HomeMy WebLinkAboutTANAINA VALLEY LT 14
MUNICIPALITY OF ANCHORAGE
Environmental Health DJvislo~
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
N.m. DISTANCES
,-~~~~[~ALI 5u~PL~ ~TO SEPTIC ABSORPTION --
Phone(s) Permi~ NO. NO. of Bedrooms WELL ~0~ ' ~/~tO ' -
-- ~ ~/ 7-/~ ~/ ~ ~/ /~/ dr,veway, water bodies, etc.)
TANKS U
Manulacturer Capacity in gallons
TYPE OF SYSTEM ~ ---
~ TRENCH U BED ~ W. DRAIN
original grade ~ FT
Fill ~dde5 above original grade Gravel depth benemh pipe
Total absorption area DiStance between lines I
~00 S~FT ~ FT~ // 7~ --
Number of lines boil rating Pipe matedal C ~ -
-
WELLS
~ PRIVATE ~ OTHER (ld~nlilv) _
REMARKS:
Inspections PeHormed by:
72-013 (3/85)
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN.SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION 'rEST
PERFORMED FOR:
DATE PERFORN
LEGAL DESCRIPTION:
1
2
6-
7-
8-
9-
10
11
12
13
14
15
17-
18-
19-
20-
%A ~l ID,
Township, Range, Section:
Y
SI'TE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED7 , ,4/r~~
S
IF YES, AT WHA'r
DEPTH? p
E
Reading
PERCOL~TION RATE __ [m~nute~mcll) PE~C HOLE DIAMETER
TEST RUN 8E'ia~EEN __ FT AND _ FT
/
t _j
I
3
I
'1
?
~4~ 550
T
21G. 44'
6
18
42,
I
,.51,O'"G
13
12
35,~20 ~L
MUNICIPALITY OF ANCHORAGE
DEPARTMENT O1: 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
HAA #
1. GENERALINFORMATION
Complete legal description Lot 14; Tanaina Valley
Locat!o,n.,.(¢!te address or directions)
7061 Lowell Circle
Anchorage, AK
/,' Property-owner
', -. Mailing address
Richard Illgen
,.706;1 Lowell Circle
Day phone
Anchorage, AK 99502
'~'"Lending agency · -,
:',Mailing address__ ' '
,¥
Agent Greg Erk}ns/ Greg Erkins Real Estate
Address 7061 Lowell Circle Anchorage,
Day phone
Day phone
AK 99502
244-5382
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well xxx
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
~ 4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site xxx
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.
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 Munic!pality 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.
S & S ENGINEERING
Name of Firm
17o34 Eagle I~iver Loop Road No, 204
Address Eagle River, Alaska 99577
Engineer's signature
Date
DHHS SIGNATURE
'-/ Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
/
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.
72~025 (Rev. 1/91) Back MOAiY21
MUNiCIPALI1'Y OF ANCHOI~GE
Municipality of Anchorage EHVIJ{ONMENTAL SERVICEj~ii,~N
DI--PARTMENT OF HEALTH & HUMAN SERVICES AUG 04
Environmenta Services Division
895 L Street, Room 502° Anchorage. Alaska ggs01 · (g07) $48J~'~4I~ J~
Health Authority Approval Checklist
LegalDescrietion: /.,oP" i~/ /-/~l~v4 V//~b~y ParcelI.D.: 011- O~-/ '-~
A. WELL DATA CO.~r. lu,~lry
Welltype ¢L4-~$ // IfA, B. orC. attach ADEC letter. ADEC water system number ~-,I/J'7~ ~
Log present (Y/N)
Total deeth
Sanitary sero (Y/N)
FROM WELL LOG /
Date of test ./
Static water level ./
Wel production / g.p,m.
WATER SAM PL,,,Fz-~ESU LTS:
Colifor/~/ Nitrate
[~oof sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/?°/~'¢¢ Tanksize ,~..5"c~
Date completed
Cased to C.~.asin~height (above ground)
~'"~ires properly protected
Collected by:
AT iNSPECTION
g.p,m.
Other bacteria
Number of Compartments ~ Cleanouts (~N) y~,~_..t'
Foundation.cleanout ~/N) Y~-~ Depression (Y/~J} ~' ~ High water alarm (Y/~_ /v
C. ABsoRpTION FIFLO DATAr
Date[nstalled cf / ~ / ~'~ Soil rating (g.p.d./ft2or~dr~' I 3 ,~ Systemtype
Len.gth (~ o Width ~' Gravel thickness below pipe ~ Total depth
Effective absorption area (~ O O Monitoring Tube present ~/N) V~-.~ Deoresslon ever fiela (Y~ ~v
Date of adequacy test ?/o%¢4 / ~r 7 Results (Pass/Fail} _ /'~/)- ~--¢ For
FhJid deeth in absorption field before tsst (in,); (~ Immediately after(; ¢¢ I gal. water added (in,):
Fluid depth ~ (ins) Minutes later: ~ ~/~/ Absorption rate = ~- 0 O '+ g,p.d.
bedrooms
· ~,/~ ,,
Peroxide treatment (past 12 months) (Y/N) lv,,¢r¢,~- ~c,vo w,,., If yes, give date
72-026 [Rev. 3/96)*
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N) "Pump on" level at*
High water alarm level at* ~
Cycles test~
E, SEPARATION DISTANCES
level at*
SEPARATION DISTANCES FROM WELLON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot
Public sewer main ..~-'~'~'~""~ Public sewer manhole/cleanout
So~ Lift station
SEPARATION DISTANCES FROM SEPTIO/HOLDING TANK ON LOT TO:
Foundation '5~ ~ Propertyline 5' +- Absorption field
Water main/service line /O ,-t- Surface wateddrainage /08 'f- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line I 0 d- Building foundation / o f--/~ Water main/service line
Surface water 1 00 r ..f_ Driveway, parking/vehicle storage area
Curtain drain ~' ~ ~' '~ ~ ~' '~ ~ "~ Wells on adjacent lots ~L~O
F.
ENGINEER'S CERTIFICATION
I certify that lhav. determined thru field inspections and review of Municipal records~.~b'O'ce~ are
in conformance with MOA H~AP.j. guide~nes in effect on this date.
~ngmeer s ~ame / ~ ~ ~ ~'~ ' ~ ~
HAA Fee $
Date of Payment ~//-TL-/? ~
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGF-
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 HEAL.TH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1. GFNERAL INFORMATION
Complete legal description
Lot 14 Tanaina Val~e~ Subdivision
Location (site address or directions) 7061 Low62.~ Circle
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Richard lll9~n
7061 Lowell Circle
Anchorage,
Day phone
AK 99502
276-1969 (w)
243-6962 (h)
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
o
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:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/gl) Front MOA If21
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 ti s. inspection.
Name of Firm
Address 1~~'"'"'--~
Engineer's signature
D/~S SIGNATURE //~-
Approved' for /~e~r~ C
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
/
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-O25 (Rev. $/91) Ba~k MOA~t21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL. CHECKLIST
Legal Description: Lo"[' IFC.- '['~,~,~I,OA (,/,A LLP.. y Parcel I.D.
A. Well Data
Well type 4~c3~,4./(2/¢/~' if A, B, o~_~tttach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller
Total depth
Sanitary seal (Y/N)
Cased to
FROM WFLL LOG
Date of test
Casing height
Wires properly protected (Y/N) ~
Static water level
Pump~lm~l
SEPARATION DISTANOES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot /~-~
g.p.m.
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS: ~--- O,~l/4C,,~/T-'f' C-}(~ZZ._
Coliform Nitrate
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts(~N)
High water alarm (Y~") ./L~.
Date of pumping
Tank size f"'~-Y~ ~/~(_ Compartments
Foundatien eleanout Y~) Y~-~ Depression (Y~..~
t.t.d
Pumper /~ 'r//'J(-'v~ ~ ~;f/-
SEPARATION DISTANCES FROM SEPTIC/144~NC~TANK TO:
Well(s) on lot /k)o,/J~"~ /'¢//-6-¢J'<C~]-On adjacent lots
To properly line [0 (¢'~ Absorption field
Surface water/drainage
72-026 (3/93)' Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
Manufacturer ~
Manh~
"Pump on" level at ~ "Pump off" Level at
High water alarm level ~ Cycles tested
Meets MOA electrical codes (Y/N~
SEPARATION DIS~M LIFT STATION TO:
On adjacent lots Surface water
Total absorption area
Date of adequacy test
D. ABSORPTION FIELD DATA
Date installed
Length C~-~' Width ~ f
CPO0~:~/ Cleanout present(~)
4;~//(¢ / ¢ ~ Results~a~/fai,)
Water level in absorption field before test / % ~h' ~
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/F¢) /,~ ¢,~,~"¢-~ System type ~-/E~-ccf-J(~/
Gravel thickness ~ / Total depth O¢
<'/~-S Depression over field (Y~
,/GjC¢ ~'_~ for '~C) 64¢~-- Cq) Bedrooms
After test / ~ /r
/UO/G~'¢ /¢~0¢~--//k~ If yes, givedate /~//¢~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ,,DO,~(~
TO building foundation
on adjacent lots
Surface water / ~_~O
Curtain drain
On adjacent lots ~.-cI.~ u,/...,/T e~' ~O) Properly line
To existing or abandoned system on lot M~
Cutbank ~ ~E~Water main/se~ice line
Driveway, parking/vehicle storage area ~ ¢
E. ENGINEER'S CERTIFICATION
I certi[y that lhave checked, verified, or conform~ t~cat/~OA and HAA guidelines in effect o~ the
Signature ...... ~
Engineer's Name ~7~3~4~ e~EIJ~oop Road No. 204
Eagle Rlver.~aska 99577 ~ /_ /lc..-~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
inspection.
72-026 (3/93)* Back
MUNICIPALITY OF ANCHORAGF
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
GI-'NERAL INFORMATION
Complete legal description
Lot 14; Tan~ina Va~ey SubdivisiOn;
Location (site address or directions) 7061 Low~ll Circle
Properly owner
Mailing address
M,bEton & Deanna Radford
Day phone
7061 Low~ Circle Anchorage, Ak. 99505
562-0022
Day phone
Lending agency.
Mailing address
Agent John Ricktenwald FORTUNE PROPERTIES~INC. Day phone_
Address 3000 A Stre.~t Sure ¢~I01 Anchorage.. A~. 99503
Unless otherwise requested, HAA wi~ be held for pickup.
NUMBER OF BEDROOMS: _~?~J//~'
TYPE OF WATER SUPPLY:
562-520#
Individual well
XX
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
NOTE:
×X
TYPE OF WASTEWATER DISPOSAL.:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State AOEC
attesting to the legality and status of system.
NOTE:
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /,--¢?/'4i '~tO ,q~)~ ~%,1~. _ Parcel I.D.
A, WELL DATA
Well type
Log present (Y/N)
Total depth_
Sanitary seal (Y/N) .
Date of test
Static water level
Well flow
If A, B, or C, attach ADEC letter.
'~ Date completed
'~, Cased to _
ADEC water system number
Driller
Casing height
Wires properly protected (Y/N)
AT INSPECTION
g.p.m, g.p,m.
Pump level
SEPARATION DISTANCES FROM WE'LL 7'0:
Septic/holding tank on lot
Absorption field on lot
Public sewer main tJ
; On adjacent lots
; On adjacent lots
_ Public sewer manhole/cleanout
Public sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
S£PTI~/HOLDIN~ TANK DATA
Date installed
Cleanouts (Y/N) ~
High water alarm (Y/N)
Nitrate __
Collected by:
Petroleum tank
Date of pumping
_ Other bacteria
_Tank size
Foundation cleanout (Y/N)
Compartments
Depression (Y/N)
Alarm tested (Y/N) /,J/~t
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK 'FO:
Well(s) on lot /kJ/~ On adjacent lots
To propertyline [O ./c Absorption field
Surface water/drainage / LO(~ / ~
'
/ ~--O ?L _Foundation /
~ ¢~- Watermain/serviceline --fO
72-026 (Rev. 3/91) Front MOA 21 CONTINtJ ED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
(Y/N) . ~P~p o~t~vel at
Vent
High water alarm level ~. J
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STAT"~N TO:
Well on lot On adjacent r~
D. ABSORPTION FIELD DATA
Date installed b'~ - ;~ O -
Length ~ 0 Width
Total absorption area /~(OO
Depression over field (Y/N)
Results (pass/fail) {jrt Cf ~
Peroxide treatment (past 12 months)
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
Gravel thickness ~ Total depth
Cleanouts present (Y/N) C}
Date of adequacy test ¢-- ff - ~ /
for ~ bedrooms
If yes, give date ~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
/ ,
Well on lot ~)
I '
TO building foundation ! O ~'"/-
On adjacent lots
Surface water
Curtain drain J/Ct
Property line
To existing or abandoned system on lot
Cutbank ~J/~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
this in~'~gtion.
Signature ~zv¢,, ,~,,u ....
Engineer's Nam~agle Ri~er, Alaska
/-// -,
HAA Fee $ ("T~
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Bsck MOA 21
DEPT. OF ENVlltONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE"
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
· July 10, 199'1
WALTER J. HICKEL, GOVERNOR
563-6775
FOR: S & S Engineering
PWSID ~214706
My review of the records on file in this office reveals that the Country Lane Estates
Subdivision Class A Public Water' System, is in compliance with the provisions of 18 AAC
80.060, State of Alaska Drinking Water Regulations.
Keven K. Kleweno
Lead E-'ngineer
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. if
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner _,I"JEI4A£1 ~u,.O,¢ L ~ Telephone: (home)
MailingAddress 7,¢~,/ Z).g/,.c7-1WO,~D P-//)~ ~,¢-%'"'/~
(c) Lending Institution /d'~-,¢ ~/) g/~ Telephone
CERTIFICATF OF INSPECTION FOR HEALTH AUTHORITY APPROVAL. OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Business
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here/(~ if held for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY ,.
Individual Well [] 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 ~ Pub(lc [] 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.
72-025 (Rev. 7/88) Page 1 of 2
5. 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 th is
Health Authority Approval 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. J 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.
~'.~ ,' .... ~. · .~,~ EngmeersSeal
6. DHHS APPROVAL ~ ~%,~'c~,
Ap~rove~ for~__ _~aOrooms ~ate
Approvod ~'.. Disapprovod Conditional
lerms of Cond~t~ona~ Approval ~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev. 7/88) 8ack Page 2 of 2
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~E~ AT'TACH~ A[3~.~
E~M MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA)
PAIJTY CE ~-~,~E~rlt~E'.~l-ST. FEBRUARY 1984
ENTAL SERVICES D~vls~o~43.4744
,J,.,l i 1989 Legal Description: Z'~7'
RECEIVED
Date Completed
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
A, B, C, D.E.C. Approved (Y/N) ~/
If
Yield
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
L ~' T'T-E:
B. SEPTIC/HOLDING TANK DATA
Date Installed ~-$4)~87 Size~2
Standpipes (Y/N) )/ Air-tight Caps (Y/N) _
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Foundation Cleanout (Y/N) ~/
Date Last Pumped A/E'C./ ¢.~5~¢r/c~//
,~x~- ~ ; for ¢~$~cr~
Temporary Holding Tank Permit (Y/N) ~ .
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line ~,~"
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
'¥o Disposal Field
72-028 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~-3~- ~¢ ,'"'
Width of Field ~" / ¢'~
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
To Water-Supply Well
To Building Foundation
Lot
Type of System Design //-'~..
Length of Field ~, ~' ./
Depth of Field _~¢ '
Gravel Bed Thickness ¢/
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
,_/,/¢- c-
To Water Main/Service Line 7¢' .~
To Stream, Pond, Lake, or Major Drainage Course ~¢~
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~5¢¢p%/o~ 5~5T~ ~ ~E¢~T~
; On Adjoining Lots /¢~''
To Cutback (if present)
To Property Line
To Existing or Abandoned System on
~ze 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 guidelines in effect on the date of this
inspection.
Signed ~.f.~
Company ,X'~P~J ~ ~¢-40~
Date / ~ Engineer's Seal
MOA No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev 7188) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
563-6775
DATE: Setp. 23, 1989
PWSID: 214706
According to the records on file in this office, the ~ountr¥
_ban~ Estates Water System is in compliance with
State of Alaska Drinking Water Regulations.
the
Sincerely,
Cindy Thomas
Environmental Engineer