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Home My WebLink AboutSAND LAKE #2 BLK 4 LT 33and Lake lock 4 Lot 33 011-135 -20 ~_ / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME LEGAL DESCRIPTION LOCATION , I DISTANCE TO: I Well 1 ~ ~ ~ ~ Man u facturer~,~-~/~- ~ ~ ~T I Well ~ezl mSTANC O: ~ ~ Ma.ufaot..~ o I I weu ~ ~= I DISTANCE TO: I 1~] ~ I No. oflines , I Length of~,~e :~1 / I ~ ~ Top of tile to finish grade ~ / ~ I Length Widt~~-2 ~ ~ I Zw. of ~Hb Crib diameter ~ Well ¢ DISTANCE TO: ~ ]Class Depth ~ DISTANCE TO: Building foundation Absorption area~5 Inside length PHONE ZNEW Dwelling lq )/Z NO. OF BEDROOMS PERM'TN OTB - No, of compartmentsZ Liquid depth Dwelling PERMIT NO. Material Liquid capacity in gallons Foundatio~ 'F~OI.-iYB Total I e n g IJ~ f~i~ es Material beneath die Depth Nearest lot line.~.. J Trench wi~/-l~ _~"~",)~ T inches /.~'~ inches Crib depth Building foundation Distance between lines Total effectives, bsorption ar~ea ,B ' p PERMIT NO. Total effective absorption area Nearest lot line Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) OTHER PIPE MATE~?c .i C]- SOl L TEST RATING INSTALLER R EMAR KS APPROVED 72-013 (Rev, 3/781 DATE LEGAL E.RF,i ! E LFff.,iHE'i" L.]:2:B4 '};.:hN!], LFhk:E ;i~2 THE LEi'.,!GTH Dii"!ENSION IS 'I"HE LEh!(3TH ( li'..i F:'EET> OF THE 'TREF.!CH OR DRF¢iNFIEL. E:,. ]"HE DEPTH OF FI TRENCH OR P ZT i'3; THE [:,t%TRNE:E E~ETkiEEN THE SURFFICE OF' THE GROUND F~!'.4D THE E~C)TTOH OF ]'HE E?,CWv'FITZON ,:lin FEET>. THERE I5 NO :BET !.,.!IDTH F:'C)R TRENC::HE:%. THE (3RI~'v'EL DEPTH ZS THE MINZHUM DEF'TH OF GRf:WEL E~ETi4EEN THE (%rI"FF~LL. F'ZPE FIHD THE BOTTOPt OF THE E;:.:;E:ff,,,'RTiOF,I ,:: iN f:'EET>. ...... -' '" ,f.h!-~ .:,~.:, ~_ ! F.£F,!!::]L - .r- ' _. THiS i::~R-:i<F!L.L..Lr.,it.4 OF ~' "?~'":'"' i41THC!UT ii'-~:5F'Er3TION iqND .'>EPFJR"rr'tENT i4 i L.L. E E '::: [2 ]'[] "~ i TEl · .i..t.E'! E~ FEET lip O i'.,! ? ~-q::: , ........ ~"~'¢~.,I;[f'11,..li'"i r-,.[.: .... .4 .................................................. ",i~: ...... ' ............ . .... 1 .... t::I ~:']',I? h!TTV -" ........... LZ!",tE IS "~'~-; ,'-:'EFT. OTHER F]:E]~...iZF::E."!E?-4'ri-'~:, MF.? FiF'F'L"¢. :.::;F:'E(3IFICFiT];E!.i'.,!::3 !:i!'.4[:, :]i'.J'~:;'T[;-'.'"T_T,'3i',I [:,ZFi(};F~:FIi"'i:E; F:!I;i:E i: i RI"! FRMIL. iFIR i.,.!ITH THE RiZQLJ!i;i:EHEiqTS FOR ON-:'3iTE SE.t,iERS Ri",ID NEL.LS F~.S SET FOF.:TH E'A" THE i'iLihiiCIPRL!T'¢ OF F:iNCHORF:tGE. 2: i !,4ILL. Ih!STf:ILL. THE S"r'STEM iH .RCCO!:(:DF!NCE Ni"FH THE CODES. ]:: I UHDERSTFiND THRT THE ON-S!'I'E SE.WE.R '.E,h"STEH ?iF:i'?' REQUIRE ENLFiRGEI"!Ei",!T iF THE ~'F':;;, T DEN ] MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG ,- ,.~ [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 ~-4 5 7 10 11 12 13 14 15 16 17 18 19 20- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) t ~ · TEST RUN BETJNEEN .FT AND . FTi COMMENTS 72-008 (6/79} Municipality of Anchorage Development· Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION COmplete legal description LOcation (site address) COSA # ~)~C I1\ '~ q ~ Expirati°n Date: //O '"'/~"'-/// Curreht Property owner(S) Mailing address Day phone -"42.o- Z?,q £~ Lending agency Day phone Mailing address Real Estate~.Agertt. .~M~iling Address' :%ii~.. Unless othdn/Vise 're~: esteS;: COSA will be held by DSD for pickup. NUMBER'iO,FBEDROOMs: % TYPE OF WATER SUpPLY: Individual Well. [] Individual Water Storage [] Community Class ~ Well [~ Public Water System Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer [] [] The Municipality of Anchorage Development Services Depadment (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm £p~e_~,~'~,~ Address ~c~ ~,, 15~~, Engineer's Printed Name DSD SIGNATURE ~ Approved for Disapproved. bedrooms. Phone Conditional approval for bedrooms, with the following stipulations: By: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (Rev. 11/05) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343~7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: -~n~/-~- t~?__ BIK LI LoJ~ .~-~ Parcel ID: OII- 135 -7_0 A. WELL DATA Well tyPe 0.. If A, B, or C provide PWSID # ~2 1 Well Log (Y/N) ~ Date completed -- Sanitary seal (Y/N) ~ Wires properly protected (Y/N) -- Total depth --' ft. Cased to ~ ft. Casing height (above ground) ~ I'n. FROM WELL LOG AT INSPECTION Date of test -'-- ~ Static water level --.- ft. -- ft. Well production ...., g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform ~colonies/100 mL Nitrate A/O mg/L Arsenic: '7..%,'L ug/L date of sample: 617.9jll I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Crr~-] ,~,t} Tank size 10CO~ ..,,~ ,,gal. Number of Compartments '-Z.- Foundati0n;c!ea~O~it (Y/N),,.,.~." . Depression over tank (Y/N) A/ Date of. : It ' '". Pumper -~a~, ' C. ABS~PTION FI,ELD DATA Dateifis..~.lled':~]2$]l~-~.7.. s0ii rating (g.p.d./~ or~ ~,.~ Length ". 3?., . ~.: ' Width ~ ff. Total depth'"' "~' ~" ft.' ..'~ E~f[ abSorption area 3. ~'~J fi2 Monitoring tube . Date of adequacy test ~2~/ll Results (Pass/Fail). ~a~5 Fluid depth in absorption field before test ~ in. Time: ~ min. Final fluid depth ~ Elapsed Any rejuvenation treatment (past 12 mo.) (Y/N & type) Collected byi vT~m~'~ Date installed CleanOuts (Y/N) High water alarm (Y/N) Ay~ Water added ~/30 gal. . in. Absorption rate >= '-'-- If yes, give.date System type I.~e(=D 'T~nc~ 'Gravel below I~ipe ~' ' ft. Depression over field ~ For ~ bedrooms New depth ,~ in. g.p.d. D. LIFT STATION 'E. Date installed "Pump on" level at ~n. Datum SEPARATION DISTANCES Size in g~...llons "Pump off" level at Cycles tested / SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot -- Absorption field on lot Public se~er main Manhole/Access (Y/N) ,..-- High water alarm level.at ,,--'"'"'-in. Cell Lo'{- On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line -- Holding tank -- Animal containment areas -"- Manure/animal excrete storage areas. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation .5 ~+ .Property line $~ Water main /v'/A Water service line Wells on adjacent lots I O~ ~ Absorption field Surface water .F. SEPARATION DISTANCE FROM .ABSORPTION FIELD ON LOT TO: Property line Water Service line Curtain drain {50'+ (/A/,O,.'~ COMMENTS Building foundation Surface water Wells on adjacent lots Water main .. /V/A- Driveway, parking~¢ehicle storage. G. ENGINEER'S CERTIFICATION, I certify that i have determined' through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date Engineer's Printed Name ~/tP...~,~ I~-~ [Av, C~ - ' Date ,, oo COSA Fee $ ~'~ (~ Waiver Fee $ Date of Payment --~ -' [ !-- [ I Date of payment Receipt Number O~5 ~ Receipt Number (Rev. 4/10) Municipality of Anchorage Community Development Department Development Services Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On-Site Systems Approval # 111243 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 33 of Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration of 28.2 micrograms per liter (ug/L) for the property's well water sample. 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. ~m >o~> rn --r z .~--ro rll .-I o~--r o z 0 0 z IT1 FI} --I --I 'T ---I ITl I-- ~- I o NORTH 50.00 m r- shed 0 2~.0 ~4.0 deck 0 o -- 14.0 r-' NORTH 50.00 SEACLIFF STREET Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O ( I - 1 3.~'- - ~. O I. GENERAL'INFORMATION · Complete legal d~scription ~Loc. aUon {site adc~ress) '.... ~ - (~uir6nt Property. 6wr~er(s) 6;t~ I~'le,,~;,,, Uailifi§ add r'e~s's COSA# OffO2 9 Expiration Date: Day phone Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: '~ e TYPE OF WATER SUPPLY: Individual Well [-'l Individual Water Storage [] Community Class. C.. Well ~. Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer [] [] [] [] The Municipality of Anchorage Development Services Depadment (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Cedificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of instaIIation. Name of Firm Address Engineer's Printed Name DSD SIGNATURE {~' Approved for ~ Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: ,,?;Ct.. ..... .. ,,.~-.-' ON-SITE ~: WATER AND ~ ~ WARTFWATER : : · PROG~M .' Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safer7 Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite !(907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST LegalDescription: 1t- . PamellD: (9 A. WELL DATA We, type P~ IfA. B. orCprovidePWSID# '~,~-~-'~-'AO~VelIL0g(Y/N) ~ Date completed ~' Sanitary seal (Y/N) ~ Wires properly protected (Y/N) --- Total depth '"'" ft. Cased to . ~ :ff. Casing height (above ground) m in. FROM WELL LOG AT INSPECTION Date of test ~ -'- ~ Static water level ft. ft. Well production ~ gpm ~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ coloniesllO0 mL Arsenic: 'Z°~,[{ mg/I 13. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size IOOO gal. Foundati.on cleanout (Y/N) Date of pumping '~113 C. ABSORPTION FIELD DATA Date installed Length 3o~ ff. Nitrate f~'[3 mg/L Date of sampie: Number of Compartments ~- Depression over tank (Y/N) ./V' Soil rating (gpd./ff2 o~ ~' Width :~- ff. Other bacteria ~ colonies/100 mL Collected by: ' //_,, rq Date ir~stal,ed Cleanouts (Y/N) High wateralarm (Y/N). AY/ Gravel below pipe Date of adequacy test. 6 Z ~ Results (Pass/Fail) ~5 For ~:~ bedrooms Fluid depth in absorption field before test ,~' in. Water added ~C(:O gal. New depth ,J~ Elapsed Time: '--' min. Final fluid depth ¢ in. Absorption rate >= ~O Any rejuvenation treatment (past 12 mo.) (Y/N & type) /~,~e (~,,~o ~ If yes. give date Eft. absorption area ~(;~' ~ Monitoring tube "/ Depression over field in. g.p.d. D. LIFT STATION Date installed "Pump on" level at/in. Datum E. SEPARATION DISTANCES Size in ga/Ions ~ · Pump off" level at ~ Cycles tested J SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldliff station on lot Absorption field on lot "-' Public sewer main ~ Sewer/septic service line Animal containment areas Manhole/Access (Y/N) .~ High wateralarm level at j Meets alarm & cir~ements?, in. b]Jt o,., LJr On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~14'' Property line ~'~ Building foundation lot Water main ,A,,,'/A, Water service line - / Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Prope~'y line 5t P' Water Service line ~5~-- Curtain drain Absorption field Surface water Building foundation lot+ Water main F. COMMENTS: Surface water ~ ~), Driveway. parkingNehicle storage Wells on adjacent lots 100~' ~ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in e, ffec~ on this date. Engineer's .Printed Name L~.~ ~q f'~.J qv~ COSA Fee $ Z~~jO ~' Date of Payment ~llZlO~ Receipt Number O 3,"{- 'L(o5 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number .Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 ~vww.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On-Site Systems Approval # 090269 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 33 of Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration of 28.4 micrograms per liter (ug/L) for the property's well water sample. 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. o~.m. O~ II ..r0 m~ m..,r Ol4 i.~ --, NORTH 50.00co m 0 0 '°\ shed° 26.0 2~.0 ~0.2 ~4.0 deck o NORTH 50.00 SEACLIFF STREET MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On'Site Services Section Parcel I.D. # .. 1. GENERAL INFORMATION Complete legal .... ' '; ;UNIcIPALITy OP ANCHop, AGd ONMENTAL SErViceS O~VlSloh! P.O, Box 196650 Anchorage; Alar;ka 99519-6650 APR 0 1997 343-4744 . APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or directions) i-','ope~ !.y owner Mailing address Lending agency Day pnor: Day phone Mailing 8, ddress Agent Address -Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER O~'" ~EDROO~S: -~ 'j' TYPE OF WATER SUPPLY: Individual well Community well RECEIVED APR 0 1997 Municipality of Anchorage Dept. Health & Human Services Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Holding tank Community on-site NOTE: Public sewer h: community wastewater system, provide written confirmation from State ADEC ~ :,~sting to ihe legality and status of system. 72~25 (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 W~stewater 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 ~,~/o '~ ~..~.~'.,c,~,J ~ ~- Phone ~b'7 ~ ! ~ Address ¢~JJ EngineeYs signature DHHS SIGNATURE Approved for ,~ . _ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date - ¢' 7 The MuniciPality of Ar~Shorage 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 re(; uirements. 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 MOACY21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~O'T'~"~ ~'-p~ L[ Parcel I.D.: O If- 1':55-~o A. WELL DATA ~¢//~ A~'~ 5 ¢ Well type ~ If A, B, or C, attach ADEC letter, ADEC water system number Log present (Y/N) Total depth ,~. /¢z~ Sanitary seal (Y/N) FAO~ Date completed Cased to ~> /~ FROM WELL LOG Casing height (above ground) Wires properly protected (Y/N) ,/ Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform '~k~p Date of sample: ¥//¢ V'/~ 7 g.p.m. AT INSPECTION g.p.m. Nitrate Collected by: Other bacteria ~-~"~ B. SEPTIC/HOLDING TANK DATA Date installed ~//~.~ ~- Foundation cleanout (Y/N) Date of Pumping Tank size /c~'O Number of Compartments ~ Cleanouts (Y/N) Depression (Y/N) i~ High water alarm (Y/N) / Pumper ~O'~d) C. ABSORPTION FIELD DATA Date installed ~:)t/'~/~ ~2~ Length ~' ,~.- Width Soil fating (~4;~L/fF or f¢/bdrm) ~-~ System type Gravel thickness below pipe ~OLP'/ Total depth Effective absorption area ~" i/ Date of adequacy test~/~Lk/[¢ ~ Fluid depth in absorption field before test (in.); Fluid depth ~-,./ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Monitoring Tube present (Y/N). ~ ¢'Depression over field (Y/N) Results (Pass/Fail) "~ For ~ bedrooms Immediately after /&'/-.&)gal. water added (in.): Absorption rate = ~ /¢/~'~(-~ g.p.d. If yes, give date LIFT STATION I"q L~ ~ ~ Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* *Datum ~UN/CmAL/ry ~ "VVlRONM£N~4L lc;ES O/ViSION APR 3 0 1997 Cycles tested E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line SEPARATION DISTANCES FROM WELL ON LOT TO: ' "'> ~ ~ Lift station On adjacent lots On adjacent lots //~ Public sewer manhole/cleanout ~'~//'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 62~O Property line J O f Water main/service line ~> J 0 Surface water/drainage Curtain drain SEPARATION DISTANCE FROM ABSORPTION FIELD ON. LOTTO: Property line .~ / ~ Building foundation Surface water /V/(.~ (o F. ENGINEER'S CERTIFICATION Absorption field Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~ LO"¢--~ I certify that I have determined thru field inspections and review of Municipal recordsthat the above systems are in conformance with MOA HAA guidelines in effect on this date. S,,,nature Engineer's Name ~ ~ % ,.~-¢' V~\.¢~6~, HAA Fee $_ Date of Payment ~ ,~,~,/,?,~"- Receipt 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number I\ 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 ~)//- /~C-~(::) HAA# 2. "UM.ER OF.ED.OOMs.' ' * GENERAL INFORMATION Location (site address or directions) Unless otherwise requested, HAA will be held for pickup. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing ~o the legality and status of SYstem. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank 72-025 (Rev, 1/91) Front MOA#21 Community on-site D..,. blic sewer : r_ ... - .. · ..... ;.- '~L. -~, - - - - ' ...... NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status ofsystem.---~: :.-, :-~ . - ~ . :--~, ,_ --: 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 verifythat 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 Fi rm///,~'~/-/'~,,~~ ~'/v'~'//t/~__~_~'A/~' d'//C~'Phone .-~-~ Address ~:~:~)'~ ~_~,t/'~~/ ~::)~_~, ,~/,/~7/4g~.,~.~'~_~/~ Engineer's signature ~,/-'~/,//~~' Date DHHS SIGNATURE k/"' Approved for '~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Humen Services (DHH$) issues Health Authority Approval Oertificates bssed only upon the representations given in paragraph ~ above by an independent professional engineer regietered in the State of Aleska. The DHH8 does this as a courtesy to purchasers of homee and their lending institutions in order to satiefy certain federal and state requirements. Employees of DHH8 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 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~'~, Z~"~' '~ ~-~//~ &/~ A/~ Parcel I.D, A. Well Data Well type // Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION SEPARATION DISTANCES FROM WELL TO: g.p.m. 5-~ Septic/holding tank on lot Absorption field on lot .~, Public Sewer main Sewer service line g.p.m. ; On adjacent lots / 0 ~/'7' ~ ; On adjacent lots / / 9~7' ~ Public sewer manhole/cleanout ./V'/~r Petroleum tank /~/,'~ WATER SAMPLE RESULTS: Coliform 0 Date of sample: ~/~/~ Nitrate ,W~'~/~- Other bacteria Collected by: ,/~/z~,~7'7/~/~ ,~'}//'V'~-Z~,~' B. SEPTIC/HOLDING TANK DATA Date installed ~/~-~/~- Cleanouts (Y/N) F Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping Tanksize /~ ~>'~-,~'~/~Compartments Depression (Y/N) Alarm tested (Y/N) Pumper /~) T'~:;) ~/~ 7"~'~ To property line Sudace water/drainage /~/~/~ 72-026 (3/93)* Fro~t SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~.-~ 7- On adjacent lots ,/~// //,/, ~:~ ~ Absorption field z~. ,~---~ (~ Foundation ~, ~'~'7"' (~ Water main/service line /~/~ CONTINUED ON BACK PAGE C. LIFT STATION 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 Date installed ~/2.~,,/'~ Length ~ ~ ~ (~) Width Total absorption area ,.:~,~.5'~ (~) Cleanout present (Y/N) Date of adequacy test. ~/~.~)/~ ~:~ Results (pass/fail) Water level in absorption field before test ~ ×/ Peroxide treatment (past 12 months) (Y/N) /4¢/ Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Sur/ace water Soil rating (GPD/Ft2) ~:~ ~) .System type ~?~'/~::' ~'~ ~) Gravel thickness .~ '~cT' (~ Total depth (~/~'~' / Depression over field (Y/N) /¥ ,~ ~.~ for ~ Bedrooms After test ~/? If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot//~ /.~/~//.- ~/V ~T' On adjacent lots /~:2,'c7" (~ Propertyline To building foundation ~ ~, .~'/'7" (~ To existing or abandoned system on lot On adjacent lots ~' ~, ~2/'7' ~ Cutbank /",//~ Water main/service line Surface water /'V/,,~ Driveway, parking/vehicle storage area Curtain drain /{¢//~ E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe~q~.~o.f this inspec~bn. Signatu re ~/"~'/' ~/'/~/~~ bng~neersmame ./,,(../z;~r--/ ~-~/ f'r/~/(-~ ! '~,~'~ ROBERTW. W, IGHT , . ~ ~ ................... _~= ~ H~ Fee $ ? ~ Waiver Fee $ Date of Payme~ ./~ ~ ~ ~ ~ ~ Date of Payment Receipt Numar '~ / ~7 ~ Receipt Number CONSTRUCTION AND OPERATION CERTIFICATE ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION . PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT · -.-'-" · 'Plans for the construction of in by ,public water system located Alaska, submitted in accordance with ~.8 AAC 80.100 have been reviewed and are I-] approved. conditionally approved (see attached.cond~itions). I~ ¥ .1~o~ ~ ,~~,e~7.,~'~ ~,"/ ~. t-~ ~,o~. · ~' ~ I r - · .;!n~-~. - TLE ' DATE -" - -~,~Y-'~-~'~:- c~' ~--- - ~ T . . .... :~ If construction has' not started within two years of the aPproval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS Change (contract orUer no. Approved by Date or descrtl3tive reference) ..~%~,r.~- . ;~,~'~.~ ;~~{. , .~-. .-~ The "APPROVAL TO OPERATE" section mu~ be completed before any water i~ made available to the public. ,,,,.,..ov,,,,.-ro The construction of the granted Was completed on d~' ~/~ --~' ~ system is hereb, y )royal to operate for 90 days following the cpm BY As-built plans submitted during the confirmed the system was con.' final:approval to operate ~; .~-.; .>-t. -: '-.. ~ · ' -"-' '-' 8Y TITLE according DATE or an inspection by the Department has approved plans. The system is hereby granted TITLE DATE ALASKA ~EPAR'Ir,tENI' OF I PUBLIC CONSTRUCTION AND CiPER TION CERTIFICATE' EI'4VIRONMENTAL CONSERVATION WATER SYSTEM . ':-i..~ TO CONSTRUCT : ." ~4"' .. /klasb-a. st;b. dtted in accordance with .-, .'. ~{ .~'.~ '"'" ~¢Ct C- (; ~C L4/~;% havebeen by ~:~,;. ~' ~ conditionally approved (seeatta~hedcunmtions)' IC~ ~'~¢x~ :~ .:. ,. ~. ~~ . .. ~.: :If construction h~s not sla~e~ within two 7ears of ~h~ a~proval d~e, lhi's cerlifi~te "~:'plan5 ~n~ specifications ~us~ be submitted for ~eview ~nd ~pproval before const . .-~ CHANGE ORDERS " [c~,,*c~ ~,o., .o. Approved by .Datb ' '"APPROVAL TO OPERATE" section must be completed before any water i~ the public. -.~PPROV~L' TO OPERATE · , .[:? The construction f the ' - ' . . . -,, - / ~ '-'< ~ (date). The system water system was Completed on .' ' ' granted interim approval to operate for 90 days following the cpmplction date. :.,: "(:'- .......... :,,~,,rin~th~ interim approval period or an inspection bythe ' .... ~- -"stem was cons~ructud accm(i; ~.l ~o the approvad plans, lhe system ~s nera~ 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 1. GENERAL INFORMATION Complete legal description /eT 33, ~LK q , $,~b LAk'~- ~z J Location (site address or directions) ;~2 52 ~/} CI./FF ~7". A~cI~o~'A~ ~ AI~ DAviD C~o~s Day phone ~2 .ooo~ Property owner Mailing address Lending agency Mailing address Agent Day phone ~-.77 -o7o~ Pf~o6~6551¢~ R6/~L'Ty Day phone Address (~¢ol VII~4RNu~ DR. J~Nctt, /~K c1~1~°~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: 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 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 F'/_,4'[¥o? 1' ~c/~ ~v'c_~ Phone '~ '1~,.~ - I35'5- Address I~g30 Echo ST, ,, ,ANctl, AK /4, Engineer's signature o-~___,~,~ ~. ~ Date 7/'~//?_~ DHHS SIGNATURE Approved bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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. 72q)25(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type ~-~ Log present (WN) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 LOT 33 ]~LK q' 5ANJ) IA/"~'~2 Parcel I.D. O//~ /':~-~'- -~ O If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Nitrate g.p.m. Coliform Date of sample: ~[28/*/3 B. SEPTIC/HOLDING TANK DATA Date installed 9 / ~' 2 Cleanouts (Y/N) High water alarm (Y/N) Date of pumping ~/~/'~;.'.'.'5 MUNICIPALITY OF ANCHORAC~I:: ENVIRONMENTAL SERVICES DIVISION "-!~ 0 9 199;~ g.p;m. RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Other bacteria Collected by: ~L/~TT0,° T'£ ¢#, .5~'~', Tank size I coo Foundation cleanout (Y/N) eR ~ Compartments 2-- ~ Depression (Y/N) Alarm tested (Y/N) N./~. Pumper ISAA£~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~, A~ On adjacent lots I 0 I To property line 12 F,~ord C,O,Absorption field Surface water/drainage >' Foundation 20' ~'~'or~ C.0. Water main/service line ~2~ 72-026 (3/93)* Front CONTINUED ON BACK PAGE WALTER J. HICKEL, GOVERNOR DEPTo OF ENVIRONMENTAl. CONSERVATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 July 6, 1993 (907) 349-7755 Mr. Ted Moore Flattop Technical Services 14530 Echo St. Anchorage, AK 99516 SUBJECT: Lot19, Block 4; Sand Lake #2 8245 Sand Lake Rd. Class C Public Water System ID no. 216075, ADEC Pr~ect no. 9421-DW~ 183-124. Dear Mr. Moore: The Department has reviewed the information received in this office July 2, 1993, regarding the above public water system which included water samples analyses for total coliform bacteria and inorganics for nitrate. Since this drinking water system has been previously approved by this Department, verification that the water supply has been recently tested will be required to maintain compliance with State Drinking Water Regulations. Results from the recent water samples submitted were satisfactory for both total coliform bacteria and inorganics for nitrate, and satisfy this concern. Therefore, for the concerns of this Department, this system is in compliance with State of Alaska Drinking Water Regulations (18 AAC 80). Attached is an "Approval of On-Site Residential Water and Sewer Systems" certificate verifying this systems status as an approved water system that is in compliance with 18 AAC 80. Thank you for your cooperation with the Department. If there are any further questions concerning this matter please do not hesitate to call. Sincerely, Michael Lu, E.I.T. Environmental Engineering Assistant II ML/pf Attachments · '~ STATE OF ALASKA ::~ ~, DEPARTMENT OF ENVIRONMENTAL CONSERVATION APPROVAL OF O~I-sITE RESIDENTIAL WATER AND SEWER SYSTEMS PROPERTY DESCRIPTION Lot, Block & Subdivision or U.S. Survey ',~r',< ..... . 2 i ',5 0 '? 5 Certificate Issued for Application No.: o2, ;,, / ..Dr,!.-.,1 ,q ?[-~1 9A This approval does not constitute a guarantee of any kind, explicit or implied, as to the performance · of the water supply and wastewater disposal systems. WATER SUPPLY A recent water sample was tested and found to meet Department of Environmental ConservatiOn,drink~ . lng water standards for total coliform bacteria. - WASTEWATER DISPOSAL The domestic wastewater system was: [] inspecte~"by-.t, he Department of Environmental Conservation and foundCto be n compliance with rec~birements of 18 AAC 72; applicable [] inspected by a Professier~l Engineer who certifies tbatC~ne system complies with applicable re- quirements of 18 AAC 72; '--.. .... ~-~- [] installed by a Certified Installer who'?j~ifies that the system complies with applicable requirements of 18 AAC 72; or *^sted b" a Professional Er~eer who certifie'~s'that the performance of the system is satisfactory [] ~r~ thai~the svst~-c~r~plies with the minimum"~'ep_.aration distances specified in 18 AAC 72, This approvaf~svahd fora [] single family [] multi-family uh'it.~wit atotalof bedrooms. -18-0404 (Rev. 8/85) DISTRIBUTION: WHITE BANK/LENDING INSTITUTION; CANARY--APPLICAN~ PIN K--DEPARTMENT MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR .SINGLE FAMILY DWELLING Parcel I.D. # 0//1~"2--0 HAA# '/'~/'¢t~ ¢'~ O ~ I ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section,'township, range) (b) Telephone: (home) Business (c) Lending Institution · . ~. '~' Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here~ [], if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESID,-~.,,' 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 DIS~SAL 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 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validationdate'sh0wn below, I verify that my investigation of this Health Authority Approval shows that the on-site wafer 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 dat'e of this inspection. Name of Firm .... ~ - Telephone " Address ' ~ Date 6. DHHS APPROVAL /.~.~' / ~.~",,¢ Approved for~bedrooms Approved Disapproved Conditional Terms of Conditional Approval ~ Date The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S 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 DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 Well Classification "Well. Log Present (Y/N) Total De~th Cased to Static Water Level . Casing Height Above Gr6und Electrical Wiring in Conduit (Y/~)' · SEPARATION DISTANCES FROM wELE: . To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on ~ot Water Sample Collected by MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: !-"- Date Completed Depth of Grouting IfA, B, C, D.E.C. Approvedi(y/N) __ Yield 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 To Nearest PUblic Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK Du,A"~A Date Installed '~ '~:'~.;' "://'Size Standpipes i(¥/N) Depression over Tank (Y~'~) /,,": No. of Compartments Air-tight Caps,,(Y/N) Foundation Cleanouti(Y/N) Date Last Pumped ~'-~"~'~ ~ 'i ' ~.,'/~. i' ; for *-/~;' Pump ng/Ma ntenance Contact on File (Y/N) Holding Ta.r~t~ Hlgh-Wa~e~4~,~[a,r.m (Y/N) __ .: ;.',' ,' SEPARAT- ON D~STANCE~,P~e~HOLDING TANK: To Wate~Su~pl~¢~[. ,.... ~. . ,:. ~ .;'-C: ,.'-,, ,'~~~/ ' To Building Foundation To PrdpeEty Line ,,_. *. To Disposal Field To water. M~(~/Secvice; bine,~' .~:'.' /d To Stream ~o~;,bake'0r Maj'? Drainage Course Comments Temporary Holding Tank Permit (Y/N) ' ,./~ ~' 72-026 (Rev. 7/88) Front ~ _ , Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Width of Field / Square Feet of Absortion Area / f Depression over Field (y/N): Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~/,~:, ' i To Building Foundation To Water Main/Service Line /' ~ '/- To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Desig~n Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present((Y/N) Date of Last Adequacy Test To Property Line .:" To Existing or Abandoned System on ; On Adjoining Lots //~: /' To Cutback (if present) ~" '/:~' D. LIFT STATION Date. lr~stalled Size 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 guidelin inspection. S i g n e d : :::: r';..": -. .¢ - .. Company Date MOA No. / ael~ne~,i~L.~e_~,~j~ the date of this .,, ' A ' · ~~~, "¢¢ Seal Receipt No. Date of Payment Amount: 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 STEVE COWPER, GOVERNOR 563-6775 DATE: PWSID: August. 9, 1989 Class C To Whom It May Concern: According to the records on file in this office, the Sand Lake ~2, Lo~?Block 4 S/D is in compliance with the State of, Alaska Drinking Water and Wastewater Regulations. Thank You, Cindy Thomas, Environmental Engineer CT: gd APPLI( NT FILLS OUT UPPER ONLY Property Owner ~,.~-}~'7'~ ~ ~:>/.~,Z~ t~_~-~ ~--7~..~/~)~.~-~-- Phone M~il~.'.g Addre~ _~ /~ ~ /~ ~ Zip Code ~5~ ~ ~-~// Buyer ~ ~[~ Address Zip Code Lending Institution ~//~ ~ ~ ~ ~-~ Phone Address / Zip Code Realty Co. & A~nt Phone Address Zip Code Legal Description ~T ~ /~/~ ~ ~-~ ~-~ ~ Street Locati~ ~'2 ~ ~. ~'-~/~--'- Type of Resi~nce ~Single Family ~ Multiple Family No. of Bedroo~ ~ ~ Other Water Supply ~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975. ~Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer Disposal ~ ~ Individual Year Individual Installed: ~ ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNICIPALITY OF ANCHORAGE RECEIVED ( ~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received ~-~_ ~ ~ Well to Tank Septic Tank Size 72.023 (3182) CONSTRUCTION AND OPERATION CERTIFICATE ALASKA I~EPARTMENT OF ENVIRONMENTAL CONSERVATION. PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT construction of by ,~ O {,t C-- public water system located , Alaska, submitted in accordance with 18 AAC 80.100 (_~ ~ L L ~ L.,;T" have been reviewed and are [] approved. EA' conditionally approved (see attached.conditions). If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVEDCHANGEORDERS Change (contract order no. Approved by Date The "APPROVAL TO OPERATE" section must be completed before any water is made available to the public. APPROVAL TO OPERATE The construction of the '~'"~ ~' ~.~:: ~'!'/) ~, 7-< & o '~ ':' ~:'~ ~/ /~/. ,~ C.-i I ~ ~ '> [ ', "~" ~ -' public water system was completed on / -~/f --~'~C_~___. (date).-Fhe system is hereby granted interim approval to operate for 90 days following the cpmpletion date. As-built plans submitted during the interim appr~)val period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted finaJ~approval to operate. /? ,// '=--'~ ,_.~'- // _-t.,cc.- /.,--,: BY TITLE DATE