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HomeMy WebLinkAboutSCHROEDER EAST BLK 7 LT 12Schroeder East Block 7 Lot 12 #050-071-14 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ® j ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME NEW 7TPHMN_E_ � UPGRADE I\ u i—1 C 7)✓Yl C MAILING APPRESS LEGAL DESCRIPTION fin ,7- / 2 �j [,/! S� / f � c� :(_ y v t� LOCATION NO. OF BEDROOMS yy ���� i Lx, �r �/(tl� DISTANCE T0: Well Absorption area i Dwelling N /a. PERMIT NO. _ F- z Manufacturer / Material No, of compartments_ to L.iq. capacity in gallons Inside length Width Liquid depth `p -� IF HOMEMADE: Well Dwelling PERMIT NO. z DISTANCE TO: nn_ 2 Z `- < Manufacturer �J Material Liquid capacity in gallons Well �/� Foundation Nearest lot line / PERMIT NO. �r i DISTANCE TO: J Z No. of lines Length of each ling Total length of lir)es Trench width Distance between lines i1 A w C ! -� .J C� inches F h Top of tile to finish grade Material beneath the / zC) inches Total effective absorptioaareai t 1 _Length Width Depth PERMIT NO. :r w Q F- Type of crib Crib diameter Crib depth Total effective absorption area as w Lu Well Building foundation Nearest lot line `n DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. wan/V �LSS7 /il/( 3:DISTANCE Building foundation Sewer line Septic tank Absorption area(s) TO OTHER PIPE MATERIALS — 1� C Iq SOILTESTRATING ii INSTALLER J �(l.�j"'J� �'1-�''✓✓Ij�S' — REMARKS — L I':? — ,! �i jAPP�1j" DATE LEGAL �.., f5 ,,6 1: iC�ifilt r ailn /�' i3 i�7 znnt�,L� 'n IIW46 I,b=1110 117) MUNICIPALITY OF ANCHORAGE Department Health and Environmenta? 'rotection 825 Street, Anchorage, AK. ._)501 264-4720 j` HANDWRITTEN PERMIT # Permit # �� W LL AND/OR ON-SITE SEWER PERMIT Applicant: Mailing Address: Location: � �� '"--iT Phone Number: Legal Description: /T G of Size Type of Soil Absorption System Is: Trench: Drainfield: _ Seepage Bed: Holding Tank: Maximum Number of Bedrooms: _ Soil Rating(sq.ft/br) A°fe4p The Required Size of the Soil Absorption System Is: DEPTH LENGTH GRAVEL DEPTH _�Q _ WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HZL-D1f*) TANK SIZE GALLONS # # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(Z) INSPECTIONS ARE REQUIRED Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or. 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3 # ,E I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enla gement if the residence s remodeled to include more that 3fboo Signed: Issued by: Ap lic nt z Date: SWP/024(1/81) X1 SOILS LOG MUNICIPALITY OF ANCHORAGE �, ❑ PERCOLATION s DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 875 L. Street, Anchorage, Alaska 99501 264-4720 �'— SOILS LOG — PERCOLATION TEST PERFORMED FOR: 1i`- "`I- t Cy .� `-Cjl'11 E:S _ DATE PERFORMED: 2� 7 —8.3 _ LEGAL DESCRIPTION: �(�2-- SLOPE SITE PLAN I P 1) QTY b F L•:P}7�J 1 C — 2 _ 4 5 Cj 6 C 8 9 e1 10 „ J — CJ WAS GROUND WATER S 11 ENCOUNTERED? � L 12 -¢ r` Ott r YES, AT WHAT E 13 - 14 (��i, Ll 15 16 �t ' 17 18 19 f+at +. eading Date Gross Time Net Time Depth to Water Net Drop 20 PERCOLATION RATE, / 'I -(minutes/inch) TEST RUN BETWEEN — F AND FT COMMENTS PERFORMED Py;.� O tlCERTIFIE �.�rIi4F1l��.�lif r,'.119 1 I �iiA 72-008 (6/79) DATE:(/ T p r.ftrb 43rd tit g .h[o by DOC Co. dba SULLMN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 s TELEPHONE 688-2759 OWNER OF LAND DEPTH OF WELL ADDRESS STATIC LEVEL, OF WATER FT. LEGAL DESCRIPTION DRAW DOWN FT. DATE - Started Ended GALS. PER HR PERMIT NUMBER KIND OF CASING _ KIND OF FORMATION: From Ft. to Ft. From From --Ft, to Ft. From Ft. to - Ft. Ft. From Ft. to Ft. From From --Ft. to—Ft.— o Ft.From From Ft. to . Ft. Ft. From Ft. to Ft. From From Ft. to Ft. From Ft. to—Ft.— oFt.From_Ft. Ft. to_ Ft. From to Ft. Frmn —Ft. From Ft. to Ft. Ft. From—Ft. to Ft. Ft. to_ From Ft. to Ft. FromFt. to Ft. _Ft. From Ft. to Ft. From From Ft. to Ft. Ft. to— From Ft. to Ft. MISCL. INFORMATION: From—_ Ft. to ----Ft. From Ft. to _Ft. From Ft. to_ Ft. From Ft. to_ _Ft. From Ft. to Ft. From Ft. to_ Ft. From to_ Ft. From _Ft. Ft. to Ft. From Ft. to_ Ft. Froin—Ft. to_ _Ft. Frmn Ft. to— Ft. Froin—Ft. to Ft. Frmn Ft. to_ _Ft. From Ft. to— _Ft. From Ft. to_ Ft. From Ft. to Ft. From Ft. to— Ft. DRILLER'S NAME Municipality of Anchorage :t• !2.1;:. -:. On-Site Water and Wastewater Program r , C (907) 343-7904 .,vel i' CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-071-14 Expiration Date: ot- ( 2 i R 1. GENERAL INFORMATION Complete legal description Schroeder East Block 7 Lot 12 Location (site address) 12719 Faith Circle. Eagle River, AK Current Property owner(s) Causey Day phone 864-6524 Mailing address same Real Estate Agent Latosha Williams Day phone 86,-6524 ^)v567 8 9 7p ). ^, ;ACa :1 ,' 7 5 2. TYPE OF DWELLING: 5. ® Single Family (w/wo ADU) MA 1 8 ZU18 ❑ Duplex - ❑ Multiple Dwellings (Single Family and/or Duplex) c><< f�� aseL .sg ° 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well . ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well El Community El Public Water System ❑ Public Sewer ❑ Received b • %I Date: 4(22,//e COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 62-10 Date: Date of Payment 512-ills Date of Payment Receipt Number O2Oy4A Receipt Number • COSA# iMCP2121S Waiver# 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, 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 NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 5/18/2018 • i° 6. DSD SIGNATURE ''� -i:-..,-- `ii z; .: :. System #1 Approved for ? `� �`�° a _� bedrooms. ,i ri -YSystem #2 Approved for bedrooms. `'' .c.---` Disapproved. '.,:.,..5/7' • •„ Conditional approval for bedrooms, with the following stipulations ,,,,,..,,-"`" *Tis Spf t c 4--orft-SC 3 5� Boars TiLD 'y Avekole 1 % el S 1 ,c`-ra c ao c .yT OL,1� 1� U ~O� � GF #4:1 ,c, 16. _,,\P#O C4v 6'/OLDttpancl. c-' By: C V,%/k--- ‘----.4 Original Certificate Date: 6_1 Z / Y The Municipality of Anchorage Devlopment Services Division(DSD)Issues Certificates of On-Site Systems Approval(COSA)based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Adviso?ry.,•:. ,? Septic System Advisory Arsenic Advisory -•r. Well Flow Advisory 'the -� c�cli r'Or► •COSA blue sheet 9-1-12.doc 1 , •-' If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of Ong-Site Systems Approval Checklist Legal Description:.SC—hOmechr E t f. g7 Liz Parcel ID:4 50 0 71 Ry A. WELL DATA Well type P If A, B, or C provide PWSID# Well Log (Y/N) y Date completed ( (7F-3 Sanitary seal (Y/N) y Wires properly protected (Y/N) >1 ZOO Cased to Z7 ft. Casing height (above ground) /8 in. Total depth ft. FROM WELL LOG AT INSPECTION Date of test. efr/P.3 S/1S/18 Static water level ft. Zy ft. Well production 3 g.p.m. S-fr g.p.m. WATER SAMPLE RESULTS: Coliform ( colonies/100 mL Nitrate S 4-S mg/L Arsenic AM ug/L Date of sample: Collected by: /V jef •2-1,6-.-_," _ B. SEPTIC/HOLDING TANK DATA Tank Type/Material cS %,t/ E .. Date installed t(76e3 Tank size /o0 gal. Number of Compartments Z. Cleanouts (Y/N) ?l Foundation cleanout(Y/N) y Depression over tankk((Y/N) A/ High water alarm (Y/N) /`/ Date of pumping 520 /i P Pumper v `r C. ABSORPTION FIELD DATA 8 e2, // Date installed ‘IP3 Soil rating (g.p.d./ft2 or ft2/bdrm) /y0 System type +e,id Length 2 1 ft. Width ? ft. Gravel below pipe ) d ft. Total depth / t/ ft. Eff. absorption area 52O ft2 Monitoring tube X Depression over field Al Date of adequacy test. .c7/5Jn /(14 Results (Pass/Fail) f/ For .? bedrooms Fluid depth in absorption field before test /2 in. Water added G/SV gal. New depth 20 in. Elapsed Time: ‘O min. Final fluid depth / in. Absorption rate >_ 9.---CO g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) V/(1/ -l- If yes, give date D. LIFT STATION AM, Date installed Size in gallons Manhole/Access (YIN) "Pump on"level at in. "Pump off" level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot /a O 1T- On adjacent lots / .0' r,A Absorption field on lot /O 0 `f On adjacent lots /00/f- Public sewer main Public sewer manhole/cleanout • /c., (74- Sewer/septic service line Z '4-4-- Holding tank /0 0 ',- Animal containment areas 50 -f- Manure/animal excrete storage areas (0 O SEPTIC/HOLDING TANK ON LOT TO: Building foundation /O+ Property line /0 4- Absorption field 5 '~ Water main Q '�" Water service line /O (4- Surface water /00 + Wells on adjacent lots / 0 0 "'- ABSORPTION ABSORPTION FIELD ON LOT TO: Property line /0 14— Building foundation /Q (-11- Water main < �i r Water Service line l 0 Surface water lvd f Driveway, parking/vehicle storage zcS Curtain drain (},(/k - Wells on adjacent lots /DG �1 F. COMMENTS 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. i . % a • V Engineer's Printed Name Date .(73-110 ..o • COSA yellow sheet_2-6-15.doc MUNICIPALITY OF ANCHORAGE '`�, DEVELOPMENT SERVICES DEPARTMENT • 907-343-7904 On-Site Water and Wastewater Section �r ` // Fax: 343-7997 www.muni.org/onsite �—/ Septic Tank Advisory Certificate of On-Site Systems Approval # 0SC181215 Subdivision: Schroder East Block:7, Lot: 12 The septic tank for this property is 35 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. ra fa X } '. 44, fir_ _ 4ro._ e r x • ...,,,tivi ' ...4h:Iiir(4:!' :40, , '""-----c.-4%.4 .-r'-'",-,...r\Abeit ..,. ‘......., • `.. 4,_•-'1' . ,...- - ,,,N.. a - ,'". W;:"4 : *:10A, .. '-,• • " .' *) -4,„, 4,1. •''.." \'..-k' . ' r' r t. ya P•, .,. '' b , 1t , t t ,a$r 4c 2(1,. Mailing Address: P.O. Box 196650 * Anchorage,Alaska 99519-6650 *www.muni.org MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT �' • F ;,'"'r 907-343-7904 On-Site Water and Wastewater Section \ `) Fax: 343-7997 www.muni.org/onsite Nitrate Advisory Certificate of On-Site Systems Approval # OSC181252 Subdivision: Schroeder East, Block: 7, Lot: 12 A water sample revealed a nitrate concentration of 5.65 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/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. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. Mailing Address: P.0. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids,and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address: P.O.Box 196650*Anchorage,Alaska 99519-6650*www.muni.org Y Municipality of Anchorage Of(dx -� Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. h5p-0,::? / U HAA # In Expiration Date: — — 3 O .r 1. GENERAL INFORMATibN ` G & ii le 7 L oT' Co(tidlete legdl,descriptior:'`�C ��� f � f (' /Z Lot:atioii (site'addres's o� directions) 12 7/9 FGr 7'� (?rrc,/e_ rte_% iCfJa✓ Current Property owner(S). um eylvrG?n Env BoK 773�/3F Mailing address'„ `. I ! c Lending agency Mailing address Real Estate Agent Mailing Address Day phone Z217— S,.?rfS ./_ e..., 995P Day phone L' Day phone Z4�4/—/ 9'30 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 Health Authority 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 h"*2AZ,.. Phone Address 17d3? 82rle-� Engineer's Printed Name 5%�EVE C/Jc Date &Z 7Z40S A 5. DSD SIGNATURE F` :, s,."n W. r %elf i•• PE 6256 Approved for 3 bedrooms. t 4 Disapproved. ,, �0\�1`�; Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other _ BY: �( ki1�iv AAOriginal Certificate Date: 53 (Rev DIM) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: akf tOedto✓ &.Pf 0 Bloale. 7 Lc, /Z Parcel ID: 050- rml1-I y' A. WELL DATA Well type P If A, B, or C provide PWSID # Date completed<W00.i' Sanitary seal (YIN) Total depth ZOO ft. Cased to 2 i ft. FROM WELL LOG Date of test 4' 3 Static water level Well production WATER SAMPLE RESULTS: Coliform _Q_colonies/100 ml. Arsenic: _ mg./I. B. SEPTIC/HOLDING TANK DATA Nitrate . SS mg.& Date of sample: LOGS Tank Type/Material Glerdi? /sem Tank size 004�' gal. Number of Compartments Z Well Log (YIN) K Wires properly protected (YIN)'-7� Casing height (above ground) in. AT INSPECTION &Z/_GS 0.2, ft. 4 g.p.m. Other bacteria (3 colonies/100 ml. Collected by: Date installed es[L 3 Cleanouts (YIN) Foundation cleanout (YIN) Depression over tank (YIN) A( High water alarm (YIN) ��— f Date of pumping %10 Pumper -f C. ABSORPTION FIELD DATA Date installed g5rIJ03 Soil rating or ft2/bdrm) 40(a System type Length Z t ft. Width 3 ft. Gravel below pipe _� ft. Total depth L�-i ft. Eff. absorption area .5-_7,0 112 Monitoring tube Y Depression over field _� Date of adequacy test •r JResults (Pass/Fail) SS T� For 3 bedrooms Fluid depth in absorption field before test 4/13 in. Water addedg..%all- New depth" in. Elapsed Time:[ min. Final fluid depth Y-!9 in. Absorption rate >= dS0 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed "Pump on' level Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (Y/N) 'Pump off' level at _ in. High water alarm level at in. Cycles tested Meets alarm & circuit require ents7 SEPARATION DISTANCES FROM WELL ON LOT TO: i Septic tank/lift station on lot _400 f Absorption field on lot /a o't Public sewer main /kt�,4 Sewer /septic service line Z 5 't On adjacent lots /OCJ i� On adjacent lots t oo'f- Public sewer manhole/cleanout ±JM Holding tank iq1 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: / r Building foundation I `) Property line Absorption field S r' Water main.t Water service line .2 S Surface water /Or9't Wells on adjacent lots /Oa 't SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: r Property line 16 /'f Building foundation1a * Water main 9 f ' S Water Service line %J� '� Surface water „JOo 't' Driveway, parking/vehicle storage Curtain drain dX Wells on adjacent lots /DO f F. COMMENTS HAA Fee $ +30 Date of Payment q— C� � O - D S Receipt Number 2 to -75' (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number G. ENGINEER'S CERTIFICATION `q• ' "`•. ��,s 1y I certify that I have determined through field inspections and review of Municipal records that the above systems are in 000. ,... . • .. F conformance with MOA HAA guidelines in effect on this date. r' Engineer's Printed Name JE % �• C ; Steven W. En y Date ��%l�S % �t'Fp�'............�''«'. PE 6256 ..•,; ,y HAA Fee $ +30 Date of Payment q— C� � O - D S Receipt Number 2 to -75' (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number !.� L Ne✓fit _ p� "'. Y4:7 G i , s S- j AS-111=11' .I:hciehy terti(y'thif1 havesurveled'the folowmg-dest;r bcd': • z :Property (rpY-l2,� Bf.•cf� �,�/�,f•_/.;t.t �.,a -. •.. r ; � ` a ,. �. l'G �/•'OJ �% f� 1',i T•Hq.�l i Iww � ': �•n . 4�+ y i",?C J-)T/'h✓R �r Y�i - N� •f JrYL /O It '•vI • \ ' Anchorage Rec6idin6 Irnciricf,•Alaska:snd th!!. the. Improve= , i •• M1 _ ,..,� ' ,.,. menta situated thereon art, wi!htn the'prol5erty_lines and do , + `� , '• 'sot overlay or, encroach on the property lying adjacent them to, that no lmprovemenU.on.property.Iyin sdjacentrthereto'. r encroach on the premises in:quest�on'and Liat there are-tro . tt a!f'Q • t roadway!, transmission lines. or other y8iblc' easements on said property except as indicated hereon';. , L' • Dated at Eagle- River,'A13sk1'• •.L ) th1iZ1� �•::�aY of A 1C �i .... S 19 •: Z ROBERT C.' .10IfNS011 Zy,Sr"':� <' ' ' SCALE. :'Registered Land SuSveyor No. 880 I •Bdx'456;,Eagle River. aska Al,. Phone Y90T) G943540, ; MUNICIPALITY ANCHORAGE DEPARTMENT OF HEALTH &HUMAN SERVICES }, Division of Environmental Services =r 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. # e JC —C' 1 - Az °I. GENERAL INFORMATION HAA# /��1�"�/ `% - Complete legal description Lot 12, Btock 7; Schnoedejr East Subdivi,5ion Location (site address or directions) 12719 Fath Ci4cte, Eag.2e Riven _ Property owner Stephen A. Koen,i-gen Day phone wk: 343--6914 hm: 563-8865 Mailing address _P.O. Box 91539, A_ chonage-; AK 99509-1532 Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XXX 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 XXX 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 P21 5. 6. 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 FirmPhone 53 s ENGTNE`EM Address 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Engineer's signature - Date DHHS SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for Additional Comments �T OF 44A-0D� �,�, : °• °Wee c• Ce "Fp �, RCGWR J. HAFER ? bedrooms, with the following stipulations: Date L/- 25 -y2 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. Ernployees 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 Municipality of AnchorageI Department of Health & Human Services_ [+ HEALTH AUTHORITY APPROVAL CHECKLIST Legal Descriptiom" r Parcel I.D. ��n�s'r Slo A. WELL DATA Well type QiF-\A/k1__5_ If A, B, or C, attach ADEC letter. ADEC water system number LogpresentoYN) Date completed g't-`-"gam Driller Total depth 200 ` Cased to Zq` t µ V --a- - Casing height Sanitary seal ON) Wires properly protected ON) Date of test Static water level Well flow Pump level FROM WELL LOG 3,0 AT INSPECTION -2 1"11 C_i g.p.m. Tri 1 `t' t.� SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot l op ` ; On adjacent lots Absorption field on lot On adjacent lots Al P 1 Public sewer main Public sewer manhole/cleanout Sewer service line ton, 2�Z Petroleum tank 25 r WATER SAMPLE RESULTS: Coliform too w, 9.-, Date of sample: �\_ \\ ` C\"Z D. SEPTIC/HOLDING TANK DATA Date installed Cleanoutso/N) High water alarm (Y60 Date of pumping N`A Nitrate_ Z [�L �`� Other bacteria fJo'Ai _ S S ENGINEERING Collected by: —170 _ Eagle River, Alaska 99577 Tank sizec/1 Compartments Foundation cleanout O/N) Depression (Ya) -� Alarm tested (Y/N) — -�� 4- - Pumper s_—LAF_:�Sfoat� - SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ko1+- On adjacent lots ti OC.N ��- Foundation t - To property line Surface water/drainage bsorption field `� I h • '\ Water main/service line v� 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed — Size in gallons _ Vent(Y/N) High water alarm level Meets MOA electrical "Pump on" level at Manufacturer Manhole/Access (Y/N) SEPARATI (STANCE FROM LIFT STATION TO: on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed G� L ength 2\' —Width "Pump off' level at Cycles tested — Surface water Soil rating � Aon `i'7- System type rrnvPlthickness C> --Total depth Total absorption area — f2p Cleanouts present `L(CXN) Depression over field (Ya Date of adequacy test— Results as fail) ?1-,� —for O) bedrooms Peroxide treatment (Past 12 months) (Y/N a J f- L4rJ 0 *L ^S If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot \Qdv�- On adjacent lots \t90 Property line_ To building foundation On adjacent lots -3o � k - l k Surface water Curtain drain �1 E. ENGINEER'S CERTIFICATION To existing or abandoned system on lot _Cutbank 1�1/." Water main/service line Driveway, parking/vehicle storage area D \ V)e 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec. _ _6o � this inspection. � F peppp�ep &� 4 ^pp� 5 ENGINFERING j^ Sj a y f> 17©;in 4=agle River Loop Road No. 20 Signature Engineer's Name — -fq; a=A�: Date` HAA Fee $ 7 d ` Waiver Fee: $ — -- Date of PaymentDate of Payment _ ReceiptNumber w Receipt Number - ,o..., a,pn P—k Una 21 Time Time E APPLIC AT FILLS OUT UPPED FOAL ONLY Property Owner Date Phone AK hailiting, (i Drywall 694-97J Mailing Address Q I 1 i' thll l •ll (T PC] Ancliornge Zip Code q Q r, 7 Inspector Buyer Koeniger Address 2641 Northrup l�Ear " 11.0 r• 0— Zip Codes' Lending Institution Alaska Mutual Savings 694-951 Address _) ,. r, r� - --- ' , g c_� Riyeer Zip Code .)95-7_�L— Realty Co. RAgent Commonwealth Area, Inc. Realtors Helga Larson Phone Address P P - Box 7 D- Ea-gjo River 44 ra_ Zip Code � � _ � t_ _ Legal Description Lot 12, Block 7 Schroeder D Sub, Spring Brook Street Location OF APPROVAL _ ._Dr _ .. Type of Residence ( ) CONDITIONAL APPROVAL' k Single Family 3 ❑ Multiple Family No. of Bedrooms BY: ❑ Other - Soils Rating Date Sewer Installed WaterSupply �/ -- ( �{ �, P as �� 8 Well to Tank k Individual . ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Sewer Disposal \� a 3 1-983 {7 Individual _ Year Individual Installed: _ 1] Public UtilityWhen Connected to Public Utility: Holding Tank - NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Dale /, i - 10— Inspector Inspector Inspector Inspector (� Field Notes:0--- 1�t- � `J /L� MUNICIPALITY OF ANCHORAGE H`T.'_T! i 2 e� v fir` /y PEPI. OF 1113� �� �` ENVIRO\7d'NlAl- FRSAKITION D O APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE —/0�(�+�1� a BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received �{ �, P as �� 8 Well to Tank Septic Tank Size /000 1111 t".) A j ol:ywcd 1. 10 D j ijo L: 1, 1t fQrOvill ku-olm QW.&CAU vower anni wailer o? ric%lnt(; (_'+ th(!)olioainq Arms. 1lov-"-! A;: Sm! CIE Ulu PlelxiBu 0101 this Allm? Of P110thrS Pho: leyal dtisporipiii on Ole u1ndiwit.hun way No hux)CQ:=- Aliumn are mn,! WWUICWITQ 111,003:0 (oil! UUS (0011M! aL MO -Mu. C J, / I_, i / E>