HomeMy WebLinkAboutANGELA HEIGHTS LT 4
fZrrtifirh [Irilling
by
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE- Started ~//~/
PERMIT NUMBER
Ended
DEPTH OF WELL /q.~ i
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
!
/doo
KIND OF FORMATION:
From O Ft. to
From
From
From
From ~'~
From
Erom 77 Ft. to
From C't~ Ft. to
3o
From /3o Ft. to /fo)`.
From__ Ft. to.__
From Et. to
From__Ft, to
From Ft. to
From Ft. to
From__ Ft. to.__
From Ft. to
From Ft. to.__
Ft. OOe'~ ~ o~~''~J From
_ Ft. ,dV~*'O0 ~ ~o~ From~
.. Ft. ~ ~ From~
~Ft. ~ ~W ~ r ~O~C From
Ft. From
Ft. From ~
Ft. From
Ft From
Et, From
.Et From ~
Ft. From
.Et From
Ft. to Ft.
Ft. to_ Ft
Ft. to Ft.
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to____Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to__Ft.
Ft. to__Ft
Ft. to Ft.
Ft. to__Ft
Ft. to Ft.
Ft. to Ft.
Ft. to__Ft
MISCL. INFORMATION:
DRILLER'S NAME
F'ER1.'I:I: l" I",10.
i"1 L.J~ Ir,,I ! ~:l: ::1: F R L. :I: l' 'T" ~l F R I'-.i KZ: H ,_., F~.' FI m'3 E.;
DEPFIRT~'IENT OF HERLTH RND ENV]'RONI"IENI"RL PROTECTTOf.,I
25:1.¢~ E. TUDOI~'. RE:,.., RNCHOF..'FIGE., Ri.,:;. '.=m.'r'm. 507
276-2221
L--IIELL F"EE."r-1 I T
,:: i'"627.~; ;:,
AF'F'L Z CANT
L ~:l C A T ~' 01'4
LEGAL
.~rOHN ..TRNE$
CH I CKRLOON
L4 FINGELR HGT$
F' 0 BL,,', ,' :,-'.. E. R:.
LOT SIZE
tt00E~ =,I...!LIHRE [--EEl'
I'11N I f'll..IN [:, I STRNCE BETWEEN R NELL RND RN~" I-gl'.4-=,'- I TE _":,ENFt' ¢'=E [>'I _,F '-'- "O=,HL" '- '=,'-'t"-=,TEM I ..,'"-'
· 100 FEET F'CR R PRIVRTE 1.4ELL OR 200 FEET FOR FI F'UBLIC NELL.
NELL Lr'3oE; FIRE E'.EI~:~UIRE[:, FII'.,ID r, IUST BE RETURNEE:, TO THE [:,EPFIRT1.,1ENT N ITHIN 3:0
F'fl=' THE NELL cor,'IPLETION.
=,FEE. I F I CR'T'IUN=,' '- RND I"-_.Ot'.,i=,TF4. UCT'- " ' I oN- [:, I AGRFIr,I$ RRE RVR I LRBLE TO I N=,URE~ PI~.m:~F""'ER'
I I'.,tSTRLLRT 1 ON.
:z=, ~. El E
:r CEF;:T I F"r' THR'¥
::L I I=t1''1 FFII"IlLI;FIR NI;TH THE REL,!UIREI'IENT=, FOE'. ON-SITE =,EI.4EF..=, FIND I.,.IELLS FIE; SET
FUF.'. 1H E:"r' I'HE I'IUN I C: I PRL I T~r' OF FINCHORRGE.
1.41 TH THE L. ODE=,.
[]
d
[]
Z (/) =J --
ndicate North
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERvICESE
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 FAMILYDWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions) /~ ,:~5 ~/z-//~'/~'/~r/_.~ /y/ ~
Prope~y owner ~~ ~, ~ ~~~/ Day phone ~ ~ - ~ 7~ ~
Mailing address /~~ ~/~~~ ~ ~~ ~/~ ~ ~77
Lending agency~~/~ ~~ ~~d~Day phone~~--~~
Uailingaddress~7/ ~ ~~~~ ~~~~,,~
A~nt ~ ~~ ~~X ~~~ ~F~y phone~~ -~~
Address /~ ~~ ~T~/~ ~., ~~ ~1~ ~ ~ '--
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
=,~."~ :C,,'~ ,,,' '" L' ).
Community well ~__..;.'- :~ ;~:> -'
Public water m'~<:~ ',~, ~'.~ ,
If communi~ well system, provide written confirmation from Sta ~t-
ing to the legality and status of system.
NOTE:
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
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 westewater 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 westewater 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..~,~--/'~,/-/'7~-/'dr/---,~d',(~-~ ~'/,/~'/,~'~"g',~'//V~' ,57Z~Phone ~:~2~-~ Z_~ ~
Engineer'ssignature~g'/~' ,,///~~~ Date ~//~.,/~'~
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with
S P
CE.-8 -
the followiflg stipulations:
· '_:.;/Additiona, I 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 ~ above by an independent
professional engineer registered in the State of Alaska. The DHH8 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. -
72-025 (Rev. 1/91) Bacl¢ MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~-~::~ T,~//~/'~/(~'/--~
A. Well Data
Parcel I.D.
Well type fl:;~/~,,'~
Log present (Y/N) ~x
Total depth / z:~ 2 ,~' ~
Sanitary seal (Y/N) Y (~)
Date of test
Static water level
Well flow
Pump level1 (~)
If A, B, or C, attach ADEC letter. ADEC water system number
~ Date completed ~,//..~'/7~ ~ Oriller,~ ~ ~-- ~/~::'/d.~//V'~
(~ Cased to /,.~d~) ~"~, ~ Casing height .,~, ~ 7 A" 7- O
Wires properly protected (Y/N) ~/ O
FROM WELL LOG AT INSPECTION
® /0/,
20 ~ g.p.m. ~ ~ g.p.m. ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main / ] ,~-,
Sewer service line ..~ ~,/~7" (~)
;On adjacent lots
;On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
/, / 4,~0/~..~/~
Collected by:
o, oob-/o, o
SEPTIC/HOLDING TANK DATA
Date installed
Tank size
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Foundation cleanout (Y/N)
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
On adjacent lots
Foundation
To property line
Sudace water/drainage
72-026 (3/93)* Front
Absorption field
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION L'//<v//Z~ )
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA (/~/~t)
Date installed
Length Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Surface water
Soil rating (GPD/Ft2)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
System type
Total depth
Depression over field (Y/N)
for
After test
If yes, give date
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
Bedrooms
I cerb'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect ~~I~l'j. is inspect/on.
· ' ~..~.
Date 2'1 1
HAA Fee $ ,,_~/.,~. ,4...) Waiver Fee $
Date of Payment c~//~ J:/r~~-''~
Date of Payment
Receipt Number ~tO ~.~ / Receipt Number
72-026 (3/93)* Back
Wright-Alaska Enginee,4ng Services · 6004 Glenkerry Dr. · Anchorage, AK 99504
February 15, 1995
W.O. 95OO6
Municipality of Anchorage
Department of Health & Human Services
On-Site Services Division
P.O. Box 196650
Anchorage, AK 99519-6650
Re:
Lot 4, Angela Heights Subd.
Health Authority Approval
Dear Sirs,
With the submittal of the following package and payment of the $300.00 Municipal review
fee, the owners of the above noted lot, Mr. & Mrs. Al Ebertowski request the issuance of
a Health Authority Approval Certificate for the above noted lot.
In addition to the Certificate and Checklist, copies of the Anchorage Water & Wastewater
Utility Sewer Location card have been attached to show that the lot is connected to the
Municipal sewer in the area.
We have also attached the Water Quality test results for the FHA required Lead content,
although we realize that this is not required by the Municipality.
Should you have any questions or require additional information, please feel free to
contact me at the numbers listed.
Sincerely,
hAlaska E n g/~,~-e r ~,2~//S_e.r v.' ~__~
t, P.E.
REC V£D
FEB 1 5 1995
Mun~c,pai:w ol /~ohorag~
Oept, Health & Human 8ervicee
Telephone (907) 338-6230 · Fax (907) 337-5182
02/15/95 10:56 COMHERC I AL TEST INS
CT&E Environmental Services Inc.
Labomtor~ Division ~_/;-L _ "-~i
I~4 ANC-ELA fits S/D a sis Repo
WATER
Pro~sc~ ~ecelved Dat~ 02/08/g~ % 15;0~ h~,
.......... .~ ............. .~. ......... .~ .......... ~ .......................... . ........... ..~ .......... ~ .......... .~___
Nitrat~-N i.14 mg/~ E~A ~3,2 lO. 02/lo/95 C~R
* 8~e Special In~truction~ Above UA - Unavailabl~
~] = Secondary diluti~. ~T - ~r~ater ~an
2~ W. Po~r Drive, Anchorage, AK 99818-1605 --, T,J: {B07) 562-2348 Fax: (907) 56~-5301
ENVIRONMENTAL FACILITIES IN A~SK~ ~AUFOHNIA, FLORIDA, iLLINOIS, MARV~D, MICHI~N, MISSOURI, NEW JER~, OHIO, WEST VIRGI~A
0~/1~/g5 10:~ COMMERCIAL TESTING ~ ]~7518R N0.716 QO~
Client Sample ID
CT&E Environmental Services Inc.
L~boratow Div~sion .............. _
~.0~5~-~ ~..~l~gp~~nalysis Repo
WATER
12:00 hrs,
~$:00 hr~_
Sallll;l~ R~marke: :~U%MD~ COLLECTED By: BOB W~IG~HT. *b4 A~GELA HTE S~D, :10045 CHICF4%LOON
ST.
QC Allowable Ext. Anal
Parameter ~sqlc~ Qual ~ltm Menhod L~ Date Date
* ~=~ S~eolal Inabruct~o~ Al)OVO UA = U~available
** See 8ample Remark~ AbO~e NA= No~ Analyzed
2~ W, P~r Or~ve. Anohor=~, AK 995~ 84 605 --Tek (907)562-23~ Fax: (907) 561-5301
;N~RONMENTAL FACIL~iES IN A~5~ CAUFORN~. FLORIDA. t~INOIS, MARY. S. ~ICHIG~, MISSOURI. NEW ~ERSE~ OHIO. WgST ~RGIN~
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)
/,,,:'T ,,;;. LLO~c~;3; Angela Heights Subdivision
Location (address or directions)
10045 Chick~oon
(b) Proper!L
Mailing Address
;wner A, H, F, _0, #69462 Telephone · (home)
520East 34th Avenue Anchorage, AK
(c) Lending Institution
Mailing Address
Telephone
99503
Business 561
(d) Real Estate Company and Agent
JACK WHITE COMPANY ATTN: Lynda Banner
Address 1na~ EGg!G P/"~' Pr, n,-/ ~,-,,~P,~ P/,,n~, Ak' a0~77
Telephone 494-5500
(e) Mail the HAA to the following address: (or check here [2~f hold for pick up.)
List contact person and day phone number below:
S & $ ENGINEERING
17034 Eacjle River L0~p Road
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family~ Number of bedrooms 3
3. WATER SUPPLY
Individual Well ~ CommL~nity [] 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,~ 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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.g
A. WELL DATA
Well Classification
Well Log Present ~'N) ~
Total Depth !z~.7_ Cased to . _
MU,NilCIPALITY OF ANCHORAGE (MOA)
NiC[PALII ,.l'fffattl~.A~u*ho~ity Approval (HAA)
ONk~L_l~' ~,.,,i.~, ~EiC~I~U~REBRUARY 1984
Date Completed
Static Water Level
Casing Height Above Ground I'-Z.- --~
Electrical Wiring in Conduit~)'N) ~
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot i~ ~ ~c..
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line I ~ t+
343-4744
Legal Description:
If A, B, C, D,E.C, Approved (Y/N)
Depth of Grouting --
Pump Set At
Sanitary Seal on Casing (~;~N) ~
Depression Around Wellhead (Y~ r-~
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
To Nearest Public Sewer Cleanout/Manhole
~-~'~ ~ ~ ~l--~l~l~-~ ; Date (~ -~..7_.. - .t~
; On Adjoining Lots
~--~=~-. ;On Adjoining Lots
Comments
B. SEPTIC/HOLDING TANK DATA ~-~/,~_/
Size / / ~No. of Compartments
Date Installed
Standpip~ Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank'~..~ ____ __ Date Last Pumped ....
Pumping/Maintenance Contac't'~(Y/N) .... ;for _____
Holding Tank High-Water Alarm (Y/N) '"~.~. Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOL~:
TO Property Line ____ To Disposal Field""--..~
To Water Main/Service Line ~
To Stream, Pond, Lake or Major Drainage Course ~
Comments ~'~ 0 I'~ ~ d-- ' ~'~1-~ ~. ~
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
Date I~talled
Width o~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION ~
To Water-Supply Well _____ To Pr~
To Building Foundation _ __~_ _ ..~.. ~__ To__Abandoned System on
Lot ; On Adjoining Lots
To Water Main/Service Line To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parkir~g Area, or Vehicle Storage Area
Comments ~ L) i.~ ~0.~ ~ t~.~-L_, ~__~L,~------'z~ '
D. LIFT STATION
Date~__~.alled
Size in G~.~
"Pump On" Level ~_
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 guidelines in effect on the date of~his
inspection.
Signed
Company
Date ,~/~/~" ~"
MOA No. C ~c"~ cP'~--~
Receipt No. ~'
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
$ & S ENGINEERING
17034 ~.agie ~i.v~,,- Lc, o~ ,~v.,., N~. zu4
F~;I. River, Alaska 995~
9-/- ??
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL ALASKA,
Cl~ont ~ple ID~L4
P~$ID :UA
Collaota~ AUG 22 89
O~de~ed By :
Analylle Completed :AUG 25 89 Send ~eports tot
Labora~ozy 3upezvlmo~ :STEPHEN C, EDE 1)3 G 3 ENG~
Special
~n.t~uct:
Chemlab Eof S: 7159 Lab Smpl ID: 1 Mat~lx: WATER
Allowable
?azamete~ Teated Eeeult/Un~te Method
NIT~ATE-N 0.72 m~/1 EPA ~53.2 !0
Sample SAN~LE COLLECTED BY ~S.
Te~te Performed ' 3ee Special lmtruotiona Above UA-Unavailable
None Detected "See Sample ~e~k~ ~bove
Not Analyzed ET-Lees Than, GT-$reatez Than
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
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~*&~ ~'¢~'/~%Telephone: Home
Applicant Address ~ ~,~.. ?2~ ~_~ ~
Applicant is (check one): Lending Institution ~ ' Owner/builder ~ ' Buyer
(d) Lending Institution /~' /~''~ '~Y' ,'~'~' ~
Address Z~ ~ ~ 7 ~,.~/~
(e) Real Estate Company and Agent ~/~
Address ~' ~-~: 7 ~ ~-Z ~ V
Telephone _~'~ T~-~<:3
(f) Mail the HAA to the following address:
_ Telephone
TYPE OF RESIDENCE
Single-Family~ Multi-Family~ []
Number of Bedrooms _ -.~
Other
WATER SUPPLY
Individual 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[] 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 '/2-025 :~84)
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
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequ~d ~'
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtaim
from the Municipality of Anchorage files and from my investigation and inspection, tile on-site water supply and/~'~
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect
the date of this inspection.
Name of Firm E/~LE RIVER EN6INEERING SERVICES Telephone
EAGLE RIVER, AK 9957?
Address ~. 0." .....
Engineer's Seal
DHEP APPROVAL
Approved for ~-~
Approved /~'
Disapproved Conditibn
Date
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Autho/
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professio,'
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lend;"
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspection?; '
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in ~
professional engineer's work.
~.,"INICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
I;NVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) ~p~ ~ ~5
CHECKLIST- FEBRUARY 1984
,,R E,,,C E LV E D
Legal Description: ~0 ~"~',~/"~ '~'/~'"5'Z' ~-,r
WELL DATA
Well Classification
Total Depth /x.,z .,~.t s d to-~ t~-'~' Grouting
Static Water Level /0 ~ ·
Casing Height Above Ground '-~ ~ /''
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
If A, B'. C. D.E.C. Approved'(Y/N)
~ ¢' ~.,,?, ,,,~
Pump Set At /'.~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
On Adjoining Lots
To Nearest Public Sewer Line ,/~P~P ''/' To Nearest Public Sewer
Cleanout/Manhole ,/~ ¢' To Nearest Sewer Service Line on Lot
Water Sample Collected by '~"'~S'""'~"~ ,~' . ;Date ~
Water Sample Test Results .~',~ ~/.~'
Comments g~/¢// z~,.,,,.~, /~.r,~¢,¢e ,~. ~-~.$.'~-~-*--~- .
SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
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
To Water Main/Service Line
Course
Size No. of Compartments
Foundation Cleanout (Y/N} 1
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1of 2~
72-026(11/84)
ABSORPTION FIELD DATA ~
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Square Feet of Absorption 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
Standpipes Present (Y/N)
Date of Last Adequacy Test
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
Co m ments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I ~ chec.,~, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Company ~/~ ~,,t~ ,~"A,,~-. '~,MOA No.
Receipt No. .3~ {~
Date of Payment ~ - ~- ~, ~'
Amount: $ ~,~ ~ Engineer's Seal
Page 2 of 2
72-026 (11/84)
GREATER ANChORaGE AREA BOROUGH
Department of~z~ironmental Quality
3330 "C" Street, Anchorage, Alaska 99503
Eagle River Area
274-4561
~ Date Received December 8, 1976
' Time of Inspection 1: .. .m.
Date of Inspection 12~76 Thursday
REQUEST FOR APPROVAL OF KEFnnqy
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Cony.
1. Approval requested by:
Mailing Address:
Phone:
2. Property Owner: John E. & Virginia K. James
Phone: 688-2430
Mailing Address: Post Office Box 733 Eagle River 99577
3. Legal Description: Lot 4 Angela Heights
4. Location:
Chickaloon Street off of Eagle River Road
5. Type of facility to be inspected
6, Well Data:
: A. Type Individual
C. Construction
Single Family
No. of bedrooms
7. Sewage Disposal System:
A. Installed
C. Septic Tank: 1. Size
D. Seepage Pit:
E. Disposal Field:
8. Distances:
A. Well to: Septic tank
.Nearest lot line
' .~B. Foundation to septic tank
B. Depth
D. Bacterial Analysis
Public Utility
B. Installer
2. Manufacturer
1. Absorption Area
Total length of lines
, Absorption area
, Other contamination
C. Absorption area to nearest lot line
3
142'
2. Material
, Absorption area
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection:
2. Property Owner:
Mailing Address:
3. Name of Buyer:
Mailing Address:
4. Name of Lending Institution:
Day Phone:
Mailing Address:
5. Name of Realtor or Agent:
Phone:.
Mailing Address:
Legal Description: L(}
Location: ~.~i0
, Phone:.
Type of Facility to be Inspected:
Water Supply
Type of Supply:
Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System:
Public Utility
If Individual, date of installation
No. Bdrms. ~'
Individual
Individual (on-site)
72-003(3/76)
~[egal Description Lot 4 'Anqela Heiqhts ,
I IJ, l,,~ I I I
Comments
Approved ~'~- Disapproved Date
/
Approval ~Valid 'for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
Tcer~ifv that *'-- -'-~- _'. ~o~.tained in tli'l~ Y~'q6es:t for approval to be a irue and
'~ ~,,~ ,nrormatlon ~Sub'ject sewer a~d Water f~acilities and these facilities
accurate representation of the
are operating satisfactorily.
SIGNED j ~ Da te
EQ-034 (l/74) ~