HomeMy WebLinkAboutBROWN LT 1
EPLANS
MUNICIPALITY OF ANCHORAGE
�,i
Development Services Department _ / Phone: 907-343-7904
On-Site Water& Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval q'
Parcel I.D. 015-163-58 Expiration Date: 7 -I
1. GENERAL INFORMATION
Complete legal description Brown L1
Location (site address) 11500 Trails End Rd
Current property owner(s) Bonita Hromidko Day phone
Mailing address 11500 Trails End Rd Anchorage, AK 99507
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family(w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 2
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well Private Septic
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee$ 5-56 Waiver Fee $
Date of Payment y/51/63 Date of Payment
Receipt Number O?-3('9,.t Receipt Number
COSA# 06Glg/O9S 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.
In conducting an adequacy test, I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the
time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems
depend on the local soil condition,ground water 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 system.All systems eventually fail and satisfactory test results
do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments.Therefore
we cannot provide any warranty for future performance,nor can we estimate remaining life of the system.The content of this report is for the
sole benefit of the owner listed above.
Name of Firm Pannone Engineering Services Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645 / `
Engineer's Printed Name Steven R. Pannone P.E. Date / / -s`/
*149 . %If
6. DSD SIGNATURE ••••
t.•
System#1 Approved for bedrooms ••Moven - •annone
CE
System#2 Approved for bedrooms r :•;•,•• 8149,•
149 .:
Disapproved •'' ES9
Conditional approval for bedrooms,with the following stipulations:
/t11.1J
ON-SITE %�
WATER
AND
WAS1E14A Ml .
pROGKA c
flQ''��
SCP )�
t3y: + \`�— �� �' Original Certificate Date: It
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 Checklist blue sheet
COSA Checklist
Legal Description: Brown L1 Parcel ID: 015-163-58
If more than 1 septic system on lot: COSA Checklist it of Structure served by this system 1
A. WELL DATA
❑Well log is filed with Onsite (or attached) Well production at time of test 2.38 gpm
Date drilled ** Water storage tank volume n/a gallons
Total depth ft Well disinfected for coliform test? ❑Yes ID No
Cased to ft 0 Coliform bacteria is Negative
0 Sanitary seal is functioning correctly Nitrate 0.954 mg/L E Nitrate less than MRL(ND)
0 Wires are properly protected Arsenic ND ug/L 0 Arsenic less than MRL(ND)
Casing height(above ground) 18 in. Collected by PES
Date of flow test for COSA 3125/19 Date of Sample 3/25/19
Static water level at beginning of test 93.1 ft.
Comments **No Well Log
B. TANK DATA C. LIFT STATION
Age of tank(s) 55 years ❑ Required maintenance completed
Tank type/material Age of lift station years
Measured operating fluid level in septic tank ** Lift station material
0 Standpipes/foundation cleanout per record drawing Comments: ** 9" below top of tank
Date of pumping 09/25/2018
D. ABSORPTION FIELD DATA Seepage Pit
Which system tested(date installed) 1964 Adequacy test date 3/25119
0 ALL standpipes present per record drawing Results OPass For 2 bedrooms
Total measured depth from grade 12.6 ft(max) Fluid depth prior to test 30 in
Measured depth to pipe invert from grade +/-7.0 ft(min) Water added 300 gal
❑ N/A—pressurized field New depth 45 in
0 Monitor tubes go to bottom of effective. If not,state Elapsed time 75 min
depth into effective
0 Code-required soil cover over field Final fluid depth 40 in
❑
Absorption rate >300 gpd
System presoaked
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) n/a
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to:(Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot> 100' 70* Community Sewer Manhole/Cleanout> 100'
❑Yes if No ft ❑✓ Yes if No ft
Neighboring Tank> 100' E Yes if No ft Private Sewer/Septic Line>25'0 Yes if No ft
Absorption Field on Lot> 100' ❑Yes if No 98* ft Holding Tank> 100' 0 Yes if No ft
Neighboring Absorption Fields> 100' Animal Containment> 50' ❑✓ Yes if No ft
Yes if No ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main> 75' E Yes if No ft 0 Yes if No ft
From Septic/Holding Tank on Lot to:(Please enter distances if less than required)
Building Foundations> 10' 0 Yes if No ft Surface Water> 100' ID Yes if No ft
Property Line> 5' ✓l Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' [] Yes if No ft Private Wells > 100' ✓❑ Yes if No ft
Water Main> 10' ll Yes if No ft Community Wells>200' p✓ Yes if No ft
Water Service Line> 10' 0 Yes if No ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ❑ Yes if No 5* ft If absorption field is under driveway comment below
Property Line> 10' 0✓ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' D Yes if No ft Private Wells > 100' IJ Yes if No ft
Water Service Line> 10' 0 Yes if No ft Community Wells> 200' 0 Yes if No ft
Surface Water> 100' ✓❑ Yes if No ft
F. ENGINEER'S COMMENTS
* Distances adequate at time of installation
G. ENGINEER'S CERTIFICATION •A IV ��9 .N-41/
I certify that I have determined through field inspections and review /"'"GJ• • "9 ��
of Municipal records that the above systems are in conformance with B*: 4 Tl I *.4-
:' ,
MOA COSA guidelines in effect on this date. /
o1<<', °' cti •r
e\x��
COSA Checklist yellow sheet
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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
Lot I; Brown Subdivision;
Location (site address or directions)
11500 Trails End Road
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Go~.~__~n P_ Haye_x, Jr~ Day phone
11500 Trails End Road, Anchorage, Alaska
City Mortgag~ Lynn LaP~rri~r Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 2 ~
TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (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
Address
Engineer's signature
S & S =HG,~;EEr~,NG
17034 Eagle River Loop Road No. 204
Eagle ~iver, Alaska y~577
Phone
Date
DHHS SIGNATURE
~ Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
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
Legal Description: D¥'T [/ 1~/7-r31/~rAJ S(.,~z~ Pa.rce I.D.
A. WELL DATA
Well type. ~[J~t~
Log present (¥/~)~)
Total depth
Sanitary seal {~N)
If A, B, or C, attach ADEC letter.
ADEC water system number
Date completed L,)~. Driller
Cased to Z.//(~ ~. Casing height
Wires properly protected i~/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 7'(2
Absorption field on lot
AT INSPECTION rn
~o
~ m
1o0
; On adjacent lots
; On adjacent lots
Public sewer main
Sewer service line ~c'o '+
'WATER SAMPLE RESULTS:
Coliform (~ Nitrate
Date of sample: ~c~-~[ ~
B, SEPTIC/HOLDING TANK DATA I ~ q~ ¢
Date installed ~.~:;:~[Lt~- lc~O Tanksize
Cleanouts(~/N) ~boE~
High water alarm (Y/~]))
Date of pumping
Collected by:
Public sewer manhole/cleanout
Petroleum tank
~' -7-/
Other bacteria
S & S ENGINEERING
17034 Eagle River Loop, Road, No. 204
Eagle River, Alaska 99577
~ ~:::~c.~c::~ ~ Compartments
Foundation cleanout (Y/~_.) ~,~(3 Depression (Y/~__~
Alarm tested (Y/I~ /~/o
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot '~ On adjacent lots
To property line ~) t'F' Absorption field
1,60
Surface water/drainage
Foundation
Water main/service line
/0 '
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Size in gallons ~'"--_,,-'""~--~- .....,, Manhole/Access (Y/N)
Vent
(Y/N)
~__ "~um~ 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
D. ABSORPTION FIELD DATA
Date installed
Length (,,~ ~-- Width
Total absorption area
Depression over field (Y/~__)
Results (pass/fail) ~'~-~'
Peroxide treatment (past 12 months)(Y/(~ ~-}0'[' ~rd0~' If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Soil rating ~t£ System type ~'~ /~T
Gravel thickness ~ Total depth /~
Cleanouts present (~N) O/dE'
Date of adeG~Jacy test - [::~-~,~, I ~2-...
for '~-. ~"~l-~'~---~) bedrooms
Well on lot On adjacent lots Property line ~O ~
To building foundation
On adjacent lots ~
Surface water ~
To existing or abandoned system on lot
Cutbank /~//A Water main/service line
Driveway, parking/vehicle storage area
Curtain drain ~i~kJOr4~z- ~-,p~oB~b~ ~--~'¥'~/f-~-I,.A ~_-~c~t~'~)'2-O~.~ 1~~ "~-~lZ~zJ
E. ENGINEER'S CERTIFICATION
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
17034 Eagle River Loop Road No. 204
Eagle River, Alaska -~;$77
Signature
Engineer's Name
Date
HAA Fee $ t'"'lO,
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
QUALITY ASPHALT PAVING, INC.
General Contractors
4025 RASPBERRY ROAD, ANCHORAGE, ALASKA 99502
Telephone (907) 243-2212 Fax (907) 248-5798
August 25,1992
S & S Engineering
17034 Eagle River Loop Road
Eagle River, Alaska 99577
Attention: Jim
RE: 11500 Trails End Road
Dear Mr. Wilson,
This is to conform our conversation today regarding the
garage at 11500 Trails End Road. The bedroom above the garage
does not and never will have, a kitchen in it.
n P. Hayes,J1 -
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
A.: 2-/~-//o b
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name t;:'~-t-~. ?~-?~.t.>~;L~?.'~/ Telephone: Home '~,~'t!~? '" /'~/)-/ Business
Applicant Address
(c) Applicant is (check one): Lending Institution [] · Owner/buitde[:[~; Buyer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-FamilyJ~" Multi-Family []
Number of Bedrooms
Other
WATER SUPPLY
Individual Well~j,' 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: 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 PROVlDIN,~ INSPECTIONS, TESTS, FILE SEARCH, D~,A 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 ali Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection. /
Name of Firm ~' ........ /' ,,,-. ~:,~,:" ' (.t.~ ~'~,; (.'~... (/...f ~:,~.' ~...~,-,~.'( Telephone
Address
· ", .; ti i,:'.)~,-?.
Date r ...,
· - ! t ~
Approved for ~ bedrooms by Date
Approved ~,.~' Disapproved Conditional
Terms of Conditional Approval
-, CAUTION
The Muncipality of Anchorage Departme,nt 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)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
SITE PLAN
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water Alter I I~!
Monitoring? ~O~1;~ Date:~1~/~ ~
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN __ FTAND
FT
72-008 (Rev. 4/85)
COMMENTS
ACCORDANCE WlTH ALL STATE AND MUNICIPAL GU DEL N~S . D' ~/~'~'"/r /¢¢&
4~oo ri'z
: I, I Ac¢,¢~
C I~GLI
'rANK
zgo' (N,q',
1, ~5-~BUIb'f Ib/XS~'I2 Oki SCAbel')' Plt, JI.~N~ION$
LI51kl~' ~b~M TAPt~,
//
C"oNC~,,~T ~ ~tN6_q
AbLLNIlNU~ ~r4p
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(b)
(a) Legal Description (include lot, block, subdivision, section, township, range)
(c)
Location (address or directions)
Applicant Name ~ ~I4,%I,-~'Yi
IF.N
Telephone: Home
Applicant Address I J .~O-~ _"r'f~../-~ i/....~ ~ 1.4,~
Applicant is (check one): Lending Institution r'-I; Owner/b'°ifdm' ~; Buyer []; Other [] (explain);
(d) Lending Institution
Address ~'¢." .~ ~,~,.e~'
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-F~'~ther
Number of Bedrooms
WATER SUPPLY
ndividual 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~l~ Publicl-I 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 PROVIDh.., INSPECTIONS, TESTS, FILE SEARCH, D~.,, A 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.
Date
Seal
¸6.
DHEP APPROVAL ~/.~"
Approved for
Approved
· Disapproved XXZ"~ ~'~"~ Conditional"
Terms of Conditional Approval
Date
Need verification that there is a separation distance of at least four (4)
feet between the bottom of the absorption area and water.
Request seven (7)
absorption field.
days water monitoring within twenty-five ~eet of the
. ~ '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)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALITY OF ANCH~ETH AUTHORITY APPROVAL (HAA)
DEPT. OF HEALTH & CHECKLIST- FEBRUARY 1984
ENVlI~ONMENTAL PI~OTECTION 264'4720
~ 3 0 ~ Legal Description: /_-
RECEIVED
Well Classification
Well Log Present (Y/N)
Total Depth :>/'7o
Static Water Level
Casing Height Above Ground /.~
Electrical Wiring in Conduit (Y/N)//V
separation Distances from Well:
TO Septic/HOlding Tank on Lot
To NeareSt Edge of Absorption Field on Lot
'~ If A, B, C, D.E.C. Approved (Y/N)
I~ Date Completed ~.)J~//¢..J~ 0 ~/N'
Cased to ~ I'~C~ Depth of Grouting
~,~ Pump'Set At
,,
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
~{~ ; On Adjoining Lots '~L/~3_O /
To Nearest Public Sewer Line ,/~//~ To Nearest Public Sewer /
Cleanout/Manhole ' ".~.//~ .,' To Nearest Sewer Service Line on Lot
Water Sample Collected' by ./~'~.._~"~/.~/t~_ .z. _,,~' _ ; Date _¢:3j/~. ~/~,~
"r- - - "L' f) /
Water Sample Test Results S~..1~.I,
Comments '~ ~'"~, ,~-..~ ~/,.~o~
d
B. SEPTIC/HOLDING TANK DATA
Date Installed (.)l~Ja~iY"s~ze I/.,~1~:) 'j'
"" No. of Compartments
Standpipes (Y/N) Y ('_,/? Air-tight Caps (Y/N) y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) N Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ./~/'//~[ ;for
Holding Tank High-Water Alarm (Y/N)/V//~ Temporary Holding Tank Permit (Y/N)/V//,~
separation Distances from Septic/Holding Tank:
To Water-Supply Well 7,(~ / To Building Foundation .,~J- /
To Property Line To Disposal Field
I
To Water Main/Service Line "IL'...~_/~ To Stream, Pond, Lake, or Major Drainage
Course
Page 1 of 2
72-026(11/84)
.ff 0o/ o oo/
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
ABsoRPTION FIELD DATA
Soils Rating in Absorption Strata ~.)14 ~ ~ ~ Type of System Design
Date Installed [~ ~g.~o,t,.~ '~ Length of Field (.~ ~ Jl~,l
Width of Field ~ ~ Je.,t4,~l..4,,~ Depth of Field
Gravel Bed Thickness '~,
U. Je,~.~.,t,4~ Standpipes Present (Y/N) Y
/'~ Date of Last Adequacy Test 9//~/~1'~/
/
To Property Line '"'J'
To Water-Supply Well
To Building FOundation
To Water Main/Service Line
To Stream/Pond/Lak~Vor Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
LIFT STATION
Date Installed
Size in .Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
To Exis~ng or Abandoned System on
;On Adjoining Lots "/"'t_~ '
To Cutbank (if present)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify tha~t I have checked, verified, or. conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed % ~ Date
Company /
Receipt No. ~L.LC;~ \ - ~:::)C:)C) \
Date of Payment Ci ~- ,.~C~ ~'~
Amount: $ ~..~, CO
Page 2 of 2
72-026 (11/84)
MOA No.
Engineer's Seal
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSPECTOJ~
MUNICIPALITY OF ANCHORAge
MUNICIPALITY OF ANCHORAGE DEPT. OF
DEPAHT~ENT OF HEALTH ~ ENVIHON~ENTAL PHOTEOTIONENVIRONMD('I','.L ~ ,..:1 ZCTION
ENVI~ON~ENTALSANITATION DIVISION A~R 1 7 lg80
RECEIVED
MAI LING ADDRESS
PROPERTY RESIDENT (If different from above) ~ PHONE
~. ~UYEH . / ~ ~ ' ~ PHONE
MAI LING ADD.SS _
MAILING ~RESS
MAI LING ADDR ESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE
NUMBER OF~BEDROOMS
J~J// SINGLE FAMILY
[] MULTIPLE FAMILY
[] One [] Four
~ Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* 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 (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
'~ ~NDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
[] OTHER
Septic/Holding Tank IAbsorption Area [Sewer Line
INearest Lot Line
5. COMMENTS
ROVED FOR .~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
~DISAPP.OVED
1BY ~ ~~'
72-010 (Rev. 6/79)
�i
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received ;9� Z�
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF �q.
INDIVIDUAL SEWER & WATER FACILITI YY
rnn E'er �
1. Approval requested by:
2.
3.
Mailing Address:
Property Owner: _
Mailing Address:
Legal Description
4. Location:
5. Type of facility to be inspected
a79 -q-33
AJ 3
J - J, No. of bedrooms 'i
6. Well Data: /J/J
A. Type s B. Depth
C. Construction D. Bacterial Analysis
61
7. Sewage Disposal System:
�g /
A. Installe ,_ B. Installer �
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank ` _, Absorption area �// Sewer Lines ,
Nearest lot line 3-0 Other contamination
B. Foundation to septic tank t Absorption area /
C. Absorption area to nearest lot line tl)- u
EQ -034 (1/74) Page 1 of two pages
r � �
Page 2 of two pages - Rei,—Jst for Approval of Individual '.. ver & Water Facilities'
Legal Description
Comments
Approved
Disapproved
Date --�Szlz2Cj
V Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
T ,,,+;f„ +ha+ +ha infnrM tion contained in this request f(
J
accurate" representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date
Of
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