HomeMy WebLinkAboutSOUTH HILLS BLK 1 LT 7outh H1*1 Is
Block I
Lot 7
#017�063�13
Municipality of Anchorage
Department of Health and Human Services :
Building Safety Div~on
On-Site Water and Wastewatef Program. 4700 Soulh Bragaw S~eet
P.O. Box1966§0 Anchorage. AK 99519~650 Page 1 of 2
www.d.anchorage.ak.us (907) ~4~-7904
ON-SITE WAST~/ATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: swSW020158 PID Number: 017-063-13
~ Mnti.~nn Whlft~ Wastewater System: [] New [] Upgrade
71~1 Hillnid~ way. 995'1t~ ABSORPTION FIELD
_~ r'lD#~Tm~n OS~T~e~ OW Ot~,~ ~o~-Tank
345-0893
LEGAL DESCRIPTION
Existinq ~ ~ re 3034 PVC
. A+ Home Services 712512002
~,,.. ~ .~.0 s.. ~,.I c..~ ,~,. ~.~. o..~,n TANK
SEPARATION DISTANCES [] Septic D Holding [] ~;.T.E.P. n other:
~ Septc Absorption Uff Holding ~r~at® Ment~caz~-
Tank Field Station Tank ,~,~t.~ Anch Tank 1000~
w,, 101 100.5 SS Steel 2
t,, u,.s~ w,, 100+55 100+22 ~~ *~' c~ ~-,~.,LIFT STATION
F,~.~ 38.7 38.9 ~"~'~' ~'~" '~ ~' ~'~'~
c~,~ ~-. 100+ 100+ ~,~,~
New Tank Only. BENCH MARK
Deck on NW Face of House
100.0
Engi~eeVa Stamp
~g..'"' . '"....?~**
Inspections performed by: Pannone Enq. Svc Dates: 1"712512002
Department of Health a~ d Human Services approval
eviowed and approved i-r
P£RMIT NO' S~/020158
NEW
100'
TANK
WELL
RECORD DRAWING
VASTEWATER ABSORPTION SYSTEM
LOT 7, BLOCK 1 SOUTH HILLS
D~x~LI-IT
LOCATE
OUTSIDE-
RADIUS
NEFIOOOgLE
STEEL
P.I.D. NO, 017-063-13
UNDEVELOPED /~
WELLS BR SEPTICS '
100' ~
E
,NK RE VED
38.7 48.3-.
37.0 49.6
38.9 45.7
73.7 63,1
/
/
/
3 BEDROOM HOUSE
10009 SEPTIC TANK REQUIRED
TANK REPLACEMENT ONLY
PREPARED FOR:
R. H~tlson & H~rl~ Vhlte
7121 Hillside
Anchor~§e0 Ak 995t6
(907) 345-0893
EXIST'G x
95.6
EXIS /
NEW lOOO9
SEPTIC TANK 91.2
PANNDNE ENG. SVC,LLC
P. O. BOX 102954
ANCHORAGE, ALASKA 99510
272-8218 Phone & Fo, x
~OATE, 9-t5-oe I RECORI)
SCALE,
I
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Jun 11. 2002
Expiration Date: Jun 11. 2003
Permit Number: SW020158
Legal Description: SOUTH HILLS BLK I LT 7
Design Engineer: 0062 Pannone Engineering Services
Owner Name: R. Matison White
Owner Address: 7121 Hillside Way
ANCHORAGE, AK 99516-0000
Parcel ID: 017-063-13
Site Address: 007121 HILLSIDE WAY
Lot Size: 54400 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of;
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well
[] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3, The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15. a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered. sealed, and heated to prevent freezing.
Received By:
Issued By:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak, us
(907) 343-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017.063.t3
Permit Number SW OZ OI~R
Property owner(s) R. aatison White
Mailing address (1) 7t21 Hillside Way
Mailing address (2) ANchorage, AK
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot Size ~ ~'~,~DO Acres ~'"~
THIS APPLICATION IS FOR:
Sewer Only []
Sewer and Well []
Sewer Upgrade []
THIS PROPERTY CONTAINS:
Hot Tub []
Swimming Pool ~
Therapy Pool
Day phone 345-0893
Lot 7, Block t South Hills
Zip Code 99516
Number of Bedrooms 3
Well Only []
Water Storage []
Jacuzzi []
Water Softening Unit []
I certify that the above information is correct. I further certify that this application is being made for a
Slngle Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees: /"j 0 ~
Receipt Number:.
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
Pannone Engineering Services, LLC
Consulting Engineers
(907) 272-8218
P.O. Box 102954
Anchorage, Alaska, 995 l0
(907) 272-8218 Fax
June 9, 2002
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject:
Lot 7, Block 1 South Hills S/d
Septic Tank Replacement Permit - Emergency Replacement Request
Gentlemen:
My firm was contacted in regards to a collapsed septic tank at the above referenced lot. The
owner has indicated the tank is completely collapsed and sewage is spilling onto the ground
surrounding the tank. There is an emanate health threat. A+ Home Services is currently
pumping the tank on a daily basis to prevent back up of sewage. I am ~witing to request an
immediate issuance ora septic tank replacement permit for this lot. I have attached n site plan
showing where the proposed replacement tank will be located.
Tank Replacement
The lot is approximately 1.2 lacres in size. Lot 7 slopes to the west-northwest at approximately
1 to 3 percent in the area of the ,septic system. The slope is considerable steeper north of the
system. The proposed installation will be located in the central portion of the lot. The existing
tank is located approximately 95 feet from the well serving this lot and will be abandoned in
place. The proposed septic tank will be installed over 100 feet from thc existing well serving this
lot. The proposed location is greater than 25 feet from the water service lines. The other
surrounding wells are located greater than 100 feet from the proposed instaLlation. The
proposed installation will not affect the future development of the surrounding or existing lots.
See the attached design.
If you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Attachments:
PERMIT ND'
LOCATE NEW
100'
DESIGN
WASTEWATER ADSORPTION SYSTEM
LOT 7, DLOCK 1 SOUTH HILLS SMD
LDT
TANK DUTSIDE
WELL RADIUS
/
PRDPDSED lO00g
STEEL
P.I.D. NOT 017-063-13
UNDEVELDPED
WELLS DR SEP~CS
100'
N, K IN /
/
?
EXIST'G
NO ELLS EIR SEP-[~"'"..
100'
C,\Wopk\DRAWINO\7-1 South Hi(Is,I)W~
f
/
/
t
/
DESIGNI
3 ~EDRDQN HOUSE
10009 SEPTIC TANK REQUIRED
TANK REPLACEHENT ~NLY
PREPARED FDRI
R. H~tlson & H~rl~ ;,/hire
7121 HiLlside
Anchorage, Ak 99516
¢907} 345-0893
EXIS
WE
NEW lO00g
SEPTIC TANK
PANNDNE ENG. SVC,LLC
P. D. DDX 102954
ANCHDRAGE0 ALASKA 99510
272-8218 Phone & Fnx
DATE, 6-9-0a I DESIGN
SCALE, I'=50'
I
GREA~,,I~R ANCHORAGE AREA BOR.
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
,,GH
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
LEGAL DESCR,PT,ON LeT ? O/j' / .~=¢~WW/// -~//~--
SEPTIC TANK:
D~STANCE
FROM WELL
INSIDE LENGTH
M A N U F AC T U R E R ~,/,~./...~~'
INSIDE WIDTH
MATERIAL
NUMBER OF
COMPARTMENTS
LIQUID DEPTH
LIQUID CAPACITY ,'~,~ALLONS.
TILE DRAIN FIELD:
fi ~ , TOTAL LENGTH
DISTANCE FROM WELL /Og J~J-FOUNDATION ~) NEAREST LOT LINE ~:) OF LINES /7
NUMBER OFLINES / DISTANCE BETWEEN LINES ~/~ TRENCH WIDT~IN. TOTAL EFFECTIVE
ABSORPTION AREA ~S--O. - SQ. FT. LENGTH OF EACH LINE
I DEPTH OF FILTER ~ / ~
TYPE _
BUILDING
FOUNDATION
CESSPOOL .
APPROVED
CONSTRUCTION
NEAREST
LOT LINE __
OTHER SOURCES
DISAPPROVED
NEAREST SEPTIC
SEWER LINE__ , TANK
REMARKS
DEPTH
SEEPAGE
SYSTEM.
DISTANCE FROM:
DISTANCES:
INSTALLED BY: ~~L__
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form EQ-032
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i-~%'.i~;]i[:'iEi",iE;lii; ];'.i:i; t:~:!ii.".HO[)iE!....!iii:D TO
\ !
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6.650, Anchorage, Alaska 99502 276-2221'
SOILS LOG.- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE SITE PLAN
SOILS LOG
PERCOLATION
TEST
5
6
7
8
9
10
11
12
13
DEPTH
~flF YES, AT WHAT
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
14-
15-
16-
17
18
19-
20-
(minutes/inch)
TEST RUN BETWEEN . FT AND FT I/~ ~ I ~
- ~'~,. ~..,, ' / . ~..~' . ·
72-008 {7/76}
[V~ 'W DRILLING, Inc.
P,O. Box 10-378 · 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
85--216
DRILLING LOG
Well Owner ,L~t~t !l~,rt: Use o£ WeD
Location (address of: Township, Range, Section, if known; or distance main road
Size of casing 6" Depth of Hole__.2_63' __feet Cased to ,qr~_? feet
Static water level___ 70 ~
Screen ( ); Perforated ( , ).
Describe screen or perforation Mone
Well pumping test at ! gallons per (h~) (minute) for
of draWdown from static level.
ft. (alx0x, a) (below) land surface. Finish of well (check one)
open end ( X );
hours with lOOZ ,'~.
Date of completion 7/24/85
W~ELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color ahd hardness
Casing
0 TO 2
2 TOi' 3.
3 TO 22
22 TO 56
56 .TO 71
71__TO 1'60
160 ,TO263 '
TO
TO
TO
TO
__~TO
TO.
____TO
TO.
Orgc~ic
Silty (;ravel
Loose Gravol
9 6[
Bedrock
~adrock '"
NOllDilOad IVIND~flNOalAN]
~ HI1VgH ~O 'id](]
NWWA Certified Contractor
Certificate No's, 814 & 973
3 -- CONTRACTOR
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. 017-063-13
1. GENERAL INFORMATION
Complete legal description
Expiration Date: //" ~ 0 - / /
SOUTH HILLS, BLOCK 1, LOT 7
Location (site address) 7121 HILLSIDE WAY, ANCHORAGE, AK 99516
Current Property owner(s) .JOSHUA HODES & ELIZABETH PIFKE Day phone
Mailing address 7121 HILLSIDE WAY, ANCHORAGE, AK 99516
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
MATT DIMMICK TEAM
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER'OFB. EDROOMS: 3
3; .TYPE :OF.WATER, SUPPLY:
IndividUal .Well []
Individual Wate~ Storage []
Community Class __. Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
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 pedod 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 08/16/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day teSted. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the sUrface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms. · ~....~..
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 Serrv|ces 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: SOUTH HILLS, BLOCK 1, LOT 7
Parcel ID: 017-063-13
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID #
Date completed 7/24/~985 Sanitary seal (Y/N)
Total depth 263 ff. Cased to 80.? f.
FROM WELL LOG
Well Log (Y/N) Y__
Wires properly protected (Y/N) Y
Casing height (above ground)... 24+ in.
AT INSPECTION
Date of test -~
Static water level
7/24/198F,
70 ff. 7~ f.
Well productiOn
WATER SAMPLE RESULTS:
1.0 g.p.m. 1.1 g.p.m.
Coliform NEG colonies/100mL Nitrate 0.1 mg/L
Arsenic: ND rng/] Date of sample: 8/12/2011
SEP'I'lC/HOLDING TANK DATA
Collected by:. ArcTerra
Tank Type/Material SeFl~t~ Date installed 7/25/2002 Tank size 1000 gal.
Number of Compartments _2 Cleanouts (Y/N) _Y_ Foundation cleanout (Y/N) X Depression over tank (Y/N) N
High water alarm (Y/N) N Date of pumping 8/I1/11 Pumper A+
ABSORPTION FIELD DATA
Date installed~8/3/1977. Soil rating (g.p.d./ff2 or ~/bdrm) 150 System type DEEP TRENC[-[
LJength 41 ft. .Width _3 ft. Gravel below pipe __6 ft. Total depth 9.95 ff. (Measured 8112111)
E~. absorption area 450 fi2 Monitoring tube Y Depression over field N__
Date of edequacy test 8/12/2011
Results (Pass/Fail) Pass For 3. bedrooms
Elapsed Time: 50 min. Final fluid depth 45.6 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past t2- mo.) ~/N-&type) N__? yes, give date ---
Fluid depth in absorption field before test 37.2 in. Water added 1100 gal. New depth 65.4 in.
D. UFT STATION
Date installed
"Pump on~ level at
Datum
E. SEPARATION DISTANCES
Size in gatlons
"Pump off' level at
Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
Property line :10'+ Building foundation :10'+
'Water Service line 10'+ Surface water :1o0'+
Curtain drain 50'+ (Nene~Knewn)
Water main 10'+
Driveway, parking/vehicle storage I0'+
Wells on adjacent tots :100'+
F. COMMENTS
Approximately 100 ~ns of water storage in galvanized tanks located in crawl space:.
G. ENGINEER'S CERTI~TION
c?rtify that l .h?ve ~lr~ed through fieid inspection, and ~ ~.
rewew of Mursc~oal ~ds that ~he above systems are in
Engineer's Printed Name KEN~-[ M. DIJ-F~32S
Date 8/:16/28~:1 .'.i~' ~ ':'31~iT~: :' ' ~.
COSA Fee $490.00
Date of Payment
Receipt Number'
(Rev. 1 t1~5)
Waiver Fee $
Date of Payment
Receipt Number
Absorption field $'+
Surface water :100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
'Building foundation S'+ Property line 5'+
VVater main 10'+ Water service line I0'+
Wells on adjacent lots :100'+
On adjacent lots 100'+
On adjacent lots 160'+
Public sewer rnar~hole/claanout 100'+
Holding. tank ,
Manure/animal excrete storage areas
lOO'+
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption §eld~on lot 1.60'+.
Public- sewer main
SeWer/septic service ,lirte,
Animal containment areas 50'+
SEPARATION DISTANCES FROM S EPTIC/HOLDING TANK ON LOT TO:
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.munt.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-063-13
1. GENERAL INFORMATION
Complete legal description South Hills, Block 1, lot 7
Location (site address) 7121 Hillside Way
COSA#
Expiration Date:
Current Property owner(s) .-Mattison & Maria White
Mailing address 7121 Hillside Way, Anch, AK, 99516
Lending agency
Mailing address
Day phone 257-8142
Day phone
Real Estate Agent
Mailing Address
Day phone
Unless othenvise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well.
Individual Water Storage
Community Class __
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
~[~ Individual Holding Tank E~]
Community On-site
[] Public Sewer []
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 th~ transfer of
title (except between spouses) for properties served by a single-family on-sita 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 wastewatar 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 102954, Anchorage, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 5/27/07
Engineers Comments: In conducting aa adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the systcm in
accordance with MOA DSD Guidelines & Regulations. The reported results deserib~ the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The olx'rational 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 b~ing served by thc system.
These conditions are outside the control of the evaluatur of this system. All systems eventually fail and
satisfactory test results do not guarantee future porformance of the system, nor do they guarantee that
them are no hidden defects or eaeroachments. PEg can therefore not provide any warranty for future
performance nor give any estimatn 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 Ix'nefit of the owner listed
above. Any reliance upon or use of this report by any other person or pa~7 is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for ~' bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
~,.' ON-SITE
E-~; WATER AND
= ; WARTEWATER .' -=
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: ~
Municipality of Anchorage
Development Services Department
Buitdlng Safety Division
On-Site Water & Westewater Program
4700 Bmgaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.o~g/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
~9~th Hills. Block 1, LO~ 7
If A, B, or C provide PWSID #__
Sanitary seal (Y/N) Ye~
Cesedto I){7.7 ft.
FROM WELL LOG
7/a41198[~
79 ft.
1,~ gp.m,
Nl~'ata [',~1'~ mg/L
Date of sample: ,5/18/2007
Number of Compertme~te 2
Depression over tank (Y/N) No
Pumper At Home
Parcel ID: 017~1(~-13
Legal Description:
A, WELL DATA
Well type Private
Date completed 7/24/198S
Total depth ~(~)' ft.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform C~ colonies/100 mL
A.entc:
.!. B, SEPTIC/HOLDING TANK DATA
Tank Typs/Matarial Seotlc/$teel
Tank size 1~10 gal.
Foundation cteanout (Y/N) Yet
Data of pumping $['I?/~.OQ?
C. ABSORPTION FIELD DATA
Date installed 8/311977
Length 41 ff.
Well Log (y/N) Yet
Wires properly protected (y/N) Y~
Casing height (above ground)
AT INSPECTION
56 ft.
1.1 g.p.m.
Other bacteria
Collected by: $.R. Pannone
Data Installed 7/25/2002
Cteanouls (Y/N) Yet
High water alarm (Y/N)
Soil rating (O.p,d./ft2 er ft2/bdrm) 1~0
Width 3 ft,
System type Trench
Gravel below pipe ~
(::::7 colonies/100 mL
Total depth 10 ft. Eft. absorption ama 4:;Q ftz Monitoring tube Y~} Depression over field No
Date of adequacy test 511812007 Results (Pess/Fall) Pp~ For_3 bedrooms
Fluid depth in abso~tion field before test 32 in. Water added4S0 gal. New dapth42 in.
Elapsed Time: 30 min. Final fluid depth 32 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) None known If yes, give date
D. UFT STATION
Data installed
"Pump on' tavel et in.
Datum
E. SEPARATION DISTANCES
Size in gallons N/~,
'Pump off" level at in.
Cyctas tasted
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station o~ lot
Absorption field on lot 11~)~
Public sewer main
Sewer/septic service line 75
Animal containment areas lQ0+
Manhole/Access (Y/N)
High water alam~ level at
Meets alarm & circuit requirements?
On adjacent lots 1(IO+
On adjacent lots 1l~+
Public sewer manhole/ctaanout
Holding tank 1l~+
Manure/animal excrete starege areas 11[~+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 38.7
Water main N/A
Wells on adjacent lots 1{)0+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 55
Water sentice line 25 +
Absorption field 7
Surface water 100+
Building foundation 38.9
Surface water 100-1-
Wells on adjacent lots 11)0+
Water main N/A
D~eway, parking/vehicle storage
Property line 22
Water Service line 25 +
Curtain drain 75+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems am in
conformance with MOA CO,SA guidelines in effect on this date.
Engineer's Printed Name Bteven R. Pannone. P.E.
Date 5/27/2007
cos^ F,, $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Prepared ~
Rober[ E. Johns, r. & Assoc.
Professional Land Surve~rs
~08-07 7939
Municipality of Anchorage
Mayor Mark Beg~ch l)cvclolmmni ~tccs l)clmrtmcnt
Novcmbcr 13, 2007
Roy and Maria White
7121 llillside Way
Anchorage, AK 99516
Encroachment: Well in Utility Easement
South llills, Block 1, Lot 7, Grid 2939, 7121 Ilillslde Way
The Right of Way Division has reviewed a request for a later of non-objection to an existing well, which
encroaches 5'-0" into the I0' Utility 'Easement along the southeasterly pamel boundary, and an existing
5'Wx40'LxS'll firewood storage shed, which encroaches in its entirety upon the 10' Utility Easement
along the southerly parcel boundary. On the as-built survey dated May 8, 2007, prepared by Robert E.
Johns, Jr. and A.Ssoc., submitted with the request, the petitioner has shown the well and the firewood
stomgu shed.
This letter of non-objection is issued with stipulations, and by using it the petitioner is agreeing to the
following:
1. Municipality of Anchorage ~IOA) will be held harmless, now and forever, for any damages or
injury to any person as a result of the encroachments.
2. All applicable codes and regulations will be observed and maintained within the easement.
3. This letter of non-objection will in no way preclude MOA from full use and enjoyment of its
rights within any portion of the easement.
4. Additional and extraordinary costs incurred during ~iny future required construction, repair or
reconstruction of MOA improvements to accommodate any or all of the encroachments shall be
paid by the property owner.
5. Obtain laters of non-objection from the following utilities:
[] Anchorage Water & Wnstewater Utility
[] Chuguch Electric Association, Inc.
[-[ Matanuska Electric Association, Inc.
[] Municipal Light & Power
[] Eyecom (Girdwood CableTV)
[] Alaska Communications Systems
[] Matanuska Telephone Association.
[] Enstar Natural Gas Company
[] GCI Cable of Alaska
[] No lelters required
All letters of non-objection should be retained in your permanent files. If you have any questions, please
call me at 343-8033.
Sincerely,
/q'r~lack L. Frost, Jr.
Right of Way Supervisor
Concar
Property Owner(s)
Community, Security, Prosperity
,,,,. /
~ (:Jll~q~, li~ J ..~_.~mm~. J Prepared by J
I
~.~.- --~__--~, J ~.. ~".~. J Professmonol Land Surveyors J
,~,~, . ~. , ~ ~.~ ..... ~ ·
, .~-~.----I .~/ ~~ I ~,-~ I
~~' I ~...~.J I~ ,~ I~- ,~ I~ ,, I
- = -~.---- I~ ~t~ ~ I 5-0?-9? I ~ I ~m I
.~ , ~ m 'Eii:~,,~%~- , ..... ~ ~
7121 ~ Way
And-,oca~, ,Nad~ 99516
southeast i~jo~ Lot 7, Block 1, In 1~e Sou~h Htlls Sulxt~on as ~c~d c~ tine ee-b~ ~g
Any ~ Incum~ by ACS f~r special cor~-a~tc~ r~c~od by this
er~o~hme~t ~ be txxme by the ~ owner.
..... ·
· G~I~'#'RC:2g:~g" ~':
4:'ROH :.PF{,li],t~ 13"13 9JC ~ NO. : 9~7272~211 Jul. 16 2:'I]07 ~l~:16q~ P6
J'uae 27, 9007
Roy & Maria Wlfi. te
C/O ?annoue F_,n~neexing 8enice% LI,C
P.O. Box 102954
Anc,~pra§¢, Ydaska ~9510-2954
ENST&R Natural Gus Company
A DIVISION' OF SEMCO ENERGy
Engineering Depar~m,.'ut
401 E. International Airpor~ Koad
Y. O. Box 190288
Anchorage, Alaska 995194)288
(907) 334-7753
FAX (907) 334-7798
Re: Lett~ of Non-Objection
Grid: 2939
To w-WtiS/i/ff ~,Sy conci:Su: ......
ENSTAK Natural Oas Company has no objection to the existing well cm~roaclunent into thc Ten Fe~t
wide utility easement lying adjac~ to Hillside Drive and situated on Lot 7, Block I, South l-lilh
Subdivlaion, according to Plat No. P-636, Records of the Anchorage Recording District, Third
Judicial District, .S. tate of Ahska.
Acco'prance and use of this letter of non-object/on by yourself, your heirs, your assigns, or },out
successors, will constitut~ agreement to tho following stipulatlon~:
o' ENSTAK will be held harmle~ now and forever'for ~ny damag~ or injur~ to ~y per$on or p~
~ a r~-~ult of this tmeroachmeat.
Any ENSTAR facility damaged or destroyed, as a rea'ult ofth/s encroachment will be r~alxed at no
'* Any cosl~ ~mxl by EN'STAK for ~ectal com~ctlon aece~ated by th/a encroaelma~mt will ~
bor~ by the gmpany owner.
· ~ applicable saf~y cod~ n~gula~ous will I~ observed and mah~talned.
· This letter of non-objection will/n no way prechdc ENSTAK from full ua, and enjoyment of its fights '
~*b!n any portloh of its tight-of-way. ·
$1nc.~rely, '/.
A.ud~w Yraizer
Right-of-Way Aaslstant
ENSTAK Natural Gas Company
cc: ' 'File·
· ~ : ~ ElqG SUC ~ IqO. : ~(372T2T~I! Jul. 16 L:~O? 03:16,q'1 PT
Amc 28, 2007
RoX ~t Ma~a ~ (Own;n)
7~21 ~alh[d~ W~,
Anchcm~, AIL 99516
By sl~i,~g ~low, you Mree to i~demnlfy au~ hold OCI Cable harzulcss, vow and
fo~wr, for any cl~e, oost~, ex.nsc OncluGru~ ~a.souable attorney's fees), liibiliti~
end injm'y t~ eay person or ff. oW. xty oeeunlng es a w~ult office encroach~nt.
Please ir~cele ),out aecepmaee by ~ignlug ami r~amlng thh
letter af uo~-d~iet4/on bee~me~ void for all
Fairbanks Stm~t · Anchorage. AraskG OgSO~ · 907 1868-~;600
.FRO~ :. PP/,gI~ ENG SL~ PHO~ NO. : ~(~7272Et211 Jul. 16 2~E~? ~..3: I"/P~ F~
O?/12/PO07 11:10 I~AX ~O? 8d~ ~4 A~ i~GINEERI.~$
Municipality of Anchorage
Anchorage Wa~er & ~.t. ewater UtLU~)'
Ju~/12, 2O07
Pannone Engineering Services, LLC
P.O. Box 102954
Anchorage, AK 99510-21~54
Re: SOUTH H~LL$ SUaOIVlS~ON BLK 1, LT 7 (Odd SW2939)
7121 Hillekle Way, Anchorage. AK 99516
Request for Letter of Non-objecOon to Encroachment
The ~e Water & Wastawater UtlBty received a request from you on June 25, 2007, in
tngards to tt~ e0~ting w~ll er,~o~ch~;a ir~ t~ F..a~trter~ Io~ o~ the So.h-East corner
of'SOUTH HILLS SUBDMSION BLK 1, LTT.
AWWU is not using the utirRy easement, ha~ no objection to the encroachment, and hereby
Issues thl~ letter with ~lpu~ations to allow the enoroeohm~t of the well and by using the
easement the property owner(s) agrees to tile following:
1. A'6.Y/U will be held harmless, 6ow and forever, for any damages or injury to any
petal", as a result of the encroachment;
2. Ali applicable codes and r~lations will be observed and maintained within the
3. This letter will in no way predudo AWWU from full uae and enjoyment of its rights
within any poalon of Ihe easement;
aooommodate the en~road~'~ent during any futura required constm~ er
reco~'ud~on ofAWWU facllltb~:
$. AV~'s ncw~oWf~cn doe~ not Imply ofher approvals that may be required for thb~
6. AWWU ~ not provide e pos~t~on for any other parcel or utility impacted by the
en~roachmenL
8houkl you have any questions, please call the AVWVU Planning 8eotJon at 564-2739.
· Englneertng Technician
2007-070467-0 ·
Rec~rdJn~ Dtst: 301 - Ar~chora§e
11~7 10:~AM Pages: 1 ~ ~
I lgllllll fll ll llliilll iltlll ll
120~-26'D
0-2939
EN07026
017-06~-13
ENCROACHMENT PERMIT
(l/ervhi ~aoh"),'vd~ose addr~ l~ P. O. Box ! 96300, Anchorage, ~la.,~ka 99~ 1 ~.6300 and Roy
~51~.
I. Eascm~ t'~,,~,-h ia the I~=tee of user of an ea~-ment for ~= co~'tmcfion and
Dedicete4 t,,/t~ p~ cf~c sulxl~v~m known
.. I~ N"mhe-r P-g~6, z~l~t on the 15~ ~ry oflqoveml~r I ~ 1, c~ ~1¢ [uRge oi~ce ofthc
D i.~i~ Recorder, A~hora~ Reco~li~ District,
The Soult~st~'iy Teu Feet (SE'lyl 0') ~dporfion ~he Somhw~t T~nFeet ~ SW lO')
of Let 7, Block 1,5out/a Hills Su~livid?, ~ to ~ ~ P~ 6, ~ on
~ 15~ ~ o~o~ I~1, ~ ~e m ~ offi~ ~c ~s~a ~, ~
Pcn=it~ aclmowied~es tile validity of the Easement. l'~-m!ttee wauan~ and rep~'~t~ that
Peanlttee t~ tho owner of the f~e ~le bt=re~t in O~c land subject to thc Ea~=mcnt and the
f~llbwins d~,ibed real prol~'~
~ "Par~.l").
Ku,:r~'cl~ne~ Pormit-Pa~e I of 4
Nov. 1~9 21~7 B4:$2PH P3
003
.4, wellhead mhd shed
5, ~ill~M~. P~ni~ nl~tll not In an~ way'~nd or ii~.-~easc the
without tl~ prior '~rit~n eensem ci'Chugach. Cbu~,chh~ ~o oblil~.ion to pmvidc aaich con,.~nt.
'% M0diflc~'to~ of Ut~ty Facililies. If th~ eLect:~c ~ti!i~ fncilitles loca+.cd ~_ thc
~ ~ upsr'~_ _. ~_~_"t ~o, ~l,lsced or r~co~-.c~l, Pnmit~cc shall l~n¥ tMt pc~im of
ClmBach's ~ costs for ~,~h Illodiflcatioll which i~ r~nably .ihi'outaMe ~ ,~.ommodatlr~ or
for ~, ~,,~ roux ~ ~ ~t ~ ~ ~ ~ ~, ~low,
8. C_.,m'cnamz 1~ --~-m with ',h~ L~,,a Thc ~l;.~ion~ oft~e Pt~nitt~c mislng t. oc~ tl~s
p,~_ t s~atl b~ eove~nu rannlnl with t~e ~ which ~ bunl~ th~ Parcel s~d ti~'Per~it~'s
~. .T~- ~ may u=ugnale C~ l~--nnit after the igvin: o f thld7 (3 O) day`
~,'~il~l r. olicc of Such terrain iliOn ~ ·
~ : ,P~OI4~ ErlG SUC ~ i,o. : 9~11 Ho,,,,. 89 &::~87 ~'-S*'~:~ P4
10. Tc~. T~s~mltebe~.ifnet~o=r!~,~L,~,~-abyCle~,ecb, e~i~forty(40)ye~-~
oft.he [~e-mt~ ~d[/~, eE~ctt~ un]c~ ~ ~g end ~n. ed'by all oft.be l~rtic~ hereto.
CI:iUOACH ~'~.c:A F, IC
A$SOC-IATION, ~qC.
Emmoachme~t Pcm~ - Page 3 of 4
STATE O'F ALAS~ )
TEIRD IUDI~ DISTRICT )
Ch~,~.h EI~.;¢ A~od~flou, Inc.
P.O. Box
Anchorage, ~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(0O7) 343-7904
ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET
To: Steve Pannone
Legal description: ~pth Hills Block t Lot7
[--~Permit []C.O.S.A. [-]Inspection Report
The attached papenvork has been reviewed and is being returned for the following reasons:
1. Well is in Utility easement, need letters of Non-Objection.
2. M.T. NOT Iocated on Survey,
3. Distance appears less Ihan 100 feet well to septic tank per Sureey.
Name of reviewer: ~leff
Date: June 11, 2007
Please supply the necessary information and re-submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
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
264-4720
Application Date Flay 5, 1986
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 7; Block 1; South Hills Subdivision
Location (address or directions)
7121 Hillside Way
(b) Applicant Name R.Fi. White Telephone: Home 345-1766 Business
Applicant Address 2211 East Northern Lights, Anchorage, Alaska 99508
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
279-8486
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
none/refinancing
Telephone
(f) :~e HAA to the following address:
S & S Engineering
SRB 196X
Eagle River, Alaska 99577
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms 2
Other
WATER SUPPLY
Individual Well I'~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
72~025 (11/84)
Page 1 o1' 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of t he 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 bedroom~ 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 S & S ENGINEERING Telephone ~'~,~¢~,'.... ~_..¢2'~y
SRB 196X
Address
EAGLE RIVER, AK 99577 ~{A¥ I 4 !986
Date
Approved for ~' Bedrooms bvYe //~ fP~l~ ~-'~ ~'~¢' ~at°
Approved '~'k Disappro ~ / Conditional
Terms of Conditional Approval
CAUTION
The Mun.cipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely 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 lending
institutions in order to'satisfy certain federal and 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
WELL DATA
Well Classification
Well Log Present {~)'N)
Total Depth ~J~ ~ Cased to
Static Water Level '-/--C
Casing Height Above Ground
Electrical Wiring in Conduit ~N)
Separation Distances from Well:
To Septic/_-IT~ Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments ~ ~J~-t..-~ ,,JI
~ MUNICIPALITY OF ANCHORAGE (MOL'~/
MUNICIPALITY OFi.i~I~THORiTY APPROVAL (HAA)
DEPT. OF HEALTH~,.~=C,~LiST. FEBRUARY 1984
ENVIRONMENTAL PROTE'~I1DT~ ' 264-4720
MAY ~ 5 1986 Legal Description: ~
RECEIVED
IfA, B, C, D.E.C. Approved (Y/N)
Date Completed ~-~ - ~ Yield
~,~ ~ Depth of Grouting
Pump Set At
Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y/~_
,~ ~L~2 I ; On Adjoining Lots
/ ~2,~ / ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/.,I~IOL-t~NG-TANK DATA
Date Installed ~' ~ ' "'] ~
Standpipes ~N) Air-tight Caps ~)N)
Depression over Tank (Y/~j~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from SepticANo~ Tank:
To Water-Supply Well ,) ~O '
To Property Line ~ ~
To Water Main/Service Lin~ \ C~ ~-Jr-
Course ~/~'
Size [. ~ No. of Compartments
Foundation Cleanout
Date Last Pumped
/
IA ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~' )
To Disposal Field Uo ~W-
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date installed
Width of Field
Square Feet of Absorption Area zJr~L~
Depression o~/er Field (Y,~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To BuildingLot Foundation ¢ Ii-/k
To Water Main/Service Line I C) I ~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field ¢¢¢t J
Depth of Field to
Gravel Bed Thickness ~.¢ !
Standpipes Present(C~N)
Date of Last Adequacy Test
To Property Line ~- ~ J'''~
To Existing or Abandoned System on
; On Adjoining Lots
To Cut~ank (if present)
OLP ~
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
\
,.~ / Vent (Y/N)
// Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify thct¢, hm,~e,,61~&k.ea;Lv_erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~.,- ...... Date
Co m panF...A~lr: .............. MOA No.
Receipt No. __,_~¢/'~ I.
Date of Payment ,c_~--_
Amount: $ (.-¢ ~- '
Page 2 of 2
72-026 (11/84)
~1: Time 3:3 · #2: Time
Date 7-20-77 Wednesday Date
MUNICIPALITY OF ANCHORAGE=
DEPARTMB ..OF HEALTH AND ENVIRONMEN~ PROTECTION
825~L Street, Anchorage, Alaska 99501
,-2511, ext. 224 or 225
Date Received:
July 19, 1977
#3: Time
Date
Insp Buchholz Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request:
Mailing Address:
Phone:
2. Property Owner: R.___M_~ White Phone: 279-8486
Mailing Address: 2211 East Northern Liqhts Blvd. 99504
3. Legal Description: Lot 7 Block 1 South Hills Subdivision
4: Single Family Residence: (
Multiple Family Residence:
Number of Bedrooms: Two
Number of Bedrooms:
5. Well System: Individual We].l (~ Conununity/Public System ( )
Permit ~ ~_/~ Depth of Well 103' Well Log on File ( )
Construction ~~_~~, .~_ Bacterial Analysis
6. Sewage Disposal System: On-site System (~ Public Utility ( )
'
Permit ~ y~ ~ Installed ~8--_ Installer.~,
Septic Tank Size /~ · Manufacturer
kbsorption Area ~ Soils Rate /~ Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 7 Block 1 South Hills Subdivision
Comments:
Affadavit Attached: (')
Letter Attached: ( )
Date:
.Disapproved:
Date:
bepartment Worksheet:
L_../4UNICIPALITY OF ANCHORAGE,by ....... ...... ....
.-//~$~ De!?artment o[ Health and ~Environmental Protectli'o}n~:,.:: :'~
99501 ...... ~ ..... ,, .,,..,Ok
' [[~~ 825 ~ S~ee~, ~c~o~age, Alas2a . : ~_~ ,= .. ~=. ,
..... ~ 279-2511, ext. 224, 225 ~',~ < <~ .,~O'::
........ ~equest for ApprovaI of Individual Sewer andWater Facilit~es~'~ '~' ''~
1. Property Owner, '~' ~' ~ ~ ~<¢ '~
Mailing Address ~%~{ f'. ~'~~ ~' ' :
e
Name of Buyer:
Mailing Address:
Lending Institution:
Phone:
Mailing Address:
Phone:
Realtor/Agent:
Mailing Address:
Phone:
Legal Description:
Street Location:
Single Family Residence:
( ~ Number of Bedrooms: ~--
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: *Individual Well (~--~Public/Community System ( )
If Individual Well, well depth ~O3 ~4.
If Community System, name of system
Sewage Disposal System: On-site System (~'~Public System ( )
If On-site System, date of installation: ~tCf ~0~-. ~
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77