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· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONIV1ENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPFCTION REPORT
ADDRESS
~GAL DESCRIPTION
~CATION NO. OF BEDROOMS
I- ~ Manufacturer
~ < ~/~ Material~T~E ~ N°' of compartments
~ ~ Liq, capacity in gallons Inside length ~ Width --~- Liquid depth
/~ IF HOMEMADE:
~ ~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material -- Liquid capacity in gallons
~ DISTANCE TO: Well /~ , Foundati~/ / Nearest lot line / PERMITNO.
:~ No. of ,ines~ Len,th of each line Total length of lines Trench width Distance between lines
~ Top of tile to finish grade _~/~ Material beneath tile Totaleffect,ve
absorption
Length Width Depth PERMIT NO.
~ Type of crib Crib diameter Crib depth Total effective absorption area
ia Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s}
OTH E R ~ -1-~
SOl L TEST RATING --I
INSTAELER
REMARKS ¢%i~ ~ ~L
A~R¢ , ;/ : DATE LEGAL
72-013 ( ,~v, 3/78)
~<~trka Ala~kan }~uilders
.%~le )liVer, Aia.~;k~. 99577
Lot i2 Leo's Sub6iivi~-~lon
If you h~ve dri:Ll.~:d the w<:ll~ a welt io%~ should
sent to this d~p,~.rt~',~)n'h 'to docun~,?nt: the in~,ta!lation
thiz Office at
PERMIT NO.
DEPFtR]"MENT OF HEFILTH RND ENVIRONMENTAL F'RO'T'EC:TICIN
825 "L."' STREET., RNCHORFIGE,, RK. 99501
( 780997 )
FIF'PL I CRNT
L..OCRT I ON
LEGAL
KtJRKR AI.RSKR BUILDERS I
L6 LEO"S S,."D
PO BO,'.'.', 2!4 ERGL..E RIVER
L.OT SIZE
694 3:49.':i:
10150 ~,QLJRRE FEET
T"r'PE OF SOIL RBSORBTION SYSTEM IS: TRENCH
f'IRXIMUM NUMBER OF BEDROOMS
SOIl... RRTING (SQ F:"T,--'E:R)= 320
THE REQUIRED SIZE OF 'THE SOIL. RBSORPTION SYSTEM IS:
THE LENGTH DIMENSION IS 'I'HE LENGTH <IN FEET.'.', OF THE TRENCH OR DRFIINFIEI...D.
Tt4E DEPTH OF FI TREI'4Ct4 OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF.' THE;
GROI. JND RND THE BOTTOM OF THE E~.~CRVFITION (:IN FEET).
THIERE IS NO SET HII)TH FOR TRENCHES.
THE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF 6RFIVEL BETHEEN THE OLrf'FRLL PIPE
RNI) THE BOTTOM OF 'THE EXC:FIVR'FION (.TN FEET).
PERMIT RPPLICRNT HRS 'THE RESPONS I BIL. I TM TO I NFORFI TH IS DEPRRTMENT BURI big TPIE
INSTRLLRT~ON INSPECTIONS OF RN'¢ WEL.LS RDJFtCENT 'fO TI-t~S PROF'ERT'¢ FIND THE
NUMBER OF RESIDENCES; THRT THE WELL HZLL SERVE.
BRCKFILLING OF RN'.r' S%.'STEM HITHOUT FINIAL. INSPECTION FIND RPPROVRL 8'~.' 'FHI%
DEPFIRTMENT WILL BE SUBJECT TO PROSEC. U'TION.
MINIMUM DISTRNCE BETI4EEN R 14ELL RND RI"4'T' ON-SITE SEWRGE DISPOSRL SYSTEM
100 FEET FOR R PRIVRTE 14EL. L.; OR
:1_50 TO 2g~O FEET FROM R PUBLIC P~EL[.. DEPENDING UPON THE T%.'F:'E OF PIJBI_IC' HELl..
OTHER REQUIREMENTS MFI't' RPPLY. SPECIFICRTIONS RND CON:~;TRUC':"FION DIR(3RFIMS RRE
FI',/R:f. LFIB/..E TO INSURE PROPER INSTRL. LRTION.
I CERTIF'¢ THFIT
t: I FIM FRMILIRR WITH THE REQUIREMENTS FOR ON..~SITE SEI4ERS BND 1.4EL. L.S RS SET
FORTH Db' THE MUNICIPRLIT~r' OF RNCHORRGE.
2: I WILL INSTRLL THE S~r'~]TEf~ IN RCCORDRNCE HITH THE
]:: I UNDERSTRND THR]' THE ON-SITE SEHER S'¢STEM fdR*¢ REQUIRE ENLRRGEMENT IF' THE
RESIDENCE IS REf~DELED T~ INCLtJDE MORE THRN ]~
..............................
RPPL. IC:~ I<IJRKFI RLRSKR E4UIL[:,ERS INC:
.,, ' ,- ./4
......... ..... ............
OEr
Russell Oyster
694-2774
Soils ~ Foundations
Performed for:
EGEOI "'CHNICAL Er DEVELOPMENT
Box 90. Davis St., EagLe River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
CO,
Earl Ellis
688-2280
Land Oeveloprrmnt
Tel, No.
Legal Descrtptton:~
~epth (feet)
o
2
Soil Chera~
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comnents:
No ~ If yes, what depth,~
Performed by:.
DATE-Started ,,}('l ~,:'~ / ~ ,~ _ Ended . / [~ GALS. PER HR
PERMIT NUMBER
KIND OF CASING ,,:: .? ,',, _ ~
KIND OF FORMATION:
' 'l/~ '. /~::.. ?l,(//i: r ',,/~,~ ,:!i/i/ From__F/. to_ Ft.
From (-fi Ft. to / Ft. () '"'
From / Ft. to ~;.f , Ft. ''~ / z? W ~, 4 ~'f (/~ ?, ?~,~[)((//~l~F(om Ft. to Et
From (/~..' '~ Ft. to/(),:~) Ft. ~ ~/)'hJ fi"~ :/
~Q /~'// v~:~ / From~Ft. to _~Ft
From/(:), '.2 . ' 7~[' "
From___Ft.
to
Ft.
From , ):() Ft. to ~- ( )/ Ft. /~ ,5/~:/) /:~fl/[./ From
From Ft. to~ Ft. From Ft. to Ft.
From Ft. to__Ft. From~Ft. to Ft
From Ft. to~ Ft. From~Ft. to~Ft.
From~Ft. to__Ft. From~Ft. to Ft
From Ft. to Ft. From Ft. to Ft
From Ft. to__Ft. From Ft. to~ Ft
From Ft. to Ft From Ft. to Ft
From Ft. to__Ft. From Fl. to _Ft
From~Ft. to__Ft. From Ft. to Ft.
From Ft. to__Ft. From~Ft. to Ft.
From Ft. to~Ft From Ft. to~_Ft
MISCL. INFORMATION:
DRILLER'S NAME '
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot 6; Leo Subdivision
Location (site address or directions) 24226 r.eo
Property owner AHFC ff85032
Mailing address WA ~94221
Day phone
Lending agency
Mailing address
Agent Lori C~-owder/JACK WHITB COMPANY
Address 10928 Eagle River Road~ Eagle River~ A1Ask~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: .3 '~
TYPE OF WATER SUPPLY:
Individual well ×
Community well
Public water
NOTE:
Day phone
Day phone 694-5500
99577
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
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, l 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.
Name of Firm,. '~ .,
· [ 7034...-:-~ ~ River i. bop i,~.aacl No. 204
Address ~:??, River, Alaska 9957~
Engineer's signature
Phone
Date-Sr-/Z Z' /~//'
DHHS SIGNATURE
-~C Approved for ~"~/~ ~) bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date ,C~'~'/~,/'~//'
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.
72~25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
Parcel I.D.
A. WELL DATA
Well type ~.,oJ
Log present (~N)
Totaldepth
Sanitary seal (~N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to '¢ro~ ~'
FROM WELL LOG
Date of test / o - 'Z-'/-- ~-I 't~
Static water level ~ ~"~'
Well flow ~'2¢'. O
Pump level '0~\~-~,',~ ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot lO,O '
Absorption field on lot /~c:~'
Public sewer main
Public sewer service line
Casing height
Wires properly protected gg~N)
AT INSPECTION
g.p.m. ,~.,, z.j, '~
ADEC water system number
/~'~-~,¢ ¢¢ Driller ~'~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Z
g.p.m?,~
WATER SAMPLE RESULTS:
Coliform ~ ~'~/~oo,, t... Nitrate
Date of sample: ~ ~ ~ ~"---- ~/ /
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed f%-I ~'Tfl
Cleanouts ~)N) ~
High water alarm (Y~j~
Date of pumping
Tank size Ic>o~
Foundation cleanout
¢- 16,,~tl
Other bacteria /-./o,-.J
$ & ~ ENGINEERING
170:!4 I~agie i~Jver ....
Eagle River, Alaska 99577
Compartments
Depression (Y~I~
Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line Io
Surface water/drainage
On adjacent lots
Absorption field
/Dc, I¢
\¢c'~ ~ Foundation
Water main/service line
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level ~Cycles tested
Meets MOA elect__
SEP~STANCE FROM LIFT STATION TO:
We"rl~on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N) ...------"--'
~level at
Surface water
D. ABSORPTION FIELD DATA
Date installed I~- - ~ ~ "7 ~
Length ~ ! ' Width ~c>'~
Total absorption area /;Z.I~ ~
Depression over field (Y/~ , /~
Results~ail) t2/k.~--~%
Peroxide treatment (past 12 months) (YIn)
Soil rating '~"J..i~ ~J~¢~ System type
Gravel thickness '~,~' ' . Total depth //¢
Cleanouts present ~/N) y
Date of adequacy test ~-- / ~-
for -'r"~ ¢..~ ¢~. ~'~) bedrooms
O/J/~-,',J~f/J If yes, give date ~/~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ ~'~:::~ '
To building foundation
On adjacent lots ~c~
On adjacent lots / O0 / ¢' Property line
To existing or abandoned system on lot
Cutbank ~1/,~ Water main/service line
Surface water I
Curtain drain
E. ENGINEER'S cERTIFICATION
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect o~4J ~)~,tbis inspection.
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
MUN CIPALITY OF ANCHORAGE MUNICIPAUTY
EPT,
U DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEg?{~,~N
~ 825 L Street- Anchorage, Alaska 99501 ..........
ENVIRONMENTAL ENGINEERING DIVISION
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing,
1. PROPERTY OWNER PHONE
MAILING ADDRESS
PROPERTY RESIDENT(If different from above) / PHONE
2, BUY~B ~HONE
~AILINg ADDRESS
~, [~NDINgINSTITUTION ~ ~t ~ PHONE
MAILING ADDRESS
/
4. REAL~OR/AGEN'F / PHONE
MAILING ADDRESS / '
S. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
,~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
NUMBER OF BEDROOMS
[] One [Z] Four
[] Two [] Five
J~ Three [~] Six
[] Other
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,)
8, SEWAGE DISPOSAL SYSTEM
",,
INDIVIDUAL/ON-SITE** 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.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR 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 SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
E~]Septic Tank or [] Holding Tank
Size: l ~)~)O If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
~ APPROVED FOR _~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
„�:': C� /✓�`�'-,w,""�" ;/+�'"��` cam=
SM,IARD & ASSOCIATES LAND SURVEYING 6 9 4 -
OF A
DATE�, .......
GRID:... !#�.
Duane Mark SewardSewardg�
Fs: ' �•.f..' LS) — 5
I