HomeMy WebLinkAboutDORA #2 LT 18Dora #2
Lot 18
#014-251-35
DE:PFtF::TMENT r ....... HEFIL'I"H FIND ENVIROh,IMENTRI .... r>~;-:O"['ECTION
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PERMIT NO. ,:: :31:L059 ::,
RPF'LICANT 'T'. STENRRT C:ONST.
LOCFiT I ON
LEGFIL L.:!.:3 DORR 2
:2,42'0 I.,t ! LL I I.,.IF! C I F.:C LEc'-'( c~ g'-Ou('
LOT S I;:"E 2F~E~00 :.:.'i;OURRE FEET
MINIMUM DISTRNCE: BETHEEN 8 t.4ELL FINE:, RN"r' ON-SITE SEI.,.IRGE [:'ISPOSRL. S"?STEM IS
:tO0 FEET FOR R PR IVRTE NELL. OR :L50 TO 2ElO FEET FROM R PUBLIC HELL DEPENDING
UPON THE T'¢PE OF PLIBLIC HELL
MINIhIIJM [:,ISTRNCE FROM R PRIVRTE HELL TO R PR I ',,,'RTE SEI.4ER LINE IS 25 FEET RIqD
TO R COMMUNIT"r' SEHER LINE IS 75 FEET.
HELL L06S RRE REQUIRED RND MUST BE RETURNED TO THE [:'EPRRTMENT HITHIN 2:0 [:'1:%"S
OF THE HELL COMPLETION.
OTHER REOUIREMEN'rS MRY RPPL.'¢. SPECIFICRTtONS RND CONSTRUC:TION [:,IFiGRRhlS; F:IRE
FiVRILRBLE TO INSLIRE PROPER INSTRLLRTION.
F" [-:2 F4.- t'.1 ]: 'T E ::..'-': F' 2[. F..' E 2':.'; E:, E: C: E r-1 B E R 2.: ::L .., 1 L~ E.' :t.
I CERTIF'"r' THRT
t: I RM F'RMILIRR FILTH THE REQUIREMENTS; FOR ON-SITE SEI.4ERS RND NEL. LS RS SE]"
LF;.;[::) R"~'H i.,.I .~,'¢ ,'HE t'LfL i f.,t,:2;.l!1...~ ,.J ~,:::I F'RL I'FHE S~"~T'~I~IRN C HOI N R,~ ~:;3Nf":E N ITH THE C :,DES
PFL ...~" T. STEHRRT C:ONST.
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•
• c_'� Municipality of Anchorage F '== Q
On-Site Water and Wastewater Program 0.
' (907) 343-7904 MAR j i:) . 1-tiltITi
Certificate of On-Site Systems Approv- s h
8L g5
Parcel I.D. 014-251-35 Expiration Date:
1. GENERAL INFORMATION:
Complete legal description DORA#2; LOT 18
Location (site address) 8541 Rosalind Street*Anchorage 99507
Current Property owner(s) Rodgers Richard & Dulcilenia Day phone 907-242-9931
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
•
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer
WaiverNariance request for: Distance:
Received by: 07 Date: -52Z,0
f
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 52-(o Waiver Fee $
Date of Payment �IJ1lir Date of Payment
Receipt Number 011 -`f% Receipt Number
COSA# (}jc`g 611 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.
Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
r
Engineer's Printed Name: Jeffrey A. Garness Date: -Ells / `I}
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o4 OF • C4%%Q
in accordance with the guidelines and regulations established by the Municipality of Anchorage and 'b' C'...
C�.•• 1.. -/A 1
industry practices. The reported results describe the condition of the system/s on the date/s of the _._,O,1: - #- VV
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells 0�* . 4 T �'• ••*v0�
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, �'
rA
groundwater levels (that may fluctuate during the year), quality of construction (materials and r, O
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary,and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the g •• ,:"f •-y A. am ss: 0
system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of vQ cE-79 3 �`��
the well or septic system. GEG makes no representation whether an alternative well or septic system 00i ed �/� �( \' 0�0
can be installed on the property in the event either of the current systems fail to perform adequately in Q & J Fc o
the future. The content of this report is for the sole benefit of the person/party that retained GEG to �Q� Protessl•o�o
perform the evaluation. Reliance upon the information provided in this report by any other person or �pppppoa
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved ` QF C/./pp_
Conditional approval for bedrooms, with the followttt stip la i ns: �'�
.i.- o*S" \AO ,•
is �-
/13y: wt Original Certificate Date: g —2-0 —1 2
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 Nitrate Advisory .. .
Septic System Advisory Arsenic Advisory ' : ,,
Well Flow Advisory Other •
•
COSA blue sheel_10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Dora #2; Lot 18 Parcel ID: 014-251-35
A. WELL DATA
Well type Privote If A, B, or C provide PWSID# N/A Well Log (Y/N) Yes
Date completed 4/29/1981 Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yes
Total depth 110 ft. Cased to Unknown ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 4/29/1981 3/6/2018
Static water level 49.6 ft. 44.6 ft.
Well production 12 g.p.m. 5.9+ g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 ml. Nitrate ND mg./L. Collected by: GEG. Ltd.
Arsenic: 76.7 ug./L. Date of sample: 3/6/2018
B. SEPTIC/HOLDING TANK DATA PUBLIC
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts(Y/N)
Foundation cleanout(Y/N) Depression over tank(Y/N) High water alarm
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft2/bdr System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption - -a ft2 Monitoring tube Depression over field
Date of adequacy test Results(Pass/Fail) For bedrooms
Fluid depth in absor• field before test in. Water added gal. New depth in.
Elapsed Ti.•-: min. Final fluid depth in. Absorption rate>= g.p.d.
• • rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at •• •• wa er alarm level at in.
.- •- Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100'+
Absorption field on lot N/A On adjacent lots 100'+
Public sewer main 75 + Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIE ' a 1 LOT TO:
Property line B • =. • oundation Water main
Water service lin- Surface water Driveway, parking/vehicle storage
.in drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION `=":--OF/4 ‘'N
I certify that I have determined through field inspections and / . 4). L ....-52:/ o0
review of Municipal records that the above systems are in 0 IV vA
conformance with MOA COSA guidelines in effect on this
date. /O ',1 -f - •. Ga ass:
,
Engineer's Printed Name JEFFREY A. GARNESS Q G ' CE 795 ,a
Date .g/1 Cl/
L A
—
av
O4rofess,0o440000o
#AECC884
(Rev. 11/05)
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT s 4c7) 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Arsenic Advisory'
Certificate of On-Site Systems Approval # OSC181091
Subdivision: Dora #2, Block: , Lot: 18
A water sample revealed an arsenic concentration of 76.7 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On-Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P. 0. Box 196650* Anchorage,Alaska 99519-6650 *www.muni.org
0 I 8470J
Lot 19
25 EAST 154.67 Lot 7
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LX -- A o
(n I 36.0 deck _ I cn o
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Z I 2.0 OH---„L N 1 1/2 Story ry �d ._ =
J Frame House o aa) I w
Lot 18
14.0 CO I 06 Zo o
N I ldk >•
CCI.J.. , .,l`, .e WvS ev 1.4.k hc; ..— co i
O �, ;:Asphalt:;:. :;�' , v I co
o Y
Z
°.:-%' tn- • '-Y 22.0 0 0 0
fix`:''a°C. idS'.1.1.�r`7:r r r i
o Well x shed o m
T'- a Chain link fence (typ)
t 11 ::-.1.-
EA T " 154 73 `� " } X
Lot 17 Wood fencei
Lot 8
25
AS-BUILT NO CORNERS SET THIS DATE I
•A � ' I hereby certify that I have performed a Mortgagee's inspection
�`• OF • �,9 f of the following described property: LOT 18,
,`P.' .S/T- DORA II SUBDIVISION
C •• 49th iN •1 II
•* #' Anchorage Recording District,Alaska,and that the
0.
•••• } • •••• F improvements situated thereon are within the property lines
vPraileth,-<.9-- / and do not overlap or encroach on the property lying
xl adjacent thereto,that no improvements on the property tying
I '•Fred Walatka . ao /
ow adjacent thereto encroach on the premises in question and
I,4%,1,• 3255 - S •• •e that there are no roadways,transmission lines or other
F'Pe' • • •• yJ� visible easements on said property except as indicated
AR • • • • • .,p`'o hereon.
1 ' 0Fessioru\ `� Dated at Anchorage,Alaska
EASEMENTS OF RECORD, OTHER THAN 1 X N.\\N this 9th day of MARCH ,2018.
THOSE SHOWN ON THE RECORDED SCALE: 1"= 20' FRED WALATKA&ASSOCIATES
PLAT ARE NOT SHOWN HEREON. Engineers and Surveyors
UNLESS OTHERWISE NOTED FB 18-3, pg 2 BE 907-248-1666
Municipality of Anchorage .
-. P O Box 196650 Anchorage AK 99519-6650' .' "
www ci anchorage.a~:dS" -
343-79O4
(907) -
CERTIFICATE OF HEALTH At~H0~lTY Afi l d [ FOR A SINGLE FAM LYDWELLING:'~ ,':V. ....
Expiration Date: ·
1. GENERAL INFORMATION
ComPlete legal description Lo ~t ~ I ~. Do,-t,, .~'
Location (site address, or direction~) ,~'Y/ ~o..r~,, h,, ~ -~
Current Property owne.r(s)' ~c41tv 0 ~ f Day phone.:
Lending agency ~n~. - Day'ph~e::'"
Mailing address
Real Estate Agent
'";.:.-.-' Mailir{g Address... :.: ~/I/ "c~,, .c~,~ faO, "-~Z~4 ~,;o¢,,7e'¢ .
Un/ess othetwise'r~quested, HAA t/i// be held by DSD for pickup.
2. NUMBI~R OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well' []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
Day phone-"'~ o"t -"/4',6 7
~-e ¢e~-42.3'
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
[]
[]
[]
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION By ENGINEER
As certified by my seal affixed hereto and as of ~e validation date shown below, I verity that my investigation,
based on procedures outlined in the Health Authority 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 verity 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 th.e. time of i,$t.a,ati.on... ..
NameofFirm i==t~,/./.¢,,/,., .7~cA,~/¢~,! ~r~,,'~,,./ Phone
Address I'f5'3~' Ec4~, -q).: ,,4~/,o,"~¢~., ,A-~' ~)~.,c/,~'
F;. ~'-~oo-z' Date r-tc,,v
Engineer's Printed Name
5. DSD SIGNATURE
~' Approved for .
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: --~'-- ..~ 0 - ~/.
Municipality of Anchorage
Development Services Department
Building ,Safety Dhasion
On-Site Water & Wastewater Program
4700 South Bregaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7004
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Des'criptioni La P /~.
A. WELL 0ATA
Wetl type
Date completed ¥/z,~/,~l
Total depth ~10 fl.
Date of test
Static water level
Wall production
WATER SAMPLE RESULTS:
Coliform ~ colonies/100 mi.
Date of sample: .¢'/3.~../Zoo ~
B. SEPTIC/HOlDING TANK DATA
Tank Type/Material
Tank size gal,
Foundation cieanout (Y/N)
Date of pumping
Co
If A, B, or C provide P~NSID #
San~r/sea (Y/N) r
Cesedto I~O fl.
FROM WELL LOG
¥/34'/~ /
'1 9.. g.p.m.
' ' ; weu Log (y/N)
· Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
5'.9 ft.
~. 9 'f" g.p.m.
~3 In.
Nitrate ~ mgJI. Other bacteria
, c_.,~ected by:
Date installed
Number of Compa,'tments
Depression over tank (y/N)
Pumper
ABSORPTION FIELD DATA
Date installed
Length
Total depth ft.
Date of adequacy test
Fluid depth in absorption field before test in.
Elapsed Time: min. Final fluid depth
Any rejuvenation treatment (pest 12 mo.) (y/N & type)
Cleanouts (Y/N).
High water alarm (Y/N)
Soil rating (g.p.d./ft= or ftYedrm)
ft. Width ft.
Eft. ab-a~'ption area ~ Monitoring tube __
Results (Pass/Fail)
Water added
in.
System type
Gravel below pipe
Depression over field
gal.
Absorption rate >=
ff yes, give date
C~ colonies/100 mi.
For bedrooms
New depth in.
g.p.d.
D. UFT 6~'ATION I~. 4.
Date installed
'Pump on' level at
Datum
Size in gallons.
in. 'Pump off' level at
Cycles tested
in*
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
Fo
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/tiff station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
· On adjacent lots
On adjacent lots
Public sewer manhole/deanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ,,U.
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /d. ,4.
Propen'7 line
Water Service line
· Curtain drain
COMMENTS
Building foundation
Surface water
. .Wells on adjacen.t lots
Water main
Driveway. parkingNehide storage
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above sys~ms are in
conformance with MOA HAA guidelines in effect on this date.
E_ngineer's Printed Name "]"*~ ~oc:~o~P- F, ,'~ ~_
Date ~o.y ~-,,~ '~OOI
HAA Fee $ ~'C,~ ~'
Date of Payment
Receipt Number
(Rev. 12/00)
,,~--/zr'
Waiver Fee $
Data of Payment
Receipt Number
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
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
Location (address or directions)
S'f/
(b) Property owner ?ou.~
Mailing Address
(c) Lending Institution
Mailing Address ~.~
(d) Real Estate Company and Agent
Address ¥00 II
Telephone "~ y q-
Telephone · (home) '~ ¥~/-O~Z'Y Business
~¢¢~ Telephone ~7¢ - E~ ~
(e) Mail the HAA to the following address: (or check here I~, if hotd for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family J~ Number of bedrooms ~
3. WATER SUPPLY
Individual Well 1~' Community [] 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 J~ 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
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.O~.~.A~ /,___~,~,~ MUNICIPALITY OF ANCHORAGE (MOA)
.~'~ ~'~ {,~t'~l Health Authority Approval (HAA)
,.,~-~,,~ ~,~// CHECKLIST- FEBRUARY 1984
,~C~ ~ ..,% ~,~'%~ Legal Description: Lo/' ~/ tgo~-~ ZT ElD
a. WELL DAT~I~C
Well Clasm~ation ~r-, ~,~'¢ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Y Date Completed
Total Depth I~ o' Cased to II ~' Depth of, Grouting N,,4.
Static Water Level
Pump Set At (X ~/~
Sanitary Seal on Casing (Y/N) Y
Depression Around Wellhead (Y/N)
Casing Height Above Ground P,.' ·
Electrical Wiring in Conduit (Y/N) Y ·
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
~ r ; On Adjoining Lots
N,~. ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ ~5''
Water Sample Collected by 1':. ~. r-/oo,-g ; Date
Water Sample Test Results ..C,~t~_,-c~..~,,.v - ~ ~1~ /l~ ~
Comments D~;~ ~ell ~(o~ ~/ o~ 3/~/~/
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
No. of Compartments
Standpipes (Y/N)
Air-tight Caps (Y/N)
Foundation Cleanout (Y/N)
Depression over Tank (Y/N)
Date Last Pumped
Pumping/Maintenance Contact on File (Y/N)
; for
Holding Tank High-Water Alarm (Y/N)
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well To Building -Foundation
To Property Line
To Disposal Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
72-028 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA N,
Soils Rating in Absorption Strata
Date Installed
Width of Field
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 ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D. LIFT STATION N,A.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
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 gui.cJ~?~kf. ~.ct on the date of this
inspection.
Signed -~°7"~~-~- ~ ~
Company ~~ ~A,~f g~r ~
MOA No. 89 -~
Receipt No. ~ ff ~ ~ W / 7 Receipt No.
Date of Payment ,~ --~/~ Waiver Fee: $
Amount: $' /~ / ~ ' ~ ~ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
...... DATE RECEIVED
' :, INSPECTION APPOINTMENTS
DATE DATE DATE // /
INSPECTOR I NSPECTOR/-~ . INSPECTOR ~,
. CIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE _ DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOt~J~'IVIRONMENTAL P~OT~'CT~ON
~/'~ ~ 825 L Street- Anchorage, Alaska 99501
l~!~'~)) ENVIRONM :NTAL SANITATION D VI ION
E , s CT 6 1981
~~ Telephone 2~720 ~ _ _ _
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA~ITY~
DIRECTIONS: Complete all parts on page 1. Incomplete requ~ will net be proceed. Please allow ten (10) days for p 'ocessi g.
1, PROPERTY O~NER ~ . . "~ ' " ~ pHoNE
MAI LInG ADDRESS
PRO E~T~ RESIDENT( d'f ere t om b e) - PHONE ~ '
2, BU~ , ' -- PHON'E
MAILING A~DRESS ~
3, LENDING INSTITUTION ~ ~. '-- .~ _ ', ' I' PHONE
MAI~ING ADDRESS ........ '- ' - - '
4. REAL~OR/AGENT ~ ' ~ ' ' I PHONE-
MAILING ~ODRESS
5. LE~.~L.i~tBDESCRIPTION/_~
STREET LOCATION~1,~ q/ ~0,~ ~ L///~p .,
B. TYPE OF RESIDENCE
S
INGLE FAMILY
[] MULTIPLE FAMILY
7. WATERJUPPLY'
"~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL S~YSTEM ....
[] INDIVIDUAL/ON-SITE**
' "NUMBER OF,I~ED~OOMS
1. One Four ' [] Other
Two ~ Five
E] Three [] 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 {attach log if available.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) ~
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
[] I NDIVI DUAL/ON -SITE
r'-I PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: .... If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
NUMBER OF BEDROOMS
[] ONE [] THREE
[] TWO [] FOUR
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE NSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank
[] FIVE
[] SiX
IAbsorption Area
Sewer Line
[] OTHER
iNearest Lot Line
IDATE
CONDITIONAL APPROVAL (lett~r must accompany certificate)
DISAPPROVED ~~
72-010 (Rev. 6/79)