HomeMy WebLinkAboutSIEFKER #2 LT A-8D , ~, pa tment of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION~¢4 ~V~O~ '):O-- 0'~l¢~//~g LEGAL DESCRIPTION_
SEPtiC TANK:
DISTANCE ~/
FROM WELL ',(~
MAILING ADDRESS
MATERIAL ,b c ,l.rJ .__
LIQUID DEPTH
PHONE
INSIDE LENGTH
MANUFACTURER
INSIDE WIDTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY~_~-~j) GALLONS.
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA ~'~ '7
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION ~_ ~ I TOTAL LENGTH
__NEAREST LOT LINE ._~El __OF LINES
DISTANCE BETWEEN LINES '~ TRENCH WIDTH~L~ IN. TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE '~ '~ /
~l~ DEPTH OF FILTER ~ ~
MATERIAL BENEATH TILE ~__~1~. ABOVE TILE (o IN.
WELL:
TYPE
BUILDING
FOUNDATION
-- ~v~,~f~0¢-~ e J DEPTH ____DISTANCE FROM:
CONSTRUCTION
NEAREST NEAREST SEPTIC SEEPAGE
LOT LINE SEWER LINE TANK. ~ ~2I_, SYSTEM_ / :LO f
CFSSPOOL
OTHER SOURCES
APPROVED
_ DISAPPROVED
REMARKS
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL: ( OS`Jr` i r"o ~,-~
LOT SLOPE: ~D¢~
Form EQ-032
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASI(A 99503
TELEPHONE 274-456 I
PERMIT ND.
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
NAME OF APPLICANT
, :>_ /->/
INSTALLAT,ON LOCAT,ON /¢ ://:/J :/,/_:/,
INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT . , DRAIN FIELD OTHER
'rv~ A~ s~z~ o~ FACm~TV ~o ~ S~RWB . / / '~ ...... .
FINANCED THROUGH TO BE INSTALLED BY ~/~//~ /~?~4~
SOIL TEST RESULTS --- / NOTE: THl~ PERMIT IS NOT VALID WITHOUT ~OIL TE~
FINAL I~SPBOTION: Z4 HOUR NOTICE REQUIRED. BAOKFILLIN6 OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEP~RTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION,
FOUNDATION TO SEEPAGE PIT ~/~ , DRAIN FIELD
SEPTIC TANK TO SEEPAGE Pit WALL
WELL TO SEPTIC TANK .//r~j'(J , SEEPAGE PIt
DRAIN FIELD ALSO CONSIDER AREA WELLS.
WATER MAIN TO 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 SIPH.ON PIPES ON SEPTIC TANK AND SEEPAGE Pit
Fitted WITH A]RTIGHT REMOVABLE CAPS.
DIAGRAM OF SYSTEM
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING IN/~ALLATION.
/ G.~..~.s.
/or
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SY TEM I IN ACCORDANCE WITH SAID CODE.
DATE ,' APPLICANT'S SIGNATURE
GREATER ANCttORAGE AREA BORO~' TM
Department of Environmental Q~ ,ity
3330 "C" Street
Anchorage, A1 aska 99503
SOIl,S LOG - PEROLATION TEST
Performed for 'IL_vY}_~ ~: (D ;/~c~W-~_ Date Performed
This form reports:~~ "~ ..... ~]~i~ ~T
Deptt]
Feet
3-
4-
5-
6-
7 -
8-
10-
1 '1 .-
12-
13~.
1 ~l .-
Was ground water encountered? Y/cD If yes, at wt~at depth?
Reading Date __G..r_o.s~s...._T_i_m_e_____, Net Time ..Pel2.~_h_}_o.~W.a_tc._]'. Net Drop
· Proposed installa~lr~h-':---~Sbi/i)a-ge Pit Drain Field ..........................
bop th of I n l et: Depth--t-~{ l~l>'t'-~b~--o'f- pi t or t;renc h
COMMEHTS:
Performed [}y: ..... ~ ...... _g~f ~?./__ ..... Cert] Fi ed By: ............................. )JoLe, _ ............
EQ 040 (6/74)
GE L<,
•t _ Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904 a F F.T Y
Certificate of On-Site Systems Approval
Parcel I.D. 015 272 39 Expiration Date: I Z- 0 1
1. GENERAL INFORMATION
Complete legal description SIEFKER #2 LOT A-8D
Location (site address) 11251 AVION
Current Property owner(s) CHRIS AND SANNA DOUCETTE Day phone
Mailing address
Real Estate Agent Day phone
v�61 8 9 Tp 77
2. TYPE OF DWELLING: ti ;'Ori'. �
0 Single Family (w/wo ADU)
❑ Duplex ii `' D
❑ Multiple Dwellings (Single Family and/or Duplex) is. ti
c.
Aw
3. NUMBER OF BEDROOMS: 4 it a 5 9 t, 9
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual 0
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received Date: V/..2, /C
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5240 Waiver Fee $
Date of Payment '` (sol rg Date of Payment
Receipt Number 6Ito Of Receipt Number
COSA# e)66, 1 Y it-1 6R- Waiver#
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,
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 C&M ENGINEERING Phone 854-5558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 8/24/18
: -49TH • * To
1*'
6. DSD SIGNATURE f. .. _ .- ... -
System #1 Approved for 1 bedrooms
System #2 Approved for bedrooms a¢ �tHARLES G['ALZARI
NT
��,,• CE-13854
• •.•���/
Disapproved $� `��F,••. ••��C�AMY
.7 pR0
Conditional approval for bedrooms, with the following s ' kk
ON-Sift
WATER AM")
.:, WASTEWATER
PROUHAMI
•
By: Original Certificate Date: `[ "
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations 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. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet2; - ..
If more than 1 septic system is on the lot:
COSA Checklist# 1 of
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: SIEFKER#2 LOT A-8D Parcel ID:015 272 39
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# -- Well Log (Y/N) YES
Date completed 5/3/2005 Sanitary seal (Y/N) YES Wires properly protected (Y/N)YES
Total depth 110 ft. Cased to 110 ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 5/3/2005 8/25/18
Static water level 82 ft. 86 ft.
Well production 15 g.p.m. +4 g.p.m.
WATER SAMPLE RESULTS:
Coliform 4/f-& colonies/100 mL Nitrate 15f mg/L
Arsenic A/b ug/L Date of sample: '�� 7//5? Collected by: Cf(44 6'L' ' "6
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP / STEEL Date installed 6/30/08
Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) yes
Foundation cleanout(Y/N) yes Depression over tank(Y/N) no High water alarm (Y/N) yes
Date of pumping 5/11/18 Pumper Drain Masters
C. ABSORPTION FIELD DATA
Date installed 6/27/08 Soil rating (g.p.d./ft2 or ft2/bdrm) 1 System typetrench
Length 40 ft. Width 2 ft. Gravel below pipe 8 ft.
Total depth 10 ft. Eff. absorption area 640 ft2 Monitoring tube yes Depression over field no
Date of adequacy test 8/25/2018 Results (Pass/Fail)pass For 4 bedrooms
Fluid depth in absorption field before test 37 in. Water added 600 gal. New depth 48 in.
Elapsed Time: <144 min. Final fluid depth 37 in. Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) none known If yes, give date na
D. LIFT STATION
Date installed 6/30/0 Size in gallons 1500 Manhole/Access (Y/N) yes
"Pump on" level at 150.5 in. "Pump off' level at 154 in. High water alarm level at 142 in.
Datum lid Cycles tested 3 Meets alarm&circuit requirements?yes
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot +100 On adjacent lots +100
Absorption field on lot +100 On adjacent lots +100
Public sewer main +100 Public sewer manhole/cleanout +100
Sewer/septic service line +25 Holding tank +100
Animal containment areas +100 Manure/animal excrete storage areas +100
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation +5 Property line +5 Absorption field +5
Water main +10 Water service line +10 Surface water +100
Wells on adjacent lots+100
ABSORPTION FIELD ON LOT TO:
Property line +10 Building foundation +10 Water main +10
Water Service line+10 Surface water +100 Driveway, parking/vehicle storage +5
Curtain drain +50 Wells on adjacent lots +100
F. COMMENTS
tank cleanout in water tight cast iron cover under walkway.
Barn does not appear to be plumbed as an ADU
G. ENGINEER'S CERTIFICATION .
c,, OF 414kk
I certify that I have determined through field inspections and Apo' ' `. •, ,,,,���j
review of Municipal records that the above systems are in -C.j'•• "• 57
conformance with MOA COSA guidelines in effect on this date. l0j
IE/
Engineer's Printed Name Charles Balzarini /1. ' ' ' *° " " « • it•
Date 08/31/2018 - • >�� • . . . . . . . » . .
110 CHARLES G BALZARINI
fl •••CE 138 4To k
ASV
'‘ ;DPROFEssatO'
COSA canary sheet_2-6-15.doc
MUNICIPALITY OF ANCHORAGE
4;.
Development Services DepartmentPhone: 907-343-7904
On-Site Water & Wastewater Section -.. Fax: 907-343-7997
Lift Station/Pump Vault
Maintenance Log
Owner
DguCE7TE Street Address I c).5 ' PtU DA/
Septic Tank:
•Sludge level / inches •Pumping: required 1110 -Pumping completed no
Lift station: 5/ 0/4
•Pump basket cleaned a no -Effluent filter cleaned vey' no
-Control floats cleaned no •Proper float settings confirmedr; no
•Operation satisfactory no
Alarm System:
-Dedicated electrical alarm circuit e0 no -Audible and visual alarm inside dwelling Oftl no
-Alarm system operation .atisfacto not satisfacto
Manhole Riser
•Ground water intrusion at riser to tank connection es o
-Ground water intrusion around pipe penetrations es no -Weep hole functional ` no
•Manhole lid: Functional al no Insulated / no Properly Secured al no
Other
-All manufacturer required inspections and maintenance completed no
Comments:
S,-(ow, 1.114 7 S'-i2 FA-6 Cc2R-205_�,.,
Qualified Maintenance Provider:
Technician C 5 F911-L--2AWDate of maintenance
Company CA/V1 EAJtiWEE.R;
Signature Date
Mailing Address: P. 0. Box 196650*Anchorage, Alaska 99519-6650*www.muni.org
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTEC'rlON
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL --
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ~////~:~ ~//~ ?
GENERAL INFORMATION
(a)
(b)
(c)
Legal De.s,/cription (include lot, block, sub(;livision, section, township, range)
Location (address or directions)
/
_/~+4~. ~-~ Telephone: Home .-~ ,~' Y~'~/ Business ¢
Applicant
Name
g
ApplicantAddress(¢ ¢¢~-2."/t.~ ~ (~~
Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address ,
(e) Real Estate Company and Agent ..,~/~ ~_.../L..¢~-~¢.~-¢-~
Address
/~n e
(f) 'J~ci~the HAA to the following address:
17034 Eagle River l. oep Road No. 204
.Eagle Rlvert Alalka 99.~77
TYPE OF RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms Y
Other
WATER SUPPLY
IndividuaIWellC¢ Community[]
Public I-I
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ 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.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDII' NSPECTIONS, TESTS, FILE SEARCH, D, . 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 S & S ENGINEERING
17034 Eagl ~[v
Address F.=,~!e Rl¥~--"~ Alaska 99577
Date
Telephone
DHEP APPROVAL
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality 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
72-025 (11/84)
i~ALIT~ O1= '~'tC-'t4OCI~ICIPALITY OF ANCHORAGE (MO~
~uN~C '~A~ ~V~CE$ DN~H AUTHORITY APPROVAL (HAA)
c. c us -
FEB 9 987 264-4720
Legal Description: LO~' ~ - ~
Well Classification _
Well Log Present (Y,t~..~
Total Depth ~ /~o t Cased to
Static Water Level ~-~
Casing Height Above Ground /
Electrical Wiring in Conduit ((~N)
Separation Distances from Well:.~
To Septic/~g Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /~.P,~.o'~. /'~ ~'5' Yield
~,o~ ~-
Depth of Grouting
Pump Set At (J ~ ((~
Sanitary Seal on Casing ~/N)
Depression Around Wellhead (Y/~))
; On Adjoining Lots
/o~'4- ; On Adjoining Lots
To Nearest Public Sewer
/OO/-/-
Cleanout/Manhole ]'"'/,/ /Or To Nearest Sewer Service IJoe on Lot
Water Sample Test Results
Comments -)(: F/z.~-~¢, c~',,,,¢/w¢.=I>_.
B. SEPTIC/HOLDING TANK DATA
Date Installed
/ / .
Standpipes ~.~N) Air-tight Caps ~N)
Depression over Tank (YIn)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) _ /N'~
Separation Distances from Septic/Holding Tank:
(o//! / :;z'5 Size ,/:~_ NO. of Compartments
Foundation Cleanout (Y/~
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
~O/ ~¢~'"'/¢~/ To Building Foundation ~"
/O/'+ To Disposal Field / O/
/O/
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course ,t'-,///::~/
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
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well //O~'
To Building Foundation .~,~/''/-
L o t /"///~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments Cf
Type of System Design
Length of Field ~
Depth of Field /I
Gravel Bed Thickness
Standpipes Present
Date of Last Adequacy Test
To Property Line -~
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) /'"//,~r
Ai"T P~c-/-.¢£i) ~ ~i~cH/~f/.~,'~/F ~.'.'.'.'~,,'.4 ~ 7~
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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & $ ENGINEERING
g ~10~ ~"u ....... L~
Com~ River, Alaska 995TI MOA No.
Receipt
Date of Payment , ~ ~ ~ ~*~¢~ ~~al ~., '~
Amou.,:
72-026 (11/84)
N unicipa.,ty x 196650
ANCHORAGE, ALASKA 99519-6650
0:~~ (907) 264-4111
Anchorage
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
February 11, 1987
Robert A. Shafer, P.E.
S&S Engineering
SRB 196-X
Eagle River, Alaska 99577
Subject: Lot ASD Siefker Subdivision #2
Waiver Request WR87-017
Dear Mr. Shafer:
Your request for a waiver of the 100 foot separation required
between the well and septic tank on the subject lot has been
granted. This distance has been waived to 90 feet.
This waiver is valid for the existing four bedroom single
family dwelling only. This waiver does not apply to future
enlargements or upgrades of the septic system. The Department
may require a test of the integrity of the existing septic tank
prior to future approvals of the wastewater disposal system.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
ROBERTA. SHAFER
February 8, 1987
CIVIL ENGINEER
694-2979
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& F LOW TEST
SITE PLANS
ROAD DESIGN
SOIL 'rEST
PERCOLATION
TEST
STRUCTURAL
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSALSYSTEM
DESIGN
Municipality of Anchorage
Department of Health and Human Services
825 L Street
Anchorage, Alaska 99501
ATTENTION: Steve Morris
REFERENCE: Lot A8D; Siefker Subdivision~
Request you issue a Health Authority Approval and grant a waiver for
the horizontal separation distance of 90 feet between the existing on-site
well and septic tank.
A well log for the well located on this property could not be obtained,
therefore, the well log on an adjoining lot drilled at approximat~y
the same depth was utilized in the risk analysis calculations.
It should also be noted that the existing trench on this property extends
into the road easement approximately four feet. An encroachment permit
has been issued and a waiver to the property line setback is required.
In addition to the information required for an HAA the following documents
are provided:
A. Copy of encroachment permit.
B. Waiver review worksheet.
C. A plot plan.
In accordance with the risk analysis performed by us there appears to
be no possibility of bacteriological pollution of the on-site well,
therefore, it is our opinion that the horizontal separation distances
prescribed by 18AAC72.021 are not required in this case.
If we may b_e of further
s~rvice, please contact us.
SRB 196X EAGLE RIVER, ALASKA 99577
DATE
.... ~, I N I!',E R:
.2~, ..................................................
CRITERIA:
])
/~'AI VER IS: ....................
With
___l. z: SO~
SCALE
$ & $ ENGINEERING
17034 Eagle River L~p Road No. 2o4c,,JMPUTATiON SHEET
Eagle River~ Alaska 99577
SUBJECT:
DATE:
SHEET
BY__
CKD
OF
THIS AGREEMENT, made this day of
198 .... , between MUNICIPALITY OF ANCHORAGE, Grantor, and
_James P~.o_ [~L..~._.$3n~'~_QL~p.~_O_~L .... r Grantee,
WITNESoE%H, The Grantor does hereby grant an Encroach-
ment Permit in the following described Public Right-of-Way or
Ea~;ement Area to Wit'-' Siefker Subdivisionz Lot A.-SD located
in 'the._N}J_~l_/4 of Section 21~ T12N,__..R. 3_~..a' S.M~ Grid -- 2635
The encroachment hereby authorized is ¢~escribed as and limited to
the followJ, ng:__{_f_e?~k_9f absorR~tj_.._qn system with stand 32~i_~e_ cut off
a~_k__~-ound level encroaches into AVION STREET Riq_h.'t__/._o~f__-_W~y_
_~a.~..e_r Attachment "A"
In c. onsideration for this permit, the Grantee agrees
that he wilj. indemnify and hold harmless the Grantor against any
and all claims which may arise or be caused by the construction,
alteration or maintenance and existence of the above described
~¢ncroachment or for any damages whatsoever arising out of the
granting of this permit.
The Grantor reserves the right to revoke this permit
upon twenty (20) days written notice to the Grantee. The
Grantee, agrees upon said notice of revocation, to immediately
remove said encroachment from the easement., street or public
right-of.-~.;ay. Should the Grantee refuse or fail to comply with
said written notice, the Grantor, may without further notice to
the Grantee, remove or cause to be remow~d the encroachment, and
the Grantee hereby agrees to reimburse the Grantor for all cost
incidental to the removal thereof, The Grantee hereby agrees to
Day an annual fee of $ 10.00
IN WITNESS WHEREOFg.._I?he parties hereto have hereunto
set their b~nds a~ s~a~s thO"day
.~_ ~ >~. ~. ~.~ and yeau first above written.
Granuee¢ ........ ~>;~,~¢~ Grantor ANCHORAGE
STATE OF ALASKA )
fHIRI_ JUDICIAL D/S'].'RICT
MuniCipal Engineer.'
']:H~S :lis TO CERTIFY that on this day of
, 198 ..... ~ before me, th~--'~'~ersigned, a Notary
Public in and for the State of Alaska t duly corem4 .~.~ ~ ~-~
$4OO
3500
34S0
S600
363O
3445.
E. 112 AVE.
3400 34~0 3500
11201 A8.4
~/.4 4/8 .41C ~/D
MOA PUBLIC GOLF COURSE
O' MALLEY ROAD
.3840
3700
10940
/0
3920
1081~
5O
/
/
4001 4041
ABBOTT
LOOP
-~°N°9~ 41~C
Z~D
11000
52~1050
2
.FP/EL MA4~ SU~4°
GR. 2635
Rabbit Creek Area Reference Map--P13
213 ~(~>.- 215
229
214
COPYRIGHT 1985 JMR
MUNICIPALITY OF ANCHORAGE ..
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIdN"- 'r-::
ENVIRONMENTAL ENGINEERING DIVISION .... ,J I:-~,.)
Telephone 264-4720 !'. ·
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILI'rlES
DIRECTIONS; Complete all parts on page 1, Incomplete requests will not be pro~essad, Please allow ten (10) days for processing.
I. PROPERTY OWNER ~ ' ' PHONE
¢/ ; / t, I
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) P
2. BUYER ~J- -- PHONE
MAILING ADDRESS
:3', 'LENDING INSTITUTION PHONE
MAILING ADDRESS
4, REALTOR/AGENT , . .. PHONE
MAILING ADDRESS
5, LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] rVlU LTIPLE FAMILY
NUMBER OF BEDROOMS
[] One ~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL'
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEI~
d~ INDIVIDUAL/ON-SITE*~
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log ~s required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available,) .-- t/~.) 2--- /
**If individual/on-site, give installation date ~z-~
If system is over two (2} years old an adequacy test is required
t is Departm.n .
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~010(3/78)
--- THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME ' TIME
DATE DATE ' -DATE
I NSP ECTOR I NSPECTO R INSPECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[~SINGLE [] THREE [] FIVE [] OTHER
ONE
FAMILY
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
I~/INDIVIDUAL DEPTH OF WELL -
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LFYY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
i~j~DiViDUAL/ON/' .SITE DATE INSTALLED .,,.~ --
I--]PUBLIC UTILITY (~' ,, ~ ~
Connection Verified INSTALLER ......
E]Septic TajLk or [] Holding Tank
Size: ~--~-"-~' . If Tank is homemade SOILS RATING
give dimensions:
M AN O F ACTU R E R~,,~Aj~a~~
TYPE OF TANK
TOTAL ABSORPTION AR EA MATERIAL
Absorption Area to nearast Lot line
5. COMMENTS
CFPROVEDFOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
' 74'161 - FO
)JEROME ST.
7.,