HomeMy WebLinkAboutSCIMITAR #1 BLK 2 LT 45
' 4
DOC Co. doa
IER WELLS
'SULLIVAN WATE
P.O. BOX 670272, CHUGIAK, ALASKA 99567 ^ TELEPHONE 600.2759
Cl
OWNER of LAND. r1 f;s
ADDRESS ter, f' �• ( - ly ,}f, rry'°7 ill
LEGAL DESCRIPTION 1
Endedi'�'------
DATE . Started, - --- r
PERMIT NUMBER --
KIND OF FORMATION:
�F t.
From -b --Ft. to z' -
From—{f�Ft, to. — Ft, ;�t ? 1'
From `,) Ft. tom -FL -7
a
2
I)EPTH OF MA -1-
ST \Tl('
[LLST,\TIC LF\'EL OF WATER FT. a ti "------------
DR:A�ti DOWN F- F.
GALS. PER HR
KIND OF CASING
t..,:,) FI. t()_t:i ��r �3_Ff �.iLd='.yJ i.i fair f.-•_c�:� ___..__..
Frain
From -----.Ft. t0 ---Ft'_-
From___ -_-Ft, to __FL..-
From_____ --Ft. to
�, 7 - ! From__ -Ft. to__.._..T F t. --
rr , t7;.Ora o"`
d, Ft. to,�-Ft - - -- MUNICIPALITY OF ANCHORA--� ��i__-R
Fromm _ F HEALTH &
'•From ___Ft to-_-FI1lM
_Ft. to_,-; Ft f ENVIRONMENTAL PROTECTION
.>T
Frotn -, ,p f, 1 a i /. l:' _!1 'r ,_, From Ft. to -_FL
From__ ---Ft. to - Ft._•'_y , r _ �.G 8
8�ejf198
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n
t. 6.., ; c. ,= __�.f• C, From_ ---Ft. to—Ft.
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From._ Ft. to -
to --Ft-- _--_-- --
.
From Z3 Ft. to . }' From
Ft. _ --Ft. to --Ft
___--- - —
From—Ft,to_——
--- A_ s `•
MISCL. INFORMATION:
,rt Il i f a t..,.
ryttl I FR'S NAME
i>f - ------
-- From..----
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- Pt_
a ,
f "'-Ft.-
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-
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Fron,-_.- ._-.
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rr , t7;.Ora o"`
d, Ft. to,�-Ft - - -- MUNICIPALITY OF ANCHORA--� ��i__-R
Fromm _ F HEALTH &
'•From ___Ft to-_-FI1lM
_Ft. to_,-; Ft f ENVIRONMENTAL PROTECTION
.>T
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From__ ---Ft. to - Ft._•'_y , r _ �.G 8
8�ejf198
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n
t. 6.., ; c. ,= __�.f• C, From_ ---Ft. to—Ft.
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to --Ft-- _--_-- --
.
From Z3 Ft. to . }' From
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--- A_ s `•
MISCL. INFORMATION:
,rt Il i f a t..,.
ryttl I FR'S NAME
MUlit( ICiPALlTY OF HNCHORAGE
Department of Hea1th & Human Services
B25 L Street, Anchorage, Alaska 99501 343~���9ƒ
Permzi ':,mber: 880�58 Upqrade
Owi Ier Name: HLHSkA 11UUSIN6 HOUSING FlNANCE Day Phone:
^ ^ b94�4200
AN�HORHGL� Ak 99504
Parce1 id: 051^13�-]�
I Subdivisioo: SC1MlTpay #1 Lot: 4 Block: 2
Section: 10 lOwn ship: 15N F.,'. 1W
Loi Size 451�5 �sq.|�. o, acres>
p^^ �eJrooms: [his Permit: 0 Total Capacity: 2
'.,/st be submitted to Null icipaliLy o< Anchorage Dopartment oj Health
Services within 30 days of well comp1eLion^
�H!�, PERMIT EXP1RES 12/31/88.
i Ci|/iFY THAT:
�tar with the requirements {or on~site sewers and wells as set
''th by the Municipality o; Anchorage 1.:: at
install Lhe system in accordance with all MOA codes and regulations
, and in comp1iance with the design criteria o� this permit. '
^. i will adhere to at I. MOA and State of Alaska requirements for Uhe set back
iancIm any existing well, wastewater disposal system or pub|ic
ewerag t or any adjacent or nearby loL"
�^Idnor r01
ermit is valid for a maximum C') 0 bedrooms. I
�10o under capacity o| the total system is 2 bedrooms and
� ,r.1arg i ermit.
�f --�--~--
'Uwner/ ALH"k HOUS1N
"z��~~
U)
Aw
10
11.R. •
y
ry S
MUNICIPALITY OF ANCHORAGE
i DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
\ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
___ z jenc,/fes r -
RSS
MAILING AD DF ...
LEGAL DESCRIPTION `1 Al
t
K NEW
❑ UPGRADE
LOCATIONNO.
OF BEDROOMS
LJDISTANCE
x
NallAbsorption ar
TO: �� s 1
Dwelling ---
qf
p
F- Z
LU
rn
Manufac r
Mate�y71
No. of cowartments
Liq.capac't in.91 I
IF HOMEMADE: Inside length
Width
Liquid depth
o Y
J t7Z
DISTANCE TO: Well Dwelling
PERMIT NO.
T F
Manufacturer
Material
Liquid capacity in gallons
G
w g
U
Well Foundation
DISTANCE TO: G; Ne rest I i
t
pE O6
~
No. of line $ Length a lige Total Isrwtl�.Qf ly nes rent witp
6-Materrte(,
Distance between lines
Q h
p:
O
Top of rile to finish rade r F
9 ial beneath the
i
Total
Total e ecyga wption area
w
Shells;
LengthWidth Depth
PERMIT NO..
C7
Q I-
LU a
Type of crib Crib diameter Crib depth Total effective absorption
area
w
rn
DISTANCE TO:
Wall
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
LU
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATE IALS
SOI I_ TEST RATING
STALL R
REMARKS
L
r
ROVED DATE LEGAL
72-013
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological A Geophysical Surveys
LOCATION OF WELL (please complete either la, Ib or to.) Drilling Permit No.A n I N�
Ia. Borough Subdivision I.ot Block
Section No. Town ehiP Range V Meridian
Fb.I/qq}rs.
N ❑ E
_of—of
Sn WE]
Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
3. OWNER OF WELL:
Address:
Street Address and Area of Well Location
-
2. WELL LOG Feat Below
4,
Surface
WELL DEPTH: (final)
5. DATE OF COMPLETION
Material Type Top
Bottom
-- ft.
6, a:.Cable fool Rotary Driven D Dug
-�
Auger ❑ Jetted Bored ❑ Other:
7. USE:�Domestic Public Supply Industry
- --
Irrigation Recharge Commerical
❑ Test Well Other:
8. CASING: D Threaded Q Weldetl
r
diam. in. to—� ft. Depth Weight-" Ibs./ft.
diam. in. to— ft. Depth Stickup ft.
(
9. FINISH OF WELL:
r„
Type' -” Diameter:
Slot/Mosh Size:Length:
Set between i-tt f}. and _ ft
Bockfllling Gravel pack
10. STATIC WATER LEVEL:
Above or D -Below land surface Date
Equipment used
11 . PUMPING LEVEL below land surface and YIELD
]
_1t. after - hrs. pumping g,p.m.
\"f
ft, after hrs. pumping _g, p.m.
/r>1`
12, GROUTING Well Grouted: Dyes 0 N
MUNICIPALITY OF
Materia l: D Neat Cement D Other:
—eF
_ _ _
IRONME.NTAL PR TECTION
13. PUMP (If available) HP_
Length of Drop Pipe ft. capacity g, p, m,
-
Q Subm. 0 Jot ❑ Cenlrifical Other
14. R E ht A R K S --—
16. WATER WELL CONTRACTORS CERTIFICATION:
------ --____
__
15_Water Temperature ._a F C
This well was drilled under my jurisdiction and this report is true to
the best of my knowledge and belief;
Registered Business Name
Contract License Number
Address: --
Signed
---"-
Authorized Representalive
'-- •——'-------------�--
Form 02-WWR (II/81) Copy Distribution: WHITE "Slate
DGGS, PINK - Driller, CANARY- Customer
�L.1 r-4 1 0 1 F=n F71 o I -T- Cl F= ����������n��
DEPARTMENT
HEALTH AND ENVIRONMENTAL OTECTION
825 /L STREET/ ANCHORAGE, AK 9%01
264-4720
CN"_—�-- I _rFE-
PERMIT NO. ( 820810 )
APPLICANT BEETER CON5T
LOCATION
LEGAL L4 B2 SCIMITAR
TYPE OF SOIL ABSORPTION S -Y. -STEM IS
(/:/]/J'
�
'
SRH BOX 1546E 99507 /-�)l-0��
\`
��
TRENCH
LOT SIZE
MAXIMUM NUMBER
OF
BEDROOMS =
]
SOIL RATING
(S8 FT/8R)= 85
THE REQUIRED
SIZE
OF THE SOIL
ABSORPTION
SYSTEM
IS:
U-14 LEE c7i -v EE L_ E -m I—= P, -r�� �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD
THE DEPTH �M TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE �
GROUND AND OTHE BOTTOM OF THE EXCAVATION (IN FEET)
THERE IS NO SET WIDTH FOR TRENCHES �
THE GR��YELTTOM DEPTHFISHTHEXCAVATION MINIMUM DrIN FEET).
EPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BO
R -4 lE 'C"! I F-, F-:- ���-r I c:_ �gg r_4 t ����� ���(�� ����������
PERMIT' APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
^.~."LLINSPECTIONS'".IvnOF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--�LLH���� I�����-������� ����� �����������
v"�^r����muWu�L Nf SYSTEM �JITHOUT FINAL INSPECTION HND APPROVAL BY THIS
"Er"r/ocn/ WILL BE SUBJECT TO PROSECUTION.
1YINIMUMDISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i°"N.EETFOR ArRYM�� �|WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
vru THE TYPE OF PUBLIC WELL
MINIMUMDISTANCE FROM HPRIYATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO .. COMMUNITY SELINE INE lS 75 FEET
�1ELLLOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENTNITHIN ]0 DAYS
OF THE WELL COMPLETION.
OTHER
HREQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
TO INSURE ��QPROPER INSTALLATION.
F::'E-- F: rel I -F ' -4 F:' I F;;! E�!E; 0 F=�������-
I CERTIFY THAT
1:IHMFAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH py/HE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CQDES
IUNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE�ENLHRQEMENT IF THE
RESIDENCE 15 REMODELED /OINCLUDE MORE THAN ] BEDROOMS,
GNED
APPLICANT BEETER CONST
ISSUED
��DFlTE
���^~V4.0
// /
S
& 0, GINEERS, INC.
3
7125 OLD SEWARD HWY.
ANCHORAGE, ALASKA 99503
❑ SOILS LOG
349-6561 PERCOLATION
MUNICIPALITY OF ANCHORA TEST
SOILS LOG — PERCOLATION �99T' h I. /
7 1962
PERFORMED FOR: f• � ER[Vf /
LEGAL
DESCRIPTION:
Z—OT+T� iC]Inc-N 6.
`mac
• Ci •,_, t �1 r' q{IQK . C. ACA r r-; t•,1. 1
rev EryLP-T
e-ul,n Son{c�e
• GI OO
�� .J0. �1 !JL^
14�a25/O;ta-/
7
rave I wl5esKc Sa-.j
-T—r,, c- e. -5i 1•i• 6 3e7e
3-0.
15
/i%Ntstn_rotis CeLbJes1
`4C
o
�a,
4 J tG0.112tt A. I 15eNI Crs%
OFAiC.�„�
r
bQ
�ira.tic,C {''irewln,.
Qbb.
5
np'.do
p(�
• 5 121 Gravel 4,5 --,Le .9.J
6
18
< 3e7n I Nubs rekS
o �,
w Co 6bles Gray
/
i> a,o
19
12
113' Vi3tAml Per, KJ-armcQ
W
SLOPE Z
SITE PLAN
st
WAS GROUND WATER S
ENCOUNTERED? lyn L
P
IF YES, AT WHAT E
DEPTH?
Reading
01,05
;o , 0
•p ,pe
/ go,
/� •� 1�areuer
13
"p ®, v
e-ul,n Son{c�e
• GI OO
�� .J0. �1 !JL^
14�a25/O;ta-/
•n,
15
,
OFAiC.�„�
r
16
17
18
T. 0.
n
o d-1': 4. SiYr}Iry s '.
)l)w` : (r' (Ia1P 91 1Sn`i �' 1
P t
19
e t
o3n° _�zi
i�laQ -I: 4�
20
SLOPE Z
SITE PLAN
st
WAS GROUND WATER S
ENCOUNTERED? lyn L
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE it"c 14a-/ (minutes/inch)
�) TESTT RUN BETWEEN (I _ FT AND / FT
COMMENTS I//S�QQ_� ��/•c l�er7"er�x2�d� cV,ufJ�,r/sc��.b�C .sc�/ /. C.��J
i
72-008 (6/79)
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. # �S - (� - I HAA #�5,
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 4; Block 2; Scimitar #1
Location (address or directions)
(b) Property owner A.H.F.C. Tel • (home) (Business _
k1 !J kCL'�/U CLi 1 �_Tpl .1
Mailing Address 520 E. 34 h AnchQraq
(c) Lending Institution Western Mo gage Telephone
Mailing Address
(d) Real Estate Company and Agent —RB/max - FVa l�kan
Telephone
(e) Mail the NAA to the following address: (or check here if hold for pick up.)
List contact person and day phone number below:
5A 5 ENGINEERING
17014 Engle River OOP Read{ NO 90.4
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family 12 Number of bedrooms
3. WATER SUPPLY
Individual Well ER Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site Cl 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 validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. 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 Telephone 11* f Z�ppr
s & S ENGINEERING --
Address 17014 Eaale River Loop Road No. 204
Eagle River, Alaska 99577
Date 12 X��.
,mom s'4
t bp(f A. Shafer l (y+
• yr
NO, 1467-6 i Ci
C�`,••o • !� .6.
FE
6. DHHS APPROVAL /
Approved for bedrooms by -G� �Date / zS -� /G
Approved C< Disapproved Conditional
Terms of Conditional Approval
wpm
wTrr
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do riot conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) OMNI
Health Authority Approval (MAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: �
A. WELL DATA
Well Classification 1 tJ V t7J /--L-- _If A, B, C1, D.E.C. Approved (Y/N) a C�
Well Log PretSentN) _ Date Completed 1 ` X17 �8 Yield
>;
Total Depth -Cased to'� _-� Depth of Grouting
Static Water Level td� t — 11 S 7 Pump Set At
Casing Height Above Ground 12th -F- Sanitary Seal on Casin dVN) v
Electrical Wiring in Conduit&Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
g
Depression Around Wellhead (Ydp
; On Adjoining Lots l �dt
I
To Nearest Edge of Absorption Field n Lot \��� k ; On Adjoining Lots CJI 4 -
To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole rJ1/11
r
To Nearest Sewer Service Line on Lot Z,G `1._
Water Sample Collected by S !k S t r z t JGi Date
Water Sample Test Results
Comments _2k_t rJf-cqn �/.�') Wim,
B. SEPTIC/ LG_TANK DATA
Date Installed9-�-Size No. of Compartments
2_
Standpipes (-Y7N) Y_ .Air -tight Caps tel) _Foundation Cleanout (Y/dam
Depression over Tank ()(�M rA DatLt Pumped \�
Pumping/Maintenance Contact on File 3Ea:iding
; for
Holding Tank High -Water Alarm (Y/N) Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
I
To Water -Supply Well ��—O To Building Foundation
t
To Property Line \ `~ To Disposal Field
To Water Main/Service Line L b I }
To Stream, Pond, Lake or Major Drainage Course \ ao 4-
Commentsy � '1
72-026 (flev. 7788) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 8��/P,�R — Type of System Design
Date Installed J
Length of Field 2�
Width of Field Depth of Field \ �- I
1
Gravel Bed Thickness
Square Feet of Absortion Area _� ��� Statndpipes Presentq! 1A
Depression over Field (YID rJ Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well d To Property Line o 14-
10 Building Foundation
Lot 0
To Water Main/Service Line �, \ J, -
To Existintq or Abandoned System on
On Adjoining Lots
To Cutback (if present) ~�
To Stream, Pond, Lake, or Major Drainage Course t �o ( 4 -
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Da tailed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
SI -k-
- Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, verified, or
inspection. conformed to all MOA and HAA guidelines ii
Signed—�SRN6INFER'
Company 17034 Eagle River Loop Read No. 20,
Eagle River, as a
Date 2 e,5: -
MOA NoCE
Receipt No. oA&� '� W
—�,y� / Receipt No.
Date of Payment �C �/ r Waiver Fee: $
Amount: $ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
es during Adequacy Test.
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 562-2343
FEDERAL TAX ID N 92.0040440
ANALYSIS REPORT BY SAMPLE for Work Order B 11390
Date Report Printed: JAN 23 89 @ 12:10
Client Sample
ID:L4,
B2, SCIMITAR
Client Name S & S ENGR
PWSID :UA
None Detected
See
Sample Remarks Above
NA-
Not Analyzed
LT -Loss
Client Acct SNSENGP
Collected JAN
19 89 @
18:00 bra.
P.O.# NONE REC D
Received JAN
20 89 @
15:00 hrs.
Req M
Preserved with
:4 DEG.
C
Ordered By : RJS
Analysis Completed :JAN 20 89 Send Reports to:
Laboratory Supexv s x STEPHEN C. EDE 1)S & S ENGR
Released By : v G �-4 / 2)
. __`.'................— ........ __..........
Special
Instruct:
Chemlab Ref 8: 4035 Lab Smpl ID: 3 Matrix: WATER
Parameter Tested Result/Units
---------------------------------------- ------------------------------
NITRATE-N
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECTED BY RJS.
ND(0.10) mg/i
Method
-------------
EPA 353.2
1
Tests Performed
See
Special Instructions Above UA -Unavailable
ND-
None Detected
See
Sample Remarks Above
NA-
Not Analyzed
LT -Loss
Than, GT -Greater Than
Allowable
Limits
10
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date 6/4/86
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
1.nt 1t Rlr 2 fir mi tar T15N R1W Sec . 10
Location (address or directions)
(b) Applicant Name _Graham Ya g Telephone: Home N/A Business 276-2761
Applicant Address Ramax 0,nn Cnaoya Anchorage .
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other ® (explain); Realtor
(d) Lending Institution Northland Mortgage Telephone 6911-7872 _
Address - 400 W---T'-ud.QV Anchorage, Ak 99503
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
picku"_y a n n 1 i n a n t ---
2. TYPE OF RESIDENCE
Single -Family ® Multi -Family ❑ Other
Number of Bedrooms 2
3, WATER SUPPLY
Individual Well ® Community ❑ Public ❑
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite E] Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025(11;64)
F ENGINEERING FIRM PROVIDING n4SPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. 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.
EAGLE RIVER ENGINEERING SERVICES Telephone —
Name of Firm ---EAGLE-R1VER, Ai_9
.� .. .. r.,, -r-r nA
Address
694-5195
Date
.r' e• f'1 i r.
r(r r�•
� "" t^uls A. 9v;sra Engineer's Seal
w CE -61,315
6. DHEP APPROVAL
��,��) Date
Approved for /=s'— bedrooms
Approved Disapproved Conditional
Terms of Cond tional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of horses and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
11_nos nvnA,
muNIUFALI I Y OF ANCHORAG2
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MO..i ENVIRONMENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) JUIN 0 5 19W
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: C'�/'�'�
'�
A. WELL DATA
Well Classification �/��� %yA 7-C If A. B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) — Date Completed -' 3 — Yield 3/c9 Gc/lnis per 14"
/ PrrF, c r Co 7-CIr �
Total Depth '!;Z C) o / Cased to /s Depth of Grouting ✓�Q
Static Water Level 70 ' de/,rte Jud, _ Pump Set At
Casing Height Above Ground _L3' /ISanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) % Depression Around Wellhead (Y/N) A/
Separation Distances from Well:
4; /H Id; T k on Lot `-
To Sep c o Ing an On Adjoining Lots
To Nearest Edge of Absorption Field on Lot On Adjoining Lots/ou /
To Nearest Public Sewer Line _ w�� To Nearest Public Sewer
Cleanout/Manhole ��� To Nearest Sewer Service Line/on Lot
Water Sample Collected by ole' Date �/ `�6 —
.SG
Water Sample Test Results �—
comments _2
B. SEPTIC/HOLDING TANK DATA
Date Installed / 62 Size 14O0'�9 G` / No. of Compartments
Standpipes (Y/N) y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N)—
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) 1 �� - ; for
Holding Tank High -Water Alarm (Y/N) !�� Temporary Holding Tank Permit (Y/N)--
Separation Distances from Septic/Holding Tank:
To Water -Supply Well
To Property Line y�o
To Water Main/Service Line
Course /7-//=1
Comments
Page 1 of 2
72-026(11/84)
To Building Foundation
To Disposal Field i
16 /
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata �S �`e
_ Type of System Design %rGl✓c+G
Date Installed 5 Length of Field _a D
Width of Field _ 3
Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area 3s -,Z lb
Standpipes Present (Y/N) X
Depression over Field (Y/N) n% Date of Last Adequacy Testes 6r6
Results of Last Adequacy Test Use _
Separation Distance from Absorption Field:
To Water -Supply Well / _? d To Property Line
To Building Foundation ::�, To Existing or Abandoned Systern on
Lot —/1-1114 '? i
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION - A
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
On Adjoining Lots – o
To Cutbank (if present)
N/tee
.9/
Dimensions _
Manhole/Access (Y/N) _
"Pump Off' Level at _
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
"" Check Permitted Bedroom Rating Against HAA Request ""
I certify that I�have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company MOA No.
Receipt No. -- 29 616
Date of Payment _ __J
Amount: $ io
Page 2 of 2
72-026 (11/84)
P `t
i
r aP�gineer's Seal
� f �
_J:
CC X736 g � %9Dsrt
APPLI
Ni FILLS ®UT UPPER HA'_ONLY
Time
Properb/ O.•mei
Date
Phone
Mailing Address (ll�� -
'. Zip Code
:: /_j C
Buyer. {, c -;r . ,,..,
Inspector
Inspector
Address
Zip Code"� `� -.i 6"
Lending Institution - V�lt't/=�-. � i
-�1' 7 t _
Phone
Field Notes:
MUNICIPALITY OF ANC IORAGC
Address �% �!� , i f >r�
/, f J c. Zip Code
e
Realty Co. & Agent "),
T
Phone
Address
Zip Code
Legal Description /_ -�- -� i
Street Location
Type of Residence
[7`Single Family
'�
171 Multiple Family No. of Bedrooms
'CONDITIONS OF APPROVAL
❑ Other
if monies are
escrowed -to have the exposed wiring
Water Supply
On the well be placed in conduit and the well
z._`
seal tightened so that it is water/air tight.
El' Individual
This will need to be reinspection after completion
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
Well To Absorption Area -. „
Well Log Received
Seweerr Disposal
T
Well to Tank
r Individual
Year Individual Installed:�-
❑ Public Utility
When 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
Date
Inspector
Inspector
Inspector
Ins ecto ,
IC t) ),�)u
Field Notes:
MUNICIPALITY OF ANC IORAGC
yr
e
r
(
ENVIRj;'� _r'. ��t1[ON
. _.'f
e'
( ) APPROVED BEDROOMS �,
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
if monies are
escrowed -to have the exposed wiring
( G��ONDITIONALAPPROVAL'
On the well be placed in conduit and the well
z._`
seal tightened so that it is water/air tight.
DATE
This will need to be reinspection after completion
BY:
of the work by this office.
C/
Soils Rating
Date Sewer Installed
Well To Absorption Area -. „
Well Log Received
T
Well to Tank
--
Septic Tank Size
72023 (3164)