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Home My WebLink AboutSTOCKLY YARD LT 4C Municipality of Anchorage Page 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 Permit Number: ~ ~[~- (~ff I PID Number: O(? - Name: ~ ~r ~ ~ ~(~ Wastewater System: ~ew ~ Upgrade Address:~, ~, ~u~ [//~ ( ~~[~ ABSORPTION FIELD Phone:~L[~,~~ ~No. of~rooms: ~DeepTrench ~ShailowTrench ~Bed ~Mound ~Other Total Depth from original grade: Soil Rating: LEGAL DESCRIPTION [, ~ ~s..~. Lot: ~ ~ Block: Subdiv~ion: t. ~ Depth to pipe ~o~om from original grsde: Gravel depth beneath pipe Township: ~ Range: I Section: Fill added above original grade: Gravel length: , ~ - / ~t. WELL: ~ . ~ Upgrade Gravelwidth: Numberoflines: ~Distance~eenlin~: Classification (P rivat e, A,B,C): ~ Total Depth: Cased To: Total absorption area: Pipe materiah Ft. ' Date install Date Drilled: StaticWaterLevel: Installer:~ ¢~¢~¢~t~ Driller: ~¢~nO~ Yield: Pump Set at: Casing Height Above Ground: SEPARATION DISTANCES ~Septic U Holding U S.T.EP. To Septic Absorption Lift Holding ~ublic/Private Manu~cturer: Capacityin gallons: From Tank Field Station Tank Sewer Lines ~¢~ ~¢d ~ Wel~ ¢OO* [¢ ( ~ ~ ~¢ "aterial~¢ C NumberofC°mpadment': su, c Water /00+ iOo~ [oO+ , LIFT STATION LOt ~ Size in gsl[ons: ~nufscturer: ~ Line ~ ~ ~0 +~ ( ~ + "Pump o~, at: ~p off" ,eve,~ ~ Hig~r alarm at: FouRdation ~ + ~ ~ ~ ~ ~ I¢ctrical Inspecti~s ped°rmed ~: Re~arks: h~ ~ [~ ~. ~=~¢~ BENCH MARK Locstion and Description' Assumed Elevation; loc ~, ¢ ~.' ~¢~ '.~, ..... ... 2nd ~[~¢*¢ Z · ' ................ Depa~ment of Health and Human Se~ices approval '~..~[¢~...:~ Reviewed and approved by: ,~/~/' ~, ~Date: ~ - ~- ~ ~ 72~013 (Rev. 9/91 ) MOA 25 Permit No. SW 98-0091 2 2 Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-47¢4 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LOT 4-C, STOCKLY YARD PID No.: 017-051-56 3.30.41' S 89°5~'00" E BENCHMARK EL~. % Z< / DOOR JAMB ~ ~ 1CO1 MARK A B C01 32.2 8.8 TC02 88.2 60.2 DC01 87,5 62.6 o I~T2 ~ / C05 84.4 97.8 C04 111.5 96.7 ' C06 119,4 1/2.4 I, ~10' ATU AND CEA ~50.~7' S 89'59'55" W ASBUILT SCALE: 1"=60' ? MARK A B C01 52.2 8.8 002 82.8 51.7 7C01 86.8 57.4 TC02 88.2 60.2 )C01 87,5 62.6 C05 84.4 97.8 C04 111.5 96.7 C05 106.5 109.2 C06 119,4 1/2.4 MT1 104.7 92.7 MT2 112 111 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW980091 DATE ISSUED: 4/30/98 DESIGN ENGINEER:ANDERSON CONSTRUCTION & ENGINEERING EXPIRATION DATE: 4/30/99 OWNER NAME:STOCKLY GARY G & MARILYN J OWNER ADDRESS:14250 GOLDENVIEW DRIVE ANCHORAGE, ALASKA 99516 PARCEL ID:01705152 LEGAL DESCRIPTION: MARILYN MYERS LT 4A LOT SIZE: 108900 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 2 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: ISSUED BY: April 21, 1998 Pi%chael Anderson P. 14250 Golden View Drive Anchorage, Al{ 99516 (907) 345-3377 home (907) 345-1391 fax Department of Health and Human Services P. o. BOX 6650 Anchorage, AK 99519-6650 (907) 343-4744 Office (907) 343-4786 Fax Re: Septic System Upgrade For bLarilyn subdivision Lot 4A & 4B To~4hom It May Concern: The shove referenced property is being replatted to vacate the lot line between 4A and 4B. Lot 4A has a small one bedmoom cabin which had a new three bedroom septic system installed in November of 1979 and approved by the Department of Health and Htu~an Services. The owner is building a new 5 bedroom residence after the cabin has been removed. The existing well was tested by Alpine Drilling and found to produce .74 GPD. The original system consists of 70 lineal feet of trench with 6 h feet of gravel. The soil rating was 250 square feet per bedmoom. This gives 910 square feet of area for three bedrooms. The additional two remaining bedrooms will be added with another trench. A test of the existing system was performed by dtur~oing 1000 gallons of water into the system. After 24 hours the level in the monitoring tube was back down to the original level even though we only needed 450 gallons. Two new test holes were excavated on lot 4A near the existing system to a depth of 17 feet on November 30, 1997 to investigate the soils. The test holes showed the soils consisting of six feet of sand (SP) , two feet of tight silty sand (ML) , then eleven feet of loose silty gravel (G~4). The sand perced at three minutes per inch and the tight silty sand at fifty n~nutes per inch. No water was encountered during excavation or after the seven day monitoring period. The two feet of ML will be neglected for design of the new trench. With a pert of three minutes per inch the required reserve area for on-site septic is 10,000 square feet. The lot has more than enough space for the reserve area. A topographical map is included with this submittal to show the elevations at the site. As the map shows a twenty five percent slope exists directly to the east of the existing system. The test holes were placed fifty feet from the edge of the slope and slightly west of the existing trench. No wells are within 200 feet of the septic reserve area except on the east side which is shown. The surface drainage from the road is channeled in the east-west direction along the road right-away thus not encroaching on the well or septic area. If more information is required please feel free call me at 345-3377. 14ichael N. Anderson P.E. VACANT VACANT VACANT GRIFFIN ROAD ~ . / 20' BLM ROADWAY EASEMDN, T '~' -~- LOT 5 h I~~M //~~ ~ SEPTIC AREA ....~+W.~.._ LOT 4A VACANT LOT $6 DESIGN CRITERIA: 2 BDRM = ,`300 GPD SOILS = 1.2 GPD/SQ. FT. .300/1.2 = 250 SQ. FT. REQ'D TRENCH: 8' DEEP 4-' EFFECTIVE 2.0' WIDE ,32' LONG LOT ,C -8' FML SEPTIC DESIGN PREPARED FOR GARY AND MARILYN STOCKLY LOTS 4A AND ,CB, MARYLIN MEYERS SUBDIVISION PREPARED BY MICHAEL N. ANDERSON, P.E. 1,C250 N. GOLDENVlEW DRIVE (907) 545-5577 / FAX (907) 345-1591 FILTER FABRIC --DRAIN ROCK SCALE: 1"=80' APRIL 21, 1998 LOT 5 20' BLM ROADWAY EASEMENT HOUSE 1,500 TANK EXISTING TO BI SEPTIC DESIGN PREPARED FOR GARY AND MARILYN STOCKLY LOTS 4A AND 4B, MARYLIN MEYERS SUBDIVISION PREPARED BY MICHAEL N. ANDERSON, P.E. 14250 N. COLDENVIEW DRIVE (907) z45-zz77 / FAX (907) ~45-m9~ SCALE: 1"=30' APRIL 21, 1998 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3- 4 5 6' ? 9 10 11- 12- 13- 14- 15- 16- 18- 19 20 :,OMMENTS Municipality o! Anchorage DEPARTMENT OF H~LTH& HUMAN ~~/ 825 "L Street, Anchorage, Alaska 995~~.~... SOILS LOG -- PERCO~TION ~T SLOPE WA~GROUND WATER ENCOUNTERED? SITE PLAN IF YES, AT WHAT DEPTH? ReKling Date Grow Net Depth to Net Time Time Water Drop PERCOLATION RATE ~O (mmnutesnnch) PERC HOLE DIAMETER TEST RUN BETWEEN (~ FT AND ~ FT PE"FORMED BY: /'~ I. g"~'~ O, e' ( /~ · ,~.~ ~, "1'~'~ I CERTIFY THAT T"I~ TEST WAS PERFORMED IN ACCORBANOE WITH ALL STATE ANO MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE J 'Z./J"/~/~ ~2 PERFORMED FOR: LEGAL DESCRIPTION: OF H~LTH & HUMAN DEPARTMENT ~ "/" ~r-et Anchorage Alaska 99502-065~ SOILS ~O,, ~ ~ ~, ~, rowhship. 5 6 7 8 9 10 11 12 13 14 15 16 18 19 3- ~---~c~. 2O SLOPE ,E.,OR.ED.Y: WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Oep~h to Water After SITE PLAN PERCOLATION RATE '-~ {mmutes~mch) PERC HOLE DIAMETER ~ TEST RUN EETWEEN '~ FT AND ~ FT e¢/~ ~ I CERTIFY THAT THIS TEST WAS PERFORMED ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. Gross Net Depth to Net Reading Date Time Time Water Drop t ~ ,.,.. ,.,,, [ -~ 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 Well DISTANCE TO: Manufacturer ]Liq. capacity in gallons IF HOMEMADE: D STANCE TO- Well Manufacturer Well ~ ~ DISTANCE TO: I No. of lines / I Length ~of~ ~ I TOp of tile to finish grade ~ / ~ / Length Width - Type of crib Crib diameter DISTANCE TO: Well Class /~ ~, Depth DISTANCE TO: Building foundation Absorption ar~ '~ MateriaIDWelling Inside length W dth Dwelling Foundation~:?.~.- Total length of lines Material beneath tile Depth Material Nearest Io~/?ne Trench wi~,/ ~,~(~7 inches No. of compartments [] NEW [~UI~G RAD E Liquid depth PERMIT NO. Liquid capacity in gallons Distance Detw?~en lings Total effective absor~on¢,~ area PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING A%o REMARKS APPR~ DATE LEGAL 72-013 (Rev. 3/78) ~-W DRIUJNG, I~- P. O. Box ~-1Z24 * 13f0c J~t~natlonal'AirDort (907) 274~6X l ._ _ ANCHORAGE ALAr;KA 99509 · ~ drawdow~ ~rom.s~atic level;~.~;~'. ' ' "' ' " ': ' ''' ':-'it" :' f ':)J'~ ' "" .~::F - . .-... . .'~.::~.':,Q~, ~ep~ ~ fee* ~om Give ~ oi[ form~lion~ penetrated, size of ~i~ color ~d h~a"~' '"'.:'":~."':'~'~i.' :~F~ '" '-" ''~ -"" ' .. . .. .... · · ' round surface TO --_TO ' ' , _TO___ 3 -- CONTRACTOR ;ii (::ti(!:;;:']' Z F:: "¢ -i"HF:;IT ~L: ;[ I:::!H F!:::I!"!:i:L;i:F:iF;i: i'.!];Ti'I THE: RE:]:;:!I...I]:F.:.':EI'"tFi?',iT:~i; FO!:;'. Oi",I'"'S;!:'i"E Fi;!i~;i,.!El';i::i!i; i::!i",i!:)HEL.L.S FI:E; Fi')I:;~:'i'H Eft'? ]"HE i"!IJhI :( C :i: F:'!:::I!... ;[ T"/ OF ;;~:: :F 14 ;i; I....L. :~ i",i:~;TF:!I..L THE S"/?;?TT~:~'! ]: H I~E:(:X)F;:DI::~NE;F:~ 14 :!: FH THtE ;~:: :i; Lii",iDEi:;;:::~?i'!::II".!i:::' TH!:::IT THE: (]i',i'""~!;:['TE S!Ei'.!Ei:~: ?'r':i~H'E:l"! i"iF::I"/ ~;~:!;;~):;!t.l]:f;;:E E:?',!!...F::Ii:,?.(i(iE:i"iI~;NT :CF:' "!'H!~:~: RES :i: i:::'E:i",!E;E ]: S REffi(:)I::;'E!...ED 'TO ;!; HE;i..I..E::'E !'"lORE 'THFii",! ::!~: ,'::l.:::'.:::"... :: '::/::~F,?. :~¢.~ ?i .~. El:;;: ]; :~:~;:~;;ijiED ,:::I'-'... !'" . ,::: .................................. ', -"- PERFORMED FOR: LEGAL DESCRIPTION: ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-222'~ SOILS LOG - PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14- 15- 16- 17 18 19- 20- TEST RUN BETWEEN PERFORMED B~~.~'~ SLOPE WAS GR(~I~IND WATER ENCOI~I'ER ED? IF YES, AT WHAT DEPTH? [] PERCOLATION TEST SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) FT AND ~ FT 72 008 (7/76) QSRE/ R ANCHORA6E AREA BOP' JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SEPTIC TANK: DISTANCE FROM WE LL/~OT- INSIDE LENGTH MANUFACTURER ~'~;~C/~ ,~t~',g/ MATERIAL NUMBER OF COMPARTMENTS INSIDE WIDTH ~ LIQUID DEPTH ~LIQUID CAPACITY ?-~) GALLONS. SEEPAGE Pit: NUMBER OF PITS I DIAMETER OR WIDTH /0 , LENGTH/~-), DEPTH ~¢~ ] LINING MATERIAL '~.,~//'~ CRIB SIZE: DIAMETER ~) DEPTH ~ / DISTANCE FROM: BUILDING FOUNDATION~ Hd~'~NEAREST LOT LINE~-~ ~ . WE LLfl//~ 7'-'/1/ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~'~)/(--) SQ. FT. ADDITIONAL ABSORPTION WELL: A/oT ,,,,,.4 TYPE BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES: INSTALLED BY: PIPE MATERIAL: C~.~'- LOT SLOPE: REMARKS: Form No. EQ-031 DIAGRAM OF SYSTEM ~,./, _ ,~ 0 ~'/'Fh- I I I I DATE GrEA'~r ANChORAge AREA BOR~ .-~h /¢/~ DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO, 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE, ALASKA 99502 TELEPHONE 279-8686 MAILING ADDRESS ~2~?~ ~9~]~_~/~//~ PHONE iNSTALLATiON LOCATION ~:~[~/ , DRA~N ~lELD . OTHER FINANCED ThROUgh ~ TO Be INSTALLed bY ~2~ SOil TEST ~eSUlTS ~/~/~ NOT=: THI= P=RMIT I= NOT VALID WITHOUT FINAL INSPECTION= 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGe PIt ~) / · DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL /"/~ SEPTIC TANK ~ , SEEPAGE PIT J~ ., DRAIN FIELD SEEPAGE AREA SIZE / ~7-~.~~'' TYPE /'~A,/;,/~'~ DIAGRAM OF SYSTEM TO NEAREST LOT LINE. DRAIN FIELD ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK /~ , SEEPAGE PIT DRAIN FIELD SEPTIC TANK· ,~ SEEPAGE Pit /~) /*, DRAIN FIELD 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 ]NST~LLATION. H E ~LT ~'l .~ IJ~ OR]TY OR LICENSED DESIGNER I CERTIFY THAT I AM FAMiliar WITH THE REQUIREMENTS OF GREATER ANCHO/WAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE _ . . APPLICANT'S SIGNATURE ~ .~. /,'"'~'~ 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # HAA# ~R0~(~') ,_~c~ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address Day phone NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual welt Community well Public water Unless otherwise requested, HAA will be held for pickup. NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. -- 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site /~' Holding tank Community on-site Public sewer 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 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 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. NameofFirm 1~'(,,"'~.¢,~(' ~(, ~-rtJ ~-vcu,1 Phone '-'~5"'-"~'~.~_ Address /~-'7.-~ o ~ ¢ ( L.~ u~ ~-~ ¢)¢' Engineer's signature ~~'~ Date ~,(/",~, (/'~. 9 Se DHHS SIGNATURE (~' Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date.. 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. ECF. IVEu Municipality of Anchorage JUN DEPARTMENT OF HEALTH & HUMAN SERVICE~ur~r..~_I~¥ Environmental Se~ices Division ~vl~o~t~v~~ 825 L Street, Room 502 · Anchorage. Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: /o~'~-t-~- ~'-~-o-~_~[~,/ Y~-~ ParcelI.D.: GL'~ OqJ(--Sc' A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or c, attach ADEC letter. ADEC water system number ~___o[. ~.. _x~) Date completed /d O~D' Cased to Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production ~ ~Z WATER SAMPLE RESULTS: Coliform (~ Date of sample: (.~ [* t (q' FROM WELL LOG AT INSPECTION g.p.m. '"~ ~__~ ~-~ Jr'-, g.p.m. Nitrate ,~O,(~ (~ Other bacteria (~ Collected by: ~w'~/,,( ~- B. SEPTIC/HOLDING TANK DATA Date installed G-/P ~/~ ~ Tank size Foundation cleanout (Y/N) "~ ~ z~ Date of Pumping f"~'~ . C. ABSORPTION FIELD DATA Date installed ~/~q ~ Length ~ ,u ~idth /~O O Number of Compartments ~ Cleanouts (Y/N) . Depression (Y/N) l',(' O High water alarm (Y/N) ~//'~ Soil rating (g.p.d./fF or fF/bdrm) [, '?-- System type ~L r,~ hicknessbelow pipe Total depth Effective absorption area ~-~' 0 Monitoring Tube present (Y/N) ~' Date of adequacy test ~ '~ ~ Results (Pass/Fail) t~ -c~o Fluid depth in absorption field before test (in.);~,~ Immediately after Fluid depth ~_Y (ins) Minutes later: ,~J. Peroxide treatment (past 12 months) (Y/N) ~ Depression over field (Y/N) For gal. water added (in~): Absorption rate = ~ ~ g.p.d. If yes, give date bedrooms 72-026 (Rev. 3/96)* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ('¢0o -~- Property line z-/(:::::) .fi Absorption field ~ O Water main/service line //O¢~- Surface water/drainage /o o 4- Wells on adjacent lots SEPARATION DIoTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~-O -[ Building foundation ~;~O ~ Water main/service Surface water_ /~ ~(- Driveway, parking/vehicle storage area Curtain drain /"~ ~¢- Wells on adjacent lots /¢ O E ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records in c°nf°rmance wi~ 7) H/~A~iTIines in effect °n this date. Engineer's Name I~L~[ ~(, ~ ~ ~¢f~ HAA Fee $. Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot ~ Block ~ of ~C~L~ ,%/~ Subdivis]~n, the well's productivity was determined to be~7.z~ gallons per minute. The minimum well productivity required by this Department (AMc 15.55) for a ~-- bedroom residence is O.~.~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of ~h~ well may fluctuate. Restriction of non-critical water uses such as washing cars ~nd watering lawns and gardens may be required. This advisory must be attached to all copies ~f the subject Health Authority Apprcval. Page 2 of,two pages - Req st for Approval of Individual S ~.~r & Water Facilities Legal Description Comments Approved Disapproved Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certif~S~¥~'~the Ln.formation contained in this request for approval to be a true and accuraf~e reorese~nt~t)~o#of the subject sewer and water facilities and these facilities a reopf ~n/~/i~ s'-~,'~A '. ~ily. SIGNED EQ-O 4 Request for Approval of Individual Sewer & Water Facilities Page .Two 9. Co~nents: Approved Disapproved Date Approval Valid for One Year From Date Signed Greater 'Anchorage Area Borough, Department of Environmental Quality DIAGRAbl OF SYSTEN I certify ' ~ tna~ the information contained in this request for approval to be a true and accurate representation of the suojec~ sewer ane water facilities 'located at: - MUNiCiPALITY OF ~NCHOXAGE MUNICIPALITY OF ANCHORAGE DEPT. OF I.IEA~TH & ~ DEPARTMENTOFHEALTH&ENVIRONMENTALPROTECTI~I~/IRONMENTAL PF~orECTIOSJ i 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION JAN 8 1979 · Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing, 1, PROPERTYOWNE~__~ j PHONE ~. MAILING ADDRESS PROPERTY RESIDENT (If different from above) / 2, BUYER PHON~ 3. LENDINGI~ITUTION ~ ~ /I '/ PHONE MAI LING ADDRESS 4, REAL~OR/AGENT ~ PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION 6, TYPE OF RESIDENCE NUMBER OF BEDROOMS ~ SINGLE FAMILY! ~ ~ One [] Four [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. Awell Icg is required for all wells drilled since June 1975, For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** **1 f individual/on-site, give installation date If system is over two (2) years old an adequacy test is required [] PUBLIC UTILITY by this Department, NOTE', THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR : , DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG. RECEIVED 3. SEWAGE DIsPoSAL SYSTENI PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC 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 Absorption Area ISewer Line I Nearest Lot Line I I WELL TO: Absorption Area to nearest Lot Line ~ CONDITIONAL APPROVAL (letter must accomp~n' y'~rt)¥i'~a~'e)": ~ y'*'"'''~ ~ DISAPPROVED .n ~ V I~ ~*' ~ DA+E ~ [..~' ~ BY(Title} ~'~ ~/ / '~v~ LEGAL DESCRIPTION 72-010 (Rev. 3/78)