HomeMy WebLinkAboutUS SURVEY 3042 LT 10 S2tj.S. S"r%Aey
3042
5 1/2
Lot 10
#075-092-55
............
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BLOCK: I LOT:
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SEWER SERVICE LINE SKETCH
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CONNECT LOCATION:
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COMMENTS:4a,
INSPECTED BY: DATE:
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SEWER SERVICE LINE SKETCH
SHOW LOCATION OF CONTROL MANHOLES/CLEANOUTS
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TYPE MAIN: 01 P CONNECT DEPTH AT MAIN _e!� CONNECT DEPTH AT Prop. Line
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COMMENTS:
INSPECTED BY: o,4vlD A. 1-aNt>V-29y llS>'e-p je"Na, DATE: '-7-'97 _.___
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MUNICIPALITY OF ANCHORAGE
Development Services Department I
p p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 075-092-55
Legal description US SURVEY 3042 LT 10 S2
Site address 616 SPROAT RD Girdwood AK
Current property owner(s) SCHIMSCHEIMER
Expiration Date: ZZ 2.f7 Z�
X The On -site system(s) is/are approved for 3 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
f
By: Original Certificate Date:
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
or
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 075-092-55
Complete legal description US Survey 3042 Lot 10 S2
Location (site address) 616 Sproat Road, Girdwood, AK 99587
Current property owner(s)
Carole Schimscheimer
2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone (907) 529-4346
3. TYPE OF WATER SUPPLY: X Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑■ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age N/A - See advisory if steel older than 20 years
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $ z g 0
Date of Payment 2 1 2 o Z 3
COSA#
Waiver Fee $
Date of Payment
Waiver #
COSA Application —June 2022
*Data pulled from 2014 COSA. **Drilled before 1996
>
Benjamin Schiller, P.E.
(907) 522-7773
Municipality of Anchorage
On -Site Water & Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 075-092-55 Expiration Date: 7 -21,1`
1. GENERAL INFORMATION
Complete legal description U.S.S. 3042; LOT 10,
Location (site address) 616 SPROAT ROAD, GIRDWOOD, AK, 99587
Current Property owner(s)
FRANS & JENNIFER
WEITS
Day phone C/0 AGENT
Mailing address
616 SPROAT ROAD
GIRDWOOD
AK, 99587
Real Estate Agent
SHARNEE EPLEY W/
REMAX
Day phone 783-4217
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
Q
F] Duplex " USM!T 6 A
❑ Multiple Dwellings (Single Family and/or Duplex)
APR 2 ? 2014
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
LJ
Public Water System
❑
Public Sewer
0
waiverNanance request for: n/O
Distance:=
Received by: SAA Date: S�y
COSA to be released to the engineer, unless othemise requested by the engineer.
COSA Fee $ 5�/e / Waiver Fee $
Date of Payment, !� [u ^� 6k Date of Payment
Receipt Number 7� �tA Receipt Number
COSA# 05CI II 't 7 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date f
Engineers Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
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 systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being sawed by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, not do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any wamanly or future estimate of how long the system will continue to meet the
operational requirements of the ADEC a MOA DSD. The content of this report is for
the sole benefit of the ownarlisted above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal tight whatsoever.
DSD SIGNATURE
System #1 Approved for
System #2 Approved for
Conditional approval for
with the following stipulations:
Original Certificate Date: "7' -2 5-/ L'
The WhiciityFbrApAorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
M.11M
L/ Nitrate Advisory
Arsenic Advisory
Other
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: U.S.S. 3042; LOT 10 SOUTH 1/2 Parcel ID: 075-092-55
A. WELL DATA *PER GEG INSPECTION. **ASSUMED BASED UPON SURROUNDING WELL LOGS.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO
Date completed 1964 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth *72+ ft. Cased to **40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml
Arsenic: , V IQag./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal.
Foundation cleanout (Y/N)
Date of pumping
t�t1:bY�] :t � 1 [�L` � y I �, �l X7_1 L•1
Date installed
Length ft.
Total depth ft. Eff.
Date of adequacy test
AT INSPECTION
4/11/2014
Nitrated "" mgdl_.
Date of sample: 4/11/2014
PUBLIC SEWER
Number of Compartments
Depression over tank (Y/N)
Soil rating (g.p.d./ft or
Width i
ft'
9.1+ g.p.m.
Collected by: GEG, Ltd.
Date installed
Cleanouts (Y/N)
High water alarm
ti System type
ft. Gravel below pipe ft.
Monitoring tube_ Depression over field
Results (Pass/Fail)
For bedrooms
Fluid dep�bsor field before test _ in. Water added _gal. New depth _in.
Elapsed n. Final fluid depth _ in. Absorption rate >= g.p.d.
Arfy'rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed - Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at wa er alarm level at in.
natum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on
*PER CODE AT TIME OF WELL DRILLING.
On adjacent lots N/A
On adjacent lots N/A
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer /septic service line *10'+ Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation
Water main
Wells on adjacent lots
Property line Absorption
Water service line Surface w
SEPARATION DISTANCE FROM ABSORPTION
Property line .
Water service
iCu� drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water
Wells on adjacent lots
I certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 4// 4y
(Rev. 11105)
TO:
Water
parking/vehicle storage
Municipality of Anchorage ,.
• '� Development Services Department
r,° Building Safety Division ': s
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99619-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. �JrJ [= 1 HAA# LEM$D L�f
1. GENERAL INFORMATION
Expiration Date: —=—
Complete legal description USS
3042• S 1/2,
OF LOT
10
Location (site address or directions)
ALYESKA
HIGHWAY
* GIRDWOOD AK. 99587
❑
Individual Holding tank
El
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
MIKE LINDQUIST AND CONNIE HIBBS Day phone (907) 783-2777
P.O. BOX 212 * GIRDWOOD AK. 99587
Day phone
ERIN EEKER w/ PRUDENTIAL JACK WHITE Day phone
783-3493
3801 CENTERPOINT DRIVE #200 * ANCHORAGE, AK. 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3, TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
❑
❑
Individual Water Storage
❑
Individual Holding tank
El
Community Class Well
❑
Community On-site
Public Water System
❑
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 engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, t 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
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 GARNESS ENGINEERING GROUP, Ltd. Phone
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
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 systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
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 will it confer any legal right whatsoever.
5. DSD SIGNATURE
(o� Approved for :3 bedrooms.
Disapproved.
337-6179
Date -7--12-310 S_
Conditional approval for bedrooms, with the following stipulations:
ON-SITE
In
WASTEWATER
Attachments: % a• •. E
HAA Checklist
Maintenance
Septic System Advisory C/ Supplemental Engineer's
o
Report JJJJ'J��11— �� c
Well Flow Advisory Other
By:�%(b
� bbi, Original Certificate Date: 3 ' 'f
ri
(Rev. 12M)
Municipality of Anchorage
oe..
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: USS 3042, S 1/2 of LOT 10, Parcel ID:
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 1964 Sanitary seal (Y/N) YES
Total depth UNK ft. Cased to 40+ ft.
FROM WELL LOG
Date of test
Static water level V ft.
NO
Well production g.p.m,
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
Arsenic: N A mg./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal.
Foundation cleanout (Y/N
o pumping
C. ABSORPTION FIELD DATA
Date installed
Nitrate 0, I mg./L.
Well Log (YIN) NO
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
2/16/2005
65 ft,
2.25 g.p.m.
Other bacteria _(9 colonies/100 ml.
Date of sample: 2/16/2005 Collected by: GEG. LtD.
PUBLIC SEWER
Date installed
Number of Compartments
over tank (Y/N) _ High water alarm (Y/N)
Pumper
Soil rating (g.p.d./ft'or ft2/bdrm) _ System type
Length ft. Width ft. /Grav�I� w pipe ft.
Total depth ft. Elf.. absorption area ft2 Monitor' tf6e_ Depression over Feld
Date of adequacy test Re ass/Fail) For bedrooms
Fluid depth in absorption field b est _ in. Water added _gal. New depth _in.
Elapsed Time: in. Final fluid depth _ in. Absorption rate >= g.p.d.
treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _in.
E. SEPARATION DISTANCES
Size in gallons
High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption Feld on lot N/A
Public sewer main 75'+
Sewer /septic service line *10'+
On adjacent lots 1000+
On adjacent lots 100'+
Public sewer manholelcleanout 100'+
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line
Water main
PUBLIC SEWER
Surface water.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water
Water service line Driveway, parking/vehicle storage
rain Wells on adjacent lots
F. COMMENTS
*WELL DRILLED IN 1964, PRIOR TO 1983 REQUIRED SET BACK OF 25'+.
G. ENGINEER'S CERTIFICATION vo�OF
I certify that I have determined through field inspections and 0 ..7*
review of Municipal records that the above systems are in """' 4"' " ' """""...
conformance with MOA HAA guidelines in effect on this date.
A. amessr
Engineer's Printed Name JEFFREY A. GARNESS
Date 2�2_2245'
ani
HAA Fee $ y U
Date of Payment 3-2-o5
Receipt Number C,3?0
(Rev. 12101) ON
Waiver Fee $
Date of Payment
Receipt Number
10
_ FI¢E RLLµ• � �:
\N
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SURVEY CER71FICAT10NAg!rrrrrrr�+++
+++
Preprred by
Robert E. Johns, Jr. &
Assoc.
?c���
Professional Lard Surveyor,
1700 BRINN DR,
...,n•« L. ma.a..a
ANCHORAGE. ALASKA 99504
Sia.: 1., = 60'
Rec. Let s.F.
Re,
w_I Fife rr.
t
r. r/
AS -811L'
LSI
/'
�r
00VX
D.N, Surveyed:
Drown Ey.
CRecLeC
06 ��o1V�K_ya�A, '"`
2-18-05
REJ
RE -7
..�.,...,
"4121-5
Dote Drown.
Grle.
w'
a�''•.
2-19-05
U. S.f3042
25-3:'
-RfR
'•. ;'
�♦i>40
Leyai DeeerlPtloe.
eirup
r ale elf.
-
. ......r......:' a f�o.�
�* N
A'aresa;OnO+L°���
South - of Lot 10
Sure} ',I 3 0 4 2
SURVEY TYPE
SYMBOLS
a;uc.nm .5-BVW
va1fs roc®
_ ,n , :lzvedar ns_&eu:
"'
..r.—
' SE'. REBAR y DRAINAGE
_ �',.,n s -ectal ..:c' w.TKT TOFO(YUFv,
c FD'JNC REBAR y__6_9 WOOD FENCE
:SNC FC.i
'- - _
ODL� ASSJMEG ELEs. �- 1E1A. FENCE
PLC7 PLANS dt LOT SURVEYS
NOTE:
' - -lE OF THE BUILDER CR CwNER, GRICR 7C
'FJC'Cn, 'C
ONLY THCSC IMPF0VEMEN7S APOVE GROUNC AN.
VERIFY PROPOSED EUILDING GRADE RELATVE
SHCw , FENCES, WELLS, SEF'OC C-AnGVT9,
:•
5 -CE [:PGCE AND �TIL!TY. CONNECTONE AMC TO DETERMINE
_vc[wAt"E,
ETC., ARE SHCWN In' THER PPRe Ok:MATE LOCA7JON.
L
!E tNCC CF A",'EASEMEN7S, COVENAN'.S OR RESTRICTIONS
MAY FRE`/FNT SOME IMPRL VEMEn'TS FROM BEING SEf I.
_.-
--1 Ai'FEAR ON THE RECO11 EC SL
1 JBDIVION FLAT_
A. c
nT '- Nc
dNDEF NO GRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRJ^TION OR FOR EFTABUSHINC cOUNCARY OR FENCE LINES
--•[ `_JF�4 FOR iAXES RCSPCNSIBIEITY FOR ME IN!T1AL TRANSACTION ONLY
AND ASSUMES FINANC.AI UABIUTY CN,Y FOR THE COST Or Tn
Rh/il
. USTED DISTANCES. PREVAIL OVER SCAUNC. REPRODUCTION MAY CAUSC ERRORS IN SCA.E.
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I. D. # & L7- 6 U Sh HAA # _ IINS -057'3
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
S% G/D u/S 5u,eve� 302.
Location (address or directions)
I (' C] sJ.
(b) Propertyowner�`7/'�C X35663 Telephone:(home) Business
Mailing Address
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent t
�/9 C
— .j 1-4C
U/4hJDr-� St
Address
Telephone
— .SS—Co
(e) Mail the HAA to the following address: (or check here if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-FamilyyXl Number of bedrooms
3. WATER SUPPLY
Individual Well Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑ PublicX Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. nae) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION,
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
Telephone G ��e_
5 & 5 ENGINEERING
17034 1:,glp River Loop Road No. 204
Eagle River, Alaska 99577 0
6. DHHS APPROVAL
Approved for bedrooms by ,- % Date f ,r�r
i
Approved- _X Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible forerrors or omissions
in the professional engineer's work.
72-025 (Rev. ]186) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: L �o �l, S . SL!/l Cly y �p2__
2
A. WELL DATA �/
Well Classification 'el UQ 7? If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y(N) Date Completed Ci C L Yield %• 9��
Total Depth 60 4" Cased to 'O t Depth of Grouting 6A- t�<
i
Static Water Level 90. S Pump Set At 64 t/
Casing Height Above Ground 2V It Sanitary Seal on Casing(Y/ )
Electrical Wiring in Condui (Y N) Depression Around Wellhead (Y No
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot / / ; On Adjoining Lots A/ 'l/4
To Nearest Edge of Absorption Field -on- Lot � ; On Adjoining Lots /J f
4t -
To
To Nearest Public Sewer Line % 'A- To Nearest Public Sewer Cleanout/Manhole X620 f
To Nearest SewerServiceLine on Lot _25- .174 -
Water
Water Sample Collected by -S ' ( S ee✓14 f, ; Date
Water Saml
Comments
B. SEPTIC/HOLDING TANK DATA
led Size
Standpipes
Depression over Tank
Pumping/Maintenance Contact on File
Holding Tank High -Water Alarm (Y/N)
No. of Compartments
Caps(Y/N)
SEPARATION DISTANCES FROM SEPTIC/H
To Water -Supply Well.
To Property Line
To Water Main/Service
To Stream, Pond e
Commen
or Major Drainage Course
Foundation Cleanout
Date Last Pumped
for
Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
72-026 (Rev. 7/89( Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Ratkiq in Absorption Strata
A
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test —
SEPARATION DISTANCE FROM
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or
To Driveway, Parking
Comments
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical-Ced
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present(Y/N)
Date of Last Adequacy
ELD:
On Adjoining
To C
Ma' rainage Course _
or Vehicle Storage Area
Line
— To Existing or Abandoned System on
Dimensions
Manhole/Access (Y/N) -
- "Pump Ofreat
Vent(Y/N)
Pumping Cycles during Adequacy Test.
Commen
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
S & S ENGINEERING
Signed 11034 -Eagle RivOF=ooP-D*aAN, 204
Company Bagle River, Alaska 99577 E G .' ti ^r
Date
MOA No. 6— Oo 3
Receipt No. -d d I a b / Receipt No. _
Date of Payment 6F_ Waiver Fee: $ —
Amount: $ 126, Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
pebrunry ib, i9s";'
Qrucu Porooli
1000 Stowari Orivc-!
lunnyvale, CA qjo&�
Subinct: 341 Lot 1Q. WS 3042 Girdwoud boa!! Prucw
War Or. Purcell,.
Anoroval. for tae individual sewer and water facilities canaot
bw qranted until the following jte-fPS. oavef�tad'
,,, coi.)
P4,z� '.'i< _,..t analysis report needs to Do ail':` mit to CUTS
offica front rho Chew Lab, 5G33 B Street, Lor our review.
Enjusu Lha seplic tank nanhole to verify its exi8tenca.
Locala and a%poae the stuaUpipe to the seepage pit for oux
inspaction. This in to in3uro two mininuw distance
xsquiraEwnts are met betwatea the well and ,sewer system.
a adequacy tes;L needs to be �3e1fc771a,'d on th� exiscizq
inuchiag orya. This tw3t Will determiae if the system 01
sdaquate according to uational itandards. A listing of
drivate liras performing too test is enclosed, %his report
awads to by 5ubmiLted to this o2fice ior our revicw.
in Oil event tho leaching arca is within E.'1[.100' rualus
to the well. or the tower systow does not paaa Its a6equ,cy
test, the leachins area will U000 to be relocated.
Frior to :.t v.''•` upgrade on the laaching area. a soils test
Aust 00 Wtainad so Last specitication5 can be determined.
if the" " not a OaPtic tank, a 1000 yallon two compart-
ment tanx will be ne3ded.
Prior Lo any Lt. graus, a tie mjt will need to be issued.
Plea6u noLify unia department for a reinapection when tha
1 0teQ have Oeunt cOrruCLed. If tner, are any
further que5rioyt4, Pluns, call this 02Ace of 204-4720.
5i"cermly,
TlrrL6
Time
r
Date
Date
Date
Inspector
Inspector
Inspector
Comments
Conditional Approval
J
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner 1:, v +..;� 2
--� C �
Phono(4 0��
Mailing Address I 0� <� ��.� �u ��
l) ��aiE �g
s X33
7
.Z(��
BuyerCL
Address 11- c� X F: -'� C� �u V— 9 9
Lending Institution (,( (JC f �
Phone
Address �y �
Ss ,-7 os3
Realty Co. & Agent
Phone
Address
Legal Description l_i
Street Location
Type of Residence
M Single Family -
❑ Multiple Family No. of Bedrooms
❑ Other
Water Supply
Individual ATTACH WELL LOG. A well log is required for all wells drilled since June
❑ Community 1975. For wells drilled Prior to that date, give well depth (attach log if
El Public Utilit available.
Sewa Disposal
a -
Individual Year Individual Installed: , Ct
7 Public Utility When Connected to Public Utility:
Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED.