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HomeMy WebLinkAboutSCIMITAR #3 BLK 1 LT 9• ) kc)(.."OVE \ 4QSI -.. \ sa -00l(o Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191411 PID Number: 051-132-76 Dwelling: Fiffi Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New W Upgrade Name DANNY & JENNIFER DUCHARME ABSORPTION FIELD [I Deep Trench ❑Wide Trench ❑ Bed ❑Mound Site Address 19626 BELDUQUE CT, CHUGIAK AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot SCIMITAR #3 1 9 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 163.9 TANK K Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water 1 00-I- i Material Number of compartments Lot Line 10+ NA POLY 2 Foundation 6.7 LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Installer NORTHERN EXCAVATING Drainfield co/MT3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 100 ft Inspection 9/27/19 Location and description dates: 2°' Bottom house trim 3,a 4u1 ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: mot "Q � � OF A(,qk Date kk � fJ' QTH evei i�.t <mr�ona `��� DICE Septic System �y Approved 11 Date II 2l t9 8149 VIZ I , Note: this approval does not include well permit requirements. 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THIS SURVEY IS A REPRESENTATION OF THE CONDITIONS THAT WERE THIS DRAWING SHALL ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION. FOUND AT THE TIME THE LOCATION SURVEY WAS RE -USE OF THIS DRAWING BY THE ORIGINAL CLIENT OR BY OTHERS, FOR ADDITIONAL PERFORMED AND THAT THE DOCUMENT DOES NOT USES AT A LATER DATE WITHOUT EXPRESS CONSENT OF JON C. GUFFEY IS A CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO VIOLATION OF FEDERAL COPYRIGHT LAW. UNLESS GROSS NEGLIGENCE IS DISCOVERED, THE LIABILITY EXTENT OF THE PREPARER SHALL BE LIMITED TO THE ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY AMOUNT OF FEES COLLECTED FOR SERVICES IN PREPARATION OF THIS PRODUCT. SURVEY MAY DISCLOSE. THE INFORMATION CONTAINED EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE ON THIS DRAWING SHALL NOT BE USED TO ESTABLISH RECORDED SUBDIVISION PLAT ARE NOT SHOWN HEREON UNLESS OTHERWISE NOTED. ANY FENCE, STRUCTURE, OR OTHER IMPROVEMENTS. ASBUILT LEGEND SURVEY ALASKA, LLC 0 SEPTIC CLEANOUT PIPE 6402 Air Guard Rd. LOT 91 BLOCK 1 O SEPTIC MP COVER Anchorage, Alaska 99502 SCIMITAR SUBDIVISION, UNIT 3 O WELL (907) 317-3140 COA#:220035 ANCHORAGE RECORDING DISTRICT 0 FOUND 5/8" REBAR DRAWN: JCG CHECKED: JCG SCALE: 1" = 30' GRID: EPNW1261 FILE S031325 F.B. 2024-0I PLAT NO: 80-51 DATE: 3/17/2025 �' ----rY MUNICIPALITY OF ANCHORAGE Iii � o� �CTIj On-Site Water&Wastewater Pro ram �,1�.,_.`_., � PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 - htloa/www.muni.org/onsite " "' '' - �• Deportment ^'•CNOP.ac'E On-Site Wastewater Disposal System Permit Permit Number: OSP191411 Effective Date: 9/17/2019 Work Type: SepticTank Upgrade Expiration Date: 9/16/2020 Tax Code Number: 05113276000 Site Legal Address: SCIMITAR#3 BLK 1 LT 9 G:1261 Site Mailing Address: 19626 BELDUQUE CT, Chugiak Owner: DUCHARME DANNY&JENNIFER Lot Size in Sq Ft: 40007 Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3 This permit is for the construction of: • ❑ Disposal Field Cif Septic Tank 0 Holding Tank El Privy Cl Private Well El Water Storage All construction shall 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 wastewater code requires inspections during the installation.The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907)343-7904(24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing • Received By: \ /6{7//////40/214.--/ Date: l Issued By: G - lti �,,,„.�- Date: ENREiIc 'I TANK MUNICIPALITY OF ANCHORAGE 141- Com munity Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water& Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-132-76 Property owner(s) DANNY & JENNIFER DUCHARME Daf phone Mailing address PO BOX 671183, CHUGIAK, AK 99567 Site address 19626 BELDUQUE CT, CHUGIAK AK Legal description (Sub'd., Block & Lot) SCIMITAR#3, B1 L9 Legal description (Township, Range & Section) Lot Size 40,007 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank ❑X Upgrade ❑X Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: g11 f1 tg Waiver Fees: Date of Payment: 95 Date of Payment: Receipt Number: 0634116 Receipt Number: Permit No. Ds P I ci f y I J Waiver No. Permit App_.:-:•. ..,.c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191411, Deb Wockenfuss, 09/17/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191411, Deb Wockenfuss, 09/17/19 MUNICIPALITY OF Hlvl nvn� 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 %NEw NAME - ❑ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION f fa / `l C -T/4-rZ _ —• Foundation Nearest lot line # Well �y DISTANCE TO: NO. OF BEDROOMS 3 LOCATION Distance between lines/ %p / = U Length of each line ' -No. of lines g Z Total length. f L 0 inches Total effective absorption area Well Absorption area Dwelling 7 o PERMIT NO. I\ TO: Material „) � /" 5 r DISTANCE PERMIT NO.. Length Width Material No. of compartments Lu Total effective absorption area _ ril�Pth � J Fz Manufacturer �� Lu a Building foundation h_ Liquid dept. a. Q LU I.- w wolf (n DISTANCE TO:Class Inside length Width ,�-- PERMIT NO. w Liq. capacity in gallons IF HOMEMADE: --G1 - PERMIT NO. O V Well Dwelli g DISTANCE TO: Y STANCE TO: - A I OTHER Liquid capacity in gallons 0 0 z DI Material _? 4 Manufacturer Foundation Nearest lot line # PERMIT NO. Well �y DISTANCE TO: lines Trench width Distance between lines/ %p / = U Length of each line ' -No. of lines g Z Total length. f L 0 inches Total effective absorption area _j w beneath tile J F ¢ Top of the to finish grade Material (� inches U z F- PERMIT NO.. Length Width De th Lu Total effective absorption area Q f- Type of crib Crib diameter ril�Pth � J Lu a Building foundation Nearest lot line w wolf (n DISTANCE TO:Class Distance to lot line PERMIT NO. Depth Driller Absorption area(s) J Building foun ation Sewer i e e is tank DISTANCE TO: - OTHER PIPE MATERIALS SOIL TEST RATING - � INSTALLER f�'14�res Gents REMARKS r _i F� 'T« i _o ,,.,1,. $hG{Er + �9 (Rev. 3/78) —112 �X S.T. Department f Health and EnvironmentG rrozecLivii 825 Street, Anchorage, AK. '-J9501 — 264-4720 c # # # HANDW TEN PERMIT # # Permit # WELL AND/ ON ITE SEWER PERMIT Applicant: ailing Address: Location: Phone Number: Legal Description: L i l ���� ��Lot Size: ���� Type of Soil Absorption System Is: Trench: Y Drainfield: e Seepage Bed: Holding Tank: Maximum Number of Bedrooms: — Soil Rating(sq.ft/br) K,5' The Required +size of the Soil Absorption System Is:' DEPTH ________ LENGTH GRAVEL DEPTH S' 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(HOLDING) 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 departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee 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 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 enlargement if the residence is remodeled to include more that 3 bedrO ms. / Signed:. �, �Lyu(� Issued by: Applicant Date: SWP/024(1/81) C P MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PACOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: DEPTH (F,EET) 1 of i 2 3 lU U� 4 5- 14 O Gross Time 6- g Depth to Water Net Drop L, ed 7 0 ° 6 16- 8 �)L 17 17 a ,, ,o..na,...o l 9 i? 'm, N�, 1457-E 19r��vA®�®��� J 10- 11 ` N 12 13 , 14 Date Gross Time Net Time Depth to Water Net Drop ed ° 6 16- 17 17 a ,, ,o..na,...o 18 i? 'm, N�, 1457-E 19r��vA®�®��� 20 COMMENTS PERFORMED BY�i 72-008 (6/79) Q� SOILS LOG ❑ PERCOLATION TEST DATE PERFORMED: WAS GROUND WATER / S ENCOUNTERED? L O P E J IF YES, AT WHAT DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN CERTIFIED (minutes/inch) FT AND V DATE. -/ —5 l� WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or Ic.)- A.D.L. No. 1/a qt rs. Section No. Township N❑ Range EE] Meridian Z. Borough Subdivision Lot BlockFlat- i..ACY _C; 1C '.Garot-ot- S❑ W❑ M. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELLjJr.''r1 t.l �. i°!f er8 Address: Chug"ak, Ak. 99567 Street Address and Area of Well Location - 2. WELL LOG Feet Surface 4. WE,i,W 12TH: (fin°I) 7 5. TE OF COOMPLET10 �(3 7 Z} -Material Type - Top Bottom ft. talacial till, . F__'ravel, sand 0 112 6. ❑ Cable tool [�Xotary ❑ Driven ❑ Dug ❑ Auger ❑ Jetted ❑ Bored p Other: Gray rock 112 130' Gray and green rock 138 540- 7. U S EXEkDomestic ❑ Public Supply ❑ Industry C-]irrigation C] Recharge El commerical ❑. Test Well ❑ Other: - Gray roc!" with quartz sea[y 54o. 5c7 7G - f-.�. ,,,,r, 1. 570 5'J `r - r 9. CASING: ❑ Thre d i�1 Welded diem. 6 in. t _f ft,Y epth WelghP, lbs./ft. dlam• in. to ft. Depth Stickup ft. - 9. FINISH OF WELL: - Type: 0142 -Slab Diameteolt Slot/Mesh Size: - Length: Set between ft. and ft. - Backfilling - Gravel pack - - 10. STATIC WATER LEVEL: ft. ❑ Above or ❑ Below land surface Date Equipment used: O '.Q 11 I. PUMPING LEVEL below land surface and YIELD ft, after hrs. pumping g.p.m. - ft. after hrs. pumping g.p.m. \\N �o ,, \"U'' ,.'} • -.\� , t* ff;l.+ 12.GROUTING - Well Grouted: O Yes ❑.No Material: ❑ Neat Cement ❑ Other: - •li"• g [ - 13. PUMP: (if available) HP - Length of Drop Pipe ft. capacity g.p.m. a,' ❑ Subm. ❑ Jet O Centrifical Other 14. REMARKS: Bail tested at @ 8 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature ❑ F ❑ C _° This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Magnuson Drilling pull, 53 5 Registered Business Name Contract License Number PO LOX `504 Da River, h's. 99577 gle - Addres imay Signed: !. .li?_yi-.. v i`^,-���' +'%�� - Date: Authorized Representot' e Form 02-WWR (11/81) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer 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. #�� - \ -1 n HAA # 0 1. GENERAL INFORMATION Complete legal description Lot 9; Block 1; Scimitar Subdivision #3 Location (site address or directions) Property owner Mailing address 19626 Belduque Jeff and Tammie Bell Day phone 688-5428 Lending agency PACIFIC ALASKA MORTGAGE Day phone 258-7534 Mailing address ATTENTION: Westa or Wendy Agent Ray Heberer - RE/MAX OF EAGLE RIVER Day phone Fa94-4200 Address 16600 Centerfield Drive, Suite 201 Eagle River, Alaska 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 1—V 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water 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 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. 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 Phone 3 i o3e1 --;lo River Loop Road No. 20¢ Address _ _ — Engineer's signature 6. DHHS S NATURE Approved for bedrooms. Z Disapproved. Conditional approval for Additional Comments Date 7 bedrooms, with the following stipulations: U JITh 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. 72-025 (Rev. 1/91) Back MOA 421 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST WENAL Legal Description: L_CrT-!3 Sur-� rte¢ 5�� 3 Parcel I.D. JUN 18 199 A. WELL DATA RECEIVED Well type If A, B, or C, attach ADEC letter. ADEC water system number $A 1,01, Log present(9/N) Date com pleted S-/9- 83 Driller Mk4r�c1Sa1J �2��Lr 1ci Total depth S*erl Cased to ) I'1 t Casing height �'I. Sanitary seal 671\1) Date of test Static water level Well flow Pump level FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /moo r Absorption field on lot Wires properly protected ON) AT INSPECTION to- I9 lCv9 r 9.p -m. % q g.p.m. On adjacent lots /Ob On adjacent lots rt Public sewer main /J�.4- Public sewer manhole/cleanout 01J/.4 Public sewer service line /}' Petroleum tank 2� )+ WATER SAMPLE RESULTS: Coliformy GDS/IiO ^•� Nitrate /✓V �° 10� Other bacteria /I/cr✓F Date of sample: L' `) - `j J Collected by: S s 2-r.,AG, B. SEPTIC/HOLDING TANK DATA Date installed S'- /2 -83 Tank size /6,00 Compartments Z Cleanouts &N) Foundation cleanout ON) T— Depression (Y//0 N High water alarm (Y& T` Alarm tested (Y/N) AVA Date of pumping G - ! 3 - 9 / ,TiQ • mss foo �- Pur/r.✓y SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: t Well(s) on lot / !, o On adjacent lots / ao r Foundation To property line /b Absorption field s Water main/service line 1 f Surface water/drainage /00 72-026 (Rev. 3/91)Front MOA 21 - CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level Meets MOA electrical. SE Well on lot Manufacturer Manhole/Access "Pump on" level at es (Y/N) DISTANCE FROM LIFT STATION TO: D. ABSORPTION FIELD DATA Date installed - Length 2-L-0 On adjacent lots "Pump off' level at Cycles tested Surface water _ 5-11 — 03 Soil rating es �/&� System type 716,­1c�ZJ Width 20 Gravel thickness .5' J Total depth a Total absorption area Z La Cleanouts present®/N) Depression over field (Ya Date of adequacy test Results ail) G<1 -.SS for CIZ) bedrooms Peroxide treatment (Past 12 months) (Y/Oy//-- If yes, give date SEPARATION DISTANCE= FROM ABSORPTION FIELD TO: Well on lot /70 On adjacent lots /pO ~ Property line f To building foundation To existing or abandoned system on lot � 4 On adjacent lots 30 � � Cutbank j 11A Water main/service line 3c> Surface water /oo Driveway, parking/vehicle storage area /b Curtain drain d E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. r e Signature 'ivnA (-nomas L15ci tfYe 90,1 � Jr fs �l i,arlc fdivWr, f,l- .,tca 9915YZ vv 11. Engineer's Name Date f/J (7,8q_ HAA Fee $ R-0 —0 Waiver Fee: $ Date of Payment (��) G� Date of Payment Receipt Number z � / Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Parcel I.D. # MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services M DIVISION OF ENVIRONMENTAL SERVICES M}j 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Dl/13 �7L 14-m3 HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 9; Btock 1; Sc,imitan Subdivsion Unit #3 Location (address or directions) Count (b) Property owner Bhyan L. Cane.6en Telephone : (home) 688-1530 Business Mailing Address P.O. Box 671854, Chugiak, A2a6ka 99567 (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Telephone RE/MAX OF EAGLE RIVER - Linda Malone Address 16600 Cente,%ie2d Dkive, Suite 201, Ea.g2e Riven, Alaska 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check here Cf, if hold for pick up.) List contact person and day phone number below: S 9 S ENGINEERING/694- 17034 EaIte Rive& Loop Road Suite 204 Eag.2e Riven A.La3ka 99577 2. TYPE OF RESIDENCE Single -Family Cf Number of bedrooms 3 3. WATER SUPPLY Individual Wella 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-siteXX 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 Address 17034 Eagle River Loop Road No, 204 Eagle Kiver, as a Date 6. DHHS APPROVAL C� Approved for 3 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 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 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. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) • NICIPAUTM5h"(r ifts�it Approval (HAA) aN,E,TA..6:CKL 4� .1lItBRUARY 1984 343-4744 `f 9 1$9 Legal Description-:{ RECEIVED �C_irm (Ar S. L. y A. WELL DATA If A, B, C, D.E.C. Approved (Y/N) Well Classification �OJIV'JUA Well Log Present (Y/N) K Date Completed Yield%` Y Ak Q D M Total Depth 1-587 to � / T Depth of Grouting Static Water Level- %4 Pump Set At 1.21 rr Casing Height Above Ground t Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 1�n ! ; On Adjoining Lots 100 /t To Nearest Edge of Absorption Field on Lot % r ; On Adjoining Lots % 00 t To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot/ fib f Water Sample Collected by _-S f L 46tJq /Need I -A) Date Water Sample Test Results _ -�+� ► t S _i to"H -- A qc. /[cV' ie+ f Comments B. SEPTIC/HOLDING TANK DATA Date InstalledSize RAI No. of Compartments Z Standpipes (Y/N) —Air -tight Caps (Y/N) K Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped 9 -3 — S 7 Pumping/Maintenance Contact on File (Y/N) A ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: r � � To Water -Supply Well --fid () To Building Foundation r t To Property Line f b t To Disposal Field i To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course 11 TA/I f ( Comments co (c Ai C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata g Type of System Design Date Installed Length of Field 112b f Width of.Field 3 d Depth of Field 9 Gravel Bed Thickness 16 Square Feet of Absortion Area 4f Statndpipes Present (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test uQ �9 Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD To Water -Supply Well / % C� t To Property Line % 0 I f To Building Foundation h f To Existing or Abandoned System on Lot Nlor ; On Adjoining Lots To Water Main/Service Line a To Cutback (if present) OnN e To Stream, Pond, Lake, or Major Drainage Course otve. h) To Driveway, Parking Area, or Vehicle Storage Area o t Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at.- High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments — Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. .���`O nA Signed Company 17034 Eagle River Loop Road Ne. qn,, Eagle River, Alaska 99577 <5 � Date MOA No.� Receipt No ���-� /»• } Receipt No. c Date of Payment r!� �Waiver Fee: $ — Amount: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 A, :.i0i0• � �; ;� bwt i+t &ham• a a ^r e•. e. APPLI(, NT FILLS OUT UPPER HAL.,, -/ONLY Time Property Ow:ier Time Phone a. 17y0rS GO:(iSl;:i'ttCt,7-Ort, I11C. Date Date Mailing Address T307 1596: 1 �t;_I_e l`•7C;r, 'S.i Zip Code 9y577 62 /,«//,1 Date Inspector Buyer Foul v. Arleen N y oro Inspector PO f30X 351.: G aur•iak, (+? 99567 Field Notes: Address Zip Code Lending Institution �zrsi; Federal r 2 Phone Address Zip Code 27%,-6565 Realty Co. & Agent Nor, e - ,.,,.,_ v _ ___.. Phone Address Zip Code Legal Description n , - 1, CiLli Car Lot 9, Bloc r> y „ ;.), cr� Street Location IT1'1 Beldti uo COL:i `L' ( 3) APPROVED BEDROOMS `CONDITIONS OF APPROVAL Type of Residence ( ) DISAPPROVED ® Single Family - ( ) CONDITIONAL APPROVAL - -0 3 ❑ Multiple Family No. of Bedrooms 3 - ❑ Other BY: ccor"' VZ 5 Water Supply Soils Rating Date Sewer Installed Q Individual ATTACH WELL LOG. A well log is required for all wells delle - 'nce June 1975. ❑ Community - For wells drilled prior to that date, give well depth (attach log if available). - ❑ Public Utility Septic Tank Size P Sewer Disposal ® Individual Year Individual Installed: 9 r 3 ❑ 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 Inspector Field Notes: MUNICIPALITY OF ANCHORAGE DEPT. OF 2 ENVIRO,\,1.'N1AL PR3-1-- fI0Iv R ECE I cr� ( 3) APPROVED BEDROOMS `CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL - -0 3 DATE -La-2'8 v BY: ccor"' VZ 5 Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received - 2 0 3 Well to Tank t �� - Septic Tank Size P 72-023 (322) MUNICIPALITY OF ANCHORAGE a CJS/ 102 DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date JA O 12) N O 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) (�T 9 &LIOC:K j `DCII ITAR -5uaQ. VWT #3 Location (address or directions) #051-132-76 (b) Property Owner r�ANW'12 MA5, Telephone: Home Business Mailing Address 3201 C Street, Anchorage, Alaska 99510 (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: or: Check here 0, if hold for pick up. List contact person and day phone number below. 2 TYPE OF RESIDENCE Single -Family Number of Bedrooms _ 3 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to 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 Mev 8/861 Front 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION , 1.1 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 334�/� Address 7,22.0 L OF, Ta AVS' Date JAAJ 1:4 f 1 160 DHHS APPROVAL Approved for y-« bedrooms by _ Approved Disapproved Terms of Conditional Approval Conditional CAUTION 00 ell V.9 C e i 4 Fe 9� a4 a eBooae/A o eo eae a eta o•e`oeoseoe e�jY..e eoea�C 4 €� nA e d e V\ �Iaeo ES � Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (Bev 8186) Back MUNICIPALITY OF ANCHORAGE (MOA) MUN/c/P HEALTH AUTHORITY APPROVAL, (HAA) f�IRCNMFNTgt oRV//cCH RqC� CHECKLIST 2744UARY 1984 64- A. WELL DATA Well Classification ""14)"" J . DIV13101V Legal Description: LOT -OL-ock– i RtCFl4 V J°ly PSI M -V ED s50MrAF- 60ED, UNEr 0 If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) NO Y Date Completed mA� j f1 �, g Yield Total Depth �> Cased to % Depth of Grouting l2-9' Pump -57( Set At Static Water Level _ Casing Height Above Ground 2,4 Y Sanitary Seal on Casing (Y/N) y+` 6 Electrical Wiring in Conduit (Y/N) �Jut�7 Depression Around Wellhead (Y/N) t o Separation Distances from Well: + To Septic/Holding Tank on Lot 16,0 ; On Adjoining Lots A)y To Nearest Edge of Absorption Field on Lot %0, ; On Adjoining Lots wo 11 To Nearest Public Sewer Line + To Nearest Public Sewer Cleanout/Manhole t f To Nearest Sewer Service Line on Lot — Water Sample Collected by LANz')FPA2 ; Dated Water Sample Test Results 3AV �,MCM(Z Comments B. SEPTIC/HOLDING TANK DATA )�Ptc1 No. of Com T Date Installed sd��' �'/ � Size � Compartments Standpipes (Y/N) IGS- Air -tight Caps (Y/N) yfa Foundation Cleanout (Y/N) yC Depression over Tank (Y/N) K0 Date Last Pumped 1 / /I/e Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well l� To Property Line To Water Main/Service Line �5 + Course Comments �/��✓�--���i% ®d Page 1 of 2 72-026 (Rev. 8/86) Front for Temporary Holding Tank Permit (Y/N) ,r To Building Foundation To Disposal Field — To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA E� Soils Rating in Absorption Strata Type of System Designllt,1-4W/ Date Installed Length of Field %41 Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Depth of Field pr Gravel Bed Thickness !(� Standpipes Present (Y/N) (VG Date of Last Adequacy Test f 4 �Afl !S A cilp" F -m_ `'s Y3l,)1?_y11 Separation Distance from Absorption Field: To Water -Supply Well 110 To Building Foundation Lot � ICJ t To Water Main/Service Line r �jG .rZ5' To Stream/Pond/Lake/or Major Drainage Course To Property Line On Adjoining Lots To Existing or Abandoned System on .-SIO' — To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storage Area " %C r Comments r" -f %� D. LIFT�,I ATION Date ��In"`stalled Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments 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 lAave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed (, eYJ J I� Date 4/1n 1 -11 f G{ ?' t Company b)vA!l ,oUqd F&&' MOA No. J „ Receipt No.� Date of Payment Amount: $ _ 'Age) � �n Page 2 of 2 72-026 (Rev 8!861 Back „ gtnp��cnaoe �, o a�, C n Care� y .Meyer. ' X6353Ile � ;y C��;> F? 1 • EJ �,� _� Y' tJ� ° BO ()6`/O .. Aaea e�eco 0° OOOB ee 4 n- �� �� ea Carey . Meye a � ci 53 o cam: pR0 coIV', BESSE , EPPS & POTTS 7220 EAST 88 AVENUE ANC11ORAGE, AR 99507 (907) 349-6451 WATER WELL TEST LOCATIO Subdivision: i 1,A E i res /- Lot: Block: Client's Name: F� WA Address: TESTER: J Initial Reading on Meter: 752.7� Date: r3 DRAW DOWN TIME GPM GALLONS VOLUME GALLONS TOTAL FIELD MONITOR LEVEL METER READING ZC1 D S n w — /C) - n. 75_ 7�l Urine > ,_a f' T5 27 11' f z. - i 17 ! `7 `5 3 `i 1,0 I Z 762- 75 Z/; 30 I , z E I/ `i, !9 7 � ( �(�� :. z..- t �- ? f, a JA 1 'Z--- SI 3 J` -7i7 /l0 U(7 G, Z(,-) -7e L rr�U S Ua L4 o q; z. NOTES: Production Rate: Ov32 GPM 24 -Hour Capacity 537 Gallons