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7R ANCHORAGE AREA BOROIV—A
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3500 i udOt 130ad -- Pouch 6•6PAF N? 930
.F rld orage. Alf, ir" 99512
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING
NAME /—� ` %� l=%�/aJl/ —ADDRESS�l� i��`/' f « 1G PHONE
LOCATION LEGAL DESCRIPTION ��T�.
SEPTIC TANK:
/
DISTANCE FROM WELL %-_S MATERIAL C�> %� NUMBER OF
COMPARTMENTS—
LIQUID CAPACITY ,Z_Ci/� / GALLONS. INSIDE LENGTH INSIDE WIDTH
SEEPAGE SYSTEM: SEEPAGE PIT,-
NUMBER
IT:
/
LIQUID
DEPTH
NUMBER OF PITS _OUTSIDE DIAMETER �OR WIDTH LENGTH X:2!�!_, DEPTH_
LINING MATERIAL 1/✓,/fex G,_ , DISTANCE FROM WELL D_% BUILDING FOUNDATION�'_Ce/',
NEAREST LOT LINE -� D TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) l f SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LI
ABSORPTION AREA
DEPTH; TOP OF TILE TO FINISH GRADE
FOUN
CE BETWEEN LIN
FT. LENGTH OF EACH
, NEAREST LOT LINE
TRENCH WIDTH
TOTAL LENGTH
OF LINES
_IN. TOTAL EFFECTIVE
DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
WELL: /
0F
DISTANCEFROM
WATER
DEPTH
, BUILDING FOUNDATION.
-SAMPLE—,-
NEAREST
LOT LINE ��
NEAREST SEPTIC
SEWER LINE.",lJ —. TANK
SEEPAGE
7� SYSTEM -2
CESSPOOL., T:
OTHER /G ✓�
, SOURCES`L�"/✓
DISTANCES:
C/.!/l: seri>fN
G✓/tLG��c' c-'r.Vr
DIAGRAM OF SYSTEM
DATE / APPROVED
HEALTH AUTHORITY
0F
1
i
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\ �
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DATE / APPROVED
HEALTH AUTHORITY
GRE/-+1"Ert ANCHORAGE AREA Bot-,uL vH ///��//
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. - "4. � L
3500 TUDOR ROAD POUCH 6-650
ANCHORAGE. ALASKA 99502
TELEPHONE 2798686
SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT
NAME OF APPLICANT MAILING ADDRESS,/ '` PHONE
INSTALLATION LOCATION
LEGAL DESCRIPTION -� �i / _-5CiCL�-��f�f`/�' -
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED --5'
SEEPAGE PIT
DRAIN FIELD OTHER
FINANCED THROUGH l� TO BE INSTALLED BY
SOIL TEST RESULTS SO / �i NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
I J Z�
FINAL INSPECTION; 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE TYPE ��'�!- SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM
S-/
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT L' DRAIN FIELD i
SEPTIC TANK TO SEEPAGE PIT WALL XlS
SEPTIC TANK SEEPAGE PIT DRAIN DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
1 J
SEEPAGE PIT
L> /
ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD
SEPTIC TANK, " SEEPAGE PIT �`' DRAIN FIELD
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
HEALTH AUTHORITY
OR
LICENSED DESIGNER
1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2868 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE /,/J Z� APPLICANT'S SIGNATURE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # r1_z�rj- rn \ - 'cAQ
1. GENERAL INFORMATION
HAA # 0 Ems') D t , -)`1 1 n
Complete legal description Lot 9; btock G; Schkoede)( Subdi.vi.5 ion East Addition
Location (site address or directions) 12730 Spkingb#.00k Dki.ve
Property owner
W. D. Kocher
9 Lunn M. Kocher
Day phone 694-4321
Mailing address
12730 Spttingbnook
D&i.ve Eagle
Riven., Ak 99577
Lending agency APaAka USA FodonnP Chodit lhiion Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 921
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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 Phone
17034 Eagle River Loop Road No. 204
AddressRiuerTAtaska577
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date (C_-
bedrooms, with the following stipulations:
Date %' 67-7 2
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.
72-025 (Rev. 1/91) Back MOA 421
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L 1_ ��� S� r1R oEDG�s� Parcel LD
F_1SIA44q+71'f_l
Well type 'F9 If A, B, or C, attach ADEC letter
Log present (YCN) Date completed
Total depth �) Cased to tz;
Sanitary seal YON) `/
Vwop. 'rqAsve-e� va„S
FROM WELL LOG
ADEC water system number
/ � % 2 Driller UK _
Casing height t 2
Wires properly protected &N)
(Z/y tea a�
Date of test
Static water level _
Well flow 9—
p.m-Pump level
SEPARATION DISTANCES FROM WELL TO:
Ik
Septic/holding tank on lot 50
AT INSPECTION
LP--1�L.—Ct2-
1�`
g.p.m
; On adjacent lots
Absorption field on lot tD0 ; On adjacent lots _—
Public sewer main N`,p. Public sewer manhole/cleanout
Sewer service line 2 S
Petroleum tank -2-S
1}
WATER SAMPLE RESULTS:
Coliform b'�, NitrateAp. Other bacteria ��"�f
Date of sample: f° "t 16 __9 Collected by: S & S ENGINEERING
17034 Eagle River koapRUD"o204
Eagle River, Alaska 99577
S. SEPTIC/HOLDING TANK DATA
Date installed ''-1 -'IL Tank size IOc"D -a&-I- Compartments 1
Cleanouts`0 N)
High water alarm (Y/9
Date of pumping
Foundation cleanout &N) —V Depression (Y(0
I Alarm tested (Y/N) 1S(4
(p- 17,
Pumper .1-9
SEPARATIONISTANCES FROM SEPTIC/HOLDING TANK TO:
t 1-
WeII(s. on lotT 5'o On adjacent lots / ad 1 Foundation
To property line Absorption field / 14- Water main/service line
Surface water/drainage lob r 7�
72-026 (Rev. 7/91) Front
CONTINUED ON BACK PAGE
AJA
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
Manufacturer
Manhole/Access (Y/N
"Pump on" level at �� "Pump off' level at
Meets MOA electrical cod N)
SEPARAT DISTANCE FROM LIFT STATION TO:
II on lot
D. ABSORPTION FIELD DATA
Date installed �'`�'I-L,
On adjacent lots
Soil rating
Cycles tested
Surface water
System type GK / 13
Length — I A Width j of Gravel thickness 91 —Total depth 13 �
Total absorption area 5��� Cleanouts present&N)
Depression over field (YQ _ r s Date of adequacy test _ s 747 % 2 -
Results 6s 'fail) for 6o /I bedrooms
Peroxide treatment (past 12 months) (YO J�p,ltr I'Wo t•1 nJ If yes, give date
pr�1i�J6s s 1r P� 2-t3rL />sPa�oVnet
SEPARAT ON DISTANCE FROM ABSORPTION FIELD TO:
Well on lot l DO t On adjacent lots 1 DO t 4- Property line tC2
To building foundation tt To existing or abandoned system on lot At
t�
On adjacent lots 3o Cutbank , 9c __Water main/service line
Surface water t as Driveway, parking/vehicle storage area
Curtain drain h, {A
E. ENGINEER'S CERTIFICATION
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
i J v oU
S Z� j I'NOINEERIN! Fad g9'� �F7�fi s o§�
Signature 17034 Eagle River Loop Roar! No. 204
Cagle River,
Alaska ;
Engineer's Name
6G sa
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $ —
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE It 55037
Chemlab Ref.# 92.2936 Sample # 1 Matrix: WATER
Client Sample ID L9 B6 SCHROEDER S/D EAST ADD
PWSID UA
Collected JUN 18 92 0 16:30 his.
Received JUN 19 92 @ 16:00 his.
Preserved with AS REQUIRED
Analysis Completed JUN 22 92
Laboratory Supevisor STEPHEN C. EDE
Released By �� C
Client Name :S & S ENGINEERING
Client Acct :SNSENGP
BPO#
Req#
Ordered By :R. SHAEER
Send Reports to:
1)3 & S ENGINEERING
2)
PO# :NONE RECEIVED
=no.„==me==.=Q.,.n=ea=eeeee.oee======o=.=sees=oma.==.e-.a==o.===a==e=e
Parameter
Results
n
Units
Method
Allowable Limits
-----------------------------------------------------------------------------------------------------------------------------------
NITRATE-N
ND(0.10)
mg/l
EPA 353.2
10
Sample ROUTINE SAMPLE COLLECTED BY: RAY.
Remarks:
=a ve61 n Tests cPerformed
=a = _ `c SeeSpecialInstructions Above UA=Unavailable
ND- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GT -Greater Than
40% B13SMember of the SGS Group (Societd Gbnerale de Surveillance)
I
4Iw- . Q
-� " ral
P-41 Aj,]'*TY -6MCRORAGR
DIVISICK cr MAUD - I
MIIVTAE�Nll (YO, 0WYLl AND E-VIVIFOOMMAL PROTIA'PION
r,"n IT)PAM N)TEORITY )PIOVAT, CERTIPIMPE
Application Date
Lqpll DaF.r-xlptwgi ("Xcludr., lott block,f�Aj)b(jiv:ir-
ioll, .9ecticn, tuc tnship/ range)
LI-XIati-C'n (adclm3ss ot- clixections)
(b) Applicants
Naim,
l`e;L(LpjcLne
Applicants
Address
Applicant is (check orf,,) londing Institution
Other F—
I (explain),
Buyor F:J
(d) Tendirq Institution
z\ddress
'? :) -.�z ,
-/� -x1-.%>_f
(e) Peal Co. FY Agent
Addres`,
Telephone
Singlo.-Fanilyf
NuTrther of
3. Water Su
Individual M�Illi
114[ulti-Famil,V
, 4
Other (dercf ibe)
Public
NOW: I"' coaMnItY SYStelTI, mi.Ist 11,-jw) viritten c.,cnf irmation frcta the Stat(�
Departimnt of Envircnnental Conservation attesting to thO legality and St"Att-I'.
Is the wall. adequate . •far the nLuw--)-,r of bedrc"iq 9pocified in this
S--v;cAqe Disposal
Holding Tark
Onsite t -, colTolinity
Is the wastewater diPp6sal system adequate I:C;r. the rj)Mker of
[PageI-
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u
2-15--84
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a
5° jnaineerirq Firm Providi.nyInspections, .Thsts, Data and Information
i re;?tify that > -M ve ctx;cked, ver if i.ed, or conformed to all. WA FVIA Cuidalines in
effect on the 6ateO. thiq,,,in .pecti.on,
j
/i bateSigned
_
Name of ix _..� r �a m_ Tb lephorr�m.__
Address
(..
tpp M's
.
OF A
S ignead by i�v Ra (i J F s _ �a a n i J *Y
fay •^'' _ x •as `Y. p
: 'ii°
r r
A. 'S10
h:rA"at • l" .1'
(I".1���dN1iJ\ JL'],t� / E'f rP'•h P: ri. �4.i �1: ,: i?''rr
h f)RF.P Approval
Approved for_._.w.�Date
Ap�.:,roved J_C Disapprroved Condit Tonal.
Terms of Conditional Approval
rCiie Municipality of Anchorage, Dapartirnnt of I1.�alth and Envi Lonrrental. Protection dces
not guara.nteo the continued satisfactory performance of the water supply and/or the
wastowat:er disposal. system. This approval indicates that, as of the validation date
shcvan abovP-f based on tFre (bta and information furnished by an engineer_ zegist.ered in
the, State of Alaska, the water supply and wastewater disposal system is, safe and rune»
tional for the number of badrooms and type of structure -indicated.
( DMEP SEAT,)
7° ,viail the HAA to the following address:
KB2/d5/s
[Page 2 of 2.1
z -15 --aa
von ,,, 1p, UTY OF ANC110P.AGN
,, . or Fu:ALTH &
brav'�;zt.>�diA, NTAI. PROIFCT10"!
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) 1111 1 r T19
CHECKLIST - FEBRUARY. 1984 f.
/ ! `•. y a�
Legal -Description: L;�i `" L.-�•,
A. WELL L1a,TA - C-Y�
Well Classification j, If A, B, or
B.
C, D.E.C. Approved(Y/N)
Well Log Present (Y ) Date Completed /ZC3X /Z= Yield y 61M,71—
Total Depth a�� Cased to /�
Depth of Grouting
Static Water Level Pump Set At
ci
Casing Height Above Ground 5c
Sanitary Seal on Casing
Electrical Wiring in Conduit �—
Depression Around Wellhead (a
Separation Distances from Well:
To Septic/HTank on Lot
On Adjoining Lots /gyp
To Nearest Edge of Absorption Field o Lot f)� ; On Adjoining Lots 100 f4
To Nearest Public Sewer Lie N �
To Nearest Public Sewer
Cleanout/Manhole Y To Nearest Sewer Service Line on Lot r/7-
%Water
Sample Collected B�' [ ;Il�+/+i t ClINf7
R'1 1 '� V� �
Water
Date_ �f
Water Sample Test Feskl
Cements cc-)
7 ., 1,0/C--Z_.4-
-L
--
LZ-
B. SEPTICAMPiNGTANK ARTA
Date Installed 'Apy9p,10< l� Size Ine—KY) _ No. of Carpartments lit /Z, _
Standpipes(yw _ _Air -tight Caps Y. ) Foun ati n Cleanout (Y '
Depression over Tank (Y & Date Last Pd
7;
Pumping/Maintenance Contract on File ( ) for _
Holding Tank High -Water Alarm (Y/N) 1A Temporary Holding Tank Permit (YjN�)-� _-
Separation Distances from Septic/Holding Tank:
To Water -Supply Well To Building Foundation
To Property Line To Disposal Field
To Water Main,4c3rvice To Stream, Pond, Lake, or Major Drainage
Course 1 - -
Comments l / �'T I T 7y �- tee �� ray �rrJ�' !lr�-�Z / lC _49
77) 1-14-1i1r, A-- C jel 9-t-> s / rte%) _6_Z_1Lk-_)
TI -115 ;F3- / ES' �! / -7-16,#,J a) ,,f' f 7-0 77/-4F 6-c_l 1F= L, C ,
[Pagel of 21 /r Z_tlf/ s l /V s l /9 U L- /2F_ L% �G`�c,19 1 2-15-84
C. ABSORPTION FIELD DATA
P(
Soils Rating in Absorption Strata (.(; Type of System Design
Date InstalledfJY�cI '? Z= "' '-_�_" Length of Fieldf
Width of Field Depth of Field —
Gravel Bed Thickness'
Square Feet of Absorption Area __ Standpipes Present /N)
Depression over. Field ( Date of Last Adequacy Test
Results of Last Adequacy Test A??5l = m
2i
Separation Distance from Absorption Field: ��
To Water -Supply vbll r� To Property Line
To Building undation _` To Existing or Abandoned System on
Lot A ; On Adjoining Lots
To Water Main/Service Line 3O6)_ �� To Cutbank(if present) /(
To Stream/Pond/Lake/or Major Drainage Course A
— --,
-- ivewa_--r_)Parking Area, or Vehicle Storage Area / �
Conuents --- ---�
D. LIFT STATION
Date Installed _ _ Dimensions _ �—
Size in Gallons Manhole/Access LY/N) —
"Pump On" Level at -- �ump Off" Level at -
High Water Alarm;Level at Vent (Y/N)
Tested for i g ycles during Adequacy Test. Meets MOA
Electrical CodesN)_--
Comments --- - --'
** Check Permi
I certify that I
on the date' of t
Signed
Bedrocm Rating Against HAA Request
e checked, verified, or, conformed to all rPDA:HAA Guidelines in effect
KB1/d5/s ! � iL iPH,
(ii, E
[Page 2 of 21
Vv T
Date,
MOA o.
s 1 pew A.� ■3fiag4sr , ,�,
2-15-84