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HomeMy WebLinkAboutSEACLIFF BLK 3 LT 64 ot k"W aa kvw 14 2 72-017 (Rev. 9/91) MOA 25 Municipality of Anchorage Page I of 3 DEPARTMENT OF HEALTH AND -HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: PID Number: 01IZZ148 Nam Wastewater System: ❑ New ❑ Upgrade Address: ABSORPTION FIELD Phone: No. of Bedrooms: Fo�2 otr ❑ Deep Trench J9,8 a4e .Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Z Total Depth from ori g)inet grade: CCI GPD/So. Ft. FT Lot: 6 Block: Subdivision: J? 50A G.(FF Depth to pipe bottom from original grade: S" Ft. Gravel depth beneath pipe iJ— Ft. Township: Range: Section: Fill added above original grade: Gravel length: 0 �» Ft. `7 Ft. WELL: ❑New ❑Upgrade Gravel width: S Numberoffines: . Distance between lines: Ft. L Z (' Ft. //C�l�assification (Private. A/,�B.C-):_ `tp it Total Depth: Cased To: Total absorption area: l� Pipe mat erlet: $7M 313311 C&ArAum 1 r S ^ Ft. Ft. J V SO. FL F )D C X Driller: Date Drilled: Static Water Level: Installer: N,��,- Dat inst lled: �j -jrr "u� Ft. , SZ'. Yield: Pump Set at: Casing Height Above Ground: TANK GPM FL Ft. SEPARATION DISTANCES (Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lin Holding Public/Private Manufacturer: Capacity in gallons: -.1",L50 From Tank Field station Tank Sewer Lines /4nl W DRALET Well 7zoo r r >zoo / iZad Material: :5-r"L Number of Compartments: 'Tw0 Surface �pNC LIFT STATION Water Loti Z$ r �s 1 3� Size in gallons: Ma er: Line Foundation /O � Z+ y "Pump on" level at: "Pump off' leve High water alarm at: Curtain Pump Make & Model Electrical Inspections performed by: Drain /V 9,4 E Remarks: D_L�n� BENCH MARK o L location and Description: T — V uTt�W ETT �� 'E1C.� LOR1.1a="i2. o r Hv DSE Assumed Elevation: ENGINEER'S SEAL U 1 n (r E Inspections by: Dates: 1st__—� ✓.�� performed 2nd9`� J] Department of Healthnd Huma ervices appy vaf , Date: Reviewed and approved by: i 72-017 (Rev. 9/91) MOA 25 Permit Nd. SW 940041 Page 2' of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ' G, QWy� 3, Jtr* Cir Fr` PID No.: oil zzl qs 6V-7 S t '1l I s NN58'06' E 145.60, 30.7 F) k ! Zgi 02 ts 36.60, N , 0 ' - 0 -TWO STORY S o HOUSF• m L — 10 �. c.o' 4' DECK PORCH c 8 \�` a.: fo•� 7'P.Ni © z6.00' 2' CANT. $ I \ * 2' CANT. 1111 ge - • Use 12 �u3aa LOT BAAnderson 0 1 CoA� 3Z.- sz — PLA,,, A s - u -r- COG 37 9 38- �. LOT 7A Permit Na. .: vW 94 aoYl Page 3 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Ld7 L• BGbCGL 3 Cu>cr PID No.: oifZz /y g t 1\ a ti N _. .. -. ..... .. y 9.... K ---o$ .. ....... ..... .... SZ £ _. ......... ... . N o tz * .._.... GLc- %1a-rl t5nl / s : i t)! LT ... _ ... . 9z 9za ..... 9z� ... z• L --I X88 a ........ Z8 .. . E� MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER.DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940041 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:RHODES R J & CLARA A OWNER ADDRESS:P.O.BOX 1947 ANCHORAGE, AK 99510 PARCEL ID:01122148 LEGAL DESCRIPTION: SEACLIFF BLK 3 LT LOT SIZE: 11000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 11 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE �/1OF 1 �� 7 ( j 3 a 41 ° L! 0�n L- bl- b DATE ISSUED: 3/01/94 EXPIRATION DATE: 3/01/95 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: DATE:. LAJt/ DATE:' ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, ALASKA 99524 February 22, 1994 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 6, Block 3, Seacliff Subdivision Septic System Design Impacts to Adjacent Properties Dear On Site Services Engineer: The terrain of the subject lot is fairly flat with no drainage problems or surface water. The drainage pattern will not be affected by the development of the lot. The subdivision is served by a community water system with no conflicts with the setback distance. Clean sandy soil was found on the lot with no subsurface water. Conditions appear excellent for an onsite system. If the system is constructed as designed, the following statements can be made: 1. The system, if constructed as designed, will have no adverse impact on the wells currently in use or those to be constructed in the future as the subdivision is served by a community water system. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. Sincerely, Michael E. Anderson, P.E. LOT 6, BLOCK 3, SEACLIFF SUBDIVISION R f^ 01 100 l52• �� � .: o � B . 42 00;E 135 ml 2a , tom i35. 11,4i O f, AL;;- q t v Z ; L j 8,4 /ppm,/ cp 7AJ AREA MAP SCALE I" = 50' 0, pp .00 \00, p �4 1 • . Andorsan%O 2% 3d[o frs a o 4.t�y vi N E g�� RsooM ci S1 -r -C7 R44 'S Q-A L,c / of = 3a' d ( CEJ O�DOOnE p q c �c� Michael E. Anderson F 1144'sHl-E O �xY 2':b a 0 JA--ruM it it 0 u Lot 6, Block 3, Seacliff Subdivision DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Wide Trench System Perc. Rate: 3 Min./Inch 1,250 Gal. Septic Tank Application Rate: 1.2 GPD/SF Min. 2' Accepting Soil 4 Bdrms. X 150 GPD / 1.2 GPD/SF = 500 SF 500 SF / 5' Wide = 100' Long X .5 Reduction 0' - Factor = 50'&--- Therefore: Therefore: Construct a Wide Trench System with Two Latera s Each 25' in Length. Place 4' of Drainfield Rock Beneath th Distribution Pipe. Place Distribution Pipe at 4' Below Surface. 1 � PAW t - � 6F JA--ruM it it 0 u Municipality of Anchorage 0* DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST (nLI�G'(L�Y !'iN� DATE PE � PERFORMED FOR: �, r P, - LEGAL DESCRIPTION: L-6, e2A &> Township, Range, Section: .IGP'IU T SLOPE SITE PLAN J4a o' a 5 0. 6'- 7 '.s. 9 10 - • WAS GROUND WAT " ENCOUNTERED? �V 11 s IF YES, AT WHAT 12 DEPTH? p E 13 f Depth to Water After 5'9� Monitoring? Date: 14 boll - 15 6 -I I rg 1 . 18 19 20 ,1 PERCOLATION RATE. 3 (minutes/inch) PERC HOLE DIAMETER �., TEST RUN BETWEEN 3 FT AND FT COMMENTS r PERFORMED BY: I.'e--C15RTIFY THAT T}iIs TSST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) �=IMEN , / f�1=EZmlw' ►3�� 20 ,1 PERCOLATION RATE. 3 (minutes/inch) PERC HOLE DIAMETER �., TEST RUN BETWEEN 3 FT AND FT COMMENTS r PERFORMED BY: I.'e--C15RTIFY THAT T}iIs TSST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) +� Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: 9g6jjii,, I or DATE PERFORwf(3 LEGAL DESCRIPTION: I,l�r ?J �{G'%� S Township Range, Section: _w-- T ;6r 1 ,. ,•I oLL 2 1 jo 4, d r I 4 5- 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS y - WAS GROUND WA'I ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After Monitorino7 N S L O P E Date: 15 PERCOLATION RATE J (minutes/Inch) PERC HOLE DIAMETER _�_ t3 � TEST RUN BETWEEN FT AND FT PERFORMED BY: I IF THATTHI$ TES//T]]WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 71."7, 72-008 (Rev. 4/85) n m m m a> -� ° 0 o O L 10 V O 1 m 0 of C61 11A G I,\ 4A O v O L I � I j "I IOA O 5,4 t C m I n C in^ 30 NN > INn Z n +o 0 �i �9�Av 11 6 A m N J �) I O O� 0� BA -7 7A i 135.86 135.86 I /4A `j 2 0 O m I ° O 0 OI 01n• om, N89058'0O'W 145.00 N; zI -�0 i 1 I 3 M j n n A /3A O o; 3 o r N I r m• 6 °' R. .nr .3.33 L� 30.1 30 S89045'00"E 14501 O z; o J. °1 1 D C m ^I Jm mi o°wI �2A ::IOI OI C mO1J JI> // O 0 Z 1 0 0� mI °• ^N n� O 1$2.11 OI 580 d200•E /' NO`N 1,5 0 I _ r°a`ry I I Q I ^ O n •n.n - n m m m a> ° 0 o O L 10 V O 1 m OI 0 O 0 C61 11A G I,\ 4A O v O L I � I j "I IOA O 5,4 t C m I RO O L m in^ 30 NN > INn Z n �i �9�Av 11 6 A m �) I O O� 0� BA I 7A i 135.86 135.86 n m N� ^ m a> ° 0 o O L 10 V O 1 m OI 0 O 0 - CC) m O v O L d m j Y Ic t C m RO O L m in^ 30 NN > INn Z n ° 94th Court Spur Street) '"- ° 8 ° 00`0 n S89°58 00. 33172 HPO 0 MV 301.72 Como !3 w O � /6, N N C' p° C O �Y1 0 00 07 �23,. ' N89°58'001W oz oN:z 10 n 145.00 o d 0•1� c 0 ° ° o C) 0 m /0 00 \ o z Q / \ F- 0 N 10A ,♦ .♦. / /03y/O6J. 2\ o" - F'—' C) 1 _ n /°�o ° \ O b3'e� 0 too°ti �A Q; -I 0 ; a; o n.00 Lijn /o / �/� vl ° ,152 o3>O` COO ^p „'2i° 3O '^ ♦// / O W "5..0 / N ti 7A i m - \00 q 3. / 1 0 f \\IX J. a, ti (1 ♦ E - \ 00 1 �1 E 0.1 117 7 154.86 57 �, �1 TRACT C ry8905313 20 / 6 \ 66.3 ✓ o/ ' ° 3Oa-0, / N f: \ A v O �` 2/ O� \ 30 loot: BYRC IV IQ / / 3. Y 0000 "C/ � �� C7 }/' ^ a 1 ♦ n 58 p0p: - 46 p: z' I 6J _ Jp N89055b0°W 331.72 HVL 82.91 u 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. # 01 1 22148 1. GENERAL INFORMATION HAA# Complete legal description Lot 6. Rlock 3 Sea Cliff Subdivision Location (site address or directions) 9422 Endicott St. Anchorage, AK 99515 Property owner Patty Singleton Day phone (51 7) 832-5415 Mailing address 4108 Stonegate Drive; Midland, MI 48640 Lending agency Premier Mortgage Day phone 563-7736 Mailing address 3000 A Street, Anchorage, AK 99503 Agent Dynamic Properties Day phone 261-7600 Address 3111 C Street; Anchorage, AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 14 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 1I 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 X Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. r. ;. IRxv. IM) rrnnt MOA 021 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 DHI Address 800 E. D Engineer's signature ULTING ENGINEERS . Ste. 13-5 6. D7Approved SIGNATURE _ for bedrooms. Disapproved. Conditional approval for Phone 345-1385 Anchorage, Alaska 99515 Date r/-/�-7-7 bedrooms, with the following stipulations: Additional Comments 1 ) Splitter Valve installed between two trenches. 2)Both trenches pressure jetted prior to test. 3) North trencch� is absorbing about 20% of daily flow. By: !/ v,��� L • 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. 72-025 (nw. im) Back MOA 021 B. SEPTIC/HOLDING TANK DATA Date installed 5/ 2 3/ 9 4 Tank size 1, 2 5 0 Number of Compartments 2 Cleanouts (Y/N) y gal. Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N DateofPumping 9/19/97 Pumper Northland Pumping C. ABSORPTION FIELD DATA Date installed 3/ 15 / 9 4 Soil rating (g.p.d./ftz or ft'/bdrm) 1 .2 System type Wide trench Length 5 6 ' Width 51 Gravel thickness below pipe 41 Total depth 1 0 ' Effective absorption area ,J (o O Fr v Monitoring Tube present(Y/N) Y Depression over field (Y/N) N Date of adequacy test 1 0/28/97_ Results (Pass/Fail) Pa s s ed For 4 bedrooms 4" 1711 Fluid depth in absorption field before test (in.);() 1+ Immediately after9 21 gal. water added (in.): --2-4 1 14" 1440 Fluid depth 0" (ins.) Minutes later: 1 2 0 Absorption rate = > > 6 0 0 Q.p,d Peroxide treatment (past 12 months) (Y" N If yes, give date Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 343-4744 MUNI6.IPALITY OFAf'r. -NVIRONMEWAL SERVICES DIVISIBIr Health Authority Approval Checklist NOV 1 1997 Legal Description: Lot Subdivision 6, Block 3 Sea Cliff Parcel I.D.: 011 221 48 11 VED A. WELL DATA Well type If A, B. or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Total depth Cased to Casing hei (above ground) Sanitary seal (Y/N) Wir properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. g.p.m. WATER SAMPL SULTS: Colifori Nitrate Other bacteria ate of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 5/ 2 3/ 9 4 Tank size 1, 2 5 0 Number of Compartments 2 Cleanouts (Y/N) y gal. Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N DateofPumping 9/19/97 Pumper Northland Pumping C. ABSORPTION FIELD DATA Date installed 3/ 15 / 9 4 Soil rating (g.p.d./ftz or ft'/bdrm) 1 .2 System type Wide trench Length 5 6 ' Width 51 Gravel thickness below pipe 41 Total depth 1 0 ' Effective absorption area ,J (o O Fr v Monitoring Tube present(Y/N) Y Depression over field (Y/N) N Date of adequacy test 1 0/28/97_ Results (Pass/Fail) Pa s s ed For 4 bedrooms 4" 1711 Fluid depth in absorption field before test (in.);() 1+ Immediately after9 21 gal. water added (in.): --2-4 1 14" 1440 Fluid depth 0" (ins.) Minutes later: 1 2 0 Absorption rate = > > 6 0 0 Q.p,d Peroxide treatment (past 12 months) (Y" N If yes, give date D. LIFT STATION Date installed Manhole/Access (YIN) High wa arm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* "Pump off' level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 11 . 5 ' Property line 4 9 ' + / — Absorption field 11 . 5 ' Water main/service line N/A Surface water/drainage N/A Wells on adjacent lots N/A SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 2 3 ' Surface water N / A Curtain drain N/A F. ENGINEER'S CERTIFICATION Water maitVservice line N / A Driveway, parking/vehicle storage area 3 0 ' + Wells on adjacent lots NIA Property line 3 0 ' + / cet-tiJv iaCl-have determined thru field inspections and review of in confoance uith 1I0A HAA gui eline. effect on this date. Signature Engineer's Name r� Date HAA Fee $ / UD , Date of Payment Receipt Number Z% Rev. 8/95 OSS: haa.wk.doc _` L ;>, nip(paf �e ards that he adovessystems are J °r. [�, c 9 O C O©- L G O L 4 N C V C o c' ♦ 'I 1�iQgineeriilg`5l Here Waiver Fee $ Date of Payment Receipt Number 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. # Ol l 7 -LI q-8 7q -IV 1. GENERAL INFORMATION Complete legal description Lo'' L, l3touIL 3, S� �F1= .SU9DI\1l9)0d Location (site address or directions) Property owner l)l v 1 /-A o1 a ��� Pn anon Day phone CS( -"C Mailing address 1111 a rNt, �A\ oo A-- h Ci01 ��R sc)SS Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: F�OU)Z- 3. TYPE OF WATER SUPPLY: Individual well Community well xx A 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 XXk 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#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 the date of this inspection. Name of Firm A±J0 G7LS0rJ 6�5GirJtZTUrJ6 Phone Address PQ90x 4-40273 n ANU4012.4Gk:-:-/�k 995 _ Engineer's signature �,wcL� Date S 30 9 6. DHHS SIGNATURE Approved for Disapproved. 0 4 bedrooms. Conditional approval for Additional Comments E, r. n ��pr -;' -�.. •:naacc:n5gno �r, ant's%i rl c�•e^xs^¢off o. ,00�000n•.r� ,1nu'orson `;;1 11 ..f',•,j;. bedrooms, with the following stipulations: 111717, The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev. 1/91) Back MOA 921 ® Municipality of Anchorage Department of Health and Human Services 44 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: I-Or6 &yoc ��A ����– Parcel I.D. o f ZZ I T19 A. Well Data ews QA � //�t_ Well type W MrvLV N 1 ry If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump levels Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot >zbt>t Casing height Wires properly protected (Y/N) AT INSPECTION ; On adjacent lots MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION g.p, m. 1AY 3 ; 1994 > zoo Absorption field on lot > zoo' ; On adjacent lots > Z -00r Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Colfform Nitrate Other bacteria Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: Date installed ��9 Tank size /. ZS'Q 6AL1,0,J Compartments Two Cleanouts (Y/N) Foundation cleanout (Y/N) —�! Depression (Y//N) High water alarm (Y/N) A Alarm tested (Y/N) A/A Date of pumping A t= v9 C" Sr a,0 C" p n ]% Pumper 14 f SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Ao/i Foundation r , To property line L 6 Absorption field /Z Water main/service line Surface water/drainage 4OA14Y a /n > /QA rt-ozs (3M)• Front CONTINUED ON BACK PAGE Date installed Size in gallons Vent(Y/N) High water alarm level NSA "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed �// /9 Soil rating (GPD/Ft) r /. Z Length S Width Gravel thickness Total absorption area 5G D r -T Cleanout present (Y/N) 4` °System type TL-nJ Ct-I Total depth Depression over field (Y/N) Date of adequacy test AJ wJ aA2,7—. Results (pass/fail) PA 5.> for R-> o (L Bedrooms Water level in absorption field before test 0 Aftertest O Peroxide treatment (past 12 months) (Y/N) /�J If yes, give date 141A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: J Well on lot ^I! A On adjacent lots ^/ /A Property line /S r r To building foundation ��L To existing or abandoned system on lot o JC >/O Surface On adjacent lots > �� Cutbank nJ o r.Jc= Water main/service line Surface water A]Q J G Driveway, parking/vehicle storage area Z D r Curtain drain AJO A r - E. ENGINEER'S CERTIFICATION I cerGYy that f have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. c�n Signature Engineer's Name A46c4-i A-Lq— / Nj D wz, () ^) - Date HAA Fee $�� U a Waiver Fee $ Date of Payment ��—`3 9 Date of Payment Receipt Number r�6 Receipt Number 72-026 (31931' Back