
specifications must be submitted for review and approva~ before construction. ~
/
Approved by Date
K
The "APPROVAL TO OPERATE" section must be completed and signed by the Department before any water
is made available to the public.
The construction of the
public
water system was completed on (date), The system Is hereby
granted Interim approval to operate f~r 90 days following the completion date.
BY TITLE DATE
As*built plans submitted during the Interim approval period, or an Inspection by the Department, has confirmed
the system was constructed according to the approved plans. The system Is hereby granted final approval to
operate.
TITLE DATE
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Inspection
Date of Inspection
e
4.
5.
6.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Approval 'requested by: ~y/F' ~ ~
Mailing Address: ~ Phone:
Property Owner: ~ Phone:
Mai 1 trig Address:
Legal Description: ' 7 ~ '~ , '
No. of bedroems
B. Depth
Location: ~_../,~,~/~',i;~,~,-.~ ~-~',
Type of facility to be inspected ~'~
Well Data:
A. Type
¢. Construction
Sewage Disposal System:~4.~l:~.~
A. Installed B. Installer
C. Septic Tank: 1. Size 2. Manufacturer
e
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank , Absorption area , Sewer Lines ,
Nearest lot line , Other contamination
B. Foundation to septic tank , Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
3330
'GREATER ANCHORAGE AREA BOROUGll
Department of Environmental Quality
"C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
Type of Inspection: CMRO VA FHA CONV J
Property Owner: ~~~
Mailing Address:
3. Name of Buyer: {~~
Hailing Addres~s:~~_ Day Phone
4. Name of Lending Institution:
Hailing Address: ~. ~._ ~'~)~ t/~.'~ Phone ~7
5. Name of Realto~ or Agent: ~-
~ailing Address: Phone
· age 2 of two pages - R~ .or for Approval of Individual . . ,r & Water Facilities
, Legal Description
Approved Disapproved ~ate
Approval ~Valtd for one year from date signed
Greater Anchorage Area Borough, .Depar.~ment of Environmental Quality
DIAGRAM OF SYSTEM
3;'
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ-034 (1/74)
Date