HomeMy WebLinkAboutSCIMITAR #3 BLK 1 LT 14I CAM LAftf)
(A
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e,4) c � c e
� psi- k sa OW li k
MUNI IPALTTY OF ANCHORA L
0n -Site 1Vster & Wastowater Program
PO Boot 19P6.50 4700 Elmore %ad
Anchorage,.Alaska 99519-66bO Phone' ) U3.7904 Fix' (907) 34:�-7997
h0F)M1m.munl.orgRmsice
On- He Wastewater Disposal System Permit
Permit Number, OSP211190
Work Type: SepUcTank Upgrade
Tax Code Number. 65113281000
Site Legal Address: SGIMITAP, #3 BLK 1 LT 14 0,1261
5ito MaiIing Address: 19655 BELDLIQUE QT, ChiugIak
Ow-1cr_ PAGE LARRY D & SUSAN L
Design Engineer- FIRST WATER CDNSI.KTING
This permit is fur the con 5tru ction of;
Effeciive Date:
Ex pl ration 'Daft*;
Lot Size in Scl Ft
Total Bedraorns--
&7x21
&712422
42716
❑ Disposal FWId R] Septic Tank 13 Hording Wank ❑ Privy ❑ Private V ell 171 water Storage
All construction shall be in accordance wlth,
1. The attached appraaed design -
2. AS requ ire menu speciried in Anchorage M unieipal code Dhapters I S.55 and 15.65 and the State -of Alaska
VVas!ewater Disposal Regutntions (18AAC,72) and Drinking Water RegWatlons (16AAC00)
3. The wastewater code requires Inspections during the installation- Tha eDgineor shall notify the Development
Services Department per AMC 15,65, Provide rk0fiication by ralring (907) 343-7904 (24f7).
4. From October 15 t -D Aprfl 15, a subsurface soil absorptlon system vender construcGDn during freezing weather
shall bO either:
a. Opened and Closed on the carne day, ❑r
b. Qovered, sealed, and healed to pment freezing
Special Provisions: Locate the beginning of the field to confirrnthat the 5' Sep ratian between
the tank and field wwilf be met.
Received B�
Issued By;
W12021
Date:
Date:
4
MUNICIPALITY
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 051-132-81
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Property owner(s) SCIMITAR #3 B1, L14 Day phone
Mailinq address PO BOX 670708, CHUGIAK, AK 99567
Site address 19655 BELDUQUE COURT, CHUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) SCIMITAR #3 131, L14
Legal description (Township, Range & Section)
Lot Size 42716 Sq. Ft. Number of Bedrooms 4
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
El
(w/wo ADU)
Septic Tank
0
Upgrade El
Duplex
ElHolding
(D)
Tank
ElRenewal
ElMultiple
Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
gnature of property owner or autnorizea agent)
Permit/Rush Fees: � g 5 Waiver Fees:
Date of Payment: CAh-1
Receipt Number: %'/203/
Permit No. 0 SP all 1 `) b
Date of Payment:
Receipt Number:
Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Cfie nt Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
May 25, 2021
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: SCIMITAR #3 BLOCK 1, LOT 14
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank per the
attached design to serve the existing 4-bedroom residence. The lot and area are served by private
wells. The design will not impact any of the neighboring properties. Please contact us if you
have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211190, Deb Wockenfuss, 06/07/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211190, Deb Wockenfuss, 06/07/21
MUNICIPALITY OF ANCHORAGE
9
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
NEW
�/7
/ "/ ,f 0,vi'
❑ UPGRADE
MAI LING ADDR ESS //�� _
/I
�, CJ. x 5 (f % 11I-.-19
LEGAL DESCRIPTION
�/ ,f�
L 1 / Y� 6 Lr r)q
` � )
LOCATIONNO.
Pe
OF BEDROOMS
LL 2 S ,GC K
Well - /
Absorption area /
Dwelling /
PERMIT NO.
DISTANCE TO:
•}
v
_
_Y
i Q
W �
Manufacturer
Material
No. of compartments r
O(
w
Liq.ca acit in gallons
mo
IF HOMEMADE:
Inside length
Width
Liquid depth
Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J(DZ
= Z'7
Manufacturer
Material
Liquid capacity in gallons
DISTANCE TO:
Well j i o / -
Foundation /r
Nearest lot line /
�®
PERMIT NO.
W =
[y _o
A
J LL z
No. of lines
Length of each lines -
Total length of lines i
Trench width
Distance between lines n�
1=. z w
(J
�%� -r
�y inches
I 4
F
Top of tile to finish grade/
Material beneath tile
Total effective absorpt-"area
4
ainches
o
Length
Width
Depth
PERMIT NO.
W
(7
a H
Type of crib
Crib diameter
Crib depth
Total effective absorption area
Wa
y
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
3:DISTANCE
T0:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
f
V
SOIL TEST RATING C� p
INSTALLER
REMARKS
� 0
71-1
�p
t7(
J
/
V
fB�
S ot, x
•r i .•
d. robort A. ofer P rc ®
\
"- '.r tato. 14 •E O`°
B
O ROFESSIONN -
1-
APP OV
DATE LEGAL
-
(((( Ir [j�/J
r � r r ri(•a' -
/ YYUI/ V hf11i11.
V;%1Ltv
/2-Y] 11 (Hev. J/ /6)
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM I!
Q EF1 FM- 1-1 ==- "To �FEE �0 -MA - �p �: -, Pa. 10 "Y" 1=7 Q KIN EE-_ 9--" -11- i A.=:�; �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) 8F THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFHCE OF THE
GROUND AND THE BOTTOM or-, THE EXCHVHTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES,
THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHYEL BETWEEN THE OUTFALL PIPE
HND THE BOTTOM OF THE EXCAVATION (Ilkl FEET).
FRUKRU X 10 W EHI 1=1 _f :1 UT: M F��Vi �. I _'E"; 1 W EE fL P. _Hy �a 5=1 U U 111:9 5�1!�
PERMIT APPLICANT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTALLATION INSPECTIONS OF HNY WELLS ADJACENT TO THIS PROPERTY HND THE
NUMBER OF RESIDENCES THHT THE WELL WILL SERVE
lF � .1 �IN I ]WE r H005 9"s FR FIE Ful IEC �U i Eb_._7 10
BACKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS
DEPARTMENT 1411-1. BE SUBJECT TO PROSECUTIOKi
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON~SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIP1U11 FROM H PRIVl-':lTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 DHYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY HPPLY. SPEC IFICHTIONS AND CONSTRUCTION DIHGRH�� HRE
AVAILABLE 08 1NSURE PROPER INSTHLLATIQN
M EEL FQ� P-1 I M EEC X 1"' 1 F-0 W AT KA IE: KV EEL 1-1 F"? EEC IFT: ��1 :3. 15U��
I CERTIFY THHT
1: 1 9M FHIIJILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS HS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE -
12 :
NCHORHGE2: 1 WILL INSTHLL THE 1N HCODES.
M MA 144 Acl.�v-,�L_ 1:
VV W F"
9=1 IN! (1: W'����� ���
PHRTMH
ENT�`�./EHLTH
HND ENVI�ONMf�NTH�\.^<OTECTIO�1
pc)
y �����
STREET�
HNCHORF�GE/
HK� 9950�
264~4720
Al EEC U 0. V4
I "T_ EEC
13 W-1 ER2 A ���
-YE W
PERMIT NO.
( 820]]] )
HPPLICHNT MYERS
CONSTRUCTION
PO BOX ]51
CHUQIHK
6944144
LOCHTIQN
LEGHL L14
B1 SCIMITHR
LOT SIZE 42C:�00
SQUHRE FEET
TYPE OF SOIL
HBSO�PT�ON SY�T�M I��
TRENCH
J
�
MAXIMUM NUMBER
OF BEDROOMS
SOIL
RHTING 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM I!
Q EF1 FM- 1-1 ==- "To �FEE �0 -MA - �p �: -, Pa. 10 "Y" 1=7 Q KIN EE-_ 9--" -11- i A.=:�; �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) 8F THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFHCE OF THE
GROUND AND THE BOTTOM or-, THE EXCHVHTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES,
THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHYEL BETWEEN THE OUTFALL PIPE
HND THE BOTTOM OF THE EXCAVATION (Ilkl FEET).
FRUKRU X 10 W EHI 1=1 _f :1 UT: M F��Vi �. I _'E"; 1 W EE fL P. _Hy �a 5=1 U U 111:9 5�1!�
PERMIT APPLICANT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTALLATION INSPECTIONS OF HNY WELLS ADJACENT TO THIS PROPERTY HND THE
NUMBER OF RESIDENCES THHT THE WELL WILL SERVE
lF � .1 �IN I ]WE r H005 9"s FR FIE Ful IEC �U i Eb_._7 10
BACKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS
DEPARTMENT 1411-1. BE SUBJECT TO PROSECUTIOKi
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON~SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIP1U11 FROM H PRIVl-':lTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 DHYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY HPPLY. SPEC IFICHTIONS AND CONSTRUCTION DIHGRH�� HRE
AVAILABLE 08 1NSURE PROPER INSTHLLATIQN
M EEL FQ� P-1 I M EEC X 1"' 1 F-0 W AT KA IE: KV EEL 1-1 F"? EEC IFT: ��1 :3. 15U��
I CERTIFY THHT
1: 1 9M FHIIJILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS HS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE -
12 :
NCHORHGE2: 1 WILL INSTHLL THE 1N HCODES.
X SOILS LOG
MUNICIPALITY OF ANCHORAGE
ac DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: / ' / II..F_ �. wJ tys l j DATE PERFORMED:
LEGAL DESCRIPTION: zQ / )IV BlA
i ,II O�- ^av\ l C,
SLOPE SITE PLAN
/ S
2 ena �- �1��
16-
17
18
19
20
COMMENTS
(r LJ - 8�-��w
jf
3
Robert A. S far
Depth to
Water
No. 145 -E
�OFFCmnv�� LP
14-
456
5-
6
4)
7
8
�..
'9-
10
10-,
.
U
11
�
12
-4)-
C7•1415
14-
15
16-
17
18
19
20
COMMENTS
(r LJ - 8�-��w
jf
Gross
Time
Robert A. S far
Depth to
Water
No. 145 -E
�OFFCmnv�� LP
WAS GROUND WATER �1 S
ENCOUNTERED? U L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE /7 (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY:CERTIFIED BY: "� [DATE:
72-008 (6/79)
I
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
SEI' 2 21988
RECEIVED
Ot ATION OF WELL (Please complete either lo, Ib or Ic.)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological & Geophysical Surveys
Drilling Permit No.
A.D. L. No.
la, borough Subdivision Lot Block Ib.
1/egtrs.
Section No. Township No Rang* E❑ Meridian
I
14 1—ot-ot_ot-
S❑ W❑
Ic. OISTA NCE AND DIRECTION FROM ROAD INTERSECTIONS
(k Pa JM,ye�
3. OWNER OF WELL: /�e4d
9 Z
Address: o #iWZUO t
7
.iv Ah*
Street Address and Area of Well Location
2. WELL LOG
Feet Below
4 WE PTH: (final)
ft.
5. DATE OF COMPLETI,QQN-�
Material TYPO
Top_
Battom
D_ _1
.[Otos andYel
0
20
6. ❑ Cable tool tory E] Driven C]Dug
E] Auger ❑ Jetted ❑ Bored ❑ Other:
25
VC
7. USE.M Domestic ❑ Public Supply ❑ Industry
[ Irrigation ❑ Recharge _ ❑ commerical
❑ Test Wall ❑ Other:
55.1 75
ea §vmvet and 4am 45 lul
Boh[NeAd
/0/
/0
8. CAS81G: - ❑ T l�gdad ❑ Welded �7
o in. to i o It. Depth Weight Abs.1 fI.
1 -
Ve
diam.
diam. - In. to ft. Depth Stickup ft.
1�
F/racie /
/,V
1359.
FINISH OF WELL:
Type: ODeR flv Lt Diameter: 6,/
j Slot/Mesh Size: Length:
Set between ft. and ft.
Backfilling Gravel pack
702 /to
FAach& e y 3'-
'AOAPO t— 170
>i= 2-;_
%%��
/72
185
y< c -}t.
jgal/
4 ock
10. STATIC WATER LEVEL: 7O
iILRQ -" �"7
�<�
r.
Above or7C CBelow land surface
(,'
Equipment used:
(�� 2,V2351. �
aacbuae
I I . PUMPING LEVEL below land surface and YIELD
f1. after Ara. pumping g.p.m.
ft. atter tire. pumping g. P.M.
12.GROUTING Well Grouted: ❑ Yes E] No
Material: ❑ Neat Cement ❑ Other:
13. PUMP: (if available) HP 3AC
Length of Drop Pip* 244 ft. capacity g.P.m. G
Subm. Jet C] Centrifieal Other
14. REMARKS:
&U iedied a# 4 QDM
16. WATER WELL CONTRACTORS CERTIFICATION:
-(/
15. Water Temperature _° ❑ F ❑ C
This well was drilled under my jurisdiction and this
report is true to the §051
of my knowledge and belief; V
A,1104 OA 04iVing.
I
M 5385
R``giVV reO0z iJpN�Xive47
ALe
Contract License NumberDLdte Q
Address:
Signed:
Authorized Representative
Form 02-WWR (11/8I) Copy Distribution: WHITE-Stote DGGS, PINK -Driller, CANARY -Customer
- n'Nl- IUXAGE
ENVIRONMENTAL SERVICES DIVISICN
MUNICIPALITY OF ANCHORAGE AUG 2 3 1987
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPR.R
E� `
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date -/ /k %
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 lt�#A Telephone: Home Business
(c)
Mailing Address /
Lending InstitutionTelephone �97 7872
Mailing Address �LLIT/h1
(d) Real Esta1
Address
Telephone &/f -X— -X4
(e) hWI the HAA to the following address: or: Check hereg, if hold for pick up.
List contact person and day phone number below.
59 S emaj'�E=No
17034 Calle River Loop Road No. 204
Eagle Rlver, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family
Number of Bedrooms _
3. WATER SUPPLY
Individual WOO Community ❑ Public ❑
I
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 IRev 8/861 Front
4
5. °ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
I
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
far 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 S g c ENGINEERING_ Telephone
Address 17034 Eagle River Loop Road No. 204
Date
V
DHHS APPRO AL /J. ,
Approved for ��"' bedrooms by _" �" `�' ��`r" Date
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
6 y �4-0_�.2 5;,
I
v" 9 pq p
.Yfh.. i 3/yq
A. ShOw
G
��a�MOe�y� y�BD
°RGFESSit AW
CF— /— a
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 ?Rev 8/861 Back
MUNICIPALLY OF AN
RAGE ` ✓
DEPT. ,)F HEALTH & MUNICIPALITY OF ANCHORAGE (MOA)
ENVIRONib1E`iTAL PROTECT'CHEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
AUG 2 8 1987 264-4720
R E C E I e J C® Legal Des tion: _ �IJk_ 1?2 LIA L
A. WELL DATA
Well Classification S •i/ If A, B, C, D.E.C. Approved (Y/N) IJ
Well Log Present/N) Date Completed 7 ' ' Yield ZS U
� t
Total Depth '5�5 0 Cased to (515 Depth of Grouting
Static Water Level Pump Set At J•
u
Casing Height Above Ground Sanitary Seal on Casing ON)
Electrical Wiring in Conduit (69N)
Depression Around Wellhead (Y/6p
Separation Distances from Well:
_
1X
E3c>
To Septic/#eFElitrg`Tank on Lot
tSD �
On 1 g Lots
Adjoining
To Nearest Edge of Absorption Field �
'
of �k
; On Adjoining Lots
To Nearest Public Sewer Line
IN To Nearest Public Sewer
1
Cleanout/Manhole
To Nearest Sewer Service Line on Lotf
S
Water Sample Collected by _?SY�(r
tri
;Date S �� l't>7
Water Sample Test Results
Comments
OrS
D— ZZ -8S
B. SEPTIC/HGI:Dt dG TANK DATA
Date Installed Size No. of Compartments
Standpipes QN) Air -tight Caps ('N) Foundation Cleanout4 DY N)
Depression over Tank (Y/a Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for -
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Q
Separation Distances from Septic/HeHtrM Tank:
L 1 -F:
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Building Foundation
t+
To Disposal Field
t
v a' To Stream, Pond, Lake, or Major Drainage
Course t r"' "t
Comments old — �'S Iry t'1 P►1�G�
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata e�� �_ Type of System Design
Date Installed Length of Field
Width of Field Depth of Field
tD
Gravel Bed Thickness
Square Feet of Absorption Area 4C;�V"p Standpipes Presen<N N)
Depression over Field (Y& / Date of Last Adequacy Test L cn _ Z--2-
Results
2Results of Last Adequacy Test �/�t5tpn� A ? lL
Separation Distance from Absorption Field:
To Water -Supply Well 1� To Property Line
1
To Building Foundation
Lot
To Water Main/Service Line t L-:-,'.4'
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
On Adjoining Lots
To Existing or Abandoned System on
To Cutbank (if present) �.3arJlZ
I Ar) I—
Dimensions
Manhole/Access (Y/N)
"Pump On" Level at "Pump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** 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.
Signe S ENGINE@RING /Z ate 8 /Y 7
47034 Engle River Loop of !
Com ffi4e River. Alaska 99577 MOA No. Cr $ 7_n0
Receipt No. 60
Date of Payment 2 ��
w
Amount: $
`Ov
Page 2 of 2
72-026 (11/84)
g t?
A. T -t.* -v z t*;
° p�4
OFES 5����
nA
F -xOo
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID # 92-0040440
LABORATORIES
I
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
\ FEDERAL TAX ID # 92-0040440
i
A
CHEMICAL &GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 B Street
�. Anchorage, Alaska 99518
�••• Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
❑ PUBLIC WATER SYSTEM I.D.# Analysis shows this Water SAMPLE to be:
PRIVATE WATER SYSTEM
Name Phone No.
5 & 5 ENGINEERING
17034 Eagle River Loop Road No 204
MailinfagbeeRiver, Alaska -49577
City fi��-�r�,;� Stale Zip Code
�
SAMPLE DATE: E L��
Mo. Day Year
SAMPLE TYPE
0 Routine
❑ Check Sample (for routine sample ❑ Treated Water
with lab ref. no. ❑ Untreated Water
❑ Special Purpose
3 1
4 1
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Satisfactory
Unsatisfactory
❑ Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
No. of colonies/100 ml.
Lab Ref. No. Result' Analyst
1010 LL01 & G
U m
U� CCl
_J CLI
I CD
BACTERIOLOGICAL WATER 'ANALYSIS RECORD
Membrane Filter. Direct Count
Verification: LTB
Final Membrane E#ter FIRS911ts
Reported By
TNTC = Too Numberous To Count
OB = Other Bacteria
�r
Coilforml100ml
Coilforml100ml
Time: /5317 a.m.
p.m.
Time
Collected
SAMPLE
NO.
LOCATION
Collected
By
1 11
T %q CL/L, )
3 1
4 1
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Satisfactory
Unsatisfactory
❑ Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
No. of colonies/100 ml.
Lab Ref. No. Result' Analyst
1010 LL01 & G
U m
U� CCl
_J CLI
I CD
BACTERIOLOGICAL WATER 'ANALYSIS RECORD
Membrane Filter. Direct Count
Verification: LTB
Final Membrane E#ter FIRS911ts
Reported By
TNTC = Too Numberous To Count
OB = Other Bacteria
�r
Coilforml100ml
Coilforml100ml
Time: /5317 a.m.
p.m.
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
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivisi n, section, township, range)
Location (address or directions)
(b) Applicant Name% Telephone: Home Business
Applicant Address 1/ '®"� !/���a
(c) Applicant is (check one): Lending Institution ❑ ; Owner u g; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institu ion t4l- o a
Address _7�/
(e) Real Estate Company and Agent
Address
Telephone
he HAA to the following address:
7
2. TYPE OF RESIDENCE
Single -Family tg Multi -Family ❑ Other
Number of Bedrooms 7
3. WATER SUPPLY
;r- < Telephone 6 %'5�'
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 (11/84)
� 1
5. ENGINEERING FIRM PROVID66 INSPECTIONS, TESTS, FILE SEARCH, A AND INFORMATION
t.
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
Date -190
d�"
A '> .11»[f�.> .t s`,'v
6. DHEP APPRO
Approved for �� V` . bed
Approved C
Terms of Conditional Approval
CAUTION
apa 0,
;
�, c ->nb
a
b
I aY n4ry OyaB
.'f: .14u'aa ooba�`p� Q
Date (lam ` 9
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 homes 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
72-025 (11/84)
CNVIRONr;aENr;.L hRcrEcrlo?J
MUNICIPALITY OF ANCHORAGE (m6w C
HEALTH AUTHORITY APPROVAL (HAA) " L;. L�'vJ _
CHECKLIST - FEBRUARY 1984
5
264-4720 1
C E I `�i.
Legal Descripti n: �-¢r 1 �'f`L- t�
9G1 ,-A rn-7 - S v-_> 3
A. WELL DATA
Well Classification t*r• If A, B, C, D.E.C. Approved (Y/N) 1A
Well Log Present (9/N) Date Completed 1 - `g -B -z- Yield ZS (sQf j
Total Depths o Cased to I'Sel Depth of Grouting
Static Water Level Pump Set At '' 14_
4
Casing Height Above Ground �µ Sanitary Seal on Casing 49N)
Electrical Wiring in Conduit (*N)
Depression Around Wellhead (Yal P
Separation Distances from Well:
To Septic/Hp{ding-Tank on Lot l So �; On Adjoining Lots
To Nearest Edge of Absorption Field Ion Lot �� t ; On Adjoining Lots «� ~
To Nearest Public Sewer Line N ha To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot t�
Water Sample Collected by SSd' t� ; Date
Water Sample Test Results
Comments /+�'��
-10lit -o C t r•5
B. SEPTIC/HCt ff#G TANK DATA
Date Installed 39 -14 -D -2 -size 1`� No. of Compartments -z_
StandpipesLqN) Air -tight Caps&/N) Foundation Cleanout4DN)
Depression over Tank (Y/ JP Date Last Pumped
N
Pumping/Maintenance Contract on File (Y/N) ; for d
Holding Tank High -Water Alarm (Y/N) 74 Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic4149 Fri Tank:
To Water -Supply Well To Building Foundation
t
To Property Line 1 e� -4 To Disposal Field
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026(11/84)
rA-
S'
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata�'� / Type of System Design
Date Installed )� ''�Z Length of Field 1'1=
L4
Width of Field
Square Feet of Absorption Area
ti (�I> %t'
Depth of Field
Gravel Bed Thickness Q.3tD
Standpipes Present 1VN)
Depression over Field (Y/ lO Date of Last Adequacy Test Lo- -7--2-
Results
2Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well 1 to CD ( �_
To Building Foundation 1
N
Lot
To Water Main/Service Line � 1�, ( A
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
0
To Property Line
To Existing or Abandoned System on
On Adjoining Lots -)Od
To Cytbank (if present)
Dimensions
N !A
Size in Gallons Man ole/Access (Y/N)
"Pump On" Level at ump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAAguidelinesin effect on the date of this inspection.
-�.it ti1tL f:E nl��fi 1. V �aQ
Signed � ��.. a r Date
{ g�) I
t 1i.` t114 L;I ,'11345 _I e, A
Company �; �;.,?,I.� MOA No.
Receipt No.
z�
Date of Payment /D �'�
'.
Amount: $ f i :r F':. �A Seal �eR
Page 2 of 2
72-026 (11/84)
a .t
,toe rt A. Shaker
No. 1457•15-
At � VAC lam. . .rry vv• v. . �.. ... .` ���.
Property Owner Myers Construction, Inc.
Phone
Mailing Address' Eagle River, AK 99577 Zip Code
694-9633
Buyer Alan &
Ruby L. Dieckman
Address Lacey
Drive, Eagle River AK 99577 Zip Code
Lending Institution
First National Bank of Anchorage -
Phone
646 W. 4th Ave. Zip Code
276-6300
Address
Date
Inspector
Realty Co. & Agent
Totem Realty, Inc:.
Phone
Inspector
PO Box 911, Eagle River AX 99577
'
Address
- - Zip Code
69 —
LegalDescription
Lot 14, Block 1, Scimitar Subdivision #3
Street Location
NHN Belduque Court, Peters Creek
Type of Residence
R Single Family
4
o
Multiple Family
11m
No. of Bedroos .
'CONDITIONS OF APPROVAL
❑ Other
( ) CONDITIONAL APPROVAL'
Water Supply
DATE
CK Individual
ej-
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 Log Received
Septic Tank Size
+�
Sewer Disposal
Well to Tank pr-
lK Individual
Year Individual installed: 1982
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time l
Time
Time
Dat
Date ( �
„ � k — '(
Date
Date
Inspector
Inspector -
Inspector
Inspector
W
'
Field Notes:
o
( APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY
ej-
Soils Rating
Date Sewer Installed
Well To Absorption Area
�'""Z9 �'
Well Log Received
Septic Tank Size
+�
LI j l� 2,
Well to Tank pr-
72023 (3182(