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HomeMy WebLinkAboutSUN VALLEY HEIGHTS BLK 1 LT 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I:NVlRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS LEGAL DFSCRIPTION 'OCAT,ON U ;~ DISTANCE TO: ! ~..OOt'{' Lq capacty ]ga ons .~'00 IF HOMEMADE: DISTANCE TO: IWell DISTANCE TO: ~.~C) ~ 'Jr Length of each line IAbsorption area Inside length Dwelling EINEW ~UP~.ADE Materi%sl'e?'I Width Material Nearest lot line I ~o~ I Trench wid~ inches NO, OF BEDROOMS /~ PERMIT NO, No. of compartments / Liquid depth PERMIT NO, Liquid capacity in gallons Top of tile to finish grade ,~,l .. ~ Length Width Foundation ~.'{~1 Total length of lines Material beneath tile Depth Distance b.e~w~n lines - Total effective ab.s.orpti area IPERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Septic tank 31ass Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Absorption area(s) OTHER PH~E MATERIALS ':PVC SOILTEST ATING INSTALLER APPR V 7~-013 (Rev. 3/78) DATE LEGAl.. I::'E;I::U~'I Z T 1"40: [:) I';:1T E: Z :~;f'-:;UIE D: O;;?.,..";2 4,./:~M- E:,I::'FFE C:L.O:!;ED: COI",ITFICT I...,ZGI::IL. E:,E:E;CF.: Z F:': :SLIE:[';, ]: 'v' Z E; ]: Obi: :SLJI'.,I VRLI_.E"r' I"I'T'~E;. L. OT: :LO E;E:C'f']: C)N: ;:i:E; FOI.4N~SH ;[ F': ::L2N RFII',IGIE:f';'.3:l.'.l LOT .El ;[ ZIE: ( '.E:;I.,! F:"- O1'4: FICF~:EL';i; ;:, I'ff:l;:':; E:IEE:'Fb:)OH~.~;: E; E:L..C[CI':::: :l.. :+::+: EiF;:l:::l'v'E;I... I..E:I'.,IEiTI'I 3:' ",':'~; F:'T. F~'.EL.3LIIREE; I"IUL..TZI::'LE: [;?.UN:.~; ENOT EXCE:EI:).TNEi ]::".25 FT. EFICH) :+::+: TFII",IK I¢IIJ:E;T FIF:I'v'I!E I:::1'1" I._.EFI:E;T THO C:OI'IPFIRTH[Ei'.,FFS i::II",ID HEL. 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Ji'.,l[;,l::;tE::iE;"f'f':li'.,l[::, 'I"I.II:::IT "FI-I;[:F.i F:'EFE:I~I :[ 'f' :I:S ',,,'RL]:D FOI-;'. FI f'IR::.::]:PILIFI O1:::' G BE;D[;?.OOH'.'.C, Rhl'.¢ EhlI...F:II:;:EiEI'IE:NT I.,.I :[ LL. I:;;:E(;:!I.J )E ~:E I;.11'.,! ]:::iE:,B, :[ 'T' ): O['.,IF:IL.. PERH ]: T. :1:1':' Fi L..E[F'F :E;q"I':I]']:ON :[?; :[I'.,t:!!TFFII._.I_.ED II'.,I I::liq i:::lF~:Ef:l CCt'v%[;;:E:E:, E:"¢ FlOR E-:UZL[)INE~i COI]:,E:E;., :I"HIEN ,:::L::, FIN I:ZI...ECTI:;;::[CFIL. F:'E:RFI]:'f' F:ll'.,l[::, ]:I'.,ISPEEC"r'):OI'.,I HI.J:iST BE: OE:I"Fi];NEB,.~ (2) FI'.5--BIrJ;[L..T21 H]:L.I... I",IOT F.,'E FIPf::'RO~,/E:D I.,.I:[THOIJ'F FIN E:I_.EC:TF?.]:CFtU ]: N'.'!iF:'E;CT ]; ON F.'.EPOF?.'f'.; RN[) C:~:) THE E:I.~.E:C:TI:;;:;[C:FIL.. I,.lO[;?.k: t"IU:E;T E:E [)ONI'.E E:"d F:I L]:C:[E['.,I:E;Ei;D ELI£CTI~'.ZC]:I::IN. MUNICIPALITY OF ANCHORAGE Departmen~ ~f Health and Environment~ Protection 825 L Street,264-4720 Anchorage, AK. 99501 ~_~~-_~ * * * HANDWRITTEN PERMIT * * * Permit ~/%/. ~'~,~, ON-SITE SEWER PERMIT Location: ~ P~ne ~er: ~>~-~ Legal Description, ~r '~ ~, / ~,F~ ~)~ Size: Type of Soil ~sorption System Is: Trench: /] Drainfield: _ Seepage Bed~ Holding Tank Maximum Number of Bedrooms: ~ soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: _ LENGTH ..... GRAVEL DEPTH c/~'cL~'~--' WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between 'the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). REQUIRED SEPTIC(HOLDING) TANK SIZE = ./'~"~ GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departmen' will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee' for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 1 * * I certify that: (1) I am f~miliar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the ~sidence is remgdeled to include more that ~edrooms. Issued bye( ~Applicant , Bate: SWP/024(1/81) SOILS LOG MtJNIClPAL. ITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchora§e, Alaska 99B01 264-4720 SOILS LOG -- PERCOLATION TEST EJ PERCOLATION TEST PERFOFtMED FOR: LEGAL DESCRIPTION: 1 2 3- 4= 6- 7- 8 9 10 11 :¸12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) SITE PLAN ENCOUNTERED? 0 P E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN sram-- pa4 k~ J~'~'-E~S /~}~L~t~ CERTIFIED BY: I DATE: GRE: 'ER ANCHORAGE AREA BOP ' GH Department of Environmental (~uality 3330 C Street Anchorage, Alaska 99503 INSPFCTION REPORT ON-SITE SEWAGE DISPOSAl. SYSTEM SEPTIC TANK: DISTANCE FROM WELL _ INSIDE LENGTH _ MANUFACTURER(, /'~--.,- ~"/'"' NUMBER OF COMPARTMENTS_ INSIDE WIDTH __LIQUID DEPTH __LIQUID CAPACITY_/'~ ~d2 GALLONS. SEEPAGE Pit: ~ / ~ /~,~ DiAMETER/~ DEPTH ~ / LINING MATERIAL~/~ /~'//~'~'RIB SIZE: DISTANCE FROM: WELL BUILDING FOUNDATION__, NEAREST LOT LINE ~-~ ~-~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) /g'~' ~I'¢; / SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE CONSTRUCTION _ BUILDING NEAREST FOUNDATION _, LOT LINE CESSPOOL OTHER SOURCES__ APPROVED DISAPPROVED _ DEPTH DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE TANK __, SYSTEM REMARKS DISTANCES: __ REMARKS: DIAGRAM OF SYSTEM 1.1~'I'-~-~, ~ ' ~ -'~"% ' - ~:J 'x.~ : " ~. ] ,. :~c:~-/<)/ /:~.~::/~ NAME OF APPLICANT GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL. QUALITY TELEPHONE Z74-4561 /~/~:~/~ SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIIT PERMIT NO. PHONE INSTALLATION LOCATION INSTALLATION OF: SEPT[C TANK SEEPAGE PIT SOIL TEST RESULTS TO BE INSTALLED ~Y TYPE L~' ~7~~7' ~ ~'~<~' SEEPAGE AREA SIZE SEPTIC TANK, CAST IRON INTO AND OUT Ob' SEPTIC TANK AND INTO CRIB CROSS]NC GAP OF EXCAVATION 5 FEE'r INTO UNDISTURBED SO]L. CONF'O~M TO BOROUGH REGULATIONS REGARDINg INSTALLATION, I CERTIFY THAT [ AM FAMILIAR WITH THE REQUIREMENTS Of GREATEr ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-G~ AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. 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. # {~)~'-'~ GENERAL INFORMATION Complete legal description t-~(-~[- Location (site address or directions) Property owner Mailing address Lending agency Day phone Day phone Mailing address. Agent Address Day phone. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Un/ess otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well '~ Public water If community well system, provide written corlfirmation from State ADEC attest- ing to the legality and status of system. 4. 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. 72-925 (Rev, 1/91) Front MOA #21 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. '()~\ \ (..~:.L~..~ '~'--,t.\ \.,'~' I~'-~ (.*t ~,:;¢~.)6-u(--',( :¢' ¢,.' !; Phone _ Address _~C,. ¢,.cx it _':'~ .c~ ,~¢-~(.~1~/~-~..-~;~/_ ,o~,. ci"l.'~-II .-I71 Engineer'ssignature_%~-~-~.~(~..~ Date ~ 75-<~i~, SIGNATURE Approved for '-%¢,~ Disapproved. Conditional approval for bedrooms. 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 conduot 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 (Roy, 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services Legal Description: A. WELL DATA Well type A Log present (Y/N) Total depth HEALTH AUTHORITY APPROVAL CHECKLIST Sanitary seal (Y/N) Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number '~' [ _2. L'~O~ [)ate completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELl. LOG ~4 //,, Date of test Static water level Well flow Pump level SFPARATION DISTANCES FROM WELL TO: I Septic/holding tank on lot Absorption field on lot AT INSPECTION g.p.m. Public sewer main ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform I,~//k Nitrate Other bacteria Date of sample: Collected by: B. SFPTIC/HOLDING~TANK DATA Date installed ~'-'1~ L'P.%~O,'~_Tank size I ZBO .~ ~o.~Compartments N© Cleanouts (Y/N) ~ ( ~¢¢ I¢ r~lt) Foundation cleanout (Y/N) Depression High water alarm (Y/N) Date of pumping Oc':~o~¢_d,p-~ Alarm tested (Y/N) Pumper _1 SA-,-q,c- $ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ,~/A, ,/.. ~.~ To property line. _~o -- Surface water/drainage 72-026 (l~v. 7/91 ) Front On adjacent lots Absorption field J(~l:~ (~) __Foundation ~ ' ('~ .Water main/service line St~_ ^rrA~'16.~2 A%-CSutL;t~ CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA ,?.-?~,[. '~-¢L~r:,,~ ~.oo¢4TM i'2.b [|:[ '~t~,-~ct~'~ Date installed ~-~ ~ %~F-¢¢A~,f~ [~ ~ Soil rating ~10 ~' ~¥ System type Length ¥~'¥ ~ Width Pvt I~; ' Gravelthickness ~I'T ~l ~otaldepth Total absorption area !~~ ~¢ ~ Cleanouts present (Y/N) % ~) Depression over field (Y/N) ~ ~ Date of adequacy test (~ -?*"ct~ Results (pass/fail) [~ A~%e~ © for (o bedrooms (P Peroxide treatment (past 12 months) (Y/N) O~',~¢;,~¢_. h~O~r-/~p ~4~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~/'~', On adjacent lots ~//~ Property line To building foundation ~- '-2;'~ ~ (~) To(~isting or abandoned system on lot On adjacent lots ~.~© ~' Cutbank'~ 1'o A~ ~,~,o -~ Water main/serviceline Surface water I ~O ~ ..F (~ Driveway, parking/vehicle storage area I ~ I=,''4-0~ <L o ¢¢.-o~,~ ~'~U~<~ FU.¢~ Curtain drain ~ 1'/'.-- E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines date of this inspection. Signature Engineer's Name Date HAA Fee $ / Date of Payment Receipt Number / 72-026 (Rev, 3/91) Sack MOA 21 Waiver Fee: $ Bate of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Musl be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (adSress o.r directions,)' , (b) Property owner ~'~ ~¢~,~ ~¢~¢f Telephone : (home) Mailing Address ~¢ ~ /O/¢ ~.o Business (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAAto the following address: (or check here,~f, if hold for pick up.) ; - '- 7: ~ List contact person and day phone number below: . ~.~ '.. ...- 2. TYPE OF RESIDENCE Number of bedrooms Single-Family¢~' 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~ Public [] Community [] Holding Tank t3 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025(Rev. 7/88) 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 ('~9 Date Telephone ¢~.,2~-- 6..DHHS APPRovAL. :'-¢,ppro d rd - e rooms by_ iApproqO'8 z~tx --~_L% Disapproved T(~.rm,s of Condit[~d~'~i A-pproval _Conditional J "f-'l*l Ipli 'l'he 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 for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88)Back Page 2 of 2 . i'¥'' <;~,,¢"~_ MUNICIPALITY OF ANCHORAGE (MOA) ,~,~.¥, .~,~,. Health Authority Approval (HAA) ,,j.?.,L,,,¢¥.? CHECKLIST - FEBRUARY 1984 ~'~ , ~ .... ,~' 343-4744 A. WELL DATA-- Well Classification Well Log Present (Y/N) Date Completed Total Depth Cased to Depth of Grouting Static Water Level Pump Set At _J Casing Height Above Ground Sanitary S~ng (Y~N) Electrical Wiring in Conduit (Y/N) Dep.~.~.jarfAround Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: ~ To Septic/Holding Tank on Lot _____ J ; On Adjoining Lots ~ ~;;rr;;; ~dugb~cOfs~;:~r[~tl;n Fie~ ~.~eOwne~i;ian~t~;taSn~_ole To Nearest Sewer S.~, Line on Lot Water Sample ~.~rt'ed by ; Date Water .~¢¢Q-est Results ...C.?..u rrents IfL",~ B, C, D.E.C. Approved (~/N) Yield j~'~ B, SEPTIC/HOLDING TANK DATA Date Installed ¢-/~-?_"¢ Size Ff.¢'~_¢~/ No. of Compartments Standpipes ON) __ Air-tight Caps (~N) _ Depression over Tank (Y/~ Pumping/Maint~nc, nce Contact on File (Y/N) Holding Tank High:w~ier SEPARA'I:IOr~ DIS.T, ANcES: FR~M SEPTIC/HOLDING TANK: To Water-Supply Well _ ¢-~'~ To Building Foundation To Property Line To Disposal Field To Water Main/Service Line ' To Stream, Pond, La'kd br Major;Drainage Course Comments ~, 'u'.¢~__///" ~"~7f' ~"! ¢t¢~ t'/a'r~' /¢u~/'¢~'~ ' Foundation Cleanout ~}1'4) Date Last Pumped /~/7-'~'~ -¢~¢~¢' /~. ?~ ; for 4,) ,/~ Temporary Holding Tank Permit (Y/N) '42¢'/4¢ 72-028 (Rev, 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /'~,5- Date Installed /'/~-~"Y' .., ¢'-/~/- ?~ Width of Field j t//.¢.t Square Feet of Absortion Area Depression over Field (Y/~ Results of Last Adequacy Test ,,~_.¢,~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well 2%~¢ ! To Building Foundation /(2¢ / Lot ~ ,/~ ; On Adjoining Lots To Water Main/Service Line ,,~"~ To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ,/00'// To Driveway, Parking Area, or Vehicle Storage Area ,/~ ~" / Type of System Design Length of Field ~ / ,,' {~ · Depth of Field ,/0.£'/ ~ / Gravel Bed Thickness ~ ,.r- ~ Statndpipes Present (~'N) Date of Last Adequacy Test To Property Line //¢¢" ~ To Existing or Abandoned System on D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for -./ Meets MOA Electrical Codes (Y/N/)---'"~'~_ Comments J~~ Dimensions Manhole/Access (y/N)~ "Pum~ (~.f" Level at P ///Ventr~ (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelj,p~'~,~. ~i~ the date of this inspection. ,._..~ ~/f .~r'~1~'o~,,",,,~l,.~,,~<~?,. Signed ~~~ ~:" ' ~'";~ Date //~I~-¢~ ~~.__- . / 1 Receipt NO. ~/~ ~2- Receipt No. *~"' ' "- Date of Payment //' / ¢ -- ~ Waiver Fee: $ Amount: $ / ~¢ ~ ~) Date of Payment ~-o~e (.~ ~/~)~ Page 2 of 2 lO ,I I I DEPT. OF ENV][RONMENTAL CONSIERVAT[ON A~CH©~ W~STER~ ~IS~T ©~FI~E 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 November 6, 1989 Dr. Leroy C. Reid, Jr. Alaska Environmental Control 1412 West 33rd Avenue Anchorage, AK 99503 Services STEVE COWPER, GOVERNOR 563-6775 PWSID: # 212005 According to the records on file in this office, the Sun Vall~ H_2ei__ghts North Subdivision Water System is in compliance with tile State of Alaska Drinking Water Regulations. Sincerely, Vera E. a'ig Environmental Field Officer VEC:bas MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE O1: INSPECTION FOR HEALTH AUTHORITY APPROVAL OF: ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Loc~tiqp (address or dff~cfions) (b) Property owner ~¢~" ~[~ Telephone: (home) "'" ' .A%:': :'0: - Mailing~dd~es~ ~,,~ ~E~. (c) Lending Institutien~' " Telephone Business Mailing Address (d) Real Estate Company and Agent_ Address Telephone (e) Mail the HAA to the following address: (or check here [~, if hold for pick up.) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family ~ Number of bedrooms. WATER SUPPLY Individual Well [] Community,J~ Public [] 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 [] 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. 72-02S (Rev. 7/88) Page 1 of 2 · ~JOM s,Jeeul5ue IBUO)SSeJoJd eql u! SUO!SS!LUO JO S JO J J@ JOJ elq!suodseJ ~ou s) e~BJOqOUv JO ~l!l~dio!un~ eq/'penss! s) ei~o!J!~Jeo e eJo~eq ~.Bp eZ~lBU~ Jo suoRo@dsu! ~onpuoo lou op SHHQ 1o seeXold~U~ 'slueuJeJ!nbeJ elB~s pu~ 18JepeJ ul~p@o ~s!~s ol Jep~o u! suo[lnlRsu! 6u!puel J!eql pue smuoq ,to sJaseqoJnd oi /,se~Jnoo ~ se s!q~ seop SHHQ eql 'mtselV ,to elelS eql u! peJ@~s!i~e~ Jeeu!Sue leuo!sse,toJd ~uepuedepu! ue,~q e^oqe S qdeJ§e~ed u! ue^!§ suo!lelueseJde~ eql uodn/[lUO peseq peleo!Jpeo le^o~ddv,~lpoq~nv q),leeH senss! (SH HQ) seo!^Jes ueu~nH pue qlleeH ,to ~,ueuJ~Jedeo eSeJoqou'c,to,~!led!o!unR eq/ leAoJddv leUO[l!puoo ].o su. JJe/ leUO!l.!puoo p@AoJddes!C] ',~ peAo,lddv 'l'¢AOl=ldd¥ SHHa '9 'uoiloedsu! siql ,to m, ep eql uo 3oe,t,ta u! suop, elnbeJ pue 'seoueu!pJo 'sep0o e3e39 pue led!o!unR lie qlF~ eoue!ldLuoo u! s! uJe~s~s lesodslp ~e3eMelSeM Jo/pue/~lddns JaleM el!s-uo eql 'uoRoedsu! pue uo!le6!3sa^u! ,~tu tuoJj pue sel!,t a6e~oqouv jo ,~!led!o!unP~ eq3 u~o~,t peu!e~qo uo!3eu~o,tu! eq~, uo peseq leql ,~,tpe^ Jeq3Jn,t I 'u!eJeq pe~eolpu! eJn~onJ3s ,to ed,~ pue suuooJpeq ,to Jeq~unu eqi Jo,t elenbepe pue leUO!3oun,t 'e,tes s! uuels,~s lesodsip Je3eMelse~ Jo/pue /,iddns ~eleM e3!s-uo eq3 ~eql SMOqS le^o~ddv /qpoq~n¥ q],leeH s! ql Jo uo!ieS!lsa^u!/~LU leq~ ,~,t pa^ I 'MOleq U~OqS e~ep uo!~epile^ eqi Jo se pue o~eJeq pex!,tje legs ,~uJ ,~q pe!,t!i~eo sV NOI~V~BO4NI aNV viva 'HOOVES ~1~ 'SiSal 'SNOIIO~dSNI 9NlalAO~d ~a14 ONI~NI~N3 'g A. ~ELL DATA we,, MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 if A, B, C, D.E.C. Approved ~N) '~h~.og Present (Y/N) Date Completed Yield Total r~__Cased to Depth of Grouting Static Water Lev'et-....,.... _ Pump Set At __ Casing Height Above G?bu~ ______ Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/Ri').... Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WEL---'~.~ To Septic/Holding Tank on Lot "'"- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~-..%.,.,. ; On Adjoining Lots _ To Nearest Public Sewer Line To Nearest P~b ic Sewer Cleanout/Manhole _ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING,TANK DATA Date installed ~f~ ¢~ ~Z::~. ~:~L...- . . _ Size I.%~0 (¢/Jz. No. of Compartmems .-¢-,~'~-~, Standpipes CN) Air-tight Caps (~N) Depression over Tank (Y~.~ Pumping/Maintenance Contact on File (Y/N) /'~ Foundation Cleanout (Y~N~ Date Last Pumped I-I?~/? ; for /~ZF/~ Holding Tank High-Water, . A arm (Y/N) /~,~ Temporary Holding Tank Permit (Y/N) SEPAR~!IQN DISTAN¢'ES FROM SEPTIC/HOLDING TANK: To W~ter]Sup,*ply Well. , O~ ~/:,:2(~) ,(-- To Building Foundation ,,.~'~ T~ Pr0perty-Line-; ;' '/~' To Disposal Field To,Water Main/Service L!h'e __¢r~_~_ .~ To Stream, Pond, Lake or Major Drainage Course /(,...O~..'-) ~ Comments 72-026 (Rev 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorptio.n Strata Date Installed Width of Field --~ Type of System De{~ign Length of Field ~ Depth of Field /~.~,?~'~, L~¢ Gravel Bed Thickness Square Feet of Absortion Area 57~'~"~'1~ Depression over Field (Y~) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well '~,~(~0 Statndpipes Present (~/N) Date of Last Adequacy Test TO Property Line /O ~z- '~' %~" Abandoned System on To Building Foqndation Lot To Water Main/Service Line T(~ Existing or ; On Adjoining Lots J/~l~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Cutback (if present) Comments Size in Gallons Dimensions "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) ~'~ ~_. Pumping Cycles during Adequacy Test. **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 Receipt No. Waiver Fee: $ Date of Payment MOA NO. 0~6'/ Page 2 of 2 Receipt No Date of Pa;ment ~ ~/:d~,~ Amount: $ / 72-026 (Rev 7/88) Back ANCHORAGE, AL, ASEA 99503 STEVE COWPER, GOVERNOR 563-6775 TO: Alan C. Wien Alaska Environmental Control Services DATE: January 4, 198~9 PWSID: 212005 To Whom It MaY Concern: According to the records on ¢ile in this of¢ice, bJ~l. G~S~I~ Water System is in compliance with Alaska Drinking Water Regulations, t he ~pN V.6L_Jl~ the State VEC:pkk Sincerely, Ver8 E, Craig Environmental Field Officer · . DATE RECEIVED INSPECTION APPOINTMENTS '~ME TIME TIME -~"A T E DATE DATE ~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCFIORAOE  D~:PARTMENT OF HEALTH & ENVl RONMENTAL PROTECTIO~EPr* ©l: ' ' r r [ ENVlRONMENTALSANITATION DIVISION AUG 2 5 1980 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8E~I~(~,~I ~1"~1~) ~, PROPERTYOWNER PHONE Her wk. 27 _J. David ~ Caro~ Wi11~ams 344-1602 SRA Box 372-W~ Anchorage~ AK 99507 ~', BUYER PHONE Unknown at this time. ~ LENDING INSTITUTION PHONE Unknown at th~s t~me. ~'. REALTOR/AGENT I PH~ONE Elliot Lawson, Jack White Company _ 77-1553 3201 "C" Street, Suite 100, Anchorage, AK 99503 6-2842 *NOTF-: Send all information to Elliot Lawson, Jack White Company at above address. ~'. LEGAL DESCRIPTION Lot 10, Block 1, Sun Valley Heights STREET LOCATION _NHN Floral Lane (off DeArmoun) 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS ~ One E] Four [] SINGLE FAMILY ~ Two [] Five [] MULTIPLE FAMILY ~_1 'three [] Six [] Omer 7. WATER SUPPLY [] NDIVIDUAL* ~ ATTACH WELL LOG. A well Icg is required for all wells drilled EX~ COMMUNITY since June 1975. For wells drilled ~rior to that date, give well [] PUBLIC UTI UTY eeptn (attach Icg if available 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** 1973 YEAR ON-SITE SYSTEM WAS INSTALLED, [] PUBLIC UTILITY NOTE: TH[: INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISFOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED ~3PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or~ % ~-~,. [] Holding Tank Size: '~'<~ ~' If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line §. COMMENTS I];~/APPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79) Tob e Spur land P.E. 8155 Cranberry St. Anchors§e, Alaska 99502. Phone (907) 2.43,5302 Mr. Llliot Lawson Jack White Realty' 3201C Street Anchorage, Alaska 99503 August 27, 1980 MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH &' ENVIRONMENTAL PROTECTION Legal A D E Q U A C T T ~ S T Lot 10, Block 1, Sun V~.ley Height SEP 1980 RECEIVED Residence 4 bedroom, fully finished Wet er Community Well From Municipal Eecords: 1250 gal, 2 compartment steel tank, Greer 4' dia., 6 feet deep concrete ring crib 15'x 15' ~b.sorption pit Total absorption area 360 sq, ft. Dato of Test August 26, 1980 Test Procedure. Ovlner had system pumped during week of August 18. On inspectisn August 26th. the fluid ~epth in i~e pitwas found to be46 inehes., A slow inflow of water from the tank was observed. Water usage in the residence was halted and the crib charged for 30 ~in. at a rate of 6 gal. per min. After 30 min. the fluid depth was 57 inches° The absorption was monotored fer 2~5 hours. At this td~e the fluid depth was 51 inches. Over~l This ~yste~ is adequate for the present residence. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3320 "C" Street, Anchorage, Alaska 99503 274-456'1 Date Received >/~/~/~ Time of REO~JBST FOR APPROVAL OF INDIVIDUAL SSWER & WATER FACILITIBS FOR (, 4, Locat2on: Type of Facility to be Inspected:_~.ff/_.4-~:~._~---. -- _ · ~F~- ~ ~ ,, Number of Bedrooms~ ~ 6, Well Data: A. Type B, Deoth C. Construction .... D. Bacterial Analysis. '7. Sewage Dtsoosal System~ C. Septic Tank: 1. Size~~_ . . 2. Manufacturer :. Disposal Field: Total Length of Lines Distances: %~'(,1~, To: Septic Tank -~ , Absorotion Area - , Sewer Lines ....... , Nearest i,et Line , Other Contamination.,. . Fr, undation to Septic Tenk ~f'~-- ',. AbSorpM. on Area ..~-~m /~ · Absorption Area to Nearest Lot Line Regal-asr for Approval et ,ndfvi~ual Sewer ~ Water · Page Two 9. Commentsl pproved. 7~/~~__-pisapprovea Approval Valid fo~ One Year From Date Signed G~eater Anchorage Area Borough, Department of Environmental quality D~AGRAM OF SYSTEM I certify that tho information conzained in this request for approval to be a true and accurate representation of the subiect sewer and water facilities located Signed Date