HomeMy WebLinkAboutDAWN VILLAGE BLK 2 LT 5Dawn Village
Block 2
Lot 5
#014-061-43
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10/09/2012 21:38 9072430742 AWPS, ih1C.
".rt::+�lo� ,rr.' :.e.r,ri�;•x: �epartm�atY
`,�Ua+ art% :;'`.',._ 'jr.l•:'ri.'h' iii �.�.
Mark SeyiGh . r'
Mayor _
PU4 Installation Lag
Well Drilling Permit Number: SW'__ I Date of Issue:
Parcel Identification Number:_
PAGE 01/01
0►y- oel- y3
Legal Description
[:)p W /V V 14 1- G'
Property Owner Name & Address:
,qabdxA —AAsGki
4; -77,1 Ale -
Pump Installation Date:—
Rump Intake Depth Below Top of WellCasing:
%,3� feet
Pump NNIanufacturre.,r''s Name: AyAt -0f311-7
Model:
Pump
Pump Size //A hp
Pitless Adapter Burial Depth: jp feet
Pitless Adapter Manuf'acturer's Anine:. H1t�P✓
P�dtesa .�.�iapn: �nst:eiier. MIA
f 'We?3 13i51n�� ted UPC a , Oul- ietloa'.' `.les 14µ
'.y
�aoty.
POW --
Comments:
i
AAA
Pumn Installer Nene:
Attention: The pump installer shall provide a puk p installation log to the DSD within 30 days of pump instal.iation.
,
T ; t• i�il_I p,l I �C- 11=• H t- I T'r' CIF='
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2515 E. TUDOR RD., ANCHORAGE, AK. 99507
276-2221
4•lELI_ F'E�t�1 I T
PERMIT NO. t 77016 )
APPLICANT PFTFF'<;l-)N rrfNtiTRUCTION SRA BOA, 1718X 3,14-8638
LOCATION TESHCAR ST
LEGAL L5 B2 DAWN VILLAGE LOT SIZE 10000 SQUARE FEET
M I t•J I t•1UM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC I -JELL.
WELL .LOGS ARE REQUIRED At -AD MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
F=^Ei*~`1'•y T T tilF=iL I C. FkDF,�* Cl"[=- VEFiF�: F=FROM I �:E; UE
I CERTIFY THAT
1: I At•1 FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
I I•JILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED:-- -- `
- -- -� .- - -------------------
APPLICANT PET RS, t- CONSTRUCTION
ISSUED BY__ - .-___--__ ___________DATE__ //- J
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Certificate of On -Site Systems Approval
OSC261142
Parcel ID 014-061-43 Expiration Date:
Legal description DAWN VILLAGE BLK 2 LT 5
Site address 6721 TESHLAR DR
4/21/2027
Current property owner(s) MUNICIPALITY OF ANCHORAGE
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for
Comments or conditions:
bedrooms, with the following stipulations:
By: Original Certificate Date: 6/4/2026
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,
pevelopment Service 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 submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
MUNICIPALITY OF ANCHORAGE
Development Services Department 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 -43 -
Complete legal description DAWN VILLAGE BLK 2 LT 5
Location (site address) 6721 TESHLAR DR, ANCH
Current property owner(s) MOA
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: ❑■ Private Well serving # 1 dwelling units
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank X Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel or fiberglass 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 $ 7 Waiver Fee $
Date of Payment 7 1 `�� L Date of Payment
COSA # t-' -S Z (Q j Waiver #
COSA Application_Ap2025.dac
COSA Checklist
Legal Description: DAWN VILLAGE BLK 2 LT 5
Parcel ID: 014-061-43
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 4/22/77 Total depth 97 ft
Cased to 40'+ ft
❑� Sanitary seal is functioning correctly
❑� Wires are properly protected
Casing height (above ground) 36 in.
Date of flow test for COSA 4/21/26
Static water level at beginning of test 12 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
❑ Required maintenance completed, ifAWWTS
Comments:
D. DISPOSAL 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
Comments/Deficiencies:
COSA Checklist_May2025.doc
Well production at time of test 5+ qpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ul No
H Coliform bacteria is Negative
Nitrate 0.282 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 10.3 ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date 4/21/26
M NA
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
in
E. SEPARATION DISTANCES
From Well on Lot to: (Please enter distances if less than required)
Septic Tank/Lift Station on Lot > 100'
Yes if No _ ft
Neighboring Tank > 100' ❑ Yes if No * ft
Disposal Field on Lot > 100' ❑ Yes if No _ ft
Sewer Manhole/Cleanout > 100'
❑ Yes if No :.75 it
Sewer Service/Septic Line > 25'❑ Yes if No **20 it
Holding Tank > 100' ❑✓ Yes if No _ ft
Neighboring Disposal Fields > 100' , Animal Containment > 50' ❑✓ Yes if No _ It
❑Yes ifNo_ft
X50 Manure/Animal Excreta Storage > 100'
Sewer Line/Main > 100' ❑ Yes if No _ ft ❑✓ Yes if No _ ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required)
Tank to Foundation > 10' ❑ Yes if No _ it Surface Water > 100' ❑ Yes if No _ ft
Field to Foundation > 10'
Tank to Property Line > 5'
Field to Property Line > 10'
❑ Yes if No ft
❑ Yes if No _ ft
❑Yes if No _ it
Wells on Adjacent Lots:
Wells > 100'
Community Wells > 200'
[]Yes if No _ it
E] Yes ifNo_ft
Water Main/Service Line > 10' ❑ Yes if No _ ft If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*AWWU SEWER SERVICE, NO ONSITE SEWER
** IN ACCORDANCE W/ REGULATIONS AT THE TIME OF INSTALLATION
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 Finn MIKE ANDERSON PE
Engineer's Printed Name SAME
COSA Checklist_May2025.doex
Phone 727-8864
Date 6/1/26
s bi: •.-yr
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MICHAEL N. ANDERSON .*mac to
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ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
DAWN VILLAGE
LOT 5 BLOCK 2 PLAT 76-229
SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property lines and no
enchroachments exist other than noted. Under no circumstance shout
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DATE: SCALE: E—MAIL:
APR 22, 2026 1 "=30' schullerak®gmail.com
26-039 DRAWN BY. CHECKED BY GRID NUMBER: BOOK AGE:
JLS SW2034 260161
LOT 6
BLK 2
LOT 4
BLK 2
�-- 0 F 4000
low
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YA
F CO
' JOHN L. SCHULLER.• o
e
LS -10408
* - 4 � �.oe,
\\)%fession&
N� LSUR r'
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1831 Talkeetna Street
Anchorage, Alaska 99508
(907) 227-1455 office
(907) 274-4992 fax
p MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES �1
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 62A/ '43 HAA#'
1. GENERAL INFORMATION
Complete legal description Lot 5; Btock 2; Daren V.i Ptaae. SubdLvia.ion
Location (site address or directions) 6721 TeahZan
Property owner AHFC 029537 Day phone
Mailing address
Lending agency
Mailing address
Day phone
Agent Ranh Uaaalrontnhy 71 Nem Hon.i_zon.t Day phone _562-6233
Address 2213 Ea6t Tudors Road, Anchorage, AK 99507
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Aev. 1191) Front MOAe21
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 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 furtherverify 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 J EERI G Phone
Address 17034 Eagle River Loop Road No. 204
T
Engineer's signature Date
6. DHHS SIGNATURE
Approved for
Disapproved.
—� bedrooms.
3Pic
� TV�t 4ES _ �f
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Date 42-/Z
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 orderto 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 errors or omissions in the professional engineer's work.
72-025 (Rev. 1.91) Bxk MOA 421
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOTS QLOGK Z DAW1J UILLA6E Parcel I.D.
A. WELL DATA
Well type PRII/AII If A, B, or C, attach ADEC letter. ADEC water system number 60
Log present QN) YE -S Date completed L��2Z/ y Z Driller PEOP JERs,EYDR1LUu6 c0.
Total depth V
Cased to
40+ Casing height 3611
Sanitary seal &N) YES
Wires properly protected DN) YCS
Z
FROM WELL LOG
AT INSPECTION00
o
Date of test
IZ �y I Z
LU
37
13�
c
Static water level
Q uwi
M
Well flow
Z�
g.p.m. �0.3 g.p.m.Q
LUN
V.
Pump level
UVKNOW/1
Ur(II(AWN
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UJ
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LU
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
NJA
; On adjacent lots
Absorption field on lot
N%p
; On adjacent lots 100f
4
Public sewer main
��
Public sewer manhole/cleanout
Sewer service line
i
Petroleum tank NONE KX10Lbt)
+ IN ACC60WCE w R66ULATUuSQT/M6
of /NSrALL4r/0N.
WATER SAMPLE RESULTS:
Coliform 0/100141 Nitrate 0.10 "A Other bacteria 0�/vom/
Date of sample: /Z /Za I giZ Collected by: S` S 6)U&1NEE21AxP
B. SEPTIC/HOLDING TANK DATA = M001JICI PAL SEW&Z
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
SEPARATION DISTANCES FROM
Well(s) on lot
:To property line
ure ater/drainage
72-026 (Rev. 7191) Front
Tank size
n cleanout (Y/N)
Compartments .
Depressio
—Ala<tested(Y/TANK
adjacent lots Foundation
Absorption field.
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION — MU1J/G(f0AL SEWCYZ
Date Insta Manufacturer _
Size In gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at " PlAn
High water alarm levet
Meets MOA electrical codes (Y/N
level at
SEPARATIO ANCE FROM LIFT STATION TO:
I on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA — MUMC(PAL SEcJEr2
Dat stalled Soil rating System type —
Length ' Width Gravel thickness Total depth
l
! Total absorption area Cleanouts present (Y/N)
Depression over field (Y/N), Date of adequac
Results (pass/fail) for
Peroxide treatment (past 12 months) (Y/N) If yes, give date _
SEPARATION DISTANCE FROM ABSORP FIELD TO:
Well on lot n adjacent lots erty line_
To building foundation.. To existing or abandoned system o
On adjacent lots Cutbank ' = Watermain/service line
Surface w r Driveway, parking/vehicle storage area _
ain drain
E. ENGINEER'S CERTIFICATION
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on th
4 -,41
S & S ENGINEERING 0`
.v
17034 Eagle River Loop RoedNo.204tQ .•'••�M
Eaglo River Alaska 99577
bedrooms
of this inspection.
Signature '% * to
Engineer's Name •�••����������•�•�
Date ' r 1 Z �5, ROGER J. CHAFER u�r�
0215 J
�6 s� ••• ,•' V �✓
�e%tA 1PRO ESSON
O
HAA Fee $ / Waiver Fee: $
Date of Payment Z Z Date of Payment
Receipt Number Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
6633 A STREE1 ANCHORAGE, ALASKA 9951,e TELEPHONE (307) 582.2343 FAX: (907) 661-6301
AMALISIS AISULTS for INPOICI 1 61509
iCheslat Raf.1 92.6775 Sample 4 1 Wilt: Mitt,
Client Semple ID : LS 12 UWX PILLAGE Client Pau :S G S I1(ClNI111I1G
P"11) : U1 Client Acct :SNSINGP
Collected r 12/10/92 l 07:49 his, 1POt r pW :NONE RICEIYID
Received : 12/10/92 1 14:0i hra. 19g4
Ptessrved with Ordered 1y +R. SNAPIR
Analysis Completed r 12/11/9:. Sorel Repotts to:
Laboratory Sapetviset : TIPNIN C. IDE 1)S Q S INCINIIAINC
Released 17 :2)
•........a..u.u...................... ......... .u....u.u.u.................... ................. .............. ............o...
patemotst ltesulto Unite N9thod Allovcble Limits
........................ ............................................... w.............................................................
NITAATI•N ND(0.10) rq/1 IPA 353.2/300.0 1C
Sample IOU7111 SSNPLL COLLECIIO DI! 9COIT S.
flematks:
......................................................................................................... 0...... I ......... a...........
1 Tute Performed . $99 Special Instructicno Above UA•Uravailable
NO• Ilia$ Detected " See Semple Rematka Above
N1• Nat Anelyzed LT -List Then, OT•Ctestet UAn
QN SGS M►•m5er c1 the SGS Group (SocI614 09'+dralo de Sdrvellince)
�� rrn nnnnnnnon nnnnnnnon nn nnnnnnnnonOOot1O00QOOst1:11 bl Z_I-2661
MUNICIPALITY OF ANCHORAGE
• �- Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY -FOR SINGLE FAMILY DWELLING
Parcel I.D. # HAA # !� ngry'1IAA
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 5; Stock' 2; Dawn V.cttage Subdiv.izion
Location (address or directions)
6721 Tech&&, Anehonage
(b) Property owner - Telephone: (home) Business
Mailing Address
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent CENTURY 21/NEW HORIZONS ATTN: Stephanie P"zek
Telephone
562-6233
(e) Mail the HAA to the following address: (or check hereX2, if hold for pick up.)
List contact person and day phone number below:
5 & 5 ENGINEERING
17034 Eagle River Looe RenA No e()4
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family ®C
3. WATER SUPPLY
Number of bedrooms 3—
Individual Well ®.Y 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 ❑ Publics Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 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.
Name of Firm Telephone fee— 2971
Address 17034 Eagle River Loop Road No. 204
Eagle
Date
6. DHHS APPROVAL
Approved for -3 bedrooms by
Approved Disapproved
Terms of Conditional Approval
Conditional
• r_
's Seal
• gobert A Shcfx • '
a�
Pb. 1457-2 • v r.
f AC
0 FES
Date l
, � CAUTION . .
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 Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 77881 Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
p`� ���` • Health Authority Approval (HAA)
PPS CHECKLIST - FEBRUARY 1984
__ 343-4744
��p �J� V Legal Description: Loi" A-17;
IN 41n�
A. WELL DATA
Well Classification iA)! i /e rA Ak (�u If A, B. C, D.E.C. Approved (Y/N) rJ1,4_
Well Log Present (Y/N) _ 14 Date Completed 4-2 ZYield 9 !j 02,id
Total Depth 3�Cased to Depth of Grouting —" ( 7 - ZO- 5,0
Static Water. Level 3 Pump Set At L) (�
Casing Height Above Ground f Sanitary Seal on Casing (Y/N) u
Electrical Wiring in Conduit (Y/N) !4 Depression Around Wellhead (Y/N) AJ
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 11 ; On Adjoining Lots / 00 f
To Nearest Edge of Absorption Field on Lot N f W ;On Adjoining Lots .. ` 00 /
To Nearest Public Sewer Line * SD To Nearest Public Sewer Cleanout/Manhole S -t-
To
To Nearest Sewer Service Line on Lot Z b
Water Sample Collected by - '-*D `f- :D t 4 e--e--tri A ; Date 7 - 1 - `1 V
Water Sample Test Results ►� "� c o d u - ►aG1 e� i r�1 �- !y �'� I e S
Comments 'r -1••N 4CG0rd 4N)Q? (.y�th /`EGu1W 11c)NS (tAc, Of 1Nsm/14 N,
AA L) tJ*(C- A S e wey.
B. SEPTIC/HOLDING TANK DATA
Date Installed Size - No. of Compartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/NDate Last Pumped
Pumping/Maintenance Contact on�FI-e Y/� ; for
Holding Tank High -Water Alarm ( /N) Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/H DING TANK:
To Water Supply Well To Building Foundation
To Property Line'Disposal Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments _Ah O N 1C-;Io,A S e LJ e r
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Area Statndpipes Present (Y/N)
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTI FIELD:
To Water -Supply Well To Property Line
To Building FoundationTo Existing or Abandoned System on
Lot ; On Adj • ing Lots
To Water Main/Service Line To utback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments AL L�(iPA eweir
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N) _
Comments
Z
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request'
I certify that I have checked, verified, or conformed to all MOA,and HAA guidelines in effect on the date of this
inspection.
Signed ,��-•..� i,
Company S & 5 ENGINEERING17034
Eagle River LOOP KOado 2e
Date
• ••••' '�e:1s
Date Ea le River, Alaska 99577 Q %/ �* o `� � "�* al
=:
Cr �!o bfl 3 --`'' ti ' 0.MOA No.
Receipt No. a s o7 7 r.2 Receipt No.
Date of Payment — C% Waiver Fee: $ —
Amount: $ l % �" U Date of Payment
72-026 (Rev. 7/68) Back Page 2 of 2
�.IM01./yQ,
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
a
5633 B STREET • ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343 ''aa
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT SI SAME for Work Order 1 2S743
Date Report Printed: JUI. 27 90 ! 09:36
Client Sample ID:LS 82 DAWN VILLAGE
FHSID :UA
Collected JLL 20 90 ! 15:00 hrs.
Received JUL 20 90 ! 17:30 his.
Preserved with :AS REQUIRED
Analysis Completed :JUL 20 90
Laboratory Sups:viscr :STEPHEN C. ED!
Released Ey : 14, Yr�<�—
/ �j
i G
Special
Instruct:
Chemlab Ref 1: 902573 Lab Smpl ID: 3 wittiz: WATER
Parameter Tested Result Units
---------------------------------------------------------------------
HITEATE-11 ND(0.10) mg/l
Sample ROUTINE SA.YPLE. SAYDLE COLLECTED EI R.S.JR.
Remarks:
Client Name S & S ENGINEERIH,
Client Acct SHSENGF
P.0.1 HONE RECEIVED
Req t
Ordered Ey : P.. SHAFER
Send Reports to:
1)3 & S ENGINEERING
2)
Allowable
Method Limits
--------------------------------
EPA 353.2 SO
.............................................................................................
1 Teets Performed See Special Instructions Above UA -Unavailable
1
HD- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GT -Greater Tian
a
�
J \�
.. . _..
MUNICIPALITY OF ANCHORAG
DEPARTMEn OF HEALTH AND ENVIRONMENT
_ _.
PROTECTION
i;
y!I
825 L Street, Anchorage, Alaska
279-2511, ext. 224 or 225
99501
#1: Time
2:30 P.m.
#2: Time
Date
5-4-77
Tues
Date
Date Received: May 4, 1977
#3: Time
Date
Insp Pratt Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: Alaska Mutual Savings Bank
Mailing Address: Post Office Box 1120
2. Property Owner:
Mailing Address:
99510 Phone: 274-3561
Pederson Construction, Inc.
Star Route A Box 1718X 99507
Phone: 344-8638
3. Legal Description: Lot 5 Block 2 Dawn Village Subdivision
4: Single Family Residence: (x)
Multiple Family Residence: ( )
5.
Number of Bedrooms: 2
Number of Bedrooms:
Well System: Individual Well (Z) Community/Public System ( )
Permit # 77016 Depth of Well 971 Well Log on File ( )
Construction Bacterial Analysis
G. Sewage Disposal System: On-site System ( )
Permit # Installed
Septic Tank Size
Absorption Area
Public Utility (yj
Installer
Manufacturer
Soils Rate
7. Distances: Well to Septic Tank
to Sewer Line
to Nearest Lot Line
Nearest Lot line
Material
to Absorption Area
Absorption Area
• l�U�lC1PALITi or. 1.NCF10
MUNICIPALITY OF ANCHORAGE DZIPT. �' I:'`'Y''
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECtibRo .. ' 1 r"�"'_CTICN
2510 East Tudor Road, Anchorage, Alaska 99504 276.2221
Y7
10
- REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES RECEIVED
1.
Type of Inspection: CMRO
VA
FHA CONV�
2.
n
Property Owner: 9,-)N, 'j C Oh
-0 P cc<_p
%1 4/1 _r_, .
Mailing Address: 21 LK
ay Phone: yF!54L/— fee? drx'�'
9VL57 7
3.
Name of Buyer:
Mailing Address:
Day Phone:
4.
Name of Lending Institution:
Mailing Address:X•
Phone:
eZZ62-O ,QCGfZic c
4javn o��
5.
Name of Realtor or Agent:
00
Mailing Address:
Phone:
6. Legal Description:
Location: e;7
7. Type of Facility to be Inspected: li" No. Bdrms.
8. Water Supply
Type of Supply: Public Utility Individual
If Individual, number of dwellings presently served
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public Utility Individual (on-site)
If Individual, date of installation
72003(3/76)
i
n �
Page Two _r
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 5 Block"2 Dawn Village Subdivision
Comments:
Affadavit Attached: ;(;) Letter Attached: ( )
Approved: 2 C Date:
Disapproved: Date:
Department Worksheet: