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HomeMy WebLinkAboutSECLUDED HILLS BLK 2 LT 3Secluded Hills Block 2 Lot 3 #017-343-11 MUNICIPALITY OF ANCHORAGE • 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 NAME PHONE ON EW �J �1 p f3FTHARD CONST POCTION 3-4S 16/r ❑UPGRADE MAILING ADDRESS A 13 ox 10g9 k ANCHORAGF_ A�A51CA TIE07 LEGAL DESCRIPTION 1,07- 3 &,0CL< 2 `ECt_UDED Wlc,l._s , ORDIVISION LOCATION /, rt or -F: 13E{DGER G.ANE HILL-51W:AJ�rz� NO. OF BEDROOMS 14 Well /00 Absorptignar� -DISTANCE TO: Dwelling a J PERMITN�,®5_� Z a Manufacturer ^ Q�� ' Material Mial No. of compartments LW (Jis k, ATE E L-- �.. Ia. N length Li ca ac�y in gallons Inside len q.E�G IF HOMEMADE: g �% Width N Liquid depth j0Z DISTANCE TO: Well Dwelling o PERMIT NO. = Z F Manufacturer Material Liquid capacity in gallons w DISTANCE TO: Well /Q� ¢ Foundation Nearest Io line i PERMIT NO. © T t O �� ,Wj u. Z Fzw0 � No. of lines Length of nblpIine Total length of lines � Trench width inches Distance between lines ` ¢F. Top of tile to finish grade�� �j Material beneath tile ' Total effective absorption area 0 ,^ WASH 6RAVE I- inches (0C)o SLV F7" Length Width Depth " PERMITNO. ' Lu 0 4 H Type of crib Crib diamet Crib depth Total effective absorption area CL Lu N DISTANCE TO: Well X Building foundation Nearest lot line .] Class Depth Driller Distance to lot line PERMIT NO. ®� J LU � DISTANCE T0: Building foundation S wer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 41, CARLON SLAper evjor 43215 A r_`ALAE c " ('06 -"rrX 0N2W SE'fIC TRCNcN SOIL TEST RATI NG � k _ l,�D SCR TT �;R - - INSTALLER �- R6THAI0 (7^)W1T7RO TION - HO t s - REMARKS o e y 33' Gftf tj rt P E (Co VEREp 'N IS fb rEL-T 1 6VL-, oJ .S+Uv r) OGvn wTT83012 � core's 95 SIEPp 'C iJI� -Fvun a"lion tri Wpll w II ` OFA �ppepe®0.'. A i A0 L IV(: U)? Y 01 3` 7 to °JOHN G. S)WANSON= Q: �tit, APPROVED�F,n;�,yj LEGAL 'tDA,fE11 72-013 (Rev. 3/78) WATER WELL. RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological f3 Geophysical Surveys Drilling_ Permit No. LOCATION OF WELL (Please complete either Is, He or to.) A.D. L. No. In. Borough 5ubd�iy��lonr, Lot Block Ib. {/a gtrs. Section No. Township Snge- W❑ Meridian r'-�1�,tL,: f 7 f 1,_—of�of—of— ❑ ❑ Ic. DISTANCE AND DIRECTION- FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Address: Street -Address and Area of Well Location 2, WELL LOG - Feet Below q WELL DEPTH: (final) DATE OF COMPLETION Surface E5 Material Type Top Bottom ft. �- i "•t ll rt ,:1:>�i. O;.i �; -1 1 I 6.-[jCable tool Rotary a Driven Dug -❑ Auger © Jetted ❑ Bored ❑ Other! ::: 5'!'1.1,?L;;',; 7. USE: ❑ Domestic Public Supply ❑ Industry- Irrigation Recharge Commerical ❑ Test Well ❑ Other: ,? I " ^';, C r ,.y ;, i_' , - ;•;-2.a -( rh� t :. e :'sl '- 'l`. S. CASING: EjThreadod- Welded- — d(am. In. to It. Depth Weight 9 1bs./fI. diem, in. to _-ft. Depth Stickup ft. i;ri�'t_•�.,'s''1 ..0 i.,'i`j> 1„ (f 11 V-1 J.!'"1 +1 '.-I. i'. i. s: . - .' -77 9. FINISH OF WELL: Type Diameter, Slot/Mesh Size: Length:_ Set between ft. and ft. Backfilling _ Gravel pack 10, STATIC WATER LEVEL:_ it. - Date Above or Below land surface Equipment used — - I I . PUMPING LEVEL below land surface and YIELD ft.offer hrs.-Pumping �ig. P. M. ft. after hrs. pumping g. p. in. 12.GROUTING Well Grouted: 0s Yes ❑ No DEPT OF HFALTII In Material: ❑ Neat Cement [] Other: ENVI�AAE{ TAL PROTG TION 13, PUMP: (if available) HP _ Length of Drop Pipe ft. capacity g.p.m. � _ - Ej Subm. Jet Ej Cenlrlfical � Other IX L 6 !/ 14. REMARKS: -- - — — _--_ 16. WATER WELL CONTRACTORS CERTIFICATION: —------`V—^-- 15. Water Temperature F ❑ C of my knowledge and belief; This well was drilled under my jurisdiction and this report is true to the best Registered Business Name Contract License Number _ Address: /F / Signed Date 1...� /,fir, i../'+-.� _--_� Date Authorized Representative - - Form 02-WWR (II/81) Copy Distribution: WHITE -State DOGS, PINK -Driller, CANARY- Customer 1"HE F:ECKITRED SIZE OF' THE SOIL_ AE;',ORPTIOI'•,I Si-'STEr'1 Z -w EE_ „ . 1-+=- 9_. FEE N a-, i ...v N _I == �n IQJ awa F-" n w"IE fL_ E> EE_ 9=" 1 11.4 == EH; "ITIE L.D.I _ITI-I G' I MEI%IS. I• OhJ I :_; 'THE LPIGTH < I N FEET".[ CSE • THE TF:Er•,IC.Fl OR CRAP. -IF I EL.C'. 1-1 IE DEPTH OF' A TRErdCa-1 OF: PIT IS THE 1'.) I'ST]"INC;E BETI'.IE-EN 'THE ' URF•FI E OF THE CiF'C (JkIE:' Ar•d) THE: BOTTOM OF "rl-1E: E;;;CA%JAT I Ot..I ':: I N FEET). 'THERE IS 11h: SET WIDTH FOP' TF:EI'dt::HE:S. THE GP,A'JEL.. DEPTH IS THE Illhdll-8.111 t:'EPT'H OF GF.AVE::L BETIdEPI THE:: iWil_i-rF'ALI... F'IF'E" FihdD TI -•IE BOTTOM OF' THE EXCAVATION (U4 FEET). ]_ F;?. F�_7 E " = E:H. E- " -T_ I a T " G =11 PA IF—: " 1. "I=- _L. � s 10 a:_n B NIL..__ R_.. Nwa PA " PET",11 I T FIPPL I ClAtJT HAS THE F:E:_ PONS I B I E_ I TY T 0 I I'•dFt-�f::r'I THIS L:'EF'ARTP PIT CURING THE: INSTALLATION ION T hl T" PECI Or• S Cir-. ANY WELLS AC,IJA_:ENT TO TI -IIs PROPEF,TY ANI) 1 -1 -IE: NUMBER OF* RE.:IDEr•.0-:E'.F THAT 'THE kIF_•LI_. WILL ".—..--- --._ 7• 11-1111-3 _:^ I &' -1 w F" FE-. a__=11— 1 C-9 W -"Y n P? S -f a. 7125 OLD SEWARD HWY. ❑ & ENGINEERS, INC. ANCHORAGE, ALASKA 99503 �3 �ob 349 -6561[] 1 sl n11nN T} II til SOILS LOG 1'ER('OI.AT 1ON IES I 5s hex `?19 K J a`7,�,O 0 Pblil (11<ME11 f 01 —16 I)ATF 1'EI/(/1OHMF II _ LEGA 1. O E S C H I P T I O N _ �_ -^ �— SI OP( w SITE PLAN a 'roa s 2,%� � 4 b 5 6 -1 v Al - 15 16 At co o�a'y�Bt 0 a s� ,�.---,•meg.-���-- 20 l_ COMMENTS PERFORMED 0Y 12.008 (61)71 JOIN". SWANS(JN 1534•E 94 ao WAS GROUND WATER ENCOUNTERED) IF YES. AT WHAT DEPTH) �1 11IOl'. .s-naite( of &4. cke S O o r Rcad,ng Date Gross-_ Time Net _-_ T�mC Depth 10 Wale, Net — Drop g 7•a 13' p . 10 "� 11 12- 2 1a 14 Al - 15 16 At co o�a'y�Bt 0 a s� ,�.---,•meg.-���-- 20 l_ COMMENTS PERFORMED 0Y 12.008 (61)71 JOIN". SWANS(JN 1534•E 94 ao WAS GROUND WATER ENCOUNTERED) IF YES. AT WHAT DEPTH) �1 11IOl'. .s-naite( of &4. cke S O o r Rcad,ng Date Gross-_ Time Net _-_ T�mC Depth 10 Wale, Net — Drop 11IOl'. .s-naite( of &4. cke S O o r Rcad,ng Date Gross-_ Time Net _-_ T�mC Depth 10 Wale, Net — Drop Sp 4COLATION RATE /•J'S/_r.I a _Inunulcs/inch) ST RUN BETWEEN _—J FT AND �-� - FT CERTIFIED BY s�""_ �Dn TE:4� r lVi'�x Municipality of Anchorage • :e Development Services Department _ Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. n� `� - �13- I HAA# 05nS31J 1. GENERAL INFORMATION Expiration Date: olsji2 I o� Complete legal description SECLUDED HILLS SUBDIVISION; LOT 3. BLOCK 2. Location (site address or directions) 13301 BADGER LN * ANCHORAGE. AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address THOMAS KIM Day phone c/o TIM RHO w/ PRUDENTIAL JACK WHITE Day phone TIM RHO w/ PRUDENTIAL JACK WHITE Day phone 242-9662 3801 CENTERPOINT DR. STE. 200 • ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: im-10 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class 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 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 samples. (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 fs(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 riles 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG. Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSDSIGWURE ��1% ,/ Approved for __V_ bedrooms. Disapproved. Conditional approval for Attachments: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the following Phone 337-6179 Date 10 IJO.5- , ons-K Of((III t� l ' pN-$��IS��E -•�"�= NV T N' R mk5l jEO` _ WASSE_ ..R _-- Vel Maintenance Agreements '/ Supplemental Engineers Report Other By: Original Certificate Date: t ti 7- (Rev 12101) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 47W South Bragaw, St. P.O. Box 196650 Anchorage, AK 9951966W www.ci.anchoregs.ak.us (907) 343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SECLUDED HILLS SUBDIVISION, LOT 3. BLOCK 2. Parcel A. WELL DATA Well type PRIVATE If A. B, or C provide PWSID# N/A Date completed 8-19-1983 Sanitary seal (Y/N) YES Total depth 205 ft. Cased to 205 ft. FROM WELL LOG Date of test 8-19-1983 Static water level 140 ft. Well production 4 9•p -m- WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 0.1 mgJL. Well Log (Y/N) Y Wires properly protected (Y/N) YES Casing height (above ground) 13 in. AT INSPECTION 9-22-2005 153 ft. 1.58 g.p.m. Other bacteria 0 colonies/100 mi. Arsenic: 0 mg./L. Date of sample: 9-22-2005 Collected by: GEG. LtD. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 6-10-1983 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 9-22-2005 Pumper DENALI PUMPING C. ABSORPTION FIELD DATA Date installed 8-10-1993 Soil rating .p.d./ ft�rbdrm) 150 System type DEEP TRENCH Length 50 ft. Width 3.5 ft. Gravel below pipe 6.0 ft. Total depth 12.8 ft. Eff. absorption area 600 ft' Monitoring tubeYES - aDepression over field NO Date of adequacy test 9-22-2005 Results (PasslFail) PASS For 4 bedrooms Fluid depth in absorption field before test 24.5 in. Water added 800 gal. New depth 48 in. Elapsed Time: 209 min. Final fluid depth 45 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - D. LIFT STATION Dale installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOTTO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /sepfic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 9.5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 30'+ Water main N/A Water service line 25'+ Surface water 100'+ Driveway, parkirVvehide storage 15'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and * 1 •.• i review of Municipal records that the above systems are In • • .. "' ' . "' • • • •' • . • • • . • • conformance with MOA HAA guidelines in effect on this date. trey . Game=. Engineer's Printed//plame JEFFREY A. GARNESS : CE 79.E Date /�l�! or��� HAA Fee $ " &U Waiver Fee $ - Date of Payment -10 - 10-C6 Date of Payment Receipt Number %-ll7 / Receipt Number (Rev 12101) W SEP -14-2005 0:51 PRUDENTIAL VISTA REAL EST 907 562 5485 P.02 N b9°,TSI 'so 1; Al y Bo e riceer —( r Pumt•NI[•Maf iA"t 111701�0( :KA:..�. O Z3 L �s SSI 4 y ti U) C. 0. a ,fib jo • - _ C; vvjc 5' • : �' , 2bP E 'LF79.74 A.: sl�� • : SURVLY CERTIFICATION-...±.�. rq♦,♦♦♦♦ Prepared by PLOT IPIAN VG •�` Robert E. Johns, Jr & Assoc. LAwAr rwy Y/ I w PPIwr w._Y•1 Aw lw.•««ti.Ar r.. .. wrl '��'` .. •f(�1 •••., Professional Land Surveyors Ww.._�urr r. MW.M w. I��M.FM«MYMIry � /J• ♦ •t 447 E 12 AVE. •�"I•A r A+rr• .wA I Y j• Y ANCHORAGE, ALASKA BBSDI b,«i. • FOUNWION AS-BULT 0 / "" ""'•'•0 .I c ' Sade; 150 Rea Lot S.F. RAa ►lel FIA No. L A►w1•C Arr i. Ver rVr M l 1... w••..r .� Ar•+• A.•w. P w.. •.wAr•rwYw«e.•_„ r •• •••• ...• ... r Date Sures Y*°: Drewn by CnAekaO by r M... A.ai !w �. 4 wtipMM ;• R ., T E^� S. JR. ; ,. �. 9-7-05 REJ Drawn: Grw. W.0. �w=nnnwir •M wY ? N! aAOat• svNALs1RUGTUReAseuLrff ♦♦/' ••'•,,. 9-7-05 2937 5-296 Legal D"We Ptlm; LA.rra i.n a. •.+r A.•Ps MI •••• Q�a�� Lot 3 Block 2 ���Mair�r•• M.�,-. '""'"" '""' Secluded Hills ❑ LOT SA Y" SURVEX TYPE ❑ FO MAMON AI-BULT SYMBOL$ E3 fl A rPu [ ASS T • SET REBAR Z=" =F' CRAINAOE ASPHALT PLAN ... AS•.aLT , , , LOT YNAFY W4PNY. ... TaPO o FOUND REBAR WOOD FENCE D CONCRETE r 'O—P•6 • :•. NO COMMPILOT tl'r r wN . - Mn !en V_W� ASSUMED ELEV. lE % M METAL FENCF_ r V PLOT PLANS k LOT SURVEYS LpTF; IT 1S THE RESPONS:BIUTY OF THE GUILDER OR OWNER, PRIOR TO CONSTRUCTION, TO VC01" PROPOSED OVILDING•GRAOE RELATIVE ONLY 7110SE IMPROV4MENT3 ABOVE GROUND AND VISIGLE WILL BE TO 19NISHED GRADE AND UTILITY CONNECTIONS AND TO CETERMINE DNOWN. FENCES, WCLLS. EEPTIO CLEANOUTS, SIOEWALK3, DRIVEWAYS. ETC., ARE SHOWN THE EXISTENCE OF ANY CASEMENTS, COVENANTS OR RESTRICTIONS Wl+ICH DD NOT IN THflR APPROXIMATE LOCATION, ONLY. SNOW MAY PREVENT SOME IMPRDV ENTS FROM BLIND SEEN AND LOCATED. APP R ON THE PECORD_ SUBDMSION PLAT. A ISTANr 5 w "'— n N UNDER NO CIRCUMSTANCES S40ULO AN AS—SULT BE USED FOR CONSTRVCf104 GR FOR CSTABLISHING BOUNDARY OR FENCE LINES THE SURWYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UASIUTY ONLY FOR THE COST Or THE SURVEY. USTED DISTANCES PREVAL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE. TOTAL P.02 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. # 017 -343 -if, HAA # ki �i1 rt `t``, 9"1 1. GENERAL INFORMATION ELI�L�` Complete legal description Lot 3; Secluded Hill -s Subdivision Location (site address or directions) 13301 Badger Lane Anchoraqe, AK Property owner Annie Mortensen Day phone 345-0575 Mailing address 13301 Badger Lane Anchorage, AK 99516 Lending agency Mailing address Agent Greg Broderick/Prudential Vista Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 `V 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water Day phone Day phone 273-7261 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. a. TYPE OF WASTEWATER DISPOSAL: Individual on-site _XX 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. "I) Front MOA *21 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 thedate of his inspection. Name of Firm ALASKA WATER 8� WAST Phone 3 3 7 - Address 6901 1 3//3 Engineer's signature Date Alaska Water & Wastewater Consultants, Inc. Shall be PAID $ 10125 at orprior �y r to, closing for the dW 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for Additional Comments By: bedrooms. 411TIC 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 courtesyto 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. 72-M (PW. 1/91) Back MOA 1121 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES R E C E I Vok Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-40,, R 16 1999 Health AuthorityApproval Checklist MUNICIPALITY OF ANCHORAGE j 9pp ENVIRONMENTAL SERVICESDIYISION Legal Description: �L/-U000 f I IUB LoT 11 _ Parcel LID.:—() �t A. WELL DATA Well type VA - If A, B, or C, attach ADEC letter. ADEC water system number V� Log present ON) & Date completed elm- In r r Total depth q _ Cased to a 0 t.� Casing height (above ground) .,2 r1 Sanitary seal (Y/N) _ ��S Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test I r Static water level L} 0 Well production g.p.m.� g.p.m. WATER SAMPLE RESULTS: - Coliform Nitrate ' m7/G Other bacteria Date of sample: _ 1 Collected by: B. SEPTIC/HOLDING TANK DATA Date installed u _ Tank size fo(L-A (YL- Number of Compartments _ Cleanouts ON) 241 _ daiAVi" Foundation cleanout (Y/N) _�Depression (Y(I v 4-ligh water alarm (Y/1) rj1A Date of Pumping 3 i `( Pumper + 'I'IomtF t'dvl 6S C. ABSORPTION FIELD DATA Date installed /U 3 Soil rating (g.p.d./ftz o�ft /bcl 1 �� _ System type Nt P TLf vl iJ II Ir UWOUT" M7 I&Ll' Length So Width Gravel thickness below pipe Total depth QSo--m Nil 2A0 Effective absorption area 16W Monitoring Tube present 6)N) o- Depression over field (Y& Date of adequacy test 32> ` T Results lSFQ/Fail) RVSSS For C1U(Z bedrooms U 60 Fluid depth in abslorption field before test (in.); b" Immediately after 6`)S- gal. water added (in.):. `I! Fluid depth U ab" (ins) Minutes later: I N 86 0141" Absorption rate = __ +? �� r g.p.d. Peroxide treatment (past 12 months) (Y/A) N01 LI Kt�c-� _ If yes, give date n2zh-_ 72-026 (Rev. 3/96)* D. LIFT STATION h / Date installed ' IT Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ICO V On adjacent lots /UU 4 - Absorption field on lot 106 a- On adjacent lots mo- Public sewer main Public sewer manhole/cleanout 041 Sewer /septic service line NI Lift station SEPARATION DISTANCES FROM SEPTIC/FI9filDING TANK ON LOT TO: Foundation 10 Property line 10 4 Absorption field Water main/service line a I Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD• ON LOTTO: Property line /0 Building foundation 10 Water main/service line Surface water \©(7 \. - Driveway, parking/vehicle storage area Curtain drain ���NE WINP^ Wells on adjacent lots I w F. ENGINEER'S CERTIFICATION I certify that I h e et m d�ru�ield inspections and review of in conforman a wit ilines in effect on this date. Signature tt Engineer's Name Date HAA Fee $ Date of Payment��/ Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number F A_ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL H6 `' � - k�'Q'�Q OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner�Telephone: Home Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent C�iJ� Address Telephone Z,776 - z Business (e) Mail the HAA to the following address: or: Check hexrx, f hold for pick upz List contact person and day phone number below.� 2. TYPE OF RESIDENCE Single-Famil� Number of Bedrooms 3. WATER SUPPLY Individual WeXI Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite] 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 (Rev 8/861 Front 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 ��'��� l hPr ^ice Telephone Address Date �e_�,4 i ow q�gs��l1' �? En Sean? t♦ *; a9T� (((ssssss��� •, •• HUGH R.BEVAN f• CE 1225 i • 4 . AW �6 6. DHHS APPROVAL Approved for�/� bedrooms by Date Approved /� Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 n-oae (Rev a/sei Back MUNICIPALITY OF ANCHORAGE v`tl O( Pt`G �pViSC� HEALTH AUTHORITY APPROVAL(MOA) (HAA) MVN�GIPP tP�S�Rvt CHECKLIST - FEBRUARY 1984 �N�IRCNMEN 2 a� 264-4744 0Aq J Legal Description: ✓� 3 ��� Z ��c�c✓ �/-✓ ,�,� ���� A. WELL DAT)�,� 4^ Well Classification If A, B, C. D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed Yield �� %'!m �� .32 Total Depth 2�� Cased to Z> -S-- Depth of Grouting Static Water Level Lam/ ;/ /E%mac r2,;z- • Pump Set At —" Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: F el Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot X, e1 ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots To Nearest Public Sewer Line A_ To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by AJ To Nearest Sewer Service Line on Lot = Date -��✓7 Water Sample Test Results Comments — p. /o �z✓/� /Jrzr�¢--s✓ B. CEP'PIC }/ iOLDING TANK DATA Date Installed _ v - Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) ✓ Foundation Cleanout (Y/N) ,✓ Depression over Tank (Y/N) — Date Last Pumped Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) A� Separation Distances from Septic/Holding Tank: To Water -Supply Well ✓� To Property Line "6 To Water Main/Service Line for -- Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field „S' To Stream, Pond, Lake, or Major Drainage Course Comments Page -1 of 2 72-626 (Rpv 8/86) Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed Length of Field Sv 2. 7 Width of Field -Ole Depth of Field �Z —: 4d C,,.9 - Gravel Bed Thickness Square Feet of Absorption Area "r' Standpipes Present (Y/N) % Depression over Field (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test Zoo _1 Separation Distance from Absorption Field: To Water -Supply Well To Property Line To Building FoundationA5 F'J Lot N�i9 ; On Adjoining Lots 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 �✓� Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments l� t To Existing or Abandoned System on 11!r_1v f To Cutbank (if present) H� Dimensions Manhole/Access (Y/N) "Pump Off" Level at '" Check Permitted Bedroom Rating Against HAA Request "" Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I hav checke ,verified, or conformed to all MOA�AA guidelines in effect on the date of this inspection. Signed �� Date ����� Company ��n/Ile MOA No. « �� vo Receipt No. O Date of Payment Amount: $ Page 2 of 2 72-026 fRev 8/86) Back a' AW Engin 's SegfF',rr, ®.•••. . . ••••. see �• .s•• •••s•�••� •, HUGH R. S. N0, CE7226 lot* �1'pfo •••....••' `�AW P.O. Box 112852 BEVAN ENGINEERING Anchorage, AK 99511 (907) 5211383 May 11� 1987 MunicipaliL.y of Anchorage Department of Hea1th &Environmental Protection 825 oL`/ Strc)et Anchorage, Alaska 99501 Re � AHFC, Health Authority Applicatioo Lot 3 Blk 2 Secluded Hills During the period from April 29 to May 1987 I site investigations, well flow analysis, and ahsorption field testing persuant to Heal�h Authority Approval on the ahove referenced lot" I performed a well flow test and found the well production to be 1"2 gallons �er minute (gpm). This exceeds the 0,4167 gpm required for a 4 bedroom home" Recent water samples for coliform analysis and for nitrates were taken and the lab results were satisfactory. I performed an absorption test on the septic system and (.1f*terIII ined that it absorbed at a rate of 600+ gallons per day (gpd)" This exceeds the 600 gpd required for a 4 bedroom home" The septic tank was pumped and the volume removed was 1250 galons. To my knowledge I have Wsembled all of the information req�ested on the HAA Application and Checklist" I am submitting this data to you for your review^ Please contact me if I can provide any additional information, (ph 522�1383) Sincerely, "c-`-'' Attachments :: HAA Application HAA Checklist Coliform Analysis Nitrate Analysis Septic Pumping Receipt 87224~ws APPLK NT FILLS OUT UPPER HAI ONLY Proper', 'wner Phone -*Railing Address - - Zip Code .- _�' Buyer Address - - ., { -r Zip Code )( - Lending Institution Date Phone Address Zip Code Realty Co. & Agent hs Phone Address C - -:.; J j -- ) Zip Code Field Notes: Legal Description MPT, OF WALTH L Street Location l _ Type of Residence Q Single Family --_ L�] ' Multiple Family No. of Bedrooms_'{_ ❑ Other Water Supply -_ EDC E I V E Q ( APPROVED BEDROOMS 'W.. Individual � 'CONDITIONS OF APPROVAL ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. r��. O Community �- t For wells drilled prior to that date, give well depth (attach log 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 REQUEST BEFORE PROCESSING CAN BE INITIATED. Riot 10 �1 c ir Q -e 4, Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector hs ---MUNICi iY-�F Ai ICHO Field Notes: MPT, OF WALTH L ley © ENV IRON)A'1NTAf'L PI1ROTECTION EDC E I V E Q ( APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE) BY: Soils Rating Date Sewer Installed Well To Absorption Area® -0 Well Log Received 0 Well to Tank A -b Septic Tank Size 12023 (3182) I I - j W- �� t Lt-�,J Pis, Octiohoj- ;)-If Vranl� Botham" ,Mlchoracj(�j Al", 991) 07 c; ubj oc L . GOL 3, 610LAI 2, 10OF SOCNIONd MUM, Al I )MV,11 3011 the DIVAChIal 01mer afRI %untur vaculAties; calmok- ho y)-inLed ulli-Al L11(" -WAJouinq itcjw; 1121v,,,1 lxu(211 0 'j.1w d,,orowuou Uve): th(� 11<wd to ho vilmol Mon's 0 Mal- �"w'.,.Lacc aslay j:rom k.hu "-;i-!%/QI: spocifinilly We tallk. j?).ua,<Io noLity lc:his D(-�)?IULWOUIIL j -0J. IAL`7.I1;.iJ)CCl-7.1717 wilk-,n 1 -hu noteu discorcopancim; have wen corm oc tied 1E wicre are my 1111:1: leiY quusLions, yh?asc' ci-ijj LAI& oklicie sit !;),I—q'/2u. ,i inco-co J J.),I l,obdi. ts'