HomeMy WebLinkAboutHANKS LT 1C
Kutul"I.Ifflu 0 9 DlI
Municipality of Anchorage
Community Development Department JUN 0 4`20%ge 1 of 3
On -Site Water & Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181082 PID Number: 011-121-79 ❑ New ® Upgrade
Name:
JAMES BURKHOLDER
ABSORPTION FIELD
�ound
❑ Deep Trench ❑ Shallow Trench ❑ Bed
Address:
7903 JODHPUR STREET, ANCHORAGE, AK
❑ Other
Phone: No. of Bedrooms:
Soil Rating:
Total Depthfrom origins ade:
(907) 243-2839 3
GPD/Sq. FL
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade:
F1��Gr.�ellenpg'th:
Grave h beneath pipe:
Ft.
Subdivision: Block: Lot:
Fill added above original grade:
HANKS - 1C
�G FL
Fl.
Owns Ip: - ange: - eC Ion: -
Gravel width: �`
FL
Beds Number of lines:
Distance between lines:
Ft.
SEPARATIONDISTANCES
Total absorparea:
Number oftrenches:
Dist. between trenches:
To
Septic
Absorption
Lift
Holding
Public/Private
From
Tank
Field
Station
Tank
Sewer Lines
SQ. FL
Ft.
well
100+
EXISTING
-
25'+
TANK ■ Septic ❑ S.T.E.P. ❑Holding ❑ Other
Manufacturer:
Capacity:
Surface water
100'+
-
-
GREER
1000
N/A
Gal.
Lot Line
5'+
-
Material:
Number of compartments:
H.D.P.E.
2
LIFT STATION
Foundation
10'+
-
-
Curtain Drain
i NONE KNOWN
Manufacturer: Ca y:
Gal.
'Pump on' level at:
"Pump off" level at:
High water alarm at:
Remarks: PER CONTRACTOR, OLD SEPTIC TANK WAS DECOMMISSIONED
PER UPC AND A 100'+ SEPARATION DISTANCE TO THE EXISTING WELL WAS
Pump Make 8 Model
Electrical Inspections performed by:
PHYSICALLY CONFIRMED PRIOR TO CONSTRUCTION
PIPE MATERIAL
EXISTING/ House to tank EXISTEXISTTank to23034 D3034
drainfield
Installer
EXISTING/
ARM SERVICES
Drainfield EXISTING CO/MT D3034
Inspector GEG, Ltd.
BENCH MARK (Assumed elevation)
100.00 Ft,
Inspection
Location and Description:
Dates: 1 St 5/24/2018 2nd
3rd - 4th -
BOTTOM OF TRIM AT SE HOUSE CORNER
ENGINEER'S S L
Community Development Department Approval
000�oo
o OD
�S/l-I0,
Conditional approval: Date:
p�
Q..� . f. .A ...arne.S::... a
OQ 9i/'•. CE -79 3
e
�I [�
, •
Approved: Date:
G
�0�"dp
LICENSE 0 rofessio�
Oo0
#AECC884
Inspection Report _1-1-12.doc
PERMIT NUMBER: RECORD DRAWING PARCEL NUMBER:
OSP181C32 011-122 1-79
A I B C
DBL1 54.0 1 40.4 59.3
DBL2
55.0
1 41.4
60.1
ST1
59.6
1 46.4
64.5
ST2
64.0
51.3
69.0
STMT
63.5
52.2
70.9
DBL3
65.6
53.7
71.6
DBL4
66.0
54.5
72.6
E01
70.7
1 62.3
82.0
JODHPUR; LOT 2
HANKS; LOT 2C-1 I \
C
44
we 40
G,A►.RNL�� E�GINLERING GROUP, ------------ � � � �� �•��
Ltd ;......................... ...0
CIVIL & ENVIRONMENTAL ENGINEERS - - ----=
3707 E. TUDOR ROAD, SUITE 101 'ANCHORAGE, AK99507-PHONE (907)337.6179- FAX (907)336-3246'WEBSITE:w g•m•ac•.gi—Mg.cam•••••••••• .............
PREPARED FOR: T24
E NUMBER: PAGE NUMBER:
JAMES BURKHOLDER 3-2839 2 OF 3 �� �.';• J• e•• . Games•, :���=
CE -79 =
LEGAL DESCRIPTION: DRAWN BY: /
HANKS; LOT 1C L.K.B. � W
TYPE OF WORK: DATE: LICENSE'SESS1"' �♦
�._ SEPTIC TANK AS -BUILT 6/5/2018 #AECC884 1�������♦♦♦
NOTE: PER CONTRACTOR, EXISTING
A \
/
SEPTIC TANK WAS DECOMMISSIONED
PER UPC AND A 100'+ SEPARATION
EXISTING
DISTANCE TO THE PRIVATE WELL WAS
HOUSE \
/
MAINTAINED DURING CONSTRUCTION.
B
1
C01
I
(NEW CLEANOUT AT END
EXISTING
OF EXISTING TRENCH)
100' WELL RADIUS
FCO DBL1 & c
C DBL2
�o
�l
��
I
i
I
DBL3
DBL4
1
APPROXIMATE LOCATION OF EXISITNG
\
-4
TRENCH PER CLEANOUT LOCATIONS
AND 1981 INSPECTION REPORT
•
�
IVE`r`�AY
/
��. D
AN
HANKS; LOT 2C-2
HANKS; LOT 2C-1 I \
C
44
we 40
G,A►.RNL�� E�GINLERING GROUP, ------------ � � � �� �•��
Ltd ;......................... ...0
CIVIL & ENVIRONMENTAL ENGINEERS - - ----=
3707 E. TUDOR ROAD, SUITE 101 'ANCHORAGE, AK99507-PHONE (907)337.6179- FAX (907)336-3246'WEBSITE:w g•m•ac•.gi—Mg.cam•••••••••• .............
PREPARED FOR: T24
E NUMBER: PAGE NUMBER:
JAMES BURKHOLDER 3-2839 2 OF 3 �� �.';• J• e•• . Games•, :���=
CE -79 =
LEGAL DESCRIPTION: DRAWN BY: /
HANKS; LOT 1C L.K.B. � W
TYPE OF WORK: DATE: LICENSE'SESS1"' �♦
�._ SEPTIC TANK AS -BUILT 6/5/2018 #AECC884 1�������♦♦♦
(�7PERSMIT NUMBER: RECORD DRAWING PARCEL 2 NUMBER:
OP181082 011-121-79
FINAL GRADE = 92.68 - 93.25
ST1 ST2
TOP OF TANK @ INLET = 89.92 2" HIGH DENSITY TOP OF TANK @ OUTLET = 89.92
INSULATION
INVERT OF INLET
BUNG = 88.99 NEW 1000 GALLON INVERT OF OUTLET
H.D.P.E SEPTIC TANK BUNG = 88.83
P,.••••••• #
.
ARNESS ENGINEERING GROUP, Ltd ............. ... ......... ...... .:......
;
- -- CIVIL & ENVIRONMENTAL ENGINEERS --- --10
3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 -PHONE (907) 337-6179' FAX (907)338-3246 'WEBSITE:-gamessengineenng.com 0 . ........ . • •„•, 0
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
JAMES BURKHOLDER 243-2839 3 OF 3 #6' •: •ffr A.•• ••_ •s :•W i
i
LEGAL DESCRIPTION: DRAWN BY: '� �� ��•. C79, <D .•'��13•� 4�4.ar
I
HANKS; LOT 1C L.K.B. �� j'Q��''.............. •�1�4W
TYPE OF WORK: DATE: LICENSE
♦� ,,"FESS\P �•
SEPTIC TANK AS -BUILT 6/4/2018 #AECC 84, was"*
H P A_L
MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program
PO Box 196650 4700 Elmore Road °',r 4,44,1
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.orglonsite
�� I), I, iitnicht
4hCNOR
On-Site Wastewater Disposal System Permit
Permit Number: OSP181082 Effective Date: 5/11/2018
Work Type: SepticTank Upgrade Expiration Date: 5/11/2019
Tax Code Number: 01112179000
Site Legal Address: HANKS LT 1C G:2222
Site Mailing Address: 7903 JODHPUR ST, Anchorage
Owner: BURKHOLDER JAMES & SALLY Lot Size in Sq Ft: 100553
Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field RI Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
"fr
Received By: _,f" Date: 5 11
Issued By: C,��. Q; Date:
51111$
MUNICIPALITY OF ANCHO '
• 40049%,,,
•,
tri •►1 rfi�
Community Development Department .„,46. i_ 11A43 7'04
Development Services Fax 0 �ie043 .•97
On-Site Water & Wastewater Program
Mayor Dan Sullivan cam`
h
cu
0L68L95
On-Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 011-121-79
Property owner(s) James Burkholder Day phone 243-2839
Mailing address 7903 Jodhpur St. *Anchorage.AK 99502
Site address 7903 Jodhpur St. *Anchorage,AK 99502
Legal description (Sub'd, Block & Lot) Hanks; Lot 1C
Legal description (Township, Section & Range)
Lot Size Sq.Ft. Number of Bedroom c- 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DEWELLING:
(®all that apply) Initial [1 Single Family (SF)
Absorption Field I I (w/wo ADU)
Septic Tank ® Upgrade Duplex (D) ❑
Renewal ❑
Holding Tank ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well n
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
N/A Distance: -
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: oZ rJ Waiver Fees:
Date of Payment: 5/q/1' Date of Payment:
Receipt Number: d(40°9A6 Receipt Number:
n.p(c,` Waiver No. No.
(Rev.01111)
-_, Quanics
GARNESS ENGINEERING GROUP, LtdAdvanced
T`e""'""S, ""
ENGINEERING SALES CONSULTING amismiffsmis2 Deader
May 7, 2018
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Proposed Septic Tank Upgrade for Hanks; Lot 1C
To whom it may concern:
The existing house is served by a private well and private septic system. The existing
steel septic tank (installed 1981) is in a state of failure and needs to be upgraded. We are
proposing to decommission the existing tank per UPC and replace it with a new 1,000-
gallon H.D.P.E. septic tank. The contractor is to have all pertinent well radii and
easements flagged prior to construction and is to maintain a 10'+ separation to all building
foundations. In addition, the contractor is to adjust grade of the sewer line to ensure soil
cover over the HDPE tank does not exceed 4 feet. We are unaware of any adverse
impacts this installation would have on adjacent wells or septic systems. If you have any
questions, please contact us at 337-6179. Thank you for your assistance.
inc-rely,
effr- j '. r am s, .E., M.S.
Pres': zit
t
3701 East Tudor Road, Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
i , it // `N
-s,
I / \
I / \
I / \ I
I
/ \I i I
1 100'WFLL RADIUS I
KINCAID
1 / HEIGHTS;LOT 5
\ / ASEPTIC AREA AWWU WATER
\ /
\ /
N //
\ __--
/
JODHPUR;LOT2
I—
W
W
I-
H
CO 2 //r \ I
a_ ../
N
O• I / \
O / \
/ EXISTING \ PROPOSED 1000 GALLON
HDPE SEPTIC TANK
F I HOUSE \
z
N1 100•WFLLRADIUS +,.
E •
KINCAID HEIGHTS a1:
\ • O / LOT 14
_J
D
D
\ ..d /
\ / AWWU WATER
6 .a /
• •ate- .. /
�e —S�—.......
r \
/ / -- \
/ \ // 1111 �+
I 1 / \ ASEPTIC AREA
...3
100'WFI L RADIUS
HANKS;LOT 2C.1 I / HANKS:LOT 2C-2 \ ►�
1 I / \
/ 1
11\ / gEPTIC AREA 100'WELL RADIUSPEI
I \ / (PROPOSED PERMIT OSP 61 7155)6 I I
L--\_ —/ t----J
/
\ //
\ )1(k\I/
i
SCALE:
1"=100'
.4�\\1111\111
•
Alf t sr • L • •/
GARNESS ENGINEERING GROUP Ltd 4Iqi'4t 1 ' ��'
ENGINEERING•SALES•CONSULTING =
•
•
3701 E.TUDOR ROAD,SUITE 101•ANCHORAGE,AK 99507'PHONE(907)337.6179•FAX(907)338.3246'WEBSITE:VA W.gamessengineerinq.com •• •• •
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ,O 'if A A. Ga ess : :
JAMES BURKHOLDER 248-2839 1 OF 2 ••0 �CE- 5
PROJECT/LEGAL DESCRIPTION: DRAWN BY: . • SIP(11.04,).•
HANKS; LOT 1C L.K.B. wit/; ESS`�::�40�
TYPE OF WORK: DATE: LICENSE ,�1�111111��.4
SITE PLAN 5/11/2018 LICENSE
GEG,Ltd.HAS A 8 PAGE SPECIFICATION
LETTER THAT PERTAINS TO THIS DESIGN.TO
NOTE: CONTRACTOR IS TO HAVE THE WELL RADII OBTAIN A COPY OF THE LETTER CONTACT
PROFESSIONALLY LOCATED&FLAGGED PRIOR TO GEG.BY PROCEEDING FORWARD WITH THIS
CONSTRUCTION AND MAINTAIN A 5'+SEPARATION INSTALLATION,THE ENGINEER,WELL DRILLER,
TO THE EXISTING TRENCH AND 10'+TO ALL CONTRACTOR AND PROPERTY OWNER AGREE
FOUNDATION WALLS. THAT THEY HAVE READ THESE
SPECIFICATIONS AND AGREE TO ACCEPT THE JODHPUR;LOT 2
TERMS AND CONDITIONS OUTLINED.
N
/ PROPOSED 1000 GALLON \
/ HDPE SEPTIC TANK
/ \ INSTALL MONITORING TUBE
EXISTING
/ HOUSE ENG PTO
1 DECOXISTIMMISSIONEDSETIC PERANKTUPBEC
IEXISTING
100'WELL RADIUS • FCO rs
IIll
\
INSTALL DOUBLE CLEANOUTS 1 ,
BEFORE AND AFTER TANK
1 �
•d •
``
\ •
/
APPROXIMATE LOCATION OF EXISITNG
\ •
4 <1 TRENCH PER CLEANOUT LOCATIONS
AND 1981 INSPECTION REPORT
•
\ ,d • < • /
•
• • 4 • <7 A' DO.VIP's( • /
• • N.
V
V
N
HANKS;LOT 2C-2
......---" 0---...„
HANKS;LOT 2C-1 V '.\SCALE: \ \
\ / 1"=40'
��S\\II\fI
/ 1 i• ,*�.
GARNESS ENGINEERING GROUP, Ltd9 •
FNGINFFRING'SALFS-CONSULTING
3701 E.TUDOR ROAD,SUITE 101'ANCHORAGE,AK 99507•PHONE(907)337-6179'FAX(907)338-3246'WEBSITE:www.gamessengineering.com •• •.
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: •r. , •. Gam�.s �=
JAMES BURKHOLDER 248-2839 2 OF 2 %v4��5 s E-• : °� /
PROJECT/LEGAL DESCRIPTION: DRAWN BY: 4. ••• �� /• ''* .
HANKS; LOT 1C L.K.B. 1���p•�p••U,1 •••• •l' P�, 4�
TYPE OF WORK: DATE: LICENSE ', 1 M"S`•:644••
SEPTIC TANK UPGRADE 5/11/2018 #AECC884 1
i~ ' 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
'NAM%IO/ I _'ONE &NEW
LEGAL DESCRIPT~N
LOCATION ~4L ¢t.,~ ~, NO. OFBEDROOMS
DISTANCE ;O: We'l~'c ("d Absorption area Dwelling ~S / PERMIT NO2/
~ ~ Manufacturer ~ ~ ~ Mater]~ ~'~;~-- No. of com~tments
L~q ca~ac~t~ in gaJlons InsMe length Width Liquid depth
~ ~ DISTANCE TO: Well Dw~Hina PERMIT NO.
~ ~ ~ Manufacturer Material ~iqu]d capacit~ in gallons
:~ DISTANCE TO: Well~x ~ F°undati~n~' * Nearest '°tli¢ /.* PERMIT NO'~/~X
-- Total Trench widt~ j
No. of lines ~ Length o~cb,,, le~line, Distance betwee~,
~ ~ ~ Top of tile to finish grade ~ beneath tile ¢~ches Total effective~tion area
~ Length Width~ ' Depth Material ~ inches PERMIT N~
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
¢ DISTANCE TO: Well Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s}
OTHER
SOILTESTRAT~NG t - ~) ~ ~
INSTALLER & ~~
REMARKS
¢ ,
A¢~ DATE LEGAL
1-4 E L L Fi ~-~
F'ERMIT NO. < 3lEntO:-':: )
RPPL I RRNT
L. OL-:RT I ON
LEGRL
JOHN E. HEF'LER
..TC DHPUF.' RD
LOT 1C HRNK"S S,..'D
DEPRRTMENT .... - HERLTH RND EN, [F _NMENTHL ROTECTZON
82.5 "' L'" STREET., RNCHORFtGE., BK.
264-47:20
10168 MRRMOT C
LOT z.I,::E J.~:Jkl .... ,~: SI~.!I_IRRE FEET
TYF'E OF :,L IL FIBS]RPTION SYSTEM IS: TRENCH
MFI::,::!MUM NUMBER OF BEr:,ROOMS =
TF1E REI]:!IJIF. IED :,t..-'E OF THE SOIL FtBSORF'TION .=,.~=,TEM
E:.. E F" rT !J-u/= -_"LIIEI L E f-,!!I3 T H = '-=' "-' _~ r~. n .
--..:. E:" E F" 1- H = ~'=-.
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
]'HE DEF'TH OF R TRENCH. OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRBVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE ENCRVRTION (IN FEET).
F'ERMIT MFFLI_.HNT HRS THE RE_,FUN=,IE, ILITY TO INFORM THIS DEF'RRTMENT [:,LIRING THE
INSTRLLRTION INSPECTIONS OF RNY HELLS RDJRCENT 'TO THIS PROF'ERTY RND THE
NUMBEF.: OF RESIDENCES THRT THE HELL HILL SER',/E.
' F" ' '-""' ~':' '
BR_.KFILLING OF RNY _,-r_,TEd HITHOU'r FINAL INSPECTION ~ND ~PPRO',/BL BY THIS
[:,EF'RRTMENT HILL BE =,LIB..E_.T 'TO PRf3SECUTION.
MINIMUM DISTRNCE BETWEEN R HELL RND RNY ON-SITE SEHRGE DISPOSFIL SYSTEM IS
t~Z.~E~ FEET FOR R PRIYRTE HELL_ OR i50 TO 2E~0 FEET FROM 8 P/JBL. IC WELL DEPENDING
UPON THE TYPE OF PUBLIC HELL
MINIMUM DISTRNCE FROM R PRI',/RTE HELL TO R PRIVFtTE SEWER LINE IS 25 FEET RND
TO Ft COMMUNIT'¢ SEHER LINE IS 75 FEET.
HELL LOGS FIRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT HITHIN ]:0 DRYS
OF THE HELL COMPLETION.
OTHER: REC.!UIREMENTS MFIY RPPL'¢. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
R'v'FIILFtBLE TO INSURE PROPER INSTBL. LRTION.
I C:ERTIF'-r' THRT
;2: I FIM FRMII_IBR HITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FL]RTH BY THE MUNIC:IF'RLIT'-r' OF RNCHORRGE.
,:.: I HILL INSTRLL THE =,~-'-,TEH IN RCCORDRNCE HITH THE CODES.
2-:: I UN[:,E~THRT THE ON-SITE SEHER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RES I[:,EN~tODELE[:, TO INCLU[:,E MORE THRN -':: BE[:,ROOMS.
S i G N E C,/( _~.~.._~_ _~C-'~_ ~_ _~_ _.~_., _~ .................
~ BF'P~.I~NT .ff]H~ E. //HEF'LEF ,
MUNICIPALITY OF ANCHORAGE
t OF ANCHORAGE
825 L. Street, Anchorage, Alaska 9950~NVi~OTAL~'~ ~' --p~:OTECTION
SOILS LOG- PERCOLATION TVt~
SOILS LO~
PERFORMED FOR:
LEGAL DESCRIPTION:
[] PERCOLATION
TEST
1
2
3
4
5
6-
7
8
9
11
12
13
14
15
16
17
18
19
20
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
-S
L
O
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
(minutes/inch)
-- FT
PERFORMED BY:
Location ............ (f~.'. ....... ,/.f~ .................... ..~..~,.:~!~._.<.; ........ ~{.?fS....: ...........................
Date completed ............... 5..:..,.J..'?,.~...~./,' .................................................................
Depth of well... ~Z--7[ ~ '
Size of casing ................... ffJ'.~
Distance to
Distance to
....... .............. ......
of
Formatxon
water ............. ..~...!...0.. ............................................................................
water while pumping ........................ .%..{...~.. ..................... at rate
fl~om
/70
to
Driller
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHORAGE, ALASKA 99507
./ : ~ ~- ~ ~D,. ERECEIVED
' INSPECTION APPOINTMENTS "---~.X,.~_~0 ~'/'
?
TIME' TIME TIME l
DATE ' DATE // D~TE .
NSPECTOR INSPECTO~ , INSPECTOR/)
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~,~,~1.~ ...................
825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
ENVl RONMENTAL SANITATION DIVISION
T .pho.. a 4.4720 AUG 1 9 1981
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PROPERTY RESIDEN~ (If different from above) PHONE
PHONE
MAILING ADDRESS
3, L~NDING INSTITUTION I PHONE
;MAILI~GADDRESS
4, REALTOR/AGENT~~. ~. I PHONE'
MAILING ADD~ ESS
5, LEGAL DESCRIPTION
;TREET LOCATION ."~0~]~ ~:J'~J'~ I~
6. TYPE OF RESIDENCE ,~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATE.R/~UPPLY
L~ INDIVIDUAL*
LJ COMMUNITY
[] PUBLIC UTILITY
NUMBER OF BEDROOMS
[] One [] Four [] Other
[] Two [] Five
.~.' Three [] Six
* ATTACH WELL LOG. A well 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**
[] 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 NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO I~] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER.
[] INDIVIDUAL/ON -SITE -DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[~]Septic Tank or (~Holding Tank
Size: //~)~)(~) If Tank is homemade SOILSRAT[NO
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
I 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
1
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
..~[~]" APPROVED FOR ~- BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
.W;ATER SYSTEM: "
liD. NO,
W{[{~r system Name ' /
City
Analysis shows this Water SAMPLE tel:be:
.~]~,Satisfactory
[] Unsa;isfactory
[] Sam~pie too~long..in transit; sample'should
not'i~e over.48: hours old at examination
~:o'i?i~idat~:reliable res'ults. Please Send
cai Method:
[]
sAMpLE
,NO,
1
~ilter
Result~
Analyst
4
READII~ .. a.m.
BEFORE
EMB BrOth 24 hours: ' Broth 48 houri;
COLLECTINGSAMPLE.- M~lltlpl®Tube Report: ' 1Omi Tubes p0~ltlve/Total ZOml p~tlM~,
Membrane Filter.' Direct Count · Collfo~/lOOml
Verification: LTB.
Final Membrane Filter Re~l
Reported By