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Home My WebLink AboutDAV-DOR LT 7r.)av� t)or Lot 7 #015�292�31 GRE"TER ANCHORAGE AREA BO~%UGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~7/'¥x/ ~'~UhC'~c,M C~,qS'T', MAILING ADDRESS I;~'0~ ~'"..~£b PHONE LOCATION H~'~',h/',~.~r~, ~r, e~V ./O'/fI' LEGAL DESCRIPTION /.-~-V SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER ~IP~ t~'~ INSIDE WIDTH ~ MATE R iAL...~.! NUMBER OF Z.//_!f~/~&"~47~COMPARTMENTS / LIQUID DEPTH ~ I IQUID CAPACITY I~ O GALLONS. SEEPAGE PIT: NUMBER OF PITS / DIAMETER ~ OR WlOTHq~/~~ LENGTH~'~3, DEPTH ~'~ "/~' LINING MATERIAL~'R~Yt" ~CRIB SIZE: DIAMETER DEPTH ~ DISTANCE FROM: WELL ~ ~' /~oc: TOTAL ~FFECT~VE ~U~LD~NO FOUNDATION ~ ; .~AR~ST LOT UN[A~SORPnON AR~A (WALL AR~A) ADDITIONAL ABSORPTION TYPE ~1~ CONSTRUCTION. BUILDING NEAREST NEAREST FOUNDATION LOT LINE SEWER LINE CESS~OL OTHER SOURCES APPROVED DISAPPROVED REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES= INSTALLED BY:/'~ PIPE MATERIAL; LOT SLOPE= REMARKS: ,~/'{ ) /~'~' Fo~m NO. GQ-031 DIAGRAM OF SYSTEM G.A.A.B. GreaTEr ANCHOragE ArEa BorouGh SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT NAME OF APPLICANT F~'~ C/~4/ INSTALLATION LOCATION MAILING ADDRESS 7 SEEPAGE PIT~'~ DRAIN FIELD OTHER TYPE AND SIZE OF FACILITY TO BE SERVED TO BE INSTALLED BY ~ FINANCED THROUGH ~ ~ ~ / ~ /~'F~/~X~ -- '~ NO~IS PERMIT IS NOT VALID FINAL INSPECTION: Z4 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEEPAGE AREA SIZE TYPE DRAIN FIELD "-- --/ · DRAIN FIELD SEEPAGE PIT INATER MAIN TO SEPTIC TANK / SEPTIC TANK.--//'~'~ / SEEPAGE FIT /~'~ DRAIN FIELD DIAGRAM OF '"=YSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE APPLICANT'S SIGNATURE. FORM NO. EG'OI ~ 't On-S)te Sewer Study .by Robert Neale 10/21/74 Owner: Location: Legal: Soil Sample: Pederson Construction - 180l E. 53rd, Anchorage Hendrickson Circle off 104th Lot 7, Davis Dor Subdivision 105 Conditions: 8' 10' 12' 14' 16' 1' to 3' top and sandy gravel Septic Tank - 1,000 gallons Concrete Rings cm P. . Box 4-1224 1310C International Airport .~oad {907) 274-461 ! · ANCHORAGE, ALASKA 99509 DRILLING LOG WeU Owner Use of WeB Dom Location (address of: Tpwnship, Range, Section, if .known; or distance main road L?, Blt Dave Dot Subdiv , · Size of casing 6 Depth of Hole P...942 feet Cased to 40 ~'~eet StaUc water level 20 ft. {~t~5~ (below) land surface. Finish of well (check one) ope~ end ( X Screen ( ); Perforated ( ). . Describe screen or perforation ' We~l pumping test at '~ gallons per of drawdown from static level. ); 0 18 19 .TO 35 .-%5 .TO 40 4O .TO -- · .TO .TO .TO TO. wm Give d;taih of Sormations penetrated, size'~ mat~~d har~e~ Date of completion Depth in feet from ground surface .TO. '~ TO 18 TO 19 (minute) for 1 hours with .!Of~'~ ~t. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.a nchorage.ak.us (907) 343-7904 O Parcel I.D. 015-292-31 1. GENERAL INFORMATION CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAHILY DWELLING Expirat,on Oats: ,/v/ox Complete legal description OAV-DOR SUBDIVISION; LOT 7 Location (site address or directions) 5321 HENDRICKSON CIRCLE * ANCHORAGE, AK Current Properly owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address STEVE HUSTON Day phone 441-7643 5321 HENDRICKSON CIRCLE * ANCHORAGE, AK Day phone BOB STANTON w/ PRUDENTIAL VISTA Day phone 4241 'B' STREET * ANCHORAGE, AK 99503 240-2560 Unless othen~ise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well E~ Individual Water Storage Community Class Well E] Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On*site ~r~ Individual Holding tank Community On-site ~] Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (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 Class C well and may be reissued with new water samples. (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 engineers work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or pdor to dosing for the engineering services provided. I 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate forthe number of bedrooms and type of strecture indicated herein. I fur~her vedfy 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 wastew~ter 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 6901 BEBARR ROAD, SUITE 2B * ANCHORAGE. AK 99504 Engineer's Printed Name JEFFREY A. 6ARNESS, P.E. Date 337-6179 Engineer's Comments: In conducting this evaluation, AKWWC, /nc. attempted to provide a thorough, -. ¢onscientiousengineedngana/ysisofthesystemthaccordancewithADECandMOA DSD Guidelines & Regulations. The reported results described 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 syster~s.depend on the local soils condition, groundwater levels that may fluctuate dud~ ~e ~ear, and the water usage of the family being sewed by the system. These conditions are outside the control of the e va/uator of the system· Satisfactory test -' .results do not guarantee future performance of the system, nor do they guarantee that there are qo hidden defects or encroachments. AKWWC, Inc. can therefore not provide · anywan:antyorfutureestimateofhowlongthesystemwi/Icontinuetomeetthe operational requirements of the ADEC or 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 wilt it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for ~ bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the fllowing supumuons: ~.,.~. \~Y-.. .... .. PROGRAM Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: Municipality of Anchorage Development Services Department Baldlng Safety Olvisinn On-Site Water & W~lewater Program 4700 Soulh Bmgaw SL P.O. Box 196650 Anchorage, AK 99519-6650 Legal Dsacdptlon: A. WELL DATA HEALTH AUTHORITY APPROVAL CHECKLIST DAV-DOR SUBDMSION; LOT 7 Parcel ID: 015-292-31 Well type t~avA'rg If A, B, or C provide PW$1D~ N/A Date completed 3/20/1975 Sanitary seal (Y/N). YES Total depth 40 ft. Cased to 40 ft. FROM WELL LOG Dam of test 3/20/1975 Static water level 20 fl. Well production 20 g.p.m. WATER SAMPLE RESULTS: Coliform' - ~ Jcolonies/100 mi. Arsenic: N/A mgJL. SEPTIC/HOLDING TANK DATA Tank Type/Matertal Tanksize 1000 gal. Number of Compartments 1 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 9/26/2002 Pumper ABSORPTION FIELD DATA Date installed 10/17/Ig74 Length 23 ft. Well ~ (Y/N) W~res prope~y protected (Y/N) Casing height (above ground) AT INSPECTION 9/26/2002 22 ft. 6.25 ' g.p.m. .._.~./L. Other bactarla Date of sample: 9/26/2002 Collected by: PBELOW EX~I1NO G~ Soil reUng (g.p.dJft~ 105 9~19 [ YES YES 12+ t~ colonies/100 mi. AKWWC, INC. Date installed 10/17/1974. Cleanouts (Y/N) YES High water alarm (Y/N) N/A CHUGACH Totaldepth ',11 ft. Eff. absorptJonarea ;;: ft= Monltodngtube YES Date of adequacy test 9/26/2002 Results (Pass/Fall) PASS Fluid depth in absorpUon field before test 5.5 in. Water added 10189al. Elapsed Time: [437 min. Final fluid depth 37.5 in. Absorption rate >,, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN System type CONCRLiL PIT Gravel below pipe 6 ff. Depression over field NO For ,3 bedrooms New depth 75.5in. 450 g.p.d. If yes, give date - D. UFT STATION Date installed "Pump on' level at in. Datum E, SEPARATION DISTANCES Size in gallons 'Pump off" Iev;l at . Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanYJliff station on lot96' Absorption field on lot 100°+ Public sewer main N/A Sewer/septic service line 25'+ ManholelAceee- (Y/N) High water alarm level at Meets alarm & circuit requirements?. On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manbele/cleanout Holding tank N/A N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/A Water service line 1 Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Curtain drain NONE KNOWN COMMENTS *WR~930076 Absorption field 5'+ Surface water 100'+ Building foundation 10'+ Sudace water 100°+ Wells on adjacent lots 100'+ Water main N/A Driveway, paddngfvehlcle storage ENGINEER'S CERTIFICATION I certify that I have determined through field inspeci~ns and review of Municipal records that the above systems ere in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Data J~.H-~<EY A. GARNESS Receipt Number ~ ~1~ "1~' ~'~. (R~. 1~ol1 Waiver Fee $ Data of Payment Receipt Number in. 0~T-02-02 09:25AU FROI,I-CT&E EKVII~NTAL SRV · ~tK CTIE Environmental Services Inc. 9075515]01 T-925 P.02/03 F-919 CT&F' Ret.# Client Name Project Name/N Client Sample 1D Matrix PWSID 0 Sample Remarks: 1026394001 AK. Water & Wastewater Consultants Inc. Dav-Dor L7 Dav-Dor L7 Drinking Water All Dates~Tlmes are Alaska Standard Time Printed Date/Time 10/01/2002 16:07 Collected Date~Tlme 09/26/2002 17:00 Received Daterrime 09/27/2002 8rio Technical Director Steph~ Released By I~~ ~al:ers Department. Nitrate-N 3.15 PQL Un/ts Metho~ L~mi~ Date Date Init 0.200 mg/L EPA 300.0 f<-lO) 09/27/02 JDT Microbiology Labo~'atory Total Coliform 0 co~]00mL SMI89222B 09/27/02 SBll 09/24/02 11:34 F~,X $07 273 8440 PRL~I~-*~TIAL VISTA I~.,AL ES 1~002/002 N 89"58'00" E 163.64' 10' UTILITY EASEMENT LOT 7 ~"~ LOT 6 R=50' HENDRICKSON CIRCLE ~RAGE. ALASKA gg~03 (907) ~'~"' LOT 7, -- ~ ,,-~ -,~ DAV-DC)R SUBDIVISION 97 L 113A ~~-, I MUNICIPALITY OF ANCHORAGE · DEPARTMENT OF HEALTH & HUMAN SERVICES' Division of Environmenthl Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY . . :. · APPROVAL FOR A SINGLE FAMILY DWE. LLING P rce # ' C>t - Complete legal description T-~'T' -"J .) Location (site address or directions) ~'~ ~' I e J Property owner ~l=j c~_o~.~:,r-_ ~_~'~.~ Mailing-address ~--~ E-- /~ /d~5~3 ~,~_-- Day phone _~ & ¢;"- ~,¢7 ~G Lending agency Mailing address Agent Address Day phone t,J' J~ · Day phone ' ~.--/_~- "T'7~ ~' ?75-o3 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYF~E oF WASTEWATER DISPOSAL: - Individual on-site ~ Holding tank Community on-site Public sewer NOTE: If community w..astewa.,te.r syst~..rn, provi'de written confirm, a!ion from Sta~e ADEC '. .. " ........... att~sti~ t'o the legality and status of system. 5. STATEMENT OF*,INSPECTION BY**ENGINEER.. As certified by my seal affixed hereto and as of the validation dat~ shown below, I verify that my ,.... Investigation of this Health Authority Approval application shows that the on-site water supply end/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verifythat based on the information obtained from the Municipality of Anchorage files a**nd fr~m r~¥ inve~tigation and inspection, the on-site water SupplY.and/or wastewater disp.osal system is in compliance with all Municipal and State codes, . ordinances,and regulations.in' effect oh the-date Of thi~ Inspection. ' . * * ~ ... A!ssks Water & Name of Firm Wa~ewat~r Eng,neer's signature Phone Date '~'/~/~ '7 Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date :.. The Municil~ality of Ahchorage Department of Health and Human Services (DHHS) issues Health Authority '- .A~ioval '~rfificat'~s-~:J only upon the representatiofls given in 'para'graph 5 above by an independent p'r o.~,es~..on~! ~r{g~'~ ~'r regis~erad In the State of AlaSka. The DHHS does this as ~ courtesy to purChasers of homes arid the. !r le.n~ip g Ih~tu~i- -°~ ~.ln. ,o_rd~r. t0 sari .s~' c.e. [rain federal and state requiraments Emp oyeasof DHHS donot · ,conduct inspections or analyze data before a .certificate is Isst~ed 'The *Mun c pa ity of Ar:~chora~e is*not · re~po~lsi'bl~ for'e~;ors or*g~mlSslo~l~ in*thep~fes~o'n'al ~n~inear's Work.;:. ' *' ' MuniciPality 0f Anch0mge DEPARTMENT OI~ HEALTH & HUMAN SERVICES Environmental Services Division J~E 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist .LOT -'/ .. [::~-~J- ~:)o,~, ~/D ParcelI.D.: A. W~LL DATA Well type ~1'" Log present (Y/N) Total depth Santtan/seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ?_.,~____ Cased to ~1'O/ Casing halgN (above ground) Wires properly protected (Y/N) ~--~ FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. WATER SAMPLE RESULTS: Coliform o.te Collected by: ~ '~ SEPTIC/HOLDING TANK DATA Datelnstallod /0/?/74 TanksizetO~ Number of Compattments J Cloanouts,(Y/N)~ Foundation cleanout (Y/N) ~ Depression (Y/N) NC) High water alarm (Y/N) K) ~,~ Date of Pumping , 7.,/,~.-//~'-~ Pumper Ce ABSORFRON FIELD DATA Oatelnstalled /0//?/~ Soilreting (g.p~d~orft=/txlrm) /O~- Length ~/ Width c~/~' /~// Grevalthicknese below pipe Effective absorption area ~ Munltodng Tube present (Y/N) ~ System type / / Total depth //. ~ -~ . Depression over field (Y/N) For ~ Ruid depth in absorption field before test (in.);.'3~''~/' Immedlateh~ after 4~gal. water added (in.): Fluiddepth ~.-(~3~ (ins)Minutes latec JO0 Absorptionrete = · 4~--O a.p.d. Pemxide treatment (past12 months) (Y/N) ~o~. t~o~,/ Ifyes, glvedate /'-/~- ~0 bedrooms 72.o26 (Rev. WgS)* Date installed ~ Size in gallons Manhole/Access (Y/N) ~at- High water alarm level at' E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot <:/fo / +- Absoq~tion field on lot 1~,"7/-to C-/o / On adjacent lots :~' Il:lC) On adjacent lots ~ ( C)O Public sewer main Sewer/septic service line ~' ~0/ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation q Water main/eewice line ~ lOt Public sewer manhole/cleanout .Surface water/drainage ~' Ic;o · SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line IO/+ · Building foundation ~C:) ~- Surface water '~' I O0 Curtain drain Absomtlon field ~-~.' ~e. F~:~R~~- Wells on a~a~m Io~ ~ / ~ ~ Wa~r ~Wss~ li~ D~y, p~ehide ~omge ~ V~ Wells on adja~ I~ ~ ( O0 R ENGINEER'S CERTIFICATION H/La, Fee $ '~ ~Z~. ~ Oate Pa nt ¢ /, 7 . , ' 72-026 (Rev. 3,~)6)' Waiver Fee $ ~ Date of Payment Alaska Water & W stewater t~UNIQI~AUTY OF A~ORAG~ fNVIRONM~NTN. $~¥1C~ D~'~lOt~ 8471 Brookridge Drive ~ Anchorage -Alaska 99504 APR 1 4 Phone (907) 337-6179 ~ Fax (907) 338-3246 Consulting Engineers Division of Environmental Services ~,~ On-Site Services Section · P.O. Box 196650 Anchorage, Alaska 99519-6650 Subject: HAA for Private Well & Septic System. Lot 7, Dav-Dor SfD. 5321 Hendrickson Circle. To whom it may concern: The subject lot has a 3 bedroom house on it which is served by a private well and septic system. The results ofthe field investigation and adequacy tests are summarized as follows: A. WELL: On the day of my inspection (4/5/97) the static level was 16 feet below the top of the casing. Water was pumped from the well at an average rate of 6.7 gpm for 68 minutes (455 gallons). The water level quickly dropped to 20 feet (4 feet of drawdown), and remained there throughout the rest of the test. In short, it was recovering as fast as it was being pumped out. Based upon this data it was determined that the capacity of the well exceeds the Municipal requirements for a 3 bedroom house (450 gallons per day). This well will .produce greater than 720 gallons in 4 hours. B. SEPTIC TANK: The existing septic tank was installed in October of 1974 (approx. 22.5 years old). According to the M.O.A records, it is 1000 gallons, has one compartment and is made of steel. Most tanks of this type have a structural life of approximately 20-25 years. No warrantee is made regarding the future life of the septic tank. : C. SEPTIC TANK IS APPROXIMATELY 96 FEET FROM THE WELL: The septic tank c/o is located near the outlet of the tank. The distance from this cJo to the well is approximately 104 feet. Assuming the tank is 8 feet long, the inlet end is only about 96 feet from the well. Based upon the fact that groundwater is so shallow, and that the soils are very porous, I am confident that this case would not meet the minimum point values required by ADEC for issuance of a waiver. Given the age of the tank, it is reasonable to assume that it is leaking. Based upon the water sample results (no bacteria, and nitrate levels of 2.8 rog/l), the water quality has yet to be seriously effected by this leakage/encroachment. In short, we are not dealing with a hypothetical situation, in which a point value evaluation is our only method for assessing the risk, but rather we are dealing with a real world ease in which the encroachment appears not to be a legitimate concern. Because of the daylight basement, it is not possible for the tank to overflow (causing wastewater to flow over the ground surface towards the well) without first filling the basement with about 4 feet of wastewater (a situation unlikely to go unnoticed). In short, surface runoff towards the well is not going to happen. Based upon these facts, it is my recommendation that the subject separation distance be waived from 100 feet to 96 feet. D. SEPTIC SYSTEM ADEQUACY TEST: Prior to beginning the test, the seepage pit had 35.625 inches of liquid in it. Water was introduced into the cleanout past the septic tank at a rate of 6.7 gpm for a total of 68 minutes (455 gallons). The liquid level rose 26.25 inches, to 61.875 inches (17.3 gallons/inch). One-hundred minutes later the level had dropped to 56.375 inches, indicating an absorption of 95.3 gallons. This corresponds to an absorption of .95 gallons/minutes. Based upon this data, it was determined that the absorption rate exceeds 450 gallons per day, as required for a 3 bedroom house. If you have any questions, please contact me at 337-6179, or on my digital pager at 1-800-451-1162. Thank ~ou for your assistance. Sincerely,~~ Jeffre, ! ~.'~ M.S. NOTE: The adequacy of a septic system is inj7uenced by tmmerous factors, #tcluding, but not limited to, seasonal surface water #ifiltration, groundwater variations, septic system maintenance (frequency of septic tank pttmphtg, usage of biological additives), condition of drain pil~, aml pipe johtts (which can be damaged by seismic activiO, attd deteriorate with age), tylx, of mtbst~ces deposited #t septic system (cigarette butts, sanitary napkins, misc. objects), ~td the amount of water be#tg #ttroduced on a continual basis. Consequently, the results of this adecluacy test are only valid for the specific day of the test. Furthermore, because of the limited nature of this #n,estigation, # is possible that there are hidden defects which may not have been detected. No warrantee is made regarding the future performance of this well or septic system C.C. Prudential Real Estate, Greg Broderick ~ CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 971591001 AK Water & Wastewater Services N/A Lot 7 Day Dot S/D Sink Dfinldng Water Sample Remarks: Sample collected by: Garncss Client PO# Printed Date/Time 04107197 12:53 Collected Date/Time 04/02197 16:00 Received Date/Time 04/02/97 16:00 Technical Director: Stephen C. Ede Nitrate-# Totat CotSform Results 0 PQL Units Method AttouabIe Prep Anatysis Limits Date Date Init 0.100 mg/L EPA 300.0 col/lOOmL $~18 9222B 06/03/97 SPH 04/03/97 RA~ / % J I I I /f, 4 22,309 2 19,733 ,% $ 25,767 Z I 19,734 e~ VENUE. -.- MuniCipality of AnchO. agc Department of Health and Human Services 825 "L" Street Rick Mystrom, P,O. Box 196650 Anchorage, Alaska 99519-6650 Mayor 343-4744 April 28, 1997 Jeff Carness, P.E. Alaska Water & Wastewater Services 8471Brookridge Drive Anchorage, Alaska 99504 Subject: Waiver Request for Lot 7, Dav-Dor Subdivision Waiver Request ~970016, PID~0t5-292-31 Dear Mr. Carness: Your request for waiver(s) of the required I00 foot horizontal separation of an on-site wastewater disposal system to a private well has been approved. The approved separation distance(s) are 96 feet. This waiver approval applies to the existing on-site wastewater disposal system to well separation only. Any future upgrade to either 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 343-4744. Daniel J. Roth Civil Engineer On-Site Services Program lJm:~6 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR% WR9?00X6 PID# 015-292-31 HAW BA970132 Date Received: 04-14-97 Legal Description: Lot 7 Day-Dot Subdivision Engineer: Alaska Water and Wastewater/Jeff Garness Permit Applicant: Thomas & Connie Kirby Waiver Requested: Well to tank: 96' Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: ~ Waiver is NOT Granted: List Conditions or Reasons for above: ~E ~TT~¢/4A-~ Date: '77 Rec #: 02829 & 02831 Amount: By: $ 625.00 Name of Reviewer Date Paid: 04-14-97 2.3 2.? 2.8 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALT~ & HUMAN SERVICES 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.# ~"~[-Z3-"~,°~} ?3\ HAA # 1. GENERAL INFORMATION Complete legaldescriptlon Lo-r '~ : bat/ hoT: Location (site address or directions) $32l I-IENbR ICKSO~4 Property owner SCOTT Mailing address Lending agency CITy Mailing address Agent Day phone Day phone Day phone ;z '~ 7 Address e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community Public water NOTE: 3 If community well system, provide written confirmation from State ADEC attest- 'n i g to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site ~ Holding tank Community on-site · Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Name of Firm F/.,4 TT'O f Address ! #5'3o EC Engineer's signature ~'~"-,,'~- 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. Phone 3q,5"- 13.5'5' Date DHHS SIGNATURE ~' Approved for '~'~ ~) bedrooms. Disapproved. Conditional approval for 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 errors or omissions in the professional engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT Pamel I.D. O/,5-- ,a c/~. ~ / A. Well Data Well type PRIVATE Log present (Y/N) ~' Total depth 42 ' Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number Date completed .3/2 o / "/_q Driller M ~- ~' Cased to Ho' Casing height ~"/. .Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION g.p.m. '~' 7o 5 '~ 20 ' REF. EIVE. D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I o,/~ To ¢, o. Absorption field on lot 13-/' TO C.O. Public sewer main >' I o~ ° Sewer service line ~ 3o ~ ; On adjacent lots ; On adjacent lots -;./oo Public sewer manhole/cleanout Petroleum tank NgNE r~RSEeV£b WATER SAMPLE RESULTS: Coliform ~:) ~.~ Date of sample: Nitrate Collected by: Other bacteria /1o~1 f. B. SEPTIC/HOLDING TANK DATA Date installed lo/l'~/ "lq Tank size ~00o Cleanouts (Y/N) Y Foundation cleanout (Y/N) High water alarm (Y/N) ti,/~, Date of pumping '7/~ / ~ ~' ' (;;/~ L Compartments I "~ Depression (Y/N) Alarm tested (Y/N) fl. ,'1. Pumper ~'o-~o - ~ooT£~' N SEPARATION DISTANCES FROM SEPTIC/HOLDiNG TANK TO: Well(s) on lot to~' F4'oh CO. On adjacent lots Toproperlyline ~,'~o~ Absorption field :2:2 Surface water/drainage '~ IOO ' F~o~ C.o. .Foundation 1'7 ,Water main/service line CONTINUED ON SACK PAGE C. UFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) 'Pump on' level at High water alarm level Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) 'Pump off' Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed lO/t'/17'~ Length 2 '~ W~dth Total absorption area ~ q ~ Date of adequacy test 7 ! =- ! ~ ct 3 Water level In absorption field before test Peroxide treatment (past 12 months) (y/N) Soilrafing(GPD/Ft=) I.'~ ~l>t>/F,[" Systemtype 5E~p ~,~ I~ Gravel thickness ~ Total depth ~' Cleanouf present (y/N) y Depression over field (Y/N) Results (pass/fall) ~.45S for ~" After test .5"~' t'{o~4~' I~No~t4 If yes, give date I~ ,/~, Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: To building foundation ~'b~ On adjacent lots ~. 5'0 ~ Surface water ~. Ioo' Curtain drain On adjacent lots ~1~o' F~o~ ¢.0. Propertyline ~25' F~o~ ¢.o. ,To existing or abandoned system on lot N.~, Cutbank N.A. .Water main/service line ~ ~0 ' Driveway. parking'vehicle storage area ~ ~ F~'e~ ¢.o. Id. oNE O~$ERVE~ F.- ENGINEER'S CERTIFICATION I cerb*[y that I have checked, verified, or conformed to all MOA and HAA guideline~..~,~ (~rt, the date of this inspection, F O ...... S,gnature ~'... .............. · ..... ~ / - ~;~;.~.. ........ · ¢ ,%'~ . HAA Fee $ / '~ 0 Waiver Fee $ Date of Payment /- '~- ~'--~.~ Date of Payment Receipt Number r,.7 '~"~,5'""7 (~'~/ Receipt Number. 72-o2e (3/g3)- Back ENGINEERING CO. . Chemlab Ref.# :93.3541-1 Client Sample ID :L7 DAV DOR Eatrix :WATE~ REPORT of ANALYSIS FEINT HOSE BIB 5633 (3 STREET ANCHORAGE. AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Client Name ~FIATTOP ~C~ICAL SRV WORK Order :68588 Ordered By : Report Completed :07/26/93 Project Name : · Collected :07/2i/93 @ 10:00 hrs. Project# : Received ~07/21/93 '@ 14~35 hrs. PWSID :UA Technical Director:ST~H~ C. Released By : Sample Remarks: ROUTINE SAMPLE cor~J~ui'bu BY: CHRIS. OC Allowable Ext. Anal Parameter Results Qual Units Method Limlt~ Date Date Init ........... _~. .... __~__~ ................ ~ ....... ~ ....... ~ ....... ~---c--~--~ ...................... Nitrate-N 2.50 mg/L EPA 353.2/300.0 10 07/23 E[~ * See Special Instructions Above UA = Unavailable ** See Sample Remarks A~ve NA = Not Analyzed U = Undetected, Reported value is the practical c~tification l~mit. LT = Less Than D = Secondary dilution. GT - Greater Than ENVIRONMENTAL SERVICES IN ALASKA. COLORADO. UTAH. ILLINOIS, OHIO. MARYLAND. WEST VIRGINIA. NEW JERSEY. SOUTH CAROLINA MUNICIPALITY OF ANCHORAGE Deparlment 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. # (~3 t --~ - ~'~'~ c~ ~'"'~ -.'~ ~ HAA# ~'-~ ~-'~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner fda ~'_"I'Y Mailing Address .-'-.~,? I (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address t"".t F.(" LF- H F LID F I,'.l: cr;kl Telephone: (home) ~'-!-, d'J Er_, Akirp. Telephone Telephone kl/A (e) Mail the HAA to the following address: (or check here'~f hold for pick up.) List contact person and day phone number below: /.-411 2. TYPE OF RESIDENCE Single-Family,,~ Number of bedrooms 3. WATER SUPPLY Individual Well.,~l' Community [3 Public n Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site)~ Public [3 Community [3 Holding Tank [3 Note:/'If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certified by my seal affixed hereto and as of the validation date shown ~3elow. 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 ~3nd 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm/"'--~) Address Date Eh'gineer's Seal 6. DHHS APPROVAL Approved ,or~)bedrooms by Approved X Disapproved Terms of Conditional Approval Conditional 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 an alyze data before a certificate is issu ed. Th e Municipality of Ancho rage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 .~.~.~. ~3~%~l~C~:(~).: Health Authority Approval (HAA) ~?~.~.~ ~,~. *' \~/ CHECKMST - FEBRUARY 1984343-4744 ~'~ ~ ~X~ ,~ Legal Description: WELL DA Well Classification Pr I ~/~R~ ' ' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Y Date Completed .'~c~/75' Yield .~O~/~ TotalDepth ~4-~' Casedto ~-0' Depth of Grouting Static Water Level /~' ' Casing Height Above Ground .~ ) ElectricaIWiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot JO)(') ' ' Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) "; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~ Jr~ To Nearest Public Sewer CleanoutJManhole To Nearest Sewer Service Line on Lot Water Sample Collected by ~)~'~-P~/ ~' ~-~'~' ;Date' /~/~/~c~ Wafer Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Datelnstalled Size Standpipes (Y/N) ~ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Ma!ntenance Contact on File (Y/N) Holding Tank High-Water:Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: No. of Compartments Y Foundation Cleanout (Y/N) Date Last Pumped JC~,7.~t' ;for Temporary Holding Tank Permit (Y/N) To Buildin~ I~oundation i0' TO Disposal Field ~- * kJ/A" ..TO Water-Supply Well J~.X~ ' TO Property I~ine /~'/ ' ' TO Water Main/Service Line .'~C) ' + To Stream. Pond. Lake or Major Drain'age Course Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ./nS"'£?~-~//~J,-,-.. Typ~of~ystem Design Length of Field ~ ~ ~ Depth of Field ~ ~ ~ Gravel Bed Thickness ~ ' ~ Statndpipes Present (Y/N) Date of Last Adequacy Test Square Feet of Absortion Area ~4' ''¥' Depression over Field (WN) Results of Last Adequacy Test _~-Tl SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~'[ [O ' ' To Building Foundation ' ~C) ' Lot ~j /~ , TO Water Main/Service Line, c-~ TO Property Line /,_%~. t To Existing or Abandoned System on ; On Adjoining Lots ~ ~,~(~ ' To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ~//'{ To Driveway, Parking Area, or Vehicle Storage Area ~"/- Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N)'~ Comments '~, Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumpin~I Cycles during Adequacy Test. **Check Per/.~d Bed!oo/~Rat!ng Against HAA Request*~ I certify th~Y~.~e~chec.~.~y~,erified, or conformed to all MOA an~ Signed f///lZ~/~ - ' MOA No. ffect on the date of this ineer's Seal Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 FEDERAL TAX ID # 92-0040440 Co!lecte40C! 25 $9 I 15:00 }ecetve~ 02~ 25 E~ I 16:00 ,.lea..~ ', : ~r/~ ~'. ~ Client Fame : CORWIF t ASSOC ~.0.1FO~ ~eq ! I)COB~IM ~ Speciel ~ illo~able 2.1 ~/l EPi 351.2 Mo~ Detected "See Semple ~ema~km ~bove Wot AnelTzet L!-Lese Than. GT-Czeate: ?ham INVOICE SEWER AND DRAIN CLEANING SERVICE RO. BOX 112688 PHONE345-2513 ANCHORAG E, ALASKA 99§11-2688 Job Address ROTO. ROOTER SERVICE CALL · HRS. STEAM THAWING HRS. TRIPCHARGE HRS. OVERIIME CHARGE HRS. ADDITIONAL LABOR CHARGE HRS. ~"~MPINGSERVICE~*"~4~) {GAL.) HRS- HYDRO-JET SERVICE HRS. PLEASE PAY FROM THIS INVOICE TOTAL TOTAL FOOTAGE CLEAN ED OR THAWED BLADES USED PROBABLECAUSEOFSTOPPAGE ~'~z~,.~ .,'~'~" ~'.~ LINE CLEANED I-I JOB NOT GUARANTEED FOR FOLLOWING REASON. WORK ACCEFTED BY MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name (.j~t4,~'~C ~-'~"'~- Telephone: Home -~'~'- ~7)7 Business Applicant Address _.~" (c) Applicant is (check one): Lending Institution D; Owner/builde¢; Buyer n; Other [] (explain); (d) Lending Institution v~"CrUTelephone Address (e) Real Estate Company and Agent 'Address Telephone (f) Mail the HAA to the following addres,s:/ TYPE OF RESIDENCE Single-Family'~ Multi-Family [] Number of Bedrooms ~,~ ' Other WATER SUPPLY Individual Well J:~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4, SEWAGE DISPOSAL ' Onsite~Z~ Public[] Community[] Holding Tank[] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72.025 (11,84) 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 flies 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. NameofFirm l,,,5~1'tl'~-'~.n~J'C~'?__ {C;"~(.l't~- ~-~'"~c"J~.-Telephone ~C~,'~'--"7(~(~*:*:~ Engineer's Seal DHEP APPROVAL App:'roved for~'''~'~=-z ('~,) bedrooms by Approved )~ Disapproved Terms of Conditional Approval ~-'"~'~'~*" Date '~- ''~ ~',CJ J Conditional CAUTION -' The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority , Approval certificates based sealy upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their fending institutions in order to satisfy certain federal end state requirements. Employees of DHEP 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. Page 2 of 2 , ~<~t41 .~'., MUNICIPALITY OF ANCHORAGE (MOA) f'~'~ r~ (~ ~ HEALTH AUTHORITY APPROVAL (HAA) · ,,,~ o CHECKLIST - FEBRUARY 1984 A. WELL DATA Well Classific;tion _~'~. ~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) ~ Date Completed [/~ ~ ~ I .~'~'~' Total Depth 4~) / Casedto ~ · ~ Depthof Grouting ~ Static Water Level ~ 4.'~' ' Pump Set At ~,~"~-~.,~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) / ~ (~X:~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ! ~'-~_'~! ; On Adjoining Lots To Nearest Public Sewer Line ~ .r~.- To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments t,~ TO Nearest Sewer service Line on/Lot '"~_v'~'"'~-~ ;Date 'Holding Tank High-Water Alarm (Y/N) ~ Separation Distances from Septic/Holding Tank: SEPTIC/HOLDING TANK DATA · Date Installed ~~z~.__.~ (:X~ No. of Compartments [ Standpipes (Y/N) ~L=:~.ma'~') Air-tight Caps {Y/N) ~ Foundation Cleanout (Y/N) ~1~ Depression over Tank (Y/N)~,~C3 Date Last Pumped7,/I Pumping/Maintenance Contr~;ct on File (Y/N) '~"~/l{~ ; for -- Temporary Holding Tank Permit (Y/N) -- To Water-Supply Well To Property Line ~ ~' / To Water Main/Service Line Course To Building Foundation To Disposal Field ~. To Stream, Pond, Lake. or Major Drainage Comments Page 1 of 2 ABSORPTION FIELD DATA Datelnstalled l:::::f~.'~' ~"7, ~ ~'7<:~ Length of Field ~--~ / "~ /~,(Vidth.~)fField' r~'''~l~----~'' ~ Depth of Field (.---~ /- i~'~ ;~ ~/O/ /~ ( ~[~~ Gravel ~ Thickne. ' (~ / /~are F~t of Absorption Area ~ ~ Standpi~ Pre~nt (Y/N) Y~ ~ Depression over Field (Y/N) ~ Date of Last Ad~uacy T~t ~/~/~' Results of Last Adequacy Test ~t SF ~ ~ ~ ,~ Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ~ / ~ To Water Main/Service Line ~-~-~ /- I ' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Ar.em Comments To Property Line ~P~'~-- I~"- '~C) To Existing or Abandon~ System on ; On Adjoining Lots [ ~ ~ To~utbank (if pre~nt) ~ ~ LIFT STATION / Date Instatled ~ Dimensions / Size in Gal, l. ons _/ / Manhole/Access(Y/N) / "Pump On Level at /~ "Pump Off" Level at / High Water Alarm Level at / ~ Vent (Y/N) / Electrical Oodes omments~ ~ , ~ Check Permitted ~droom Rating Against HA~est "* ' I cedi fy that I hav~ c~, or conformed to all MOA and HAA guidelines in eff~t on the date of this ins~tion. S ign~ ~ Date ~~~ Company Receipt No. Date of Payment Amount: $ <~.~ Page 2 of 2 MOA No. D~...~,RECEIVED ,NSPECT,O" ^P INTMENTS DATE DATE DATE INSPECTOR INSEECTOR INSPECTOR .- DEPT. OF HEALTH & MUNI~PALITY OF ~CHORAGE ~I~M~NTAL ( ENVIRONMENTAL S~ITATION DIVISION REQU~T FOR ~PRO~AL OF INDIVIDUAL WATER ~D 8EWE~ FACILITIES 1. PROPERTY~NER J PHONE~ ~OPE~ RE~I~ENT (If d~ffer~nt from ~o~) PHONE 2. RUYER PHONE I ~ R~LTO~AGENT J PHONE I ~I'REE. TiLOCATI ON TYPE OF RESIDENCE NUMBER OF BEDROOMS I-'1 One r-'l Four .,~ SING LE FAM, LY ~j~ Two D Five MULTIPLE FAMILY Three I-'1 Six ~ INDIVIDUAL' [] COMMUNITY r-I PUBLIC UTILITY [] Other · ATTACH WELL LOG. A well log is required for all walls drilled since June 1975. For wells drilled prior to that date. give well depth (attach log if available.) SEWAGE DISPOSAL SYRTEM ~' INDIVIDUAL/ON.SITE·* I--I PUBLIC UTILITY /~'7/'~O'~/~R ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO r-I FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY r-I INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []PUBLICI'-IINDIVIDUAL/ONuTILITY -SITE DATE INSTALLED / O Connection Verified INSTALLER I'--I,~pt ic T~a~ or [] Holding Tank Size: /(~ C) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER ' TOTAL A~SORPTION AREA MATERIAL ~.~ WELL TO: I I Ablorption Ar~ to nearest Lot Line 5. COMMENTS [] APPROVED FOR . BEDROOMS [] CONDITIONAL APPROVAL (tetter must accompany certificate) [~ DISAPPROVED DATE BY 12-010 (Rev. 6/79)