HomeMy WebLinkAboutDAWN VILLAGE BLK 2 LT 4Dawn V ill ag
lock 2
Lot 4
014-061
-42
PERItIT NO.
~'IU~! I C I PI:IL I T~r~ L-)F 8~lt3HORI--IG ~F,
DEP~R~IiENT OF HERLTH 8ND ENVIRONHENTSL PROTECTION
~516 ~. TUDOR RD. ~ RNCHORRGE~ AK. ~9507
276-2221.
I~ELL. PERI'I I T
( 77015 >
APPLICRNT
LOCATION
LEGRL
~ETERSON CONSTRUCTION
I'ESHCSR ST
L4 82 DAHN VILLRGE
SR8 80X i?iS×
LOT SIZE
344-86~8
10000 SQURRE FEET
MINIHUI'! DISTRNCE BETWEEN 8 NELL 8ND RNY ON-SITE SEN8GE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVRTE NELL OR 200 FEET FOR R PUBLIC NELL
HELL LOGS RRE REQUIRED RNO MUST BE RETURNED TO THE DEPRRTHENT NITHIN
OF THE NELL C~tPLETION.
SPECIFICRTIONS AND CONSTRUCTION DIRGRRHS RRE RYRILRBLE TOiINSURE PROPER
INSTRLLRTION,
PERI'"I I T ',./8L I D FOR O~E ~E,~]R FROIfl ISSUE
I CERTIFY THaT
i: I RIi FRHILIRR I,IITH THE REQUIREHENTS FOR ON-SITE SENERS RND NELLS RS SET
FORTH BY THE ItUNICIPRLIT~ OF RNCHORRQE.
2: I HILL INSTRLL THE S~STEI'I IN RCCORDRNCE NITH THE CODES.
/ )~, ,,":j ~,;.;..~ ...... . :..~
S 16NED: ___~_~ ....... r ........ ~--~' --
RPPLIC~NT PETE~SgN CON_TRLCTION I
SUBSURFACE EXPLORATION
Shift Report of Operations
PEDERSC~I CONS~UCTI~;, INC. Dawn Subdivision, Lot ~, Block 2
Domestic Well
· WESTERN STATES ASSOCIATES 22W
FROM
TO
Ken Johnson
TIME DISTRIBUTION HOURS
RIG HOURS
NO.
6
7
8
9
10
11
CASING LOG
LO ' 3~,"
,o. SOILS LOG.
Test pumping:
DRILLER
DEPTHS
TO
MATERIALS AND REMARKS
Sand and gz-~vel with surface water -- loose
Compact ~z-~vel and silt
Compact 6~-~vel and silt
Black silty clay
Gravel with clay - seeps water
Gl-avel and g-r~y silt. Water seel~d into 70'
while welding.
Casing pulled ~ck to depth of
Water cleared after brief ttmo. Pumped 10 gpm.
INSPECTOR
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. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. o~4,-o6~-42
GENERAL INFORMATION
Complete legal description Dawn Villaqe, Block 2 Lot 4,
Location (site address) 673~ Teshlar Drive, Anchorage, AK 99~o7
Expiration Date:
Current .Property owner(s)
Mailing address
Lending agency
Mailing address
Deborah & Scott Mitchell
67~ Teshlar Drive, Anchorage, AK 99qo7
Day phone 360-4605
Day phone
Real Estate Agent Raney Hardman/ReMax of Eaqle River
Mailing Address 36th
Unless Otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4,
Day phone /+~0-72~7
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site j--J
[] Individual Holding Tank J--J
[] Community On-site J--J
[] Public Sewer J~
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 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(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services, LLC Phone 272-8218
Address P.O. Box ~LOO2ZT, Anchorage, AK 995xo
Engineer's Printed Name Steven R. Pannone, P.E. Date '~/(~; / [ ~
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water
levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
!/ Approved for L//. bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Dawn Village Block 2 Lot 4
A. WELL DATA
Parcel ID: o=~-o6a-42
Bm
Well type _P
Date completed altair, q?7
Total depth 96 ft.
Date of test
Static water level
Well production =o
WATER SAMPLE RESULTS:
Coliform _~:~)_colonies/100 mL
Arsenic: [~,~ ug/I
iEPTIClHOLDING TANK DATA
If A, B, or C provide PWSID # ~
Sanitary seal (Y/N) Y
Cased to ~ ft.
FROM WELL LOG
~1" q77
Not Noted
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 24+
AT INSPECTION
7/3.6/2o~o
ft. 24 ft.
g.p.m, zr.o8 g.p.m.
Nitrate ~)~) mg/L
Date of sample: ?1~612o~o
in.
Other bacteria ~ colonies/100 mL
Collected by: .L.aura Pannone
Tank Date installed
Tank size ~ gal. Number of Compartments ~ C (Y/N)
Foundation cleanout ~ High water alarm (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date installed ~ Soil rating System type
Length ft. ~ ft. Gravel below pipe ft.
Total depth ft. Eft. area ft2 Mon'~ng tube. Depression over field
Date of adequacy test Results (Pass/Fail) ~For bedrooms
Fluid depth in absor~on field before test. in. Water added~~ New depth in.
Elapsed Tim~e~~ min. Final fluid depth in. Absorption~ rat =
g.p.d.
Any~enation treatment-~ (past 12 mo.)(Y/N & type) If yes, giv~e ate
LIFT STATION ~P;cYe~P~
Date installed Size in gal
"Pump on" level at~ in. .
Datum
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
On adjacent lots NIA
Absorption field on lot N/A
On adjacent lots N/A
Public sewer main ~o+ Public sewer manhole/cleanout .~o+
Sewer/septic service line ~.e+ Holding tank N/A
Animal containment areas ~.eo+ Manure/animal excrete storage areas ~.oe+
Building fern ~ Property line /- Absorption field.
Watermain ... ~ Water se 'p~~line Surface water_
Wells on adjacent lots ~ -
SEPARATION DISTANCE F/I~IMABSORP'TIQ~IELD ON LOT TO:
Property line ,,~ Building foundation . ~ Water main
Sewi~e Sa rface water ~ng/vehicie storage
Water
. Curb~l'drain ~
Wells on adjacent lots
COMMENT~
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.
Engineer's Printed Name Steven R. Pannone, P.E.
COSA Fee $ ~-~
Date of Payment
ReCeipt Number
(Rev, 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewatcr Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # 101133
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 2, Lot 4 of
Dawn Village Subdivision. This inspection revealed an arsenic concentration
of 17.5 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. Information on arsenic is
available from the On-Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1103495001
Pannone Eng. Srv.
Dawn Village Bk2 Lot4
6731 Teshlar Dr
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
07/21/2010 8:57
07/16/2010 13:00
07/16/2010 15:00
Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic 17.5 * 5.00 ug/L EP200.8 C (<10)
07/16/10 07/19/10 KDC
Waters Department
TotalNitrate/Nitrite-N ND 0.100 mg/L SM20 4500NO3-F B (<10) 07/19/10 AYC
Microbiology Laboratory
E. Coli Nelzative 1 100mL SM20 9223B A 07/16/10 DLC
Total Coliform Negative 1 100mL SM20 9223B A 07/16/10 DLC
/ 25' ~42.?s' Nsoo 52'
l
/
~ 47.~~ t ............ I, -.
7.0' 5.0
3
PLOT PLANS ~ LOT SUR~YS NOTE:
~ONS~UG~ON, TO ~FY ~OP~ ~I~INQ ~ADE EELA~ ~O~, ~S, ~. ~C CLE~T~ ~OEWALKS, ORI~A~.
SUR~Y ~R~RCA~ON '- -*~~1 Prepared by
,,~. ,~g ~. A ~,. Robert E. Johns, Jr. & Assoc.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
C(~mplete legal description
Location (site address or directions)
Property owner
Mail{ng address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone.
Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Communiiy well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOAl121
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 of this Health Authority Approval application 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.
Name of Firm / G~.~.g~'f 'J ¢' [/'---/.z~. J ~>~ Phone
Address ~.4~ '~ 12~'
Engineer's signature ~-- ?,?,,~-'~ ' Date
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
. bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections.or analyze data before a certificate is Issued. The Municipality of Anchorage is not
responsible for error~ or omissions in the professional engineer's work. '. ,.
72-025 (Re~. 1/91) Bac~ MOA #21
Municipality of Anchorage r '
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ..~OM.4A~ Parcel I.D. ,. (~) / ~ -- ~) (P// - ¢7/7._
A. WELL DATA
Well type ~
Log present (Y/N) y
Total depth · ~ (,~
Sanitary seal (Y/N) Y
Date of teSt
Static water I~vel
well flow
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed · 1¢77 Driller
Cased to ' ~(.~ Casing height
Wires properly protected (Y/N)
FROM WELL LOG
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot ~//~
'Public seWer main ~
Sewer serVice line ~ /
WATER SAMPLE RESULTS:
~01iform '~' '* Nitrate
,
Date of sample: .~' ~' ~'
B. SEPTIC/HOLDING.... TANK DATA :
Date installed Tank size
Cleanouts (Y/N)
High water alarm (Y/N)
Date of Pumping · ~
g.p.m.
AT INSPECTION
': On adjacent lots
; On adjacent lots /~/~ ' '
Public sewer manhole/cleanout '~'~)
' ' ,Petroleum tank
Nb .. Other bacteria Tj~rT"~'"'/ ~-//~?v~''
Collected by: ~-.-'~
Foundation cleanout (Y/N)
Alarm tested (WN)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Compartments,
Depresslor~ (Y/N)
Well(s) on lot ' Onadjacentlots Foundation
'To p~operty line ....... Absorption field ........ ;Water main/serVice iir~e "' "
Surface water/drainage
· :" ' CONTI':"-'-'DNUE
72-026 (Rev. 7/91) Front ~ '
ON
BACK
PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) ' '*
."Manu'facturer ,"
Manhole/Access (Y/N)
.... Pump off" level at.
"Pump on" le~/el at"
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N) ~ '" r' '
SEPARATION DISTANCE FROM LIFT STATION TO: '" ' "::. ' :~
Well on lot *'" On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
~' * · '- Surface Water
Length ': Width -
Total absorption area
DepressiQ.!~ over field (Y/N)
Results (pass/fail) for
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
' Well C~n 10t On adjacent lots
Soil rating System type
Gravel thickness Total depth
cleanouts Present (Y/N)"'
Date'of adeqUacy test
'" : I'f Yes, give date !
'Property line
bedrooms
~To building foundation
On adjacent lots
Surface water
Curtain drain ·
E. ENGINEER;S CERTIFICATION
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effecton the date of this inspection.
Engineer's Name I "~, ~ *
Date F"~'/") / "~t [ ~ I~.~ ~_
HAA Fee $
Waiver Fee: $
Date 0f Payment
Date of Payment
Receipt Number
Receipt Number
72-02~ (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET
ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
A~A~$I$ I{ESULT$ for INVOICe. ! 51057
Chemlab P, ef.I 92.0554 $~ple ! I ~trtx: WATEP,
FAX: (907) 561-5301
Client Sample ID : POTABLE 4/2 DA~N
PW$ID : UA
Collected : ~EB 12 92 ~ 10:30 hrs.
~eceivod : FEB 12 92 ! lA:30 hzt.
Preserved vlth : AS
Client HaM :YOBBEN SPUI~KLAND, P.E.
Client lcct :TOBBEN3
BPO! : POt :NONE hECEIVED
heql :
Analyele Co~pletod : PEB 12 92
Send Reports to:
I)~08BEN SP~[LAND, P.E.
2)
ParaMter [osults Units Method Allowable Liaits
NIT~ATE-N ND(GAO) hq/1 IPA 353.2 lO
~mple BOUTINE 5A~LK COLLECTED BY: 5P~KLAND.
I Teats PerforMd * See Special lnftzuctions Above UA-Unavailable
ND- None Detected '* leo Sanple ReMrks Above
NA- Not Analyzed LT-Leee Than, GT-Greater Than
Member of the SGS Group (SociOtd Gdndrafe de Surveillance)
TIME TIME TIM'I~
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE E~IRONM~NTAL Pr, OTE~ION
) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 LStr.t-Anchor~.AI.k.~501JUN 2 3 1981
ENVIRONMENTAL SANITATION DIVISION
~ ~ ~/REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all pa~s on page 1. I~omplete r~u~ will not ~ pr~d. Please allow ten Il0) days for processing.
1. PROPERTY OWNER I PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
MAILING ADDRESS
4. REALTOR/AGENT q ~O . ~LL~I,[ ~f ~m* ~
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
kLe ,
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
I--'1 One [] Four
15q SINGLE FAMILY [] Two [] Five
MULTIPLE FAMILY '~ Three [] Six
[] Other
7. WATER SUPPLY
/~ INDIVIDUAL'
COMMUNITY
t-'1 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.) .~
8. SEWAGE DISPOSAL SYSTEM/
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
.YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(Rev. 6/79) //.,~,~, ~
THIS SIDE FOR OFFICIAL USE ONLY ..
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY I-'] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SiX
PERMIT NUMBER
2. WATER SUPPLY , ·
[] 'INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
D ' PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
Connection Verified ~"["'~ (--' INSTALLER
[--ISeptic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
I
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
~APPROVED
DATE BY
72-010 (Rev. 6/79)
f(~"-~<' 'DEPARTMENT ~'F HEALTH AND ENVIRONMENTAI,'-PROTECTION
1st Inspection: Time 11:30 a.m. 2nd Inspection: Time
Date 3-14-77 Mondav
Inspector. Kennedy
Date
Inspector
REQUEST FOR APPROVA5 OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: Alaska Mutual Savings Bank
Mailing Address: Post Office Box 1120 99510 Phone: 274-3561
2. Property Owner: Elden Pederson
Mailing Address; Star Route A Box 1718 99507
Phone: 344-8638
3. Legal Description: Lot 4 Block 2 Dawn Village
4. Single Family Residence:
Multiple Family Residence:
Number of Bedrooms:
Number of Bedrooms:
5. Well Data: Type Individual
.Construction
Depth Well Log Filed ( )
Bacterial Analysis
6. Sewage Disposal System: On-site system ( ) Public Utility (x~
Permit #~/~Ff Installed .Installer
Septic Tank Size
Absorption Area
Manufacturer
Soils Rate
Material
7~
Distances: Well to Septic Tank
to Sewer Lines Nearest Lot Line
Absorption Area to Nearest Lot Line
to Absorption Area
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRO,NMENTAL PROTECTION .,-., ,~" ~
2510 East Tudor Road, Anchorc, ce, Alaska 99504 276-2221 .~L/~'~,
REQUEST FOR APPROVAL OF ~\'
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA.. FHA CONV X
2. Property Owner:. Elden Pederson
Mailing Address: $~, Box 1718 Anchor-age 99507 Day Phone:~344-8638
Name of Buyer: Walter J. ~rtin
Mailing Address:
4. Name of Lending Institution:
Mailing Address: ?' O.
5. Name of Realtor or Agent:
Mailing Address:.
6. Legal Description: Lot 4,
Location:
1101 West 7th Anchorage 99507 Day Phone: 274-4518
Alaska' l.[utual Savin~s Bank
Box 1120, Anchorage 99510 Phone:. 274-3561
N/A
Phone:,,
Block 2 Dawn Village Addn.
Type of Facility to be Inspected:
SF [~o. Bdrms. 2
Water Supply
Typ~.of_~;upply: Public Utility.
If Individual, number of dwellings presently served.
Individual,
If Individual, depth of well
Sewage Disposal System
Type of System:
Public Utility
Individual (on-site,).
If Individual, date of installation..
,, I.-
Page,Two .... ~ ~
o Department of Health and Environmental Protection
.. Request for Approval of Individual Sewer.and Water Facilities
Legal Description: Lot 4 Block 2 Dawn Village Subdivision
Affadavit Attached: ' (~)
Approved:~
Disapproved:
~partment Worksheet:
Letter Attached: ( )
Date:
4.
5.
6.
Approval 'requested by:
Mailing Address:
Property Owner:
Mailing Address:
Legal Description:
LocaEion:
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received December 13,
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Conv.
Alaska Mutual Savings Bank
Post Office Box 1120
Elden Pederson
Star Route A Box 1718 99507
Lot 4 Block 2 Dawn Village
Type of facility to be inspected
Well Data:
A. Type Individual
C. Construction
Sewage Disposal Systen:
A. Installed
C. Septic Tank: l. Size
D. Seepage.Pit: 1. Absorption Area
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
1976
% Debbie Johnson
Phone: 274-3561
Phone: 344-8638
Single FaJ~ily No. of bedrooms 2
B. Depth
D..Bacterial Analysis
B. Installer
2. Manufacturer
2. Material
., Absorption area
, Other contamination
, Absorption area
C. Absorption area to nearest lot line
, Sewer Lines ,,,
EQ-034 (1/74) Page I of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA~FHA CONV X
2. Property Owner:. Elden Pederson
Mailing Address: SRA Box 1718 Anchorage 99507 Day Phone: 344-8638
3. Name of Buyer: Walter J. Martin
1101 West 7th Anchorage 99507
Mailing Address:
4. Name Of Lending in{titution: Alaska Mutual Savings Bank
Mailing Address: P' O. Box 1120, Anchorage 99510 Phone:
5. Name of Realtor or Agent: N/A
Day Phone: 274-4518
274-3561
Mailing Address: Phone:
6. Legal Description: Lot 4~ Block 2 Dawn V~llage Addn.
Location:
7. Type of F;cility to be Inspected: SF
8. Water Supply
Type of Supply: Public Utility
No. Bdrms.
Individual X
2?
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation
Individual (on-site)
72-003(3/76}
UNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
DEC 1 3
RECEIVED
Page 2 of tM pages - Re(~st for ApprOval of Individual .~.~r & Water Facilities
Legal Description Lot 4 Block 2 Dawn Villa~ie
Cc.,inents
Approved
Disapproved Date
Approval~Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the infomation 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 Date
EQ-034 (1/74)