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HomeMy WebLinkAboutBOREALIS #1 LT 18 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name Address Phone(s) I Permit No. '~ INd. of Bedroo'm~ LEGAL DESCRIPTION Township, Range, Section TANKS ~:~ SEPTIC/~ ~"1"' [] HOLDING Manufacturer Capacity in gallons I~lateri'al TYPE OF SYSTEM ~ TRENCH ~~~. DRAIN [] OTHER Depth to pipe bottom from originalgrade 'J' t,~' FT Fill added above original grade Gravel length Total absorption area Total depth from original grade Gravel depth beneath pipe ~), '-P ET Gravel w~dth Distance between ~ines FT I ~nsta,.r [ "Z.~::::t~O FTI Number of Bines I Soil rating ] Pipe material ~~ ~ ~ ~Oa~ ~s~a,~ WELLS [] PRIVATE .~HER (Identify) J Total Depth I Cased to Classification (A,B,C) ~ ~ FT FT ~ller /Date Installed: REMARKS: DISTANCES WELL SEPTIC TANK ABSORPTION FIELD WELL LOT LINE 1c:~....~ ~ c:::,! ~ FOUNDATION ~,.~.)l ~, / AS-BUILT DIAGRAM (Show location of well, septic system, property Bines, foundation, driveway, water bodies, etc.) Inspections_Performed by: ~ Date: I'~,' -- (~ -- I~ I = · i:- ~,if"~,~i~:ea'~l~ - certily that this insp~ion w~ pedormed according Io all 72-013 (3/85) Ne, 14a7.~ .I F' t!ii: I::;.'. 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'l:..cfi'..al ~y~'[:.~.:.:~m :i.~ 4 t::~e~c:lr',:::~cm'~i~ and PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~;:~I"" 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S J L iF YES, AT WHAT E SITE PLAN · I Deplh to Water After I Monitoring? ~" Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE I~:~' (m,nutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN I ~- AND ~ FT S & 5 eNGii~iEER;;'- '" -.~: COMMENTS ~ ?~:~4 Eaale Ri~er L~ R~d No. 2~ ~.- ~ ~ , PERF ...... : ....... I / / //~ ~ CERTIFY THAT THIS TEST WAS ~ERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE~O. THIS DATE. DATE: /¢ GRE,. .R ANCHORAGE AREA BOE Depsrtment of EnvironmentsI Quslity 3330 C Street Anchorage, Alaska ggs03 GH INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ?~'e~ LOCATI ON MAILING ADDRESS /,~'"'C/I-~, ~___, ~'f-'fJO/' PHONE LEGAL DESCR,PT,ON ~0~'~"~ I,'~ t~ f' / ~ SEPTIC TANK: DISTANCE FROM WELL ~ ~-,O MANUFACTURER INSIDE LENGTH INSIDE WIDTH MATERIAL LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPACITY !~.)"O GALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL I20 '+ FOUNDATION ABSORPTION AREA ~ ~ <~ SQ. FT. DEPTH: TOP OF TILE TO FINISH GRADE ,.~ NEAREST LOT LINE TOTAL LENGTH OF LINES J DISTANCE BETWEEN LINES ~ TRENCH WIDTH~::) IN. TOTAL EFFECTIVE LENGTH OF EACH LINE DEPTH OF FILTER MATERIAL BENEATH TILE ~ //'~' Ifil. ABOVE TILE ~ .IN. WELL: BUILDING FOUNDATION CESSPOOL APPROVED _ CONSTRUCTION DEPTH DISTANCE FROM: NEAREST LOT LINE __, OTHER SOURCES DISAPPROVED NEAREST SEPTIC SEEPAGE SEWER LINE__, TANK__, SYSTEM /~'~ ' ~ REMARKS DISTANCES: __.~-- ~(- DIAGRAM OF SYSTEM INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL' LOT SLOPE: Form EQ-~/32 J DATE G.A.A.B. GR ' ; ANCHORAGE AREA BC  Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 JGH INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION MAILING ADDRESS '~X '<~-D~'~ /~f0d/~ PHONE ..~Z'~/ _.z./,~-~,~,// LEGAL DESCRIPTION /"0-'[' IQ '~O'~ ~lClLl~ .~,~U..L.~ . .:/'1'1 SEPTIC TANK: DISTANCE FROM INSIDE LENGTH MANUFACTURER INSIDE WIDTH - MATERIAL NUMBER OF COMPARTMENTS LIQUID DEPTH ~ .LIQUID CAPACITY /~ GALLONS. SEEPAGE PIT: I / NUMBER OF PITS / . DIAMETER -- OR WIDTH , LENGTH /~' DEPTH Iff LINING MATERIAL~:~-~ CRIB SIZE: DIAMETER~DEPTH q DISTANCE FROM: WELL U ~ TOTAL EFFECTIVE BUILDING FOUNDATION~© '~, NEAREST LOT LINE c~l~ I. ABSORPTION AREA (WALL AREA) /20 SQ. FT. ADDITIONAL ABSORPTION WELL: BUILDING FOUNDATION __ , CESSPOOL APPROVED / CONSTRUCTION NEAREST NEAREST LOT LINE , SEWER LINE DEPTH DISTANCE FROM: SEPTIC SEEPAGE , TANK __ , SYSTEM , OTHER SOURCES DISAPPROVED REMARKS DISTANCES: INSTALLED BY: I PIPE MATERtAL:(~ ~ I~Or~ LOT SLOPE: Form No. ED~031 DIAGRAM OF SYSTEM DATE u---~-/.~'-¢-4 1(o,/~'7~''~ APPROVED ~)¢JJq-"' ~ ~ /~)'L'[..~e~"lO.X.,~-- ~-- / ' G.A.A.B. GRP_.~ .'r ANCHORAGE Area Bo, JGh DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 // TELEPHONE 274-456 ! SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. INSTALLATION LOCATION LEGAl DESCRIPTION INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH ~' SOIL TEST R ESU LTS :5 ,~"-'~"'~ DRAIN FIELD · SEEPAGE PIT TO BE INSTALLED BY NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL G}UALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION, SEPTIC TANK SIZE ~.~ · ~ . ;., . , Z~'~'~''/~"~ MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIt SEPTIC TANK TO SEEPAGE Pit WALL SEPTIC TANK , SEEPAGE PIT TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD WATER MAIN TO SEPTIC TaNk DRAIN FIELD SEPTIC TANK, , SEEPAGE PiT TO RIVER, LAKE, STREAM. DRAIN FIELD .. DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. SEEPAGE PIT DRAIN FIELD CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING iNSTALLATION. SYSTEM I CERTIFY THAT i AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THe ABOVE DESCRIBED S~(/STEM/~S IN ACCORDANCE WITH SAiD CODE. APPLICANT'S SIGNATURE ,~/~ ~ ' ' ~ FORM NO, EQ-01 6 ~" 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 HAA # b,. ~'~ qC~C"~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Lot 18; Borealis #I Location (address or directions) 4911 Omega Circ6e (b) Property owner Mailing Address (c) Lending Institution Mailing Address Nat. First Mortqage 180 Fort Couch, Telephone: (home) PZ~t~ b~rq, Pa. Business Telephone (d) Real Estate Company and Agent Address 3201 C Street Telephone 563-5500 Jack White Company Attn: Vince Palma Sure #I00, Anchorage, Alaska 99503 (e) Mail the HAA to the following address: (or check here ID¢if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family t~ Number of bedrooms 4[ 3. WATER SUPPLY Individual Well [] Community [~X 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 [] 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. 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 Telephone Address Date S & S ENGINEERING 17G,34 ~=~!e giver Loop Road No. 204 Eagle River, Alaska 99577 Approved ~" Disappr0~ved 'Conditional Terms of Conditional Approval /~¢~ Date 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 for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 A. WELL DA~ Well Classifi'cation ~ ~ ~ MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: /..-O~ If A, B, C, D.E.C. Approved (~t~l) y Well Log Present (Y/N) __ Date Completed Yield Total Depth Cased to __ Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ;Date Water Sample Test Results Comments B. SEPTIC/~ TANK DATA Date Installed ./2-_~-~? Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ,/_~"~;) No. of Compartments Air-tight Caps (Y/N) ~/ Foundation Cleanout (Y/N) Date Last Pumped ~/1~ ; for '-"--' Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line ,.f- To Water Main/Service Line / 0 To Stream, POnd, Lake or Major Drainag~e Course Comm;nts ~-'~(-./"~/¢>~ // To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /2. · Width of Field ,,2-0 Type of System Design Length of Field Depth of Field '~ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM AB§ORPTION FIELD: Gravel Bed Thickness / _,~ ~ Statndpipes Present (Y/N) /~/ Date of Last Adequacy Test /~)//'~ To Water-Supply Well To Building Foundation Lot ~:,~ / ~- To Water Main/Service Line /0 ~'t-' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area I To Property Line ! 0 ; On Adjoining Lots To Cutback (if present) / oo To Existing or Abandoned System on Comments D. LIFT STATION Date Installed ( ;;2 Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical C. odes (Y/N) Comments r' ' ~ ~''' - ~ _ ~)C~ Dimensions .I ~--~:~ ~ ~' I Manhole/Access (Y/N) ¢ "Pump Off" Level at Vent (Y/N) Y 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 inspection. S & S ENGINEERING Sig ............. , .__ n-__,., Company Ea,,le River, Alaeka Date ~'~2-~/c~'~ Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE / 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 January 19, 1990 STEVE COWPER, GOVERNOR 563-6775 S & S Engineering 17034 Eagle River Loop, Suite 204 Eagle River, Alaska 99577 PWSID: #210786 According to the records on file in this office, the Borealis Omega Water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, VERA E. CRAZG Environmental Field Officer VEC: bas MUNICIPALITY OF ANCHORAGE ~) / ~ DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block,.subdivision, section, township, range) Location (address or directions) (b) Property Owner ~[.~.'['- ~',¢'£ Jr ~"(.,~, Telephone: Home MaitingAddress i~)t~/t~ 'T~D~. ~..lf~.. ~'~ (c)Lending Institution Telephone m~.~OBusiness Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the foltowina 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'~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [~ Public [] Community [] Holding Tank [] Note:/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 fRev 8/86~ Front 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 comptiar~ce with all Muni,cipal,,and State codes, ordinances, and regulations in effect on the date of this inspectior~ ~- ~t,,~p ~' ~, ,~t4,O~.~/, Name of Firm ~ ~ Telephone Address Date Engineer's Seal DHHS.AP, PROVAL Approved for/'7'b~ (~ bedrooms by Terms of Conditional Approval Z¢~ ~',,~ CAUTION The Municipality of Anchorage Department of Health and Human Services fDHHS) 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. Page 2 of 2 72-025 fRev 8/86/ Back MUNtClPALIrY OF/'d'-~r.:H~/V~,.~J~l~CIPALITY OF ANCHORAGE (MOA) ~ AUTHORITY APPROVAL (HAA) EF.IVI;~ONMt~NWd- CHECKLIST- FEBRUARY 1984 264-4744 WELL DATA Well Classification ~ ~'~/!~,.~ Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distanceb'fr~m Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot' To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments A if A, B, C, D.E.C. Approved (Y/N) Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casi'ng (Y/N) Depression Around Wellhead (Y/N)' .~ ,.~O . · On Adjoining Lots ~ ~ O 'On Adjoining Lots To Nearest PUblic Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed l ~ 1 ~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well _~. ~ To Property Line "~ To Water Main/Service Line Course Size I ~ ~'~""~ No. of Compartments ~) J~ ~" Air-tight Caps (Y/N) Y Foundation Clean. out (Y/N) Date Last Pumped ~/~'./~' '~; l~///5~ 'for ~///g~ Temporary Holding Tank Permit (Y/N) ~//',¢~ To Building Foundation -'~ *~ To Disposal Field _~-~.~ /~'~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 fRev 8/861 Front ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~'~,~ Date Installed /~ ?t,f/ .../~'"' Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot 1'4/A To Water Main/Service Line ,9..0 + To Stream/Pond/Lake/or Major Drainage Course Type of System Design Length of Field l.~--~ t'~ F Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test ~ To Property Line To Existing or Abandoned System on · On Adjoining Lots ~ ~ ~ To Cutbank (if present) NO N To Driveway, Parking Area, or Vehicle Storage Area Comments P~'~.; ~ L~'J C Y'O~$; ~ 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 ~~d~ve,~.fi.e.d~o~onformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ Date / Company MOA No. Receipt No. Date of Payment Amount: $ Page 2 of 2 Engineer's Seal 72-026 (Rev 8/86) Back 203 W. 15th AVE "C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAl_ SEEVICES DIVISION LEGAL: LOCATION: OWNER:" RESIDENCE: WELL: Lot 18, Borealis Subdivision 4911 Omega Street First National Mortgage Single ResidenCe, Three Bedrooms Class A Communit~ System · JUNE. 25. t97], ~ '. , SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: TANK: Greer 1250 Gal. Steel One Comp. ABSORPTION SYSTEM: Log Crib + Trench ABSORPTION AREA:594 sq.ft. + 468 sq. ft. SOIL RATING: 250 INSTALLATION DATE: 1974 & 1975 DATE OF LAST PUMPING: September 5, 1987. Isaacs Pumping DATE OF TEST: September 7 & 8, 1987 TEST PROCEDURE: System was inspected and measured on September 5, 1987. Tank was foUnd with three feet of cover and with 50 inches of liquid. Tank is partially under garage (shop). Log crib could not be found, most likely under shop. Clean out to trench was located. Clean out is six feet deep./' Tank was pumped on september 5. On September 7 approximately 500 gallons of clean water, was added'to the trench clean out. This caused water to enter the tank. 24 hours later water was again added to the clean out until water could be heard entering the tank. Again approximately 500 gallons were used. TEST RESULT: This sysqem meets the operational code requirements of the Health and Social Services Department of the Municipality of Anchorage. The location of the tank and log crib, under the'.shop floor, are not 'in accordance with code. NOTE The operational life of all septic systems depends on the local soil conditions, 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 this septic system. We can therefore not give any estimate of how long this system will function satisfactory for current or future occupants. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Time of Inspection Date of Inspection 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: 3. Legal Description: 4. Location: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Phone: Phone: e e Type of facility to be inspected No. of bedrooms Well Data: A. Type ._.O..~w~ C. Construction Sewage Disposal System: A. Installed ~ C. Septic Tank: 1. Size D. Seepage Pit: E. Disposal Field: B. Depth D. Bacterial Analysis B. Installer '~ ~ 2. Manufacturer 1. Absorption Area ~--~IL 2. Material .~.~ Total length of lines ---- Distances: A. Well to: Septic tank , Absorption area Nearest lot line ~ , Other contamination B. Foundation to septic tank ~ ~, Absorption area C. Absorption area to nearest lot line ~ , Sewer Lines /c3 .~- EQ-034 (1/74) Page 1 of two pages Page 2 of two pages - P ;t for Approval of Individual ir & Water Facilities Le.~al Description Comments , Approve ~.~.~ ....... ~<~.=,A'~ ~ ~r~, Disapproved Date .... .... Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) Department of Environmental ¢~uality Water and Sewer Questionnaire Lot / ~¥ Owner's Name: Mailing Address: Questions: 1. How many bedrooms are now in your house? _~.~ 2. How many bedrooms were in the house at the time of purchase? c~ 3. Were the basement bedroom walls "roughed in" at the time of purchase? ~)j~ 4. Was the basement bathroom plumbing "roughed in" at the time of purchase? ~_/j__~/ 5. Did the realtor or builder inform you that you would have to enlarge the existing sewer system if you finished the basement bedroom? ~ (~ De OTHER COMMENTS: If on a public water supply, do you always have an adequate supply of water? ~/~~ Is the pressure always adequate? ~'~_/q__~/