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HomeMy WebLinkAboutSAMPSON ESTATES BLK 2 LT 2• �� 1 ,. COSI-b53-S3 Municipality of Anchorage Page Of 3 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: SU_)92-030S PID Number: Name: L�s�.2 Wastewater System: `'$t New ❑ Upgrade Address: ABSORPTION FIELD Phone: 4 , � No. ofBe rooms: (Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: . GPD/Sq. Ft. Lot: Block: Subdivision: Z epth to pipe bottom from original grade: Gravel depth beneath pipe !S /+M PS ni S Ft. Ft. Township: Range:/ 3 Section: ? �% Fill added above original grade: Gravel length: , i A w 1�i �. J Ft. Ft. WELL: �(New [I Upgrade Gravel width: 2-160 Number of lines: Distance between lines: 1 Ft. y Ft. Classification (Privat�e.'A.8,C): P21v11Z_ Total Depth:Cased Ft. To: % Ft. Total absorption area: 2.,40 SQ. Ft Pipe material: 11`` �^rM V 3o34- Driller: q SULU VAt.I OU W' l C" Date Drilled: Static Water Level: S3 Ft. Installer: CrR J G�+tl, Gu +ri Date installed: �+ 1 — zo — % Z— Yield: Pump Set at:Casing Height Above Ground: TANK Z O GPM &JC)-' SE.T FL 'Z Ft. SEPARATION DISTANCES Xseptic C Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: n d' �+ �1� A` J4o R,1}fi-� Capacity in gallons: l 0 From Tank Field Station Tank Sewer Lines •y c TAkV, Well'I Ma SL Number of Compartments: Surface LIFT STATION Water Lot ��/ W Size in gallons: Manufacturer_ Line Foundation 2Z' 2b ' 'Pump on"" level at: "Pump off' level at: High water alarm at: 1 Curtain Pump Make & Model Electrical Inspections performed by: Drain BENCH MARK Remarks: and Description, r Location and cr `�� — V 7, C7 A 0 ! Z (_4`0 ADC - Assumed Elevation: 01?1,e)� ENGINEER'S SEAL OF A4 �D Inspections by: Dates: 1st performed ®... .......0„a. . 2nd /0 _ 22'F12' 0 II ••a•a•�•••••Nt• Department of Health and H m Serv' approval S *'IWAS 0. FLWINt ®� •.� CE7009 .•' Date: Fy ®,4A Reviewed and approved by: =3L �/ ,WOW10UL 72-013 (Rev. 9/91) MOA 25 °e :j Permit No. SLO12-030sr Page Z" of 3 Municipality of Anchorage 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 Legal Description: Lo j L ,dGlc Z 5 f`� >yIP� a,J 9—&J PID No.: w4 zo -- fo 40 0� 72-013 A (2/91) MOA 25 :5`,it/ 1 roe - IES -Tc-, C(_F_AN - 0 v7 __ FRor Poor TO Ta. -30 i o" 32, o„ #, 32 4! FROty\ P01QTg) "R3: 5" 4 # � f,'qL 6ff 60'-F316o la .I 72-013 A (2/91) MOA 25 Permit No. 'S(*V 22.6 30� Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 9 Anchorage, Alaska 99519-6650 9 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: (.QT_ P. P, rz-OHNNa- PID No.: sar - z 1-6 of Fl. 4" PEAV. PIK. - LF-VSL EL&V — 9 S F -C711 01-4 C — C_ z, - 6/, tooaA F, -A�A v 55,ex or lcar r-6 TV F .4- cllv'1\5v4 64 -,Roe, - P-00 OC- Fiei-D , I OZ�lq P1 72-013 A (2/91) MOA 25 Permit No. :S 1 z6 % Q Page of Municipality of Anchorage 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 Z l,l� � SFAMP�S00 lA_7 Legal Description: •- � � �-=- 45 PID No.: ell � 0 tai � �Q J._ i f �i i 1 T oQ�( O ®*y: 49TH ee� �. � /••es eoeeseeeooa� ei 2a 00e•eeoiiooae ®®THOMAS 0. FLODINd ®�°e• Ci7009 eo° Ar 0000,4000 72-013 A (2/91) 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW920305 DATE ISSUED: 9/23/92 DESIGN ENGINEER:O & E ENGINEERING, INC. EXPIRATION DATE: 9/23/93 OWNER NAME:LESTER, RICK J. OWNER ADDRESS:18120 HARBOR PT. LP. EAGLE RIVER, ALASKA 99577 PARCEL ID:05105353 LEGAL DESCRIPTION: SAMPSON ESTATES BLK 2 LT 2 LOT SIZE: 41639 (SQrL. FT.) NUMBER OF BEDROOMS:"THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: DATE: r2 S' - 9 z_ I SSUED BY: c � DATE: Cj — 2, 3 f 2— 0 & E ENGINEERING P.O. BOX 671651 CHUGIAK, ALASKA 99567 688-3941 Sep;tenht:er 10, 1992 Rick Lester 18120 Harbor Point. Loop Eagle River, Alaska 99577 RE: 'Septi.. System Design Jarhhpson Estates - Delilah Circle Lot 2 - Clock Dear Rick: THOMAS FLODIN P.E. STEVEN FLODIN P.E. L?uri ng the perTi=d oTUaU-:t 'l', 199through August -Z9, 1992, ourfirmconducteda :soil: i nvestir ation and septic system design for your propertla on Delilah Circle; lot 2, block 2`017 Sampson Estate_.. Field rneasur-ement s to neighbori rna }wells ariJ septic sha:terns revealed that adequate clearances exist bet•v:een those and your well and septic system. Thur, no �waivers on then: distances are requi red and no i mpact to ad acent properties exists. Ttie soils encountered in the vicinity of the proposed :optic system consists of silty sands arhd gravel vrith some clay/glacial till rnixed'v,ith rocks. This is Shown on the attached Municipality of A -c: harage 'Soil _. log. Groundwater was not enc�:ctuntered. 4' 1 have deter rninrd, the :tisterih de -sign is :j:. TIM 15:r_: M A`.IIMU!"1 TRENCH DEPTH -- 10 FEET TOTAL •`t'tASTEWATER LOAD -- 600I_PD (4 Bedroom) SOILS RATING -- 250 SFiBP ABSO RPT 1ON AREA -- 1000: F BACKFi LL DEPTH OVER TRENCH -- S to 3 FEET ( note z" rigid I nsulation is requi red over pi p; rug less than 4`I" 1 n depth.) GRAVEL DEPTH IN TRENCH-- `I FEET ` a&° TF:ENH LEriGhH TR.ENi;HL_IAl, l [10 F E E T I rl �;_::bTrt SACH :SEPTIC TAtIK -- 12 5 0 GALL0NS ' C C I r- 10 A R T M EL NT The re-,ultant .,cistern is sho`•,ti� n on the attached drawing. if uou have anti questions about tike design, please do not hesitate to call. Sincerely, Thoma 0. Flodi n, P.E. a�fsA� v 2 peaeaoso a i� : • • °Boords� •A 7 T1Ar • • eee•aoo•o•6 0 0 0°0 i •oseeeeovoeoeoomeoa¢asa� THOMAS o. FLoolrt;° �•• CE7009 r•:J rn �z cn n M $ r7l cm r 0 co C Z rZ M p z rn Z Field rneasur-ement s to neighbori rna }wells ariJ septic sha:terns revealed that adequate clearances exist bet•v:een those and your well and septic system. Thur, no �waivers on then: distances are requi red and no i mpact to ad acent properties exists. Ttie soils encountered in the vicinity of the proposed :optic system consists of silty sands arhd gravel vrith some clay/glacial till rnixed'v,ith rocks. This is Shown on the attached Municipality of A -c: harage 'Soil _. log. Groundwater was not enc�:ctuntered. 4' 1 have deter rninrd, the :tisterih de -sign is :j:. TIM 15:r_: M A`.IIMU!"1 TRENCH DEPTH -- 10 FEET TOTAL •`t'tASTEWATER LOAD -- 600I_PD (4 Bedroom) SOILS RATING -- 250 SFiBP ABSO RPT 1ON AREA -- 1000: F BACKFi LL DEPTH OVER TRENCH -- S to 3 FEET ( note z" rigid I nsulation is requi red over pi p; rug less than 4`I" 1 n depth.) GRAVEL DEPTH IN TRENCH-- `I FEET ` a&° TF:ENH LEriGhH TR.ENi;HL_IAl, l [10 F E E T I rl �;_::bTrt SACH :SEPTIC TAtIK -- 12 5 0 GALL0NS ' C C I r- 10 A R T M EL NT The re-,ultant .,cistern is sho`•,ti� n on the attached drawing. if uou have anti questions about tike design, please do not hesitate to call. Sincerely, Thoma 0. Flodi n, P.E. a�fsA� v 2 peaeaoso a i� : • • °Boords� •A 7 T1Ar • • eee•aoo•o•6 0 0 0°0 i •oseeeeovoeoeoomeoa¢asa� THOMAS o. FLoolrt;° �•• CE7009 r•:J -A rr < F D ro LN 11A 0 f ,n 0 in VN V� D LA rri jp, ul rn I m la o ,,I Ij m 33 t1 M in LD �g r 1, r r Q ni Ln • e • • e a t�D TOQ• � � e � t i A ai 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: oc< LE t GK DATE PERFORMED: M ,fwhW7 ej �.®o.000ee®oseAe.e©ao THOMAS 0, FLOD 1 rd a u '.• CE7009 /3 LEGAL DESCRIPTION: LCAI 2- �LC(44� Z Township, Range, Section: 7/S- AJ, R3 W N!/z 59C, DEPTH Sf}/hP„O,\J 24-5'TAFMS SLOPE SITE PLAN (FEET) 1 3 Vt.- 4 s 0 4 5 6 v 7 A 8- q 10 11 12 13- 14 3 14 15 16 ` 17 81920 18- 19- 20 COMMENTS -rr-,S-k— A r ,&A zao sr'/8p, Ilrp3• s>=/6J . G-1'SM 51 OV / &LAC, 4(- JILL 1 ylq�o w l l rl WAS GROUND WATER fC>0kL., j ENCOUNTERED? i IF YES, AT WHAT DEPTH? Depth to Water Aller Monitoring? itJ r� s L O 6 P E Date: $'25 -91- Reading Date Gross Time Net Time Depth to Water Net Drop lei !O S /0 41/4., 3 IO '/ CP '' /0 a / , .3j A,:• /S la S 1 3 9 r a) i 7.. —5y /U 6 3 I ' v S /0 9:SS /L) 7 1 „ PERCOLATION RATE �7� (minutesiinch)nPERC HOLE DIAMETER 6 / TEST RUN BETWEEN -5- FT AND `� FT /x/1.7 -,T�flh/1 // 2+T r- /) 9 z S'r7 S9 1441 i . 6 &P0/ PERFORMED BY: % 'y,"&S lfcoo l 'i'i 2 wa, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:—�'z" 2,Sq %LLS 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST Ycv I ®OOp00pOGC Ofj�g0r, loos eoveeevvv0000eevevp•�a¢ oo HOMAS 0. F"LOOIN� PERFORMED FOR: 0c< LE6 t 60, DATE PERFORMED: LEGAL DESCRIPTION: 1-61 -2- 6LOC4e- Z Township, Range, Section: 7/S'nf. R3 SRmPsa+U ESTA-'TLS SLOPE SITE PLAN DEPTH (FEET) ^(� Cr141Jt�S 1 lJ rt, 2 3 4 5 6 7 v 8 1 9- 10- 12 10 12 J v 13 40 14-6 15 ii r 16 17- 18- 19- 20 71s1920 COMMENTS CSM 510`1 G(L.AUL.I_ GGGM / 5 m st c71 / <-0�V1ru A(- 'I -ILL ii'k4 WAS GROUND WATER PookL.y C,,,,L" W ENCOUNTERED? C44L -L) 1�? i,-- "C kS IF YES, AT WHAT DEPTH? 12 -) is' _ QJ---Z5i Depth to Water After Monitoring? i$ Z ■■■■■■■■■ ■■■EN■■■■ mdeFONENEENEEM I. Reading Date Gross Time Net Time Depth to Water Net Drop —ZZ -yL ID ' O� .r + /0 :0S /0 %40 5 -7 31 S!/ ° 0i PERCOLATION RATE 2-0 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN S FT AND (0 FT -7 LA. . _ �,-P0 /5,a 2 66\ J PERFORMED BY: ? / AIAJ R-00/ IVV I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Z •� Municipality of Anchorage ®O°•O %a°®oo°°a®3o°9=° DEPARTMENT OF HEALTH & HUMAN SERVICES ®6 im°�'�uY < A°°°®ip090mC9ne°e 825 "L" Street, Anchorage, Alaska 99502-0650 99® HOP9A5 0. FLOD I N I- r SOILS LOG — PERCOLATION TEST �m °°°°90 CE7009 God ' eo..o°ooa ,4d' PERFORMED FOR: 1 G� ��� 1 Gri. DATE PERFORMED:''" 'i Z LEGAL DESCRIPTION: 1-ni -2- r3Loc4- Z Township, Range, Section: 1 /S A) , DEPTH SRMP-a .7+�J �5TAFMS SLOPE SITE PLAN (FEET) 1 J 2 �i4 3L V ' 5� 6 v ? 7 9- 10- 11 10 11 12 13 r 14-- 15- 16- 17 4 151617 18- 19- 20- COMMENTS s1920 COMMENTS C --K - 51%�l 6-ri-U1JI&L 2,13 s r- ( 6 P-. NUT. zz.s- 5c- j R(-, Gv"I is (V\ s1 Or(/ CIL&Y 1 Cs i,o4C1 roc- TIL PAVY-i=-O w iT►+ PDOP Ly ■■■■ ■.2■■ moloo ■.1■■ ■9I■■` ■N1■■ ■110■ ■,1■■ ■is■■ promo C'4L&iJ&1-( ,c.4cl�s WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? yT )Li Depth to Water Aller Monitoring? gbTMVVN to 1- -j-e-ST' }Ad(q- ■■■■■■■■■■ Reading Date Gross Time Net Time Depth to Water Net Drop i.as s s'' 3 ii 13S S PERCOLATION RATE -70 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 4Z FT AND .S FT R,po- r oC- Z S /b4. 1 6 y0/5F) c.'� 0��� PERFORMED BY: r /'� �"S �w!jA I CERTIFY TH AT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: D -LL ` Z'" t ;4'd Municipality of Anchorage 4 coo8000 0OGaAi©O�€GOtGOO�oO`oODEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 o&0a�aG" y GeG_ 9, SOILS LOG — PERCOLATION TEST%HCVAS 0. FLORIN o 0- CE7009 PERFORMED FOR: RN c< LE►J t so, DATE PERFORM D� '� L LEGAL DESCRIPTION: '2- 6LaL4,:�� Township, Range, Section: 16 tj , R Z W q �, 5gC, -3 iQ F_ b-�T SLOPE SITE PLAN MENNOWN—M ■■■■■■■R■■ ■■■■■■■M■■ MEMENMEMEN 1114 ■fil • SMR We ra •`r�i iil� 11%_ CMI N ■■■■Iiffil�a�W ■■■■■■EMSE NEEM■■■■■■ ■■■■NOMMEN ■■NEEM■■■■ 2 3 4 `- — 15- 16- 17 151617 18- 19- 20- COMMENTS a1920COMMENTS u &P4- - s i C -P-/ 64-A vf�, -TSS 1 0 t,A 2_2A6 SPI !SPL Allo . — z:, -b sl✓/,arc. 6�1vw1 s5 !& /6LAy�� -r lL,L w iTI4 PwILI-y Cwt -r.>j-v%'ii­ � WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After Hata. Monitoring? �^ 4 0 ■■■■■■■■■■ Reading Date Gross Time Net Time Depth to Water Net Drop 7 it -3 41114_ 3 1 L'..30 '14, It L'• 35- ; / 5 1Z:yo SS -3j-4,# 3 ' ,o 121, us, s,2/t, 7Z;Ss" / : O d J' , 6" PERCOLATION RATE `� (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND 5' FT n. I Iii-'!1c2x] s j)A,., j\' PERFORMED BY: �N%eVS ® 6 0JA) I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /�— ZZ —(72, 7IS7 ;LQS s1�)`Za3c3s- Crrrt140 irb 43rilltng ern by IECEIVED DOC Co. dba SULLIVAN WATER WELLS DEC 41992 P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.27 Municipality of Anchorage ept. Health & Human Services OWNER OF LAND #� i c ; a' , DEPTH OF WELLj-- ADDRESS LY . f -' H4 613 `' % / - 42 ` �` STATIC LEVEL OF WATER FT. LEGAL DESCRIPTIO i` } ,`DRAW DOWN FT. DATE, - Started Ended ! ,fey GALS. PER HR KIND OF CASING PERMIT NUMBER KIND OF FORMATION: From Ft. to Z Ft. Froin Ft. to Ft. From Ft. to �7 Ft 1 �'" i `:`� From Ft, to Ft. From f` Ft. to ` —!Ft. r °i c ;., C -a , y'r C=,-V'From Ft. to Ft. From Ft. to I' Ft. + i �, - =� 4'From Ft. to Ft. From Ft. to Ft. } From t. to Ft ` i " Ft %'i• " ' `4' From Ft. to Ft. From i Ft. to <. From Ft. to Ft. From Ft. to —'Ft. From Ft. to Ft. From - Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. — From Ft. to Ft. From Ft. to Ft. From Ft. to FY. From Ft. to � Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From1Z-E0 ' EwtE, - From Ft. to Ft. From—Ft. t - od�►�Ft.,(/r� — Ft.QE xi)p92 From Ft. to Ft. From From nn�rtiu lma ity Ot chorage From Ft. to Ft. „_ ,,� sHuman MISCL. INFORMATION: DRILLER'S NAME ; MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES] Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage. Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 0, j y3 6-3 1. P 4. GENERAL INFORMATION HAA # t J �9 �C > 1 2) Complete legal description Z T # Z A&ocl& # Z .SdiYAS6,0 561-Hj�S 1 11; >J k 3 VV w''/2 5F -C :i* 3 Location (site address or directions) 2�ze!f9 Property owner «%k- 44o �YAA)CT- L.&Siff. Day phone C/ – Szizv Mailing address V, O t &Y, 6-762S 3 9'9S& 7 Lending agency Nby-714(AWD M0a:1 C'A F_ Day phone �Y?L Mailing address 1 Ju1Z1 UL>o /Lfj)j5�� +r–, 9L7s7-2 Agent '7 1514 g,&5TK)&L- Day phone 6'11-717-. Address ilclLJ 01-0 14")y F%i4Ccg It.►t.Ar=,L A -k.- qc/s 77 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site x 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 N21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm a + E G,t)G-jkoC3, 9,P,I )' 6— Phone 688` -;cl q Address R. r2 J cb X 716cS� Engineer's signature 6. DHHS SIGNATURE Approved for d'% bedrooms. Disapproved. Conditional approval for Additional Comments By: rG�` rp Vk k vkk Date 3 - 7A -513 bedrooms, with the following stipulations: 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 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 Municipality of Anchorage Department of Health & Human Services Mk HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L0742-, 6aL-id z- ,J Parcel I.D. ©S-10 �_3'S 3 A. WELL DATA Well type L If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed 06L 07L Driller. ii Total depth—1 781 - Cased to % j� Casing height Sanitary seal (Y/N) yZ -s Wires properly protected (Y/N) y1t;1S Date of test Static water level Well flow Pump level FROM WELL LOG �T. I Cit /0-3 / Za 9.p -m. /7®' AT INSPECTION /h/iYLGif /C! %_-3/1U !11'OP!-ITV nF W''H0KAUE ENVJkGNMFNT/,L _'ER` I -is AVISION 2 1993 2.0 g.p.m. /Z®` RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot is? / ; On adjacent lots Absorption field on lot �`-/ ; On adjacent lots /S Public sewer main �/� Public sewer manhole/cleanout J1 Sewer service line A/ Petroleum tank /I/ WATER SAMPLE RESULTS: Coliform Q Nitrate ae�trYlel %� M%) L Other bacteria Date of sample: -) - 9.3 Collected by: B. SEPTIC/HOLDING TANoK DATA // Date installed OCT 15517 Tank size )ZS—0 644• Compartments Cleanouts (Y/N) ��5 Foundation cleanout (Y/N) y 5 Depression (Y/N) A)0 High water alarm (Y/N) Ai a Alarm tested (Y/N) Date of pumping E1J >t7 546717 1 •- F)U" Jr063W Pumper Wi7)f w0c,(- PLD. 7W5 % . SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: )�7 On adjacent10L. �7� Foundation Well(s) on lot To property line Absorption field Water main/service line Surface water/drainage / 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent(Y/N) High water alarm level — "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water Date installed ®�.1 1 `t a Soil rating d �� �4?•1"% System type �0��' Length 2 612- Width 2 ' 6 Gravel thickness Total depth 'Total absorption area / L 4-C) 5 • F. Cleanouts present (Y/N) y91 Depression over field (Y/N) V0 Date of adequacy test � " � ° 5' 3 Results (pass/fail) f -,4 -, for F-U"tom bedrooms Peroxide treatment (past 12 months) (Y/N) 10 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ! / q On adjacent lots Z 3,S Property line 1 2t'— 6 To building foundation ?) To existing or abandoned system on lot Ly/ A On adjacent lots 3Z, ' Cutbank rV / 14 Water main/service line tv/ Surface water sJ IZA Driveway, parking/vehicle storage area 6G Curtain drain tv E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature A/Z4WLt%,, i1 iC s Engineer's Name 77 -JO M✓-t.S Date HAA Fee $ / Waiver Fee: $ Date at Payment Receipt Number qF41Y Qa Date of Payment Receipt Number NORTHERN TESTING LABORATORIES, INC. - - 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 4563116 • FAX 4563125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 2778378 • FAX 274-9645 Jan & Rick Lester P.O. Box 670753 Chugiak AK 99567 Attn: - Our Lab #: A122654 Location/Project: Sampson Estates Your Sample ID: Lot 2 Block 2 Sample Matrix: Water Comments: Lab Number Method Parameter -------------------------------------- A122654 EPA 353.3 Nitrate -N Report Date: 03/18/93 Date Arrived: 03/12/93 Date Sampled: 03/11/93 Time Sampled: 1000 Collected By: JL * Definitions * B = Below Regulatory Min. N- Above Regulatory Max. E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Units Result * MDL --------------------------------- mg/l 0.5 0.1 Date Date Prepared Analyzec ----------------- 03/17/9: