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HomeMy WebLinkAboutFYFE BLK F LT 21Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: 5 We? 70 5 5_q PID Number: Lnl? - �2-7'23> ` 3 2— Name.- Name: > Wastewater System: ❑ New ❑ Upgrade Address:L/ 3 `{ 0 �,C��c 3 f �-� ABSORPTION FIELD Phone: No. of Be r ms: ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: GPD/Sq. Ft. Lot: Block: Depth to pipe bottom from original grade: Gravel depth beneath pipe T J l C� FY Ft. Ft. Township: Range: Section: Fill added above original grade: Gravel length: Ft. Ft. WELL: [.New ❑ Upgrade Gravel width: Number of lines: Distance between lines: Ft. Ft. Classificatiorrivate, A,B,C): (P Total Depth: Cased To: Total absorption area: Pipe material: 1L L? 3 Ft. 'Z 3 Ft. SQ. Ft. Driller: Date Drilled: Static Water Level: Installer: Date installed: 9,11W . ,� [ j W' fC 7 ; r Ft. Yield: t Pump Set at: I '3a �wi Casing Height Above Ground: 1 TANK GPM Ft. Ft. SEPARATION DISTANCES ❑ Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines Well- ?7J/30 Material: Number of Compartments: Surface Water LIFT STATION Lot Size in gallons:Manufacturer: Line Foundation "Pump on" level at: "Pump off" level at: High water alarm at: Curtain Pump Make & Model Electrical Inspections performed by: Drain Remarks: L06 -L hQ-,TALLfi2 A5WLJ Hr's BENCH MARK Location and Description: Assumed Elevation: Ft ENGINEER'S SEAL Inspections performed by: Dates:1st 2nd Department of Health and Huma Services approval Reviewed and approved by: Date: rZ';?z 17 72-013 (Rev. 9/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW970354 DATE ISSUED:10/07/97 DESIGN ENGINEER: EXPIRATION DATE:10/07/98 OWNER NAME:MATTHEWS, MATT OWNER ADDRESS:3340 ARTIC BLVD. SUITE *106 ANCHORAGE, ALASKA 99503 PARCEL ID:00927352 LEGAL DESCRIPTION: FYFE BLK F LT 21 LOT SIZE: 7500 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: %� DATE: ISSUED BY: ✓ �""'-� DATE: STATE OF ALASKA DEMRTMENT OF NATURAL RESOURCES DIVISION of MINING & WATER MGMT %",'ATER WELL MORD WOM- OWNP: sECTioN TOWNGHIP FIA',%JOB I ME ESIDIAN' 13N C-1 E [Is Mw WELL 0�'PTK�! D r -P P i-'� zv" iti�, a n g t 0 p c Li n r! a u r f DATE OF COMPL51110,11 Depth of ho1-,.-: Depth From To ,,.±v--� . jy-t = `°--..�.�. „ _... _.._�_�_.._ ,�..�.�._�.�._._ -�� :„-.,s�.�_.�.�_ ��.�_ ' DEPTH TO ST Alf 10 VIATER LEVEL, of casing 13 ground surface ep J Date; A/ e -!' ly ! METHOOD OF DRILLINIQ: air rotary cable tool T-1 USE OF dornestic irrigation monitor public supply other, F `} . r .. s_. .d - _� . i' C 'ING S' f A' S iCK-up; t. Man-,- ?6—In. W�,, ;Mg typF,ft 14VE 'LL INt TAKE OPENING TYPE: Wr 41 ❑parf ------- Grated ©aped hole jol/ Depths of openings: to ft Diarn: In. TYPL e� Slot/Mesh Size: Length,. ft Ii GRAVEL PACK TYPE: VolumeDousan,pth -",Q tcp: 0 11%0VT TYP9:,, I I I i 4,� JDepth., from io ft ; RECEIVEDM;VCLOMENT METHon, Duration; DEC 3 1997 . _ �._ .r._ __ i PUMPING 1. -±VEL AND YIELDi ft after hrs pumping -9prn lurlicipality of AnGnorage- ------ Dept. Health & Human Services r PUN -11p IN! AKS; D-EPT.H', it :40r$epoWp ti*lvl E: L L D I S I N F E C. T. E D '0N C 0 M, P L E 11- 10 IM -t 'Gk& E N Oj REMARKS; LOC )1C7 -,,,,PLEASE MAIL W� ITE 'OPY rX TO: DNR/DIVISION OF MINING & WTAiR MGM)' 3601,0- St, $111te 800' - ANCHORAeGE AK 99503-5935 - Phone Phone (907)762-2538, Fox J907)562.1384 L 0 1 T Or STATE OF ALASKA DEMRTMENT OF NATURAL RESOURCES DIVISION of MINING & WATER MGMT %",'ATER WELL MORD WOM- OWNP: sECTioN TOWNGHIP FIA',%JOB I ME ESIDIAN' 13N C-1 E [Is Mw WELL 0�'PTK�! D r -P P i-'� zv" iti�, a n g t 0 p c Li n r! a u r f DATE OF COMPL51110,11 Depth of ho1-,.-: Depth From To ,,.±v--� . jy-t = `°--..�.�. „ _... _.._�_�_.._ ,�..�.�._�.�._._ -�� :„-.,s�.�_.�.�_ ��.�_ ' DEPTH TO ST Alf 10 VIATER LEVEL, of casing 13 ground surface ep J Date; A/ e -!' ly ! METHOOD OF DRILLINIQ: air rotary cable tool T-1 USE OF dornestic irrigation monitor public supply other, F `} . r .. s_. .d - _� . i' C 'ING S' f A' S iCK-up; t. Man-,- ?6—In. W�,, ;Mg typF,ft 14VE 'LL INt TAKE OPENING TYPE: Wr 41 ❑parf ------- Grated ©aped hole jol/ Depths of openings: to ft Diarn: In. TYPL e� Slot/Mesh Size: Length,. ft Ii GRAVEL PACK TYPE: VolumeDousan,pth -",Q tcp: 0 11%0VT TYP9:,, I I I i 4,� JDepth., from io ft ; RECEIVEDM;VCLOMENT METHon, Duration; DEC 3 1997 . _ �._ .r._ __ i PUMPING 1. -±VEL AND YIELDi ft after hrs pumping -9prn lurlicipality of AnGnorage- ------ Dept. Health & Human Services r PUN -11p IN! AKS; D-EPT.H', it :40r$epoWp ti*lvl E: L L D I S I N F E C. T. E D '0N C 0 M, P L E 11- 10 IM -t 'Gk& E N Oj REMARKS; LOC )1C7 -,,,,PLEASE MAIL W� ITE 'OPY rX TO: DNR/DIVISION OF MINING & WTAiR MGM)' 3601,0- St, $111te 800' - ANCHORAeGE AK 99503-5935 - Phone Phone (907)762-2538, Fox J907)562.1384 Certificate of On -Site Systems Approval Parcel I.D. 009-273-52 Legal description Fyfe Block F Lot 21 Site address 1713 E 59th Ave Current property owner(s) Reutov Expiration Date: $ z-1 Z X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: !0 / V ?0Z 3 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory ?i Other COSA Approval_June 2022 HUHMPA UTY OF " HCHOF-,�IAOF= Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section t Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 009-273-52 Complete legal description FYFE BLOCK F, LOT 21 Location (site address) 1713 E 59TH AVENUE, ANCHORAGE, AK 99507 Current property owner(s) IAKOV & TRIFENA REUTOV 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ® Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ Date of Payment COSA # Waiver Fee $ Date of Payment Waiver # COSA Application—July 2022.doc Arsenic Advisory Certificate of On -Site Systems Approval # OSC231003 Subdivision: Fyfe, Block: F, Lot: 21 A water sample revealed an arsenic concentration of 16.7 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. Ma�lmg Address F OBox 196650*Anchorage, Alaska 99519 6650 *www muni org COSA Checklist 2022 WELL ONLY.docx COSA Checklist Legal Description: FYFE BLOCK F LOT 21 Parcel ID: 009-273-52 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 11/20/1997 Total depth 93 ft Cased to 93 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 12/30/2022 Static water level at beginning of test 14 ft. Well production at time of test 4+ gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 1.62 mg/L Nitrate less than MRL (ND) Arsenic *16.7 ug/L Arsenic less than MRL (ND) Collected by - (PIWA SAMPLES) Date 1/3/2023 Comments: TOTAL DEPTH 45’+ PER INSPECTION. ASSUMED CASING IS 40’+ PER WATER SAMPLE RESULTS & AREA WELLS. MET SEPARATIONS AT TIME OF INSTALL. NEW SEAL BY SULLIVAN. AWWU DOCS ATTACHED. SEE 2ND PAGE. *RECOMMEND A POINT OF USE WATER TREATMENT SYSTEM FOR DRINKING WATER WITH HIGH ARSENIC. B. TANK DATA – PUBLIC SEWER Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA - PUBLIC SEWER Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist 2022 WELL ONLY.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No NA ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No NA ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS Per AWWU documents. Lang survey and site investigation it appears that from the center of CO, MH and sewer main that the center of well is approximately 41’ to on site sewer CO, 123’ to MH in street & 98’ to sewer main. G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 1/18/2023 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 1/18/23 0 .-X ` � r t y �r ■. .0 .0 1�i-­,b fAUNICIPAL17Y OF ANCHORAGE VM1MR a WASTMAIM-R UTILITY 316@ ARCTIC BLVD. PHONE: 4907)ff44762 SMKLOTITRACT BLK F LT 21 SU WWON FYFE TAX CEDE 827352 GRID $MET ADDRESS 1713 E 59TH AVE MIINER SHELTON JOHN A r 1933 WASTEWATER CONNECT PERMIT DATE OF APPLICATION r —w- 97 - 001111 iw"z7a-A SCHEDULED COMPLETION DATE 12!31/97 AS -BUILT SINGLE FAMILY a MULTI-wDWELLING No. APTR*— COMMERCIAL PHONE IN& ADDR688 2921 LEEWARD PL ANCHORAGE, AK 99516ok -aw �R ASSESSMENTS ° ftpelr ExMnlg Service IX Main Line Extension On Propse�r Only � City Tap � Have Been Levied Hydrant Only Gl 50' or Longer � To Be Levied kkin Tip - To Properly tine Only Comments: Iftin Top &-On Properly Connect Row No,, Dleoonnvat R & R - Main Tap Only ner. t C ONNECT SIZE 4 " ISSUED cfidces INSPECTION FEES 104.00 PAID CASH PERMIT FEE $ 35.004 CHECK $ 0.00 OTHER DEPOSIT E 0.00 INSP TED MMBURGLE�gTOTAL $ 139.00 �.,����s�,� DATE l�YWIKs POWIITEB (Pin" Print) *IAME AS OWNER{��t PHON� ,IIAI. ADIDRE94 . *IL � .3 � ��- �j� 570 SIGNATURE r s POST IN A CONSPICUOUS PLACE AT THE JOB SITE AWWU INSPECTOR orqirnl Lot 2 Lot 11 7L Lot 12— WOODEN FENCE N ,89'51'25"E 50;00' 5' UTILITY EASEMENT NOTE: DUE TO SNOW & ICE COVER, SOME SURFACE LEVEL FEATURES ARE APPROXIMATE. SEWER MANHOLE E. 59th AVENUE o w - x PLOT PLAN ___ AS BUILT _x_ SCALE _1"_= 30__ GRID --jt-123-3 project No. _—_?3=0031A1____ Lang & Associates, inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 (907) 522-6476 Phone Professional Land S u rve ors y ken0longsurvey.com jonothanOlangsurvey.com travisOlongsurvey.com �? "Nk` r OF A� 1 r Q'��! Als"1�1, G WOODEN FENCE Z Lot 21 O -'- 7,500 S. F. 11.5'x12.0' BALCONY O O 2.0'x13.3' CANT OD L Lot 20 L ..19. ' (n Lot 16A _ 24.3' o O N O O] O O w 01 U WELL iw N f+1 N N Z p w O CANT w/ PORCH BELOW - 4.0' m -< p —, - m o_ 20.3' 6.2' SEWER ASPHALT (P ..'CLEANOUT-. - DRIVEWAY 89'51'25"W 50.00 w 0 0 NOTE: DUE TO SNOW & ICE COVER, SOME SURFACE LEVEL FEATURES ARE APPROXIMATE. I hereby certify that I have surveyed the following described property: �.' 9 LOT 21, BLOCK F, FYFE SUBDIVISION (PLAT No. P-251) /*' 49- Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that ••l no Improvements on the property lying adjacent thereto encroach on the surveyed / • • & ; . . premises and that there are no roadways, transmission lines or other visible 9 •• KENNETH G. LANG ,• easements on sold property except as indicated hereon. �, Fc o ppp J� j Dated this the 2- _ Da of---�Lt' _ y ' :o' '' % , �19F ' .� ...... 'SJQ�i __,_ y--�'�____, ______, at Anchorage, Alaska p �p D .� ' l` ROfESSIONPI�P � It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 SEWER MANHOLE E. 59th AVENUE PLOT PLAN ___ AS BUILT _x_ SCALE _1"_= 30__ GRID --jt-123-3 project No. _—_?3=0031A1____ Lang & Associates, inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 (907) 522-6476 Phone Professional Land S u rve ors y ken0longsurvey.com jonothanOlangsurvey.com travisOlongsurvey.com �? "Nk` r OF A� 1 r Q'��! Als"1�1, I hereby certify that I have surveyed the following described property: �.' 9 LOT 21, BLOCK F, FYFE SUBDIVISION (PLAT No. P-251) /*' 49- Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that ••l no Improvements on the property lying adjacent thereto encroach on the surveyed / • • & ; . . premises and that there are no roadways, transmission lines or other visible 9 •• KENNETH G. LANG ,• easements on sold property except as indicated hereon. �, Fc o ppp J� j Dated this the 2- _ Da of---�Lt' _ y ' :o' '' % , �19F ' .� ...... 'SJQ�i __,_ y--�'�____, ______, at Anchorage, Alaska p �p D .� ' l` ROfESSIONPI�P � It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # C�� -7 3 Z- HAA # �\ Q '�:1D Q -)L 1. GENERAL INFORMATION j Complete legal description (— J 1' e t U L o t �2- Location (site address or directions) L-- j`i�-Lt Av- Property owner y����4 �h z =� Day phone Mailing address Lending agency Mailing address. Agent _ Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. 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 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 this inspection. Name of Firm —_ <�- '> u r v l� Phone Address Engineer's signature L f Date 1 �li_w '' .? 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 12-2-3 .%7 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 courtesyto purchasers of homes and their lending institutions in orderto 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 MOA #21 '1NMENTALSFRVICES DI\YISI, Municipality of Anchorage ALS 17 i9Am DEPARTMENT OF HEALTH & HUMAN SERVICES !Laqu)6Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4 4 � Health Authority Approval Checklist Legal Description: Y-1 f e � 1 i:>: L4 al, T3 .V__ E- Parcel I.D.: 0 C19 I — 62 73 .5 Z— A. WELL DATA Well type Z If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed /1- z )— T / -7 r Total depth 4-3 Cased to Casing height (above ground) Sanitary seal (Y/N) ``/ Wires properly protected (Y/N) , FROM WELL LOG Date of test f, - 7-0. q Static water level 3 a Well production WATER SAMPLE RESULTS: AT INSPECTION Coliform Nitrate N Other bacteria % Date of sample: 1 �I /i 1 q ? Collected by: �• B. SEPTIC/HOLDING TANK DATA Date installed Tank size Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Date of adequacy test Pumper '--114'� Soil rating (g.p.d./ft2 or ftz/bdrm) System type Gravel thickness below pipe Total depth Monitoring Tube present (Y/N) Depression over field (Y/N) Results (Pass/Fail) Fluid depth in absorption field before test (in.); Immediately after For bedrooms gal. water added (in.): Fluid depth (ins) Minutes later: Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION N Date installed Manhole/Access (Y/N) High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at" *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* Septic/holding tank on lot On adjacent lots Absorption field on lot On adjacent lots i tl Public sewer main ? 7G Public sewer manhole/cleanout Sewer /septic service line y i5 Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: 1q A Foundation Property line Absorption field Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO Property line _ Surface water Curtain drain F. ENGINEER'S CERTIFICATION Building foundation Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots / certify that 1 have determined thru field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. 1 > Signature 1717 Engineer's Name Date iL_. e_ 17 HAA Fee $ U 6—'D Date of Payment / 2/ Receipt Number 72-026 (R iev. 3/96)* r2 ((- S 13 Waiver Fee $ Date of Payment Receipt Number