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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL. SYSTEM AND/OR WELL INSPECTION REPORT
NAME/ � iI�P''HONE
A,rJ2/<,4 �l /� S KAA/ F / V/L P EO S 1//C,
_ �Nr_W
❑UPGRADE
MAILINGADDRESS
LEGAL DESCRIPTION
_
LOT i > ffo20ED�F AP_
LOCATION
NO. OF BEDROOMS
Well Absorption area Dwelling
j
PERMIT NO.
DISTANCE TO: / �j�j 2 �i / ,1 �
Uy /
'78 / D $/D
1-C
��QC2
Manufacturer
Material
SiFc
No. of compartments
_
V)
Liq. capacity in gallonsInside
IF HOMEMADE:
_
length
Width
Liquid depth
/pQp
DISTANCE TO:
Well
Dwelling
PERMIT NO.
Z
O Z Q
Th
_
Manufacturer
Material
_
Liquid capacity in gallons
O
w S
DISTANCE TO:
Well r
4 -LU
Foundation
Nearest lot line
PERMIT
LL Z.
No. of lines
Length of each line
Total length of lines
Trench width
Distance between Ines
F- 2 w
6 Q inches
N:
Top of tile to finish grade
Material beneath the
Total effective absor tion area
inches
Length
Width
Depth
PERMIT NO.
w
Q ♦-
Type of crib
Crib diameter
Crib depth
Total effective absorption area
n. a
Lu
W
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE TO:
Building foundation
Sewer line
_
Septic tank
_
Absorption area(s)
OTHER
o
f? -
PIPEMATERIALS �encZ- 4,1 prC --5F-
_
46
46 lJC 0.P_/111v.
I
_
SOIL TEST RATING
INSTALLER
/J
moi(%/7/fi /fL//LACQ S
REMARKS
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I
APPROV DATE LEGAL
1� rIO,rt_. OYO,
I IP 11. Jr -V N 11 F"o VA I A n.... � 11, ::A ul—� Yxr6 ) I (p
DEPFIF-111ENT OF HEALTH W.K.", E t-1 %.'11;! OtIrl PT I Fil'. Pk!OTFcTTor-.I
;D05 1_-' STIVIE117T, F1,111HORAGE, AW 9950-1
P.1-11 F -E L_ L_ B B 8411:2 13 R�11 S__-, I A" FE 13 RE: 11,1 k -E If F'- 0 r, -_,1;!! 11-11 'H:1....
F,ERP1IT NO. ;T1,040
FIPPL. I CANT' [,'1JRI%o.Fi fit ... WSKAt-1 BUILDER".; PO BOX 214
LOGAT I ON EAGLE RIVER
LECiAl- SCI-IRLDEC-ER LOJ,
TYPE oF `H�, VDIL. AB-SORBTIM-1 SYS"FEVI :IS: rF,.ENC:H
MAXIMUM NLIFIBEF'. OF d. ,fill-. rMTP-IG 1_2Jj
THE :�.--IZE OF' TI -1€: `5011- ABS;ORPTION F'. I'll 1-`.;:
oc--- F,ir It .... It == "kE.3 9L., IEE P-4 Ii ,-d -F, 1-0 cni RAN 1=0 V IT: R_'..
THE. LENGTH DIMENSION Tviu LENGTH (IN FEET) OF' THE TFRF,,NcII OR
THE DEF"TIA OF F! WENCH COT PIT IS THE l)I5.TAf-JC:E
CiF:()LIND FIND TFIL B-OTTCIM OF THE F',XCAVATI0111 IN FEFT).
711EPT,.IS NO SET 1,11C)TH FOF! TITUNUIES.
TviE." GMIVEL [)EPTI-I IS; THE 1-UNIVILIM DEPTH O[i:' GFUIVF.L.
Fir -c, Tt-w*: Bca-rom OF THE E:x.'.C:A%,-vf,r:rot-4 rAN
F;? FE: PJ 1 F.'" If �*. U__n 117— V-11" "T" :1 10 _T, K r_4 PA, A: FT no- 1L. G.". �5:m C-,-fi ro i k pI__ 11._. 9�� _,n
PEAMIT APFAL&VANT HAS THETO mr�
OF ANY WELLS, Fff.*)JAC*ENJ 10 TIMI PFROFUTTY MR) THE:
NU11BER OF THAT THE [AEL.L. Wfl, L
11-11. C"A 0-- ", 3., rr-.q K W K KC01 " X c::u P -A "S-,, F -e. FE E._-& 1 F;;,!: 11:.`
OF FINITI S" !,5T WITHOLIT- FINAL. INSPECOT ION FIND AMAROVI'T. BY
DEPARTMENT tilIt L. BE To PRO.SA"C:UTIC1N.
PUNIMUM ElISM14CE BETWEEM A WEIA. AND AN'y' OI`A-,.,,,TTE*
FEE."T F'OF! ti PR1%,IATF.' WELI ... OP
V..50 TO 20L-1 FEET FP?.0tr1 A PLIBL.IC: PIELI (:;EPPJADIN13 IJF'ON THE": CIF. t-11 IBI fC,* I,_IF'JJ_
WELL LOC.i.C. AFRE FREQUIFRED AND IMUST BE TC) THE.: [.11TI ITI,-I
(:It-' THE WEIA, C:OMPLETION.
IDTFIEF!. MAIr' FI FP L Y. C., I%I
Al.)AILABLF" TO INSURE [`�P.OPEF'.:
Fo, Q W Wil X W EFETWO" I C:: VE. Irwil E-,.." E.E. fP� -:'= �, 9 ... -W.,
I THAT -i - T Olq_-, "EJ
1: 1 AM FFINTLAAk: HIM THE FREQUIREVIEWITS'. Fik �.yq_:
FID[TITI BY THE MUN.T.CAPFILITY OF ANCHORAGE.
I lal It ... L. INSTALA. THE Qns"rEpi IN ACOUIRDANC:FE 1,11 -1 rHF, COD
T
I UNClERSTF94) THAI �-IE CiNSITE '.-, -IER tifilrl RF:GWII`RF: f-_'NLFO!CiF:Mf -,If IF I"HF:
le.EC.'S DEWE I.C, fTEr,i(x:,,,yri-W'T0 tiA�E. -,Ie ;.
FI 1. 1 NT KLIFTV'Ti ALF19 ki F:011 DERS, I
.. .... ....
0 & E GEO 2CHN1 CAL & CEVEL PMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russe// Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Soils Et Foundations — Land Development
Performed for: Name: 1 �'LL<i) A// //JXQ/'V �'[�%c Tel No. l `/�l - yV`3
Mailing Address:
Legal Description: el,:"/p,
Depth feet Soil Characteristics
0
2
3
-- 4/rte
5�
6 �.sW
7
8
9 .�.
i_ /la'i-`-x
l0�
Alec-`/-)�Lf
12
13 �.
].L -
1.5
16
Ground Water Encountered: Yes- No t- If yes what depth��
Proposed Installation: Seepage PitDrain Field
Comments:
Performed by: Date:_
cS"r_
MUNICIPALITY C) ANCH
MUNICIPALITY OF ANCHORAGE DEPT
DEPARTMENT OF HEALTH &ENVIRONMENTAL pROT:�L: E 'T1 v_ ;¢ io
t.,v L
825 L Street - Anchorage, Alaska 99501,J)
•
ENVIRONMENTAL ENGINEERING DIVISION
-telephone 264.4720
�>�
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND CIl.ITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. - -
1. PROPERTY OWNER
PHONE
MAI G ADDRES - - -. - - -
PROPERTY RESIDENT (If different from bove) , / /- PHONE: -
2. BUYER PHONE
MAILING ADDRESS
3. yLENDING INSTITUTION
MAILING ADDRESS
y— TJ
4. REALTOR/AGENT PHONE
M LING ADDRESS
5. LEGAL DESC51PTION _—/
STREET LOCATION
�!
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
1:1 one ❑ Four 0 Other__
EJTwo EllFive
❑ MULTIPLE FAMILY
X Three ❑ Six
7. WATER SUPPLY
f INDIVIDUAL*
*ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
ElPUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
)NIINDIVIDUAL/ON-SITE**
**If individual/on-site, give installation date
If system is over two ('L) years old an adequacy test is required
E71PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. 'TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS__
❑ ONE ❑ THREE ❑ FIVE
❑ TWO ❑ FOUR ❑ SIX
❑ OTHER
-
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified —
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
—
LOG RECEIVED / J
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified _--
PERMIT NUMBER
DATE INSTALLED
-
INSTALLER
F—ISeptir Tank or ❑Holding"Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING��-
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELL T0:
MATERIAL
Septic/Holding Tank Absorption Area Sewer Line
� 'Z
Nearest Lot Line
Absorption Area to nearest I_Ot Line
-
-
5. COMMENTS
6T APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY (Title)
LEGAL DESCRIPTION
-
72.010 (Rev. 3/78)
WAIVER OF LIEN
In exchange for $ 25.00
, receipt of which
is hereby acknowledged, the undersigned hereby waives and
releases any and all claims, rights to lien, liens or stop -
payment notice rights created under AS 34.35.050-120 attrib-
utable to labor, materials, services or equipment furnished
on or. before May 25, 1979
premises:
Lot 7, Schroeder S/D
located in the Anchorage
District, State of Alaska.
DATED this
upon the following described
Recording District, Third Judicial
day of
STATE OF ALASKA )
) ss.
THIRD JUDICIAL DISTRICT )
, 19
Municipality of Anchorage
Dept. of-Tnvirome�i ua i y
THIS IS TO CERTIFY that on this_ day of ,
19`, before me appeared and
, to me known and known to -me to be the persons
who executed the foregoing instrument and acknowledged volun-
tarily signing and sealing the same.
NOTARY PUBLIC FOR ALASKA
My commission expires:
L-74 (8-78)