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HomeMy WebLinkAboutLODGEPOLE LT 5 Municipality of Anchorage... Page" DEPARTMENT OF HEALTH AND HUMAN SERVICES/ ?3/ ' ENVIROi~MENTAL SERVICES DIVISION . P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~d~/"/d 2--?~ PID Number: Name: P~/~ ~. ~ /~o~ ~. ~e~ Wastewater System: ~ New ~ Upgrade Address: ~2~0 ~uT~ C/~c~E ABSORPTION FIELD.. ~WCffO~G~j ~ ~O7. Nc. of Bedrooms:~ ~Deep Trench ~ Shallow Trench D Bed ~ Mound ~ Other LEGAL DESCRIPTION so,, Rating: Total Depth from original grade: Lot: ~: Subdiv~ion: Depth to pipe bo~om from original grade: Gravel depth beneath pipe Township: ~ Range: Section: Fiji added above original grade: Gravel length: WELL: ~New ~ Upgrade Gravel width: 2 '~t. Number~of lines: Distance /~be~een lines:Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Ddlled: Static Water Level:Ft. ~t~ler:~ ~ ~~1~ Date installed:~o Yield: ~ Pump Set at: Casing Height Above Ground: TAN K GPM~ Ft. Ft. SEPARATION DISTANCES ~septic ~ Holding ~ S;T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Fidd Station Tank Sewer Lines ~C~ ~ ~ Number of Compa~ments: su,.c~ ' LIFT STATION~ Lot ~Sizein gallons:~ Manufacturer: ~ "Pump on" level a~ off" level at: High water alarm at: Foundation Cu~ainDrain ~ ~0~ ~l ~' ~1 IElectrica'lnspect'°nspe'°rmedby: Remarks: BENCH MARK Location and Description: Assumed ]~. CO Ft. Elevation: ENGI~ SEAL 17034 Eagle River Lo~ Road, No. 2~ ~./ : :. ~ Department of He It d HDm ~, <>.~.,. .... .~.~; Reviewed and approved b Date: / ~.~.~ Permit No.Sw940285 Page 2 of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LODGEPOLE SUBDIVISION, LOT 5 PID No.: 01506157 C01 C02 NEW 1500 GAL S.T. FINAL (cos) A B FCO" I:5:0 CO1 t9.5 20.0 C02 ,)9.5 22.5 C03 36.5 28.5 CO,l 86.5 72.5 C05 t8.0 1%0 C06 84.0 65.0 MT1 61.5 50.0 Mr¢-2--~-2-~0, .-6~,0 N.T.S. Ai81.5' NO WATER! FOUND MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 0N-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940283 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:VARELA DANIEL V & DONNA L & OWNER ADDRESS:3220 SOUTH CIRCLE ANCHORAGE, AK 99507-3961 DATE ISSUED: 8/10/94 EXPIR3tTION DATE: 8/10/95 PARCEL ID:01506137 LEGAL DESCRIPTION: LODGEPOLE LT 5 LOT SIZE: 29386 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED A_ND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: _/'~ ISSUED BY: ~~ DATE~: DATE: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. July 22, 1994 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER &WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lodgepole Subdivision; Lot 5 Request you issue a permit to drill a well and install a septic system to servethe proposed fivebedroo~house~the referenced property. Test holes were excavated and percolation tests performed. The approximate locations of the test holes are located on the attached site plan. The monitoring tubes within the test holes have been checked and found to be dry. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review~ontact us. kShafer,~P~.E. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA99577 SCALE C) ISITE PLAN / I / o / -~ / ~ / oc~ >~o o II .o II ON-SITE W~-~fEWAT~ DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MA'£h~IAL SPECIFICATIONS ~: Lodgepole Subdivision; Lot 5 1. The scope of this project includes the installation of a 1500 gallon septic tank and a leachfield trench to serve the proposed five bedroom residence located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4' of cover shall be insulated. Page Two Lodgepole Subdivision; Lot 5 July 22, 1994 o A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10' from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION ~RENC~/DRAINFIELD INST;%~.r.~TION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (roughed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. ~ 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. 1. MATF~tlAL SPECIFICATIONS: Any septic tank proposed for installation must Municipally approved septic tank manufacturer. be constructed by a Page Three Lodgepole Subdivision; Lot 5 July 22, 1994 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (P¥C) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. Page Four Lodgepole Subdivision; July 22, 1994 Lot 5 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required, especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractor's activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractor's activities. Final acceptance of the contractor's work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECT[ON & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DEStGN DATE: ****INVOICE**** INVOICE NUMBER: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 TIN ~92-0103405 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 TERMS ARE DUE ON RECEIPT CHARGES OF 1.5% AFTER 60 DAYS INSPECTIONS will be invoiced after system installation. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 7 8 9 I0 11 12 13 WAS GROUND WATER ENCOUNTERED? IF YES, AT DEPTH? Depth to Water'iAfter ~ollitoring? '\ v,-~ Date: DATE P~( Township, Range, Section: ~' SLOPE SITE PLAN 14 15 16 17 18 19 2O COMMENTS '-~ ~ , 17034 Eagle River PERFORM~ B~' ~g~ ~iver, Alaska 99577 ACCORDANCE WITH ALL STATE AND MUNIC Reading ~ ~ Net Depth to Net i ~me Time Water Drop /&,,.ts - / Yz PERCOLATION RATE __ minutes/tach) PERC HOLE DIAMETER TEST RUN BETWEEN __ i:T AND ~-/ FT CERTIFY THA'~ THIS TEST WAS PERFORMED IN )N THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE P~ Township, Range, Section: SLOPE SITE PLAN 7 8 9 10 11 12 13 14 15 16 17 18 19 20 -} ENCOUNTERED? IF YES, AT WH.~ DEPTH? p Depth to Monitoring? PERCOLATION RATE c~,.'~ (minutes/inch) PERC HOLE DIAMETER ~' Gro/' Net Depth to Net Reading I~., T.T.T.T.~e Time Water Drop lo V;z S & S ENGINEERING . ./ /~__. / I 17034 Eagle River Loop Road No. 204 / '~'~ ~ .,).-/ / PERFORMED BY: ~..~,~ ~[':c;', ~!&.-~;r: ??_=?~ ~/~/ / ~I I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEL~S~EC~ON THIS DATE. DATE: 72-008 (Rev. 4/85) :Xs.~ified:bg~:Se~ :~h~d':h'er~{o and:'~s ~{the V~lidat 0n aat¢'sh~n~b~i0~. I investigatiOn of:this Health Authori~ 'Approval application shows that the on-site water supply an0/or wastowator'di~po~al ~yst, m i~ ~o,.funcfional and adoquato for th~ and ~p~ of ~tmcturo indicat~ horoin. I fu~h~r vori~ t~at ~asod on tho informationo~tain~d from the Municipali~ of Anchorage files and from my inves~ation and inspection, the on-site water supply and/or wasto~at~:disP0Sal.sY~temis in compliance ~ith all Municipa~ and State codes, ordinances;,and r~lat[on's in'eff~t on.the date of this insp~tion. ~ : ~ . ::~ ~ } The ~0n[~ipali~:9[~fhorage:.DePa~ment' of Health and Human Semices:(DHHS) .i~beS Health ' '.,, pmfessmna~e.ngm.eerr~stered~ntheState~fA~ka~TheDHHSd~esth~sasac~u~esyt~purchasem~fh~mes:~;: 'and'(~l~qendlh~:institutions in:6~er t'o ~tis~ ce~ain f~eml and state r~'Uiremefits: EmPl°Y~Sof DHHS do not - condum:inspeCtions or analyze data before a ce~ificate s ~u~ The Mun c pa ~:of-AhCh.0~age:~S' nOt :: ,. responsible for erromor om ~ions in the profe~ ona engin~fs Wo~.::'V~ "::: :~':~: :. ~. ':::~'. ~,;~:~ :'. ~ · Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type Log present (~N) Total depth Sanitary seal (~N) Date of test Static water level Well flow Pump level1 If A, B, or C, attach ADEC letter. ADEC water system number )/,E...g Date completed c~/~.)J?~ Driller ,~ ~ Cased to --~' Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION ~ g.p.m, g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/heldh~ tank on lot Absorption field on lot Public sewer main Sewer service line ~ ~< '-/- ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~-I~ Nitrate Date of sample: ~ - ~ ~ % . B. SEPTIC/I-.I~EBIN~ TANK DATA Collected by: Other bacteria ' ~.4 & $ ENGINEERING '~ 7.fl3~ ~1~. P. Iver tLeop Roa~ No, Ea. gle t~iver~ Alaska 9~577 Cleanou.ts'i~/N)' ~' Y~$.'. ":~Foundation cleanout (~N) High wate. rla!arm (Y!l~), ~ . ,, Date of pumping ~/~ ~/~ '-/',~,~- SEPARATION DISTA'NCES.FROM"SEPTIC/HOED1NG TANK TO: Well(s) on lot~' , '-I~O ' -~ To property line I~ ~-~ Tank size [ ,~2x~ ~,~-c Compartments ~ Depression (Y/~N) Alarm tested (Y/I~ Pumper Surface water/drainage On adjacent lots /. o (3'-/ Foundation Absorption field .~-t- Water main/service line '\ -,, ~, , CONTINUED ON BACK PAGE Vent (Y/N) ~"Pu~ s / "Pump off" Level at ~ High water alarm level ,~Cycles tested ~ ~11 on lot On adjacent lots Sudace water '-"-.-. D. ABSORPTION FIELD DATA Date installed ]0/,/~ /~c( Soil rating (GPD/Ft2) ~,~ System type Length [01' Width ~, ~ ' Gravel thickness ~ t Total depth Total absorption area /~//~ .~F Cleanout present (~ON) ~-g Depression over field (Y/I~ Date of adequacy test~'J/A ' AJ~-W' ~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~__~ Results (pass/fail) ,~../~ for ~/A After test J'~ ~ I! yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Sudace water Curtain drain On adjacent lots ( ©0 ~ J- Property line ,/~ ~ I~ .,L To existing or abandoned system on lot ,'J/,~ Cutbank t'J//~ Water main/se[vice line Driveway, parking/vehicle storage area E, ENGINEER'S CERTIFICATION in~p:.ection. I certify that l have checked, verified, or conformed to all MOA and HAA guidelines in e~f this H~ Fee $ '~ (~ ~ ~ Waiver Fee $ Date of Payme~ ~ '~ / '~-~ ~'~ Date of Payment ReceiptNum~r ~ ~ ~5~Z// ~ ReceiptNumber cT, Laboratory Analysis Report Matrix WATRR Client Name E & $ ~NGINEERING WORK Orde~ Ordered By R. COWA/g PN~$e~ D&be 06/13/9~ ~ ~3:51 hr~, P~o~ecc ~ame C~lleoted Date 06/0~/9~ ® 11:19 Pro]acE~ Received Date 06/0~/9~ · 16:05 PWS~D UA Technical Directo~ ~TEPF. EN c. EDE Sample Remarks: SAMPLE COLLECTED BY: O.W. QC Allowable ~E, Anal Parameter Reeul=8 Qua1 L~nite Method Ltmi=B Date Date Init Nl~ra~e~N 6.~1 mg/L EPA 3S~.~ 10, 06/1~/9~ DJB UA - t~ava~labl~ Undetected,see Sample R~m&rks Abov$ NA - Not Analy2ed ~T - Greater Than 200~. Po~er DHv8. A,~ho~a~e, AK 9~18.1805--1ek(907)~2-2343 ~sx~(907)561-SS0~ ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA, FLORIDA, ILLINOIS. MARYLAND. MICHIGAN, MISSOURt, NEW JERSEY, OHIO, WEST VIRGINIA 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) (073o Propertyowner PF_.'rE R CA,~J~c Dayphone Lending agency ~E'~ 1~lk; Day phone Agent N, // - R~~C'n~c~- Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 72*025 (Rev. 1/91) Front MOA fl21 NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer 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 F'L, AT'roP T_~¢H. $vc$, Phone Address I ~r ~3 o Engineer's signature DHHS SIGNATURE Approved for -~v~,,~¢~ bedrooms. Disapproved. Conditional approval for Date /~¢~' lO I¢¢Z 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 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~)25 (Rev. 1/91) Back MOA ~21 ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: ~o-~ .~ ~j.~2_~ ]-~TTLg BEA,'~ ParcelI.D. O(z-~L~ A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to 5z¢ ' Date of test Static water level Well flow Pump level FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ .,A. Absorption field on lot N. ~ · Public sewer main Sewer service line ;> 2.5' WATER SAMPLE RESULTS: Coliform Date of sample: ADEC water system number 2-//2~/1 '7 Driller Casing height Wires properly protected (Y/N) Y AT INSPECTION g.p.m. I¥ ; On. adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate .~, O, I ~'/f-~ Other bacteria C,? col %J Collected by: ~'/-~l'To? T£C/Y B. SEPTIC/HOLDING TANK DATA LN, Date installed Tank size Cleanouts (Y/N) Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping Compartments Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line on adjacent lots Absorption field Surface water/drainage Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE c. UFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA ,~, Date installed Width Length Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain E, ENGINEER'S CERTIFICATION Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water -- ,4 ¢,./cu '.,( Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area System type Total depth I certify that I have checked, verified, or conformed to al~ MOA and HAA guidelines in effect on the date of this inspection. Signature '~~ Engineer's Name Date I~c,.y 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 fo× INVOICE ~ 53414 Chemlab Re£.~ 92,1894 Sample $ I Matrix: WATER P~$ID : UA Collected : 0 Are. Received : ~T 4 92 @ 3.3:20 hfs, Preserved with : AS REQUIRED Client Name :FLATTOP TECHNICAL SRV Client Acct :ELATTOT BP08 : PO~ :NONE RECEIVED Req$ : Ordered By :TED Analysis Completed ; I~AY 4 92 Laboratory Supervisor : STEPHEN C. EDE : Send Reports to: 1)FLATTOP TECHNICAL SRV Parametez P, esult ¢ Units !~ethod Allowable Limits NITRATE-N ND(O.iO) rog/1 EPA 353.2 10 Sample ROUTINE SAI~LE COLLECTED BY: UA. NO TAG BO~ THIS SAldPLB. Rema~k~: I Tests Performed ' See Special Instructions Above UA-Unavailable ND= None Detected ~ See Sample Remarks Above NA~ Net Analyzed LT=Less Than, GT~Gzeater Than Member of the SGS Group (Soci~t~ G6n~rale de Surveillance) :- MUNICIPALITY OF AN RA DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION  825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 R REQUEST FOB APPBOVAL OF INDIVIDUAL WATEB AND SEWE~ FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PHONE 1. PROPERTY OWNER ~AILIN~ PROPERTY RESIDENT (If different from~bove) PHONE 2, BUYER MAILING ADDRESS II1 /7 /O 3. LENDING INSTITUTION ~AILIN~ ADD~ESS / MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [~]~SI NG LE FAMILY [] MULTIPLE FAMILY 7. WATER SUP~EP~-~ ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM [] ]N DIVI DUAL/ON-SITE** [~/'~ PUBLIC UTI LITY - - NUMBER OF BEDROOMS T e/ [] Four [] Other~ o [] Five ree [] Six *ATTACH WELL LOG. A well log is required for all wells drilled since .June 1975. For wells drilled prior to that date, give well depth (attaeh log ii available.) ('92,-1 If ~y~t~m i~ ~wr t~ (2) y~r~' ~ld ~n ~dequ~y test i~ r~quir~d 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 INSPECTOR INSPEOTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF REDROON]S /[~ SINGLE FAMILY [] ONE~[~'~THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2, WATER SUPPLY PERMIT NUMBER L~j INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED I~IPUBLIC 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, DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line [ Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line 5. COMMENTS E;;;;]-~P'~ROVED FOR ~-~-~- BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany~oert~icate) [J~ DI SA P PROVED DATE '-~-¢..~-~/~ '-~ LEGAL DESCRIPTION #1: Time Date Insp '~MUNICIPALITY OF ANCHORAGE ~ ~ DEPARTMEN: 3F HEALTH AND. ENVIRONMENTA 'PROTECTI 825 L Street, Anchoraa~, Alaska 99501 264-4720 Date Received: October 28, 1977 11:00 a.m. #2: Time ~3: Time 10-31-77 Monday Date Date Aller1 ~/'-~ ~' Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Alaska National Bank of the North Mailing Address: 3301 C Street, Calais II Phone: 2. Property Owner: Lawrence J. Sebrinq Mailing Address: Star Route A Box 1540C 99507 Phone: 544-3069 3. Legal Description: Lot 2 Block 2 Little Bear Subdivision 4: Single Family Residence: (x) Number of Bedrooms: Three Multiple-Family Residence: ( ) Number of Bedrooms: Se Well System: Permit ~ Construction Individual well (x) Community/Public System ( ) Depth of Well 80' Well Log on File Bacterial Analysis Sewage Disposal System: Permit ~ Septic Tank Size Absorption Area On-site System ( ) Public Utility (x) Installed Installer Manufacturer Soils Rate Material 7. Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line iUNICIPALITY OF ANCHORAGE ', :,,.' ,', '- .' · · Department of Health and Environmental Protec~iO~ ,.' "' ".. "" ' ' 99501 825 L Street, Anchorage, Alaska. 279-2511, ext. 224, 225 [. ,: :;[.. Property Owner: ./~/~..~.~. ~~~ Mailing Address: Phone: 3. Lending institution: Mailing Address: ~_~/~/-J_ ~_~_~_~cf~ ,,~--cC~3_ Phone: .4. 'Realtor/Agent: ~t" ~./.~ '~ [ ~Mailing Address: Phone: e Legal Description: Street Location: ~.~.~ Single Family Residence: d~) Number of Bedrooms: Multiple Family Residence: ( ) Number ~Sf 'Bedrooms: Water Supply: * IRdividual Well (%nS Public/Community System ( ) If Individual Well, well depth _ ~O If Community System, name of system Sewage Disposal System: On-site System ( ) Public System If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/'75. 3/77 rase ~wo Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 2 Block 2 Little Bear Subdivision Comments: Affadavit Attached: ( ) Letter Attached: ( ) Approved: ~ Date: Disapproved: Date: Department Worksheet: