HomeMy WebLinkAboutSOUTHPARK BLK 4 LT 1A ~ "~ MUNICIPALITY OF ANCHORAGE ,
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
[] UPGRADE
MAILING ADDRESS
LOCATION ~ '
~ ~ell ~.~ Absorotion area ~ / PEBMII ~0
~ DISTANCE TO: ~C~ ~*~] J [ Dwellin9~
~ Z Manufacturer~z Material No. of compartments
Uq. c~ ~sagons IF HOME~DE~ Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material kiquid capacity in gallons
~ W I , Foundation Nearestlotline]v
Distance between ~ines
~Z No, oflines ~ Leng'h~fe~ ~ Total'T Trench wid~,~
~ ~ Top o' ,lie to fin,sb ,rada ~ Material Beneath the ~ ~ inchOSlnch.s Total .ffeet,v~b~r~tio~
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ CJass Depth Driller Distance to lot Jine PERMIT NO.
~ DISTANCE TO: Building foundation Sewer llne Septic tank Absorption area(si
OTHER
INSTALLER /
REMARKS
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
PERMIT NO.
MLI~'-t I: C: 1' ~ FILI T"¢ L]F FIi'--I¢:H__-F:t-]GE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
8-'--"5 "L' STREET., ANCHORAGE., AK. 9950±
264-4?20
CIN--S I TE SE~4ER F"iE:f4 I T
( 821091 )
APPLICANT
LOCATION
LEGAL
UNLIMITED 7800 DEBARR ~206 99504
LiB4 SOUTHPARK ~ LOT .~I-E
~49-80±4
999999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: DRRINFIELD
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING (SD FT?BR)= 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[)EPTH= 6 LE~-~GTi4= 44 GAR'eEL [)EPTH= ----<
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAtNFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE 8ETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THE TRE~46:H 14 I [)TH IS .~ 00El FEET.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE 80TTOM OF THE EXCAVATION (IN FEET).
REL~U I RE[) SEPT I C: TA~4k'- S I ZE= ±El80 GALLE~F~S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE NELL WILL SERVE.
T~llw (2) I~SPECTIO~S ARE RE~]IJIRED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A NELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
t08 FEET FOR A PRIVATE NELL OR 150 TO 200 FEET FROM R PUBLIC ~4ELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERI-4 I T E:~-~F" I RES [-~ECEI~18ER __?-i.. 19:[32
I CERTIFY THAT
t: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BV THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ]: BEDROOMS.
.........
SIGNED:
APPLICANT [:,&S UNLiMITECI ~ ~¢
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: * DATE PERFORMED:
SLOPE SiTE PLAN
10
11
12 --
13
14
15
16
17
18
19
20
WAS GROUND WATER j~ ! S
ENCOUNTERED? ~/VG OL
iF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
COMMENTS
PERFORMEDBY: ~'~'~'~'~
CERTIFIED BY:
72-008 (6/79)
Si REI 1
tORAGE, Al ASKA 99501
I 2Gi ,lill
January 4, 1982
Dick Goslin
P.O. Box 261
Wasilla, AK 99687
Permit ~ 810989 ~
Subject: L1 B4 Southpark ~t~zz~u~-~
A permit issued by this department for a well
system has expired as of December 31, 1981.
Permits are
the permit,
and/or sewer
issued on a calendar year basis, as stated on
by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
~eroSg~mB~hnha~lerZ~c_~~'
Sewer and Water Program
Enclosure: Copy of Permit
PEEIIT
FtF'F'L ~ CFI~.,!T
LOE:AT Z ON
LE)3F~L
DEPFtRTi"IEN"I" Or' I'4ERLTH R~',IE) EI",!',¢':[F..'OI",!MENTRL PROTECTZON
825
264-,4728
[:,IE:K 61J~L"~-_, P. 0.
SOUTHPFIRK
Li B4 %OLITHPRRK ~, LOT SIZE 4]:560 S};!LIRRE FEET
T?PE OF ~.::;--I_ RESO,~'PTi:N ..-¢_,TEll : "IF.E.,IL.H
~,F!XIi',1L.I[,! F4LIi',IE;ER OF ~3EL")~'COi',F; = 4
SOIL ERTIN.~
THE RE~ZIIF'Fn, ._,Z .... OF THE: :,LIL FtE:SORF"rloN S'-?S;TEM
THE [..EF,~GTH £.II'!Ef'LIUI! ].=, THE L~Eit(-~TH ,::'rl,.~ FEET) OF THE Tf4. Ei'L.H OR E:,F...'RIf..IFZEL[:,.
'rl.4E E:,EF'TH OF FI TRENC:H OR F'ZT ZS THE [:~ZSTFII';!~:E BET.~,.IEE;'.,I THE E;URFFICE OF THE
~]l~'.OLIk~[:, Ri'.,IE:, THE E~OTTOi',t t~F TI-IF ¢;,.,;C:~¢FIT:[;iE~N ",:';IN FEET",
THE; Gf4. FI'¢EL B, EF'T~-t ~S THE l,'i;[l'.,!II'~tl~lf,1 DEPTH OF G.RFiYEL BE'f}.EEN "}IE OI. ITFFIL_. PJ;F'E
F:IJ'.,!B, 'EIE ELi F FUI','t OF THE E -',LH ?PI7 ~UI'-~ ,' Z!'.~. FEET).
F'E~'.I,1:[T FF'F'LI-Rr. JT F. ld:, THE RESF'Of'.L~IE:ILIT'-? TO I~-,iFORi','! THIS £EFHf~.T.tENI [',IIR'I~.,Fi THE
I~,I.:71--LLH'I ILN I~t_FEL. T.t _N:, OF RN'-r' I.,ELLS RD,.;rRi;;:ENT TO 'THt_ r'r',_r_r~'~ RI',I..P., THE
NIII"tBE~;' OF R~.=,:(E,-'[,IL.E::, THEft THE ~'.IELL ~,L~LL ~";EF.:",,'E.
E,i"IL.,~--.F ZLL.[I"L~ OF FtN'¢._ '¢-.,TEi'I I-IYTHr~IIT ....... F'rNI=IL [i~',!"%F'E-:TZ ~i",l RI",tE:' FIPPRO',,'RL E;"r' T."IZ:,~ ' '-
[:'EF'RRTI'IENT ~'-!;[LL E~E SUEL'rECT TO F'F'~SEZ
t¢ I'.,rr I',t .... If't. E:,I STRI',!C:E E:ETt.4EE.! Fl ~.~IE:LL Ri'.!E:, RN'¢ ]'.FG~[ TF ....... ':-'-,bl..IHl=E' - '" ' E' I:,,'-r':' k,l'-IL':: S'¢STE!"I _'r':_
±00 FEET FCt~' R F'RI',,,'FITE [,.IE:LL _-iR :1..50 TO 20E F'EE;;'r F'ROH R F'UE:LZI3 J-,JELL
I.F,."'i'-! THE T?F'E OF FUE, L~.C .~,ELL ~,.,
,~.~ FEET
TO R COM,~,tt,jNZT'¢ SE~,.!ER LINEI...'~ ?5 FEET. :'
.~,.IEIl. ,_._ LI]Fi';_ ~ _ FIRE: REi;!UIREE:, Fti'-.!B, t"IlJ~T~ b,._-:'~' RET:O¢:NE[.', 'r~z THE E:,EF'FtF'Tr,EN"r.. . . I.,.I;I.'THZi'.,I 3:0 [.H'r:,'",-' "-
OF' THE .t,.IELL COi"IPLET:~ON.
-}'HER' ....REIZIlREMENT9 f'tR"? RF'F'L?. c'-",_,hE_." -'TFIL. H F.[LN:,-' .... '- Ri",~P _"':l]l'-,?~Ty' ..... ":Tt-N DIRGRRi','t$
FI',,,'FIILFiE:LE TO INSURE F'ROF'ER :[t'-fSTFLLRT;[C~N.
! C:ERTIFY THFtT
l: I FtP1 F?]I"IILIFIR E[TH THE RE~ZIIRE1ENTS FOR ON--SITE SEERS RND [,.IEL. LS FIS SET
FORTH E¢ THE MU~.~ZC:ZPFILI'T'¢ OF RNCHORFIGE.
2: Z I,.IILL INSTF~LL THE SYSTEM IN RC:COR:DFtI',ICE I,~ITH THE CO[:,ES.
3:: I LINDERSTRND THRT THE ON--.SI"rE SEI.qER S'¢9TEr,1 t,'lR'¢ RE~;~UIRE ENLRRGEf,IE~.~T IF THE
RESIDEd,ICE IS REMODELED TO INCLUDE MORE THRN 4 8EDROOf,IS.
S I GNE'E,:
FF L.t .~.171 [:,ICi-,:;
........... ,. E?¢ - ..................... [:'FITE. ,
',,,'4.. 0
F~d',] [ r i'
,o. u. OOX '-;XS~,, HffS[LLR,
t'lfl:.'~[i"~Jit HiJNS-c_-F: ,3F L-¢,EzO~CION5 = 4
PERFORMED FOR:
2
3
4
§
7
8
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
, , -~, . ~/~
' '' SLOPE ~ SiTE PLAN
f,
OILS LOG
[~P~RCOLATION TEST
10
11
12
13
14
15
16
17
18
19
WAS GROUND WATER ~ 0 Sd
ENCOUNTERED? L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
20 PERCOLATION RATE O~. ~ · (minutes/inch)
TES~ RUN 6ETWEE. ~ E~ :D''~' 0 'PT
PERFORMEDBY: K~ ~ t~ ~
72-008 (6/79)
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
1. GENERAL INFORMATION
Complete I~gal description Lo~-- (j
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING -
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent -~ ~V--
Address'
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
Individual well
Community well ~C
Public water
NOTE: if community well system, provide written confirmation from State. DEC attest-
lng to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
Individual on-site
H01di~ig'tank L
Community on-site
Public sewer
~UNICIPALITy ~ · ~
ENVIRoNME~.,~-..' ~F ANCHoP, AGE ;. .
'~L SERVICE8 DI~ISIo~
:.-RECEIVED
NOTE: If Community waStewater system, pro'vide written confirmation from State ADEC
attesting to the legality, and status of system.
72-025(Rev, I/91) Front MOA#21
'As certified by my seal affixed hereto and as of the validati0n date shown belo~v, 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
[hu~ plM; ~,nCid~;~tYwaOsfte.~;aCtheOrl;igs; foils;~ ;ynsdt~l rmO ,n~ ,mnyc~n~lsitiagn cat~;it~ndall n;Puen ic~i;:,I
ordinances, and regulations'i, effe6t (~nthe ~[at(~ Ofthis'inSpection."'.~ : ". '.-" .
Engineer,s signature ~.~¢/~/~, ~/ .~¢'/~/,/( h 'Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additioha~Comments
The Mun c pa ty of Andhorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates 'basc:~ only upon the mpr~entations givee in paragraph 5 above by an independent
profeesional engineer registered in the State of Alaska. TI!e DHHS doesthis as a courtesyto purchasers of homes .
and their lending institutions in order to sati~ffy certain federal and state requirements. Employees of DHHS do not
conduct inspections o,r/analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errom o~' omissions in the professional enginesr's Work;
LegalDescription: i..-o'T~ (j /~j~z~-
MUNiCIpALITY OF ANCHORAGE~,,.,~=~I
Municipality of Anchorage ENVIRONMENTAL sERVICES u,~,?~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division JU~[ 0 2 1997
825 L Street, Room 502 · Anchorage, Alaska 99501· (g07) 34~ ~z~ iV- ,7, ~ D.
Health Authority Approval Checklist ~./
Parcel LD.: ~2-D --0~/~
A. WELL DATA
Well type
I~B, or C, attach ADEC letter. ADEC water system number
Static water level , ~;,~ ,,
Well production
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Collected by:
g.p.m.
T~~/N ) Date completed
Cased to Casing height (above ground)
Sanitary seal (Y/N)'~ Wires properly protected (Y/N)
Date of test ~ ~SPECTION...
Nitrate Other b~,,,,,,,,.,,~
B. SEPTIC/HOLDING TANK DATA
Date installed / 0,~'~- Tank size /(~ Number of Compartments
Foundation cleanout (Y/N) ~ ~(~ Depression (Y/N) /JO
Date of Pumping ~"/~-'7/~ Pumper /~' 'to
-- Cleanouts (Y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed [ O/~?~,
Length ,~llrZ~ Width
Effective absorption area ~ '7~
Soil rating ~ft~or ft~/bdrm) /~'~'~ System type
Gravel thickness below pipe ~:'/'Total depth
Monitoring Tube present (Y/N) 7 Depression over field (Y/N)
Date of adequacy test/~'"/)-,~/~':~- Results(Pass/Fail, p,.~c,~' For J~ bedrooms
i1~~'
4 Z 0n.):
/~Fluiddepth ~" (ins, Minutes later:_~ _ Absorption rate =_ ~4~ .g.p.d.
LPeroxi~eatment (past 12 months)(Y/N) - ~
72-026 (Rev. 3/96)*
Date installed --.. Size in gallons
Manhole/Access (Y/N) ___~~ "Pump off" level at*
High water alarm level at* "~ *Datum -'""~'~'~._
Cycles~~~'~-
E. SEPARATIGN DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: ,,~/,,//
Septic/holding ~ On adjacent lots
Absorption field on lot ~~~~
/... -~..~._....
Public sewer main .-.- ..~----'"~ Pub c sewer man~
Sew. e r/s~.~.~c.-se~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation -~ -- Property line ~' I0 '~ Absorption field
Water main/service line '~,/0 Surface water/drainage "~lO0' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIE~I~
ON LOT TO:
Property line ~ 0 "' P'~'~'- l¢lS'Z' I/4~'P' ¢,6¢on-'?--'*'~"-"
Surface water
Curtain drain
/
Building foundation /~ .Water main/service line ~'/O
Driveway, parking/vehicle storage area
I¢/.~c~-,.J¢...¢ Wells on adjacent lots ~' Z~ P~J &L.f~.~ ·
F. ENGINEER'S CERTIFICATION i
I certify that lh/¢~ ~errn',Jn~¢ n~field inspections
in conforma~e I~.~01~ ~A u,~,,~ in effect on this date.
Engineers N~/~d ~'~ ~ ~
Date ~/'A~ ~/~
HAA Fee $
Date of Payment
Receipt
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
M~y-23-g7 08:33A Bo)~nie Mmhnmr & Associate 907762-1858
.L
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
/
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
(c)
(d)
Location {address or directions)
Property Owner/"~-~',~"~ /~.~'~;"¢~/~ Telephone: Home
Mailing Address'"'/~2;~,'') ~' ~.,.2,¢'?~/t~,4~ ~-';~'~,./:~': (Y.-)/~.'< /~
Lending Institution. Telephone
Business
Mailing Address
Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the followina 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
Individusl Well [] Community [] PublicA
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
SEWAGE ~.ISPOSAL
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.
72-025 (Rev 8/86) Front
Page 1 of 2
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 Mueicipality 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.
Nameof Firm ./~,~5'~ ~¢/e.~$ ~//~/"~ Telephone
Address '~-'~ 2.--¢:~ ~./J¢,53- ~> ~
DHHS APPROVAL
Approved for _~.~./,J_/(/~?~bedrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Engineer's Seal
Conditional
CAUTION
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.
Page 2 of 2 72 025 IRev 8/86) Back
WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
MUNiCi?ALi.[,~H.~AI,~'JrI~I~HORITY APPROVAL (HAA)
ENVtgONM~N~AL $;~F,~, ,G~E~:KI~I~,,tl- FEBRUARY 1984 264-4744
Legal Description: ~' /,'~ "~//'~' '~
~/~? :~ ~' ,'~'- If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) /'/'/~ Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around WelLhead (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from 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
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Size
Date Installed
Standpipes (Y/N) Y' Air-tight Caps (Y/N)
Depression over Tank (Y/N)
L
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 /~' r
To Water Main/Service Line
No. of Compartments ~
Foundation Cleanout (Y/N). ''/
Date Last Pumped ~'/~5'~ /~'~'~
;for
Temporary Holding Tank Permit (Y/N) .
To Building Foundation ~ /
To Disposal Field //z
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026 fRev 8/86) Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed J O,~./ ~' lI ~' ~''~
Width of Field '/~d~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
J7¢ ~'~'
,,7
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
. ~.. z-/~,.~,.._ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments /'~¢/ /4'~'~"
?
To Property Line /'~-"'/~' ''~
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ,/¢"~
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.
Signed Date
Company MOA No.
Receipt No. ~ -(~'O/"%~ O/~
Date of Payment /o~
Amount: $ ! o ¢ ~
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 "C" STREET, SUITE 1334 /
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE:
PWSID #: ___21~4Z5 .........
To Whom It May Concern:
According to the records on file in this of?ice, the
E~!8!E~__~UBQIWI~IO~ ....... Water System is in compliance with the
State o? Alaska Drinking Water Regulations.
Sincerely,
Ronald S. Klein
Environmental Field
-~o* **r Or e'
/
/
o%/
q
LEGEND
0
NOTESx'
LOT CORNERS
FOUNDATION
ORAINAGE ARROWS
I. IT BHALL IE THE REBPONBIDILITY OF THE IUILDEB OR OWNER TO VERIFY THA~
BUILDING LOCATION EHOWN MEETC ALL BUICIVIBION COVENANTS AND ZONiNg
OROINANDEB. ,
B. IT Ii THE REEPONCIRILITY OF THE BUILDER TO VERIFY ALL ELEVATIONB WITH
RESPECT TO ALL UTILITIES, N DRAINAGE.
B. TNIB PLAT REPREBENTB THE PARCEL OF PROPERTY DEBCRIRED BELOW TAKEN
FROM THE RECORDED PLAT DEBDBIBINO THAT PARDEL. INBTRUMENTC REDOROED
~FRIOR 'TO OR AF'~'ER' THE FiLiNG OF THE RECORDED PLAT ARE NOT EHOWN ON
THIS PLAT.
4. THE INFORMATION ON THIB PLAT lB FOR THE UBE OF LENDIN~ INETtTUTIONB
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXIE'rlNO STRUCTUREE AND
PLATTED LOT LINER OR EABEMENTB , THE PLAT I! NOT TO BE USED FOR
FOEITIONIN~ ADDITIONAL STRUCTURSB OR FENCES.
BESSE, EPPS IA POTTS
2220 E. 88'th. AVE.
349-6451 ANCHORAGE ~ ALASKA 99507 344-1352
ORAWNDY, K~L. IeOALE' '"~0' IC-C IDw'*No*
CHK. SY~ DATE~ ~ ,/~J FLD.