HomeMy WebLinkAboutDAWN VILLAGE BLK 1 LT 3
PERI,1I T NO.
~qLIN I C ] "F;L I l"~r~ OF Al-ICI g~:m~GE
DEPARTMENT UF HEALTH AND ENVIRONHENTAL .r~ROTEOTION
~516 E. TUDOR RD., RNCHORR~E, AK. 995~7
276-2221
~IELI~- PERr-I I 'F
77888 )
RPPL. ICANT
LOCATION
LEGAL
PETERSON CONSTRUCTION
TESHCAR ST
L~ Bi DA~4N VILLAGE
SAR BOX l?iAX
LOT SIZE
~44-8638
i~00 SQUARE FEET
HIHIMUH DISTANCE BETHEEN A WELL AND ANY ON-SITE SEHAGE ~ISPOSAL SYSTEM IS
i00 PEET POR A PRIVATE b~ELL OR ~00 FEET FOR A PUBLIC WELL.
~ELL LOGS ARE REQUIRED AND HUST BE RETURNED TO THE DEPRRTHENT HITHIH ~0 DRYS
OF THE HELL COHPLETION.
SPECIFICATIONS AND CONSTRUCTION DIRGRRHS ARE AVAILABLE TO IHSURE PROPER
INSTALLATION.
PERI'I I T ~..~AL I I];, FOR Ol%.IE 'v'EI~R FF2OI'.I ISSUE
I CERTIFY, THAT
1: I RH FAliILIAR HITH THE REOUIREHENTS FOR ON-SITE SEHERS RND HELLS RS SET
FORTH .BY THE 14UtIICIPALITY OF RNCHORRGE.
.2: I HILL INSTALL THE SYSTEH IH ACCORDANCE HITH THE CODES.
C/?:, n
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MUNICIPALITY OF ANCHORAGE
o
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel 1.0- 014-061-54
Legal description Dawn Village Block 1 Lot 3
Site address 6740 Teshlar Dr Anchorage AK 99507
Current property owner(s) Susan Pallach
Expiration Date:
12/28/2022
X The On-site system(s) is/are approved fe-r 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
CEJ
Original Certificate Date: 9/28/2022
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, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval—June 2022
H MHMPAUry OGS AHCHO ROE
Development Services Department 7 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 014-061-54
Complete legal description DAWN VILLAGE BLOCK 1, LOT 3
Location (site address) 6740 TESHALR DRIVE, ANCHORAGE, AK 99507
Current property owner(s) SUSAN PALLACH Day phone
2. ON-SITE SYSTEMS SIZED FOR 4 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: ❑
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 $ a'�U
Date of Payment 6111yb- ' gougS
COSA # DbC2,2- 1 TA
Waiver Fee $
Date of Payment
Waiver #
COSA Application—July 2022 copy 2.doc
COSA Checklist 2022 WELL ONLY.docx
COSA Checklist
Legal Description: DAWN VILLAGE BLOCK 1, LOT 3 Parcel ID: 014-061-54
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled CIRCA 1977 Total depth 98 ft
Cased to 98 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 9/14/2022
Static water level at beginning of test 18 ft.
Well production at time of test 7.1+ gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date 9/14/2022
Comments WELL WATER LEVEL ONLY DROPPED TO 31’ FROM TOP OF CASING W/ CONSTANT WATER
FLOW OF 7.1+ GPM. PLUMBING AT SPIGOT MAY HAVE REDUCED PRODUCTION.
B. TANK DATA – PUBLIC SEWER
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA - PUBLIC SEWER
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
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) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
E. SEPARATION DISTANCES
COSA Checklist 2022 WELL ONLY.docx
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No NA ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No NA ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No *40+ ft
Community Sewer Manhole/Cleanout > 100’
Yes if No **78 ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes 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 ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*MOA WAIVER – WR#040003 IN MOA DOCS. **MET SEPARATON REQUIREMENTS AT TIME OF WELL
DRILLING.
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.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 9/20/2022
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
9/20/22
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-061-54
1. GENERAL INFORMATION
Expiration Date:
Complete legal description DAWN VILLAGE SUBDIVISION; LOT ,3,
Location (site address or directions) 6740 TESHLAR DRIVE
Current Properly owner(s)
Mailing address
Lendin~ agency'
Mailing address
Real Estate Agent
Mailing address
BLOCK 1;
DEBORA &: DARRELL FLOYD Day phone
C/O DONNA ORR
Day phone
DONNA ORR Day phone (907) 240-7493
RE-MAX PROP~'RTIES 2600 CORDOVA ST. ANCHORAGE AK. 9950,:5
Unless otherwise requested, HAA will be held by DSD for pickup.
2, NUMBER OEBEDROOMS:
3.~ TYPE OF WATER SUPPLY:
4
TYPE OF WASTEWATER DISPOSAL:
Individual Well I Individual On-site D
Individu'al Water Storage D Individual Holding tank D
community class Well r-] Community On-site F'I
Public Water System [--~ Public Sewer I
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Appro.val (HAA) based only upon the representations given in paragraph 4 .by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or ClassC well and may
be reissued with new water samples. (Cedi[icates may be reissued for a period of up to one year with valid
water samples.) Cedificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
Legal Descnpbon:
A, WELL DATA '
Well type !rPRIVATE ·
Date corn ~pleted ~.UN
Total depth. ! :98 ft.::;.'~ :! .Casedto ~ 98
~ ~ ~ : "' '~'
Date oftes~
static water le~/el '
.Well ....... '" '
producbon ..~:.. .... UNK .... ;,, g.p.m.
' WATER SAMPLE RESULTS:
"
~ ~ ~' 'i~s/lO0
cOlifo~ !~';O:; c I
· Municipality of Anchorage , :
DeVelopment Services .Department
Building safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St. i:
. P.O. Box 196650 Anchorage,AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904 :
· HEALTH':AUTHORITY APPRovAL CHECKL ST
! DAWN vILLAGE suBDIvISION; LOT' 5, BLOCK 1; Parcel ID:
014-061-54
If A, B, or C prs~,ide PWSID#
Sanitary seal (Y/N) YES .
Nitrat~ ~ 0-10 mg./L.
N/A 'well L~og (Y/N)
:Wires properlylprotected (Y/N)
ft.- 'Casing hei,gh! ',!above ground)
i AT INSPECTION
10'//50~5
" ;1028 ~' g.p.m.'
Other"
bacteria
YES
YES
19+ in.
O colonies/100 mi.
Municipality of Anchorage
Mark Begichi Mayor
Building Safet3, Division
P.O. Box 196650 · 4700 Bragaw Strcct
Anchorage, Alaska 99519-6650 · (907) 343-8301 · F,mx (907) 343-8200
h ttp://xx~x~v.munt.org
1/8/2004
Jeff Garness
Alaska Water Waste Water Consultants, Inc
3701 East Tudor, Ste 101
Anchorage, Alaska 99507
Subject:
Waiver Request for 40 foot separation from well to sewer trunk
Waiver Request #WR040003
Parcel ID #014-061-54
HAA# 040007
Dear Jeff Garness:
Your request for a waiver of the required 50 feet horizontal separation from the
sewer service line to private well has been approved. The approved separation distance
is 40.0 feet.
This waiver approval applies to the existing sewer service line to private well separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
~Civil Engin°etehr
On-Site Water & Wastewater Program
I
cab-), b'r- qz.-5' ¥ Fe e"r.
'~TtY L-
Z
.88
ALASKA WATER & WASTEWATER
CONSULTANTS, INC. '
December 16, 2003
Municipality of Anchorage
Development Service Department
Building Safety Division
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Waiver for Private Well at Lot 3, Block 1; Dawn Village
To whom it may concern:
The subject lot has a 4 bedroom house on it which is served by a private well and public sewer.
The results of the field investigation and adequacy test are summarized as follows:
The static water level in the well was measured on 10/30/2003 to be 25 feet below the top of the
casing (BTC). Over a period of 2.5 hours, 1626 gallons was pumped, which corresponds to a
flow rate of 10.8 gallons per minute. The maximum drawdown was 5 feet (to 30 feet BTC).
Based upon our test results, it was determined that the capacity of the well exceeds the Municipal
requirements for a 4 bedroom house (.41 gallons per minute), and FHA requirements, in that it
will produce 3 gallons per minute for at least 4 hours. It is important to note that seasonal
fluctuations in the well flow may occur, and that future performance is not guaranteed.
According to Anchorage Water & Wastewater Utility (AWWU) records, public sewer was
installed in 1976. The connect card at AWWU indicates that the service line was inspected on
10/8/1976. The well permit was issued on 1/18/77, which post dates the installation of the sewer
main & service lines. Based upon our field measurements, and the AWWII drawings, the
well is approximately 78 feet from the manhole, and 40 feet from the sewer main. Before
1983 department regulation dictated that a private well to sewer main separation must be 50 feet
or greater.
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc, com
The encroachment has existed for over 20 years with no apparent adverse impact to the aquifer.
Recent Coliform and Nitrate samples drawn on 11/4/2003 indicated no bacteria, and 0.1 mg/1
Nitrates.
We were able to locate the drilling log for the subject well, but it contains no data on the drilling
date, or the well strata information; however, the log indicates that the depth is 98 feet. Attached
are drilling logs obtained from the wells on the lots surrounding the subject property. These logs
indicate that the water bearing aquifer exists at approximately 75 - 95 feet below the surface, and
that it is under pressure based on the wells static water level of 25 feet. The drilling logs also
indicate numerous layers of tight sands and gravels within the strata. Lot 2 Block 1 Dawn
Village's (Lot immediately east of the subject property) drilling log shows tight sand and gravel
from 10 - 30 feet, and "Very hard packed sand and gravel" between 30 - 51 feet. The well logs
for Lots 4&5 Block 1 Dawn Village indicate protective layers of dense gravel & clay at roughly
42 -54 feet.
The wells casing extends 19 inches above grade, and there are no physical depressions around
the well. The Anchorage Water & Wastewater Utility storm drainage system serves to divert '
surface runoff. Based upon these facts, it appears that there is minimal risk in granting the
subject waiver. We request that a 40 foot separation distance waiver be issued by your
department.
If you have any questions, please contact Brad Gamess at 337-6179.
assistance.
cerely.
Vr~sidqnt1
Thank you for your
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
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12/19/2005
~SI~ ~TER & ~STE~VATER ~: ~--m..' ~4~"~
-- .............................. CONSULTANTS, lNG. ~ ....... rs
DARRELL FLOYD 240-7495 (AGENT) 1 OF 2 ~[~ft ....................
DAWN VIL~GE SUBDIVISION; LOT 3, BLOCK 1
'
~E OF WORK:
SITE P~N FOR WAIVER PACKAGE
/ DAWN VILLAGE S/D', MANHOLE
J J / LOT 4, BLOCK 1,~
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ALASI_C~L!VATER & WASTEWATER s~: ff~54, i-/r~,~' "..~?0~,
.............. "- CONSULTANTS, INC., ....... , ....... ~ ......... ",:,*
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
DARRELL FLOYD (907) 240-7493 2 OF 2
LE~L DESCRI~ON: V&~"YJ' ' "~'~"~":'"
, ~,f~,":I.. ..."o~ '
~E o. WORK:
SITE PLAN FOR WAIVER PACKAGE
Sent~Ry:'~eNN& ORR REMA× PROPERTZES
907 348 7767; Dec-lO-03 15:11; Page 2/2
LOT 3, BLOC~ I HAS
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FOR: ~l-19-03
~ v~a ~,. ~ ~os
] he,by ee~y that ~e prope~y deathbed hereon
by me, or at ~ d~tion. ~d ~at ~e imp~vemen~
prope~y ly~ ~dJscent ~e~to ~le~ o~e~ee nho~.
~p~vemente on ~e prope~y ]~ng adjacent ~ere[o e~eroae~
premises ~ questto~ and ~at there ere no roadway,
It ia the respo~hi~ty of ~e .o~er or builder, prior'to conn~uction,
conae~ns and to dete~e ~e e~nt~nee of any ean~men~, coveneutn.
or ~st~ctJons which do not appe~ on the recorded ~u~i~on
Reproduction may cause distortion.
MUNICIPALITY OF ANCHORAGE
/~ ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ; - , ,.
825 L Btmet. Anchor~e, Alask~ g9501 · '~' .: "~
ENVIRONMENTAL ENGINEERING DIVISION ' '. 2, ' i [ ~ ! I
Telephone 264-4720
REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page $. Incomplete requesl~ will not be processed. Please allow tan (10) days for processing.
1, PROPERTYOWNER I PHONE
John Bradford I 344-4004
MAILING ADDRESS
6740 Teshlar 99507
PROPERTY RESIDENT (If different from above) PHONE
Z, BUYER PHONE
Edwin F. Pauley 277-9144
MAILING ADDRESS
3830 Parsons #5 99504
3. LENDING INSTITUTION I PHONE
Lo~_~_s and Nettleton Company [ 274-7661
MAILING ADDRESS
4449 Business Park Boulevard 99503
4. REALTORJAGENT '1 PHONE
Bob Booth ! 276-2766
MAILING ADDRESS
1709 Bragaw Suite A 99504
LEGAL DESCRIPTION
Lot 3 ~lock 1 Dawn Village Subdivision
NUMBER OF BEDROOMS
[NCE
Xg~l( SINGLE FAMILY
[] MULTIPLE FAMILY
1-'1 One [] Four
[] Two [] Five
g~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON*SITE**
:X~)[ PUBLIC UTILITY
* 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.)
** If individual/on-site, give installation 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.
72.010131781
. ~,JTHIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
.5 -~- %' tD~,d/
INSPECT~/~i ~ INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY ~ ONE ~ THREE ~ FIVE D OTHER
~ MULTIPLE FAMILY ~ TWO ~ FOUR ~ SIX
PERMIT NUMBER
2. WATER SUPPLY
~ INDIVIDUAL DEPTH OF WELL
D COMMUNITY
DATE DRILLED
~ PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISP~AL SYSTEM PERMIT NUMBER
~ INDIVIDUAL/ON -SITE DATE INSTALLED
~ PUBLIC UTILITY
Connection Verified . INSTALLER
~Septic Tank or ~ Holding Tank
No. 742472
TYPE OF TANK MANUFACTURER
TOTAL A~ORPTION AREA MATERIAL
4. DISTANCES ~ptic/Holding Tank lAnD.don Area
WELL TO:I
A~o~ption Area to neer~t Lot Line
5.
COMMENTS
-- ....
~ APPROVED FOR BEDROOMS
~ CONDITIONAL APPROVAL (letter must accom~ny certifica]
~ DISAPPROVED
OATE BY (Title).//~
72-010 {Rev. 3/78)
r"T. UN C PA,- V ^Ncuo.AG
Department of llealth and Environmental Protection
825 L Street, Anchorage, Alaska 99501.
279-2511, ext. 224,. 225
~quest for Approval of Individual Sewer and Water Facilities
Property Owner:
Mailing Address:
John Brad fo?d
6740 Teshlar ,Anchorage,Ak.99507
Phone:
344-4004
e
Name of Buyer:
Edwin F. Pauley
Mailing Address: 3830 Parsons ~;5 ,Anchorage, Ak.99504 Phone:
277-9144
Lending Institution:
The Lomas &'Nettleton CoJ
Mailing Address:
4449 Business Park Blvd. Phone: 274-7661
Realtor/Agent:
Bob Booth
Mailing Address: 1709 Bragaw '!Ste.A~Anchora~e~Ak.
Legal Description': Lot 3,Blk.1 Dawn Village s/d
Phone: 276-2766
Street Location: Te.~hlar
0
Single Family Residence:
Multiple Family Residence:
(X) Number of Bedrooms:
· ( ) Number of Bedrooms:
'7.
Water Supply: *Individual Well ~)
If Individual Well, well depth
If Community Sys'tem, name of system
Public/Community System
( )
Sewage Disposal System: On-site System ( ) Public System (W)
If On-site System, date of instal].ation:
*NOTE:
A well log is required on ALL wells drilled since~tlr~ OF ^NCHO2A$~
DEPL OF HEALTH &
[NVIF-ONMENTAL PROfECTION
APR 2 ? 1978
RECEIVED
~/~0~''~ MUNICIPALITY OF ANCHORAGE
~.,,,,,,.~':, D EPARTM E~'"',OF HEALTH AND ENVI RO NM EN T~'~, PROTECTION·
~?,~ ~.0 82,5 .L Street, Anchorage, Alas~ 99501
279-2511_./~ ~ Date Received: May 4, !977
'~'~'~"'-/"\'~') ,/~Oj' , ext. 224 or 225
#1: Time 2:30 p.m. #2: Time ~3: Time
Date 5-4-77 Tues Date Date
Insp Pratt Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request:
Mailing Address: Post Office Box 1120
Alaska Mutual Savings Bank
99510 Phone:
2. Property Owner: Pederson Construction Phone:
Mailing Address: Star Route A Box 1718X
3. Legal Description:
99507
Lot 3 Block 1 Dawn Village Subdivision
274-3561
344-8638
4: Single Family Residence: (x)
Multiple Family Residence: ( )
Number of Bedrooms:
Number of Bedrooms:
Well SYStem: Individual Well (x) Community/Public System ( )
Permit # 77008 Depth of Well 98' Well Log on File ( )
Construction Bacterial Analysis
J
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System ( ) Public Utility ~x)
Installed Installer
Manufacturer
Soils Rate Material
Distances: Well to Septic Tank
to Sewer Line Nearest Lot line
to Nearest Lot Line
to Absorption Area
Absorption Area
'Page Two ..,' .
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description:
Lot 3 Block~l Dawn Villa~e~Subdivision
Comments:
Affadavit Attached: ~(~)
Letter Attached: .( )
Approved:
Disapproved:
Date:
Department Worksheet: