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HomeMy WebLinkAboutSEACLIFF BLK 3 LT 10Aeacliff Block 3 Lot I OA #011-221-29 01, GREAT; ANCHORAGE YAREA BORCjH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME MAK14 &WZY1&t& MAILING ADDRESS 39/,5/.30e/9NV AIC PHONE �2 %7'�`�' iC1 LOCATION JAC/A/k ` .fd0,0eeJe r LEGAL DESCRIPTION Ze 7- /019 -j�& ic7 l�Cti /la° SEPTIC TANK: DISTANCE C01049 / t� NUMBER OF f FROM WELL ,4 E MANUFACTURER 1/-/�FE!l' MATERIAL COMPARTMENTS / INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY/S��>GALLONS. TILE DRAIN FIELD: a /� TOTAL LENGTH DISTANCE FROM WELL FOUNDATION —NEAREST LOT LINE—OF LINES A111Q NUMBER OF LINES / DISTANCE BETWEEN LINES TRENCH WIDTH— IN&.-/at/TOTAL EFFECTIVE / ABSORPTION AREA 55100 SQ. FT. LENGTH OF EACH LINE //4 I DEPTH OF FILTER �yj DEPTH: TOP OF TILE TO FINISH GRADE _ MATERIAL BENEATH TILE_/W .Cl�. ABOVE TILE IN. WELL:: TYPE624/M 4Q 4IF CONSTRUCTION BUILDING NEAREST NEAREST FOUNDATION -,LOT LINE , SEWER LINE CESSPOOL , OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES:fid. INSTALLED BY: I�FN��n EKC 1 SEWER LINE DEPTH: A/ PIPE MATERIAL:F/Ex- foist ON LOT SLOPE: IEU��/ t . REMARKS:0" T3S'�iFF1/VG- PTH DISTANCE FROM: SEPTIC SEEPAGE TANK , SYSTEM_ DIAGRAM OF SYSTEM _ 1 DATE APPROVED Form EQ -032 &ckF// A& ,6&,6Atiy i I C IEAN CI'NT G A � �U F CA4 Crt� _ 1 DATE APPROVED Form EQ -032 &ckF// A& ,6&,6Atiy i NAME OF APPLICANT INSTALLATION LOCATION LEGAL DESCRIPTION GREA? ',:R ANCHORAGE AREAGUG PERMIT NO. DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 -' - / a TELEPHONE 274-4561 _ - w SEWAGE DISPOSAL SYSTEM - APPLICATION .AND PERMIT /�- INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FA FINANCED THROUGH SOIL TEST RESULTS I MAILING�ADDRESS w ■� r r SEEPAGE PIT _, DRAIN FIELD ja OTHER E�7,7- JJ� COMPLETION DATE ANTICIPATED NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION, / r/AG� SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE 0 MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT Isl DRAIN FIELD-`-� SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK SEEPAGE PIT -ss DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK SEEPAGE PIT , DRAIN FIELD ALSO CONSIDER AREA WELLS. »_ WATER MAIN TO SEPTIC TANK SEEPAGE PIT , DRAIN FIELD -_ SEPTIC TANK, , SEEPAGE PIT , DRAIN FIELD , TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIY� FITTED WITH AIRTIGHT REMOVABLE CAPS. ``�• GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. \ P/ DIAGRAM OF SYSTEM G.A.A.B. w{��■ OR ICENSED DESIGNER .� V 1 CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. � As DATE S ' v APPLICANT'S SIGNATURE w4'` -104L FORM NO. EQ -016 1# c; w ■� r r iw � ■ ■.,'■�. moi■' nCCG�loll ■■� NMI No ■�■■■!�■■��■�■ ���CN11t�� .=MM ■w ■ MEN NEms ■■m i®�91G� G.A.A.B. w{��■ OR ICENSED DESIGNER .� V 1 CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. � As DATE S ' v APPLICANT'S SIGNATURE w4'` -104L FORM NO. EQ -016 1# c; F• •� yP GREAi`ER ANCHORAGE AREA BOROOGH gJ Q .a DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT .1{1-}g l� ri17O Ka II MAILING ADDRESS ^��/`"l •�"�-`�'�t' f r� PHONE L; INSTALLATION LOCAT LEGAL DESCRIPTION V INSTALLATION OF: SEPTIC TANK L )P _ SEEPAGE PIT TYPE AND SIZE OF FACILITY TO BE SERVED - FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTICIPATED DRAIN FIELD OTHER TO BE INSTALLED BY THIS PERMIT ISN T V LID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE i 0 MINIMUM DISTANCES, REQUIREMENTS y- f SEEPAGE AREA SIZE FOUNDATION TO SEPTIC T.�NK -� V1C4i--i'L / ._ FOUNDATION TO'BE'E'FA E -RFT /�� DRAIN FIELD -:PAGE EL i l SEPTIC TANK TO Sf EPPIT \WALL SEPTIC TANK ,tet-EPAGG PIT DRAIN FIELD TO NEAREST LOT LINE, bA, WELL TO SEPTIC TANK U ( SEEPAGE'PIT DRAIN FIELD ALSO CON EU,�REA WELLS. WATER MAIN TO SEPTIC TANK r A E PIT LU dil DRAIN FIELD I d 6 ( SEPTIC TANK, — PIT / DRAIN FIELD , TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS, GRAVEL BACKFILL CONFORM TO BOROUGH—REGULATIONS REGWRDIN(b INSTALLATION. G.A{A.B. OR LICENSED DESIGNER TYPE DIAGRAM OF SYSTEM 1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. bd DATE ZQ / IZZr",G ��'?,i�APPLICANT'S SIGNATURE _._ _JII__..1_ _._ .-____ I 1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. bd DATE ZQ / IZZr",G ��'?,i�APPLICANT'S SIGNATURE I L I PROPOS)7,11 DYWCLfJN1(' LOCAMN NM.- To,p f4 1) o is w34/ Cuune of bIw--k FA V TP xoy MA I '-V a flp�l , V 9A I hereby certify that I have surveyed the following described property:— Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on prop- erty lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this —day of and Surveyors Engineers FRED WALATKA & ASSOCIATES The sediments were loose with a moderate .Gw moisture content. The ten foot contact repre. sents an average, because the contact wa� erratic. No CIXIIII.;tvi�'S: 2 f eet°otoI 'PI—r feet 0 105sqft/bdrm crrf Leu erage1� 0 s f t s it o qgr to,4 fu �j --Z-a 5.. 5 many -3C. __xx The sediments were loose with a moderate .Gw moisture content. The ten foot contact repre. sents an average, because the contact wa� erratic. No CIXIIII.;tvi�'S: 2 f eet°otoI 'PI—r feet 0 105sqft/bdrm crrf Leu erage1� 0 s f t p4 9 ED JA DEPARTMENT -7 ----- __ - ---------------- - ----- SUBJECT: ------- DATE OF MEMO: INITIATED BY: .......... Y� .. 1Z, FROM: GREATER ANCHORAGE AREA BOROUGH ©DATE ANSWER TO: DEPARTMENT: AJ --------- REQUESTED: RECEIVER: REQUESTED ACTION SCHEDULE I '411,11 PREPARE BACK-UP INFORMATION 411 CALL ME BEFORE YOU ANSWER I NEED YOUR RECOMMENDATION e,7 /' ,-,5 se// L�, C ------------------- ------- ----------- - - 1-111-11-----, ------ I----"- S/Z= - ----- - ---------- 11 ------- -- — -------- I -------- I - - --------------------- - -- - ---------------------- -___l ---- ------------ - --- --- ----------- r 4b I—P SIGNATURE --- -- ------- FOR INFORMATION ONLY _R FOR IMMEDIATE ACTION FOR YOUR CONSIDERATION - ------ OTHER -------- REQUESTED ACTION SCHEDULE I '411,11 PREPARE BACK-UP INFORMATION 411 CALL ME BEFORE YOU ANSWER I NEED YOUR RECOMMENDATION e,7 /' ,-,5 se// L�, C ------------------- ------- ----------- - - 1-111-11-----, ------ I----"- S/Z= - ----- - ---------- 11 ------- -- — -------- I -------- I - - --------------------- - -- - ---------------------- -___l ---- ------------ - --- --- ----------- r 4b I—P SIGNATURE 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 Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of.Wdrooms and type of structure indicated herein. I further veri�jt pt based on the information obtained from tp icipality of Anchorage files and from my investigation and ion, the on-site water supply an %bNater disposal system is(are) in compliance with all applicable �AlyinfClp and State codes, ordin gLe;d * regulations in effect at the time of installation. 4r ; " -cell cell ]27-886"{ I�/�� Name of Firm a (- N K 4 ri S ,n 1p f Phone _34 sz 33.E 7 Address _ '41b &I / h(,f i IvFot 46G f Engineer's Printed Name )4t -cA&r/A/ I•h Al <I vrs(s.r . Date (o 2310 9 49 S. DSD SIG O MICHAEL N. ANDERSON . C1 ct: 9469 �y ,! rO ved for Approved bedrooms. • r 1 '1l Pcoffl J,�(`� Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory . Other By: Original Certificate Date: (e s"g, c'! ' d 9 (Rev 1405) Municipality of Anchorage Development Services Department 4+, Building Safety Division --- On -Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST �1 Legal Description: 5 e u r( , U 5/o L u 4- / 0.4 y 13 k, 3 Parcel ID: A. WELL DATA Well type /4 If A, B, or C provide PWSID # 2-10'IYr Well Log (Y/N) Date completed _ Sanitary seal (Y/N) _ Wires properly protected (Y/N) -Total depth ft. Cased to ft. Casing height (aboveground)in. FROM WELL LOG AT INSPECTION Date of test Static water level Well product' g.p.m. g•P•m• WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate m Arsenic: _ date of sample: B. SEPTIC/HOLDING TANK DATA 'Tank Type/Matedal 0i t colonies/100 mL Collected by: Date Installed Tanksize /SoD gal. Number of Compartments Cleanouts(Y/N) V Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y!N) �— Date of pumping 2a Pumper J e,,- b rt- r h.. C. ABSORPTION FIELD DATA p,rr n Date Installed d jL Soil rating (g.p.d.W or fflbdrm) L90 System type t. �c h Length Width R ft. Gravel below, pipe A0 !a ft. Total depth I L4 ft. Eff. absorption area S Doig Monitoring tube Y_ Depression over field Date of adequacy test —$061 Results (Pass/Fail) dN ,0 For=bedrooms Fluid depth in absorption field before test 69 �tp in. Water added 900 gal. New depth in. O Elapsed Time: L!L101nin. Final fluid depth in. Absorption rate >_, g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date / D. LIFT STATION Date installed 'Pump on' level at_ in. E. SEPARATION DISTANCES Size in gallons Cycles tested _ in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot -11,4. Absorption field on lot /� ✓<� . Public sewer main Sewer /septic service line Animal containment areas Pf Manhole/Access High water alarm level at Meets alarm 6 circuit requirements? On adjacent lots /`//� , On adjacent lots n'/ 6 Public sewer manhole/cleanout N . Holding tank /1 LW - Manure/animal excrete storage areas W 14 SEPARATION DISTANCES FROM SEPTIC/HOLIMNG TANK ON LOT TO: Building foundation S Property line 2-0 4- Absorption field 10 Water main 5 ti Water service line SO r F' Surface water /00 / Welts on adjacent lots 1 A . In. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Zp Building foundation Z -D Water main S t Water Service line V r Surface water / Ot 14- Driveway, parking/vehicle storage 50 /'f' Curtain drain_ Wells on adjacent lots h��, F. COMMENTS G. ENGINEER'S CERTIFICATION h�P;•• •SQ91� I certify that I have determined through field inspections and *: 49TH 6� • •�;yt�I� review of Municipal records that the above systems are in � � � I conformance with MOA COSA guidelines in effect on this date...... . . . ...... .... 0 / I O MICHAEL N•, ANDERSON :� / Engineer's Printed Name M. r(n a rci A (J," [T 7 I i •. CE=9469 . � Date G�2 S 19 4 + l iso .• ��: OEESS%i��= COSA Fee $ 0 i Z.tiLA % 7`b L+ Date of Payment (< ZI r/m 5 Receipt Number -12-16 9-6 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number 30• POWER x\ N LOT 11A 10, A10 ��Cj V �Q \ V Q \ � c x LOT 10A Drive W x ry0' 40• O ° '40 'b f EXISTING / ov 0 4 rya. V O bry HOUSE N o - ® 9A 44 O LOT Cl)h 3. 30. // ^� 623,30ry \+ rye. +/ S 00 \ yp\ + FSR ogoo�0004 FSI' op � .ACq .,.....5,00 oo�P. . ................ .D QOO�b A tho P. Hoffman •- �QO p4s� LS -9020 >a0 �Op a5oo °fessionot NOTE: 4�DOOppO�� THIS DRAWING SHALL NOT BE MODIFIED FOR USE AS A PLOT PLAN WITHOUT THE EXPRESSED WRITTEN CONSENT OF LANTECH. Lead Description: AS—BUILT Ordered By Barb Scott with Remax Properties Legend: Septic stondDipe QConcrete.',. Lot 10A, Block 3, Water Well ilii[:;:: Replat of Seacliff Subdivision Fence—X—X— Wood Deck SURVEY CERTIFICATION: Ln hos conducted o survey o/ lhs property as shown on this drawing and certifies that the knpro"menla I ophysical situated thereon are within the property lines and no encroochmenls axial the p other than noted. LAND & CONSTRUCTION SURVEYORS—PLANNERS—ENGINEERS EXCLUSIONARY NOTE: It Is the owners' resDonelhlllty to determine the existence of any easements, covenants, reslrkllons or right—cf—woy plot. Under to whichdo plot. takings which do not appear on the recorded Bused 440 West Benson Boulevard, Suite 200 Phone: 562-5291 ngs far construction. mould any nolo hereon be used far Anchorage, Alaska 99503 Fax: 561-6626 for establishing property lines, or far plot—plan purposes. Plot: 65-124 Grid: 2424 Ootr. June 10, 2009 Drawn By CB Work Order. 2009—L-75 Ref: 94L725 scale: 1"=30' lChocked By JMZ MUNICIPALITY OFANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section 44 P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.Q. # 9-li HAA # t A l L C 1. GENERAL INFORMATION Complete legal description -_U i A C. t r` F_7 Location (site address or directions) ` a` I n_%�L r o voicing ianK 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 921 S. 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 furtherverify 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 1) l' Phone Address 6. By: 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 courtesyto 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. Engineer's signature 4 4. Date 71f I DHHS GNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 72-M(Rev.1/91) Back MOA #21 T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Subject: HAA for Lot l0A Block 3 Seacliff S/D PID 011-221-29 Gentlemen; RECEIVED AN 2 71995 Municipality of Anchorage Dept. Health t& Human Services June 27, 1995 A conditional HAA was issued for this property on Dec. 12, 1994. The conditional was based on correcting the status of the standpipes to the trench. These standpipes have now been replaced, giving unobstructed access to the leach field. Please issue an unconditional HAA for this property. Yours l � c Tobben Sp ' kland P.E. 1 T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Subject: HAA 940665 Lot 10, Block 3, Seacliff S/D Robert Robinson; December 21, 1994 Due to winter conditions we request a conditional HAA approval for this property. The conditions being that the standpipes be repaired or replaced no later than July 1, 1995. Funds will be escrowed to cover the cost of this work. On December 20, 1994, a 2 -inch perforated steel pipe was driven 8 feet into the ground next to one of the standpipes. According to the files at DHHS the trench is 14 feet deep with 10 feet of rock and 4 feet of cover. The steel monitor may have reached 4 feet into the rock. No water was observed. When this system was tested in May of 1992, the standpipes were open to a depth of 10 feet. Water was not observed at that time either. Based on these observations it appears to me that this system is operating satisfactory. Yours �✓(y� Tobbennurkland P.E. RECEIVED DEC 21 1994 Municipality o1 Anchorage Dept. Health & Human Services Parcel I.D. # ;2- 1. GENERAL INFORMATION HAA # H -A q -t o(a&-!�- Complete legal description Loi i (�A 3 Lac.K 7, SCAc.(._.i r �= Location (site address or directions) Property owner l �� U' t Day phone Mailing address Lending agency Day phone .72-M (Rev. 1/91) Front MOA M21 : ' ' _ iL's' 3t 3.i Mailing address I �e f i �a ��y- Day phone Agent Address - Unless otherwise requested, HAA will be held for pickup. r{ .3,;Yr,-�? s ,, _: .x tf ,. �� _ - z x , h •tL.� 2. ,. _NUMBER OF BEDROOMS: s. 3. TYPE OF WATER SUPPLY: Individual well Community well PV-,Sio 210gg� L� i 11 G[ ` Public water_ CA , NOTE If community well system, provide written confirmation from State ADEC attest in-tothe legality and status of system. r .\ `4. TYPE OF WASTEWATER DISPOSAL Individual on-site Holding tank „ Community on -'sit e �• s. ,: t`~ Public sewers 1 �cn 1 �•YS' S 4slj �� Yj SA ysF.... � _ .+i" . elm. FJif'Yia a/i i -i`• °. NOTE 1f community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system s 3' F .72-M (Rev. 1/91) Front MOA M21 : ' ' _ iL's' 3t 3.i 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 furtherverify 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 �RU y-U`�'% V_W Phone 974 -3 9 / (o Address 5 �—� ,20 3 Engineer's signature -� Date "LIE- /9 �-- lve4,i Municipality of Anchorage ® Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo� to A. 3u 3 4C—U Parcel I.D. 0 A A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number aUfflSll) a / & y 85 Log present (Y/N) Date completed Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump levell Driller Cased to Casing height FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Wires properly protected (Y/N) M AT INSPECTION o z rt�l m C I.P.M. 9.p -m. n tri Cn o Cn R z ; On adjacent lots On adjacent lots is sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: Other bacteria Date installed _5r 9.77 Tank size /5&cD Compartments Cleanouts (Y/N) ij Foundation cleanout (Y/N) J Depression (Y/N) High water alarm (Y/N) Alarm tested I !d(Y/N) N/iA- Date of pumping De 3 l R Y Pumper am e,4Ce s5 pc)© SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /� On adjacent lots 7q/A Foundation To property line /0 Absorption field Water main/service line Surface water/drainage o 7z-ozs(s/ss)'Front CONTINUED ON BACK PAGE C. LIFT STATION VA Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water Date installed 5 / ` Zz�—:) Soil rating (GPD/Ft2) go System type I e P—N C H Length 6�_--5 Width > 3 Gravel thickness l0 Total depth I L% Total absorption area 50-0 Cleanout present (Y/N) Depression over field (Y/N) Date of adequacy test /2/ 3 Results (pass/fail)� for Bedrooms Water level in absorption field before test Oea 14 o v F/k J i �c!'/After test Peroxide treatment (past 12 months) (Y/N) 0 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot N To building foundation �, Zy If yes, give date _ II-7ogad ad6(( l On adjacent lots t/A !Z7 S�. IA R7G c4�r Property line j L) To existing or abandoned system on lot N�/-\- On adjacent lots 7 3 y Cutbank N 0 K 2 Water main/service line Surface water _ No o /4 e— —Driveway, parking/vehicle storage area } l� Curtain drain IY 0 4 ­�_ E. ENGINEER'S CERTIFICATION t certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature () Engineer's Name Date b,--,� "A� HAA Fee $ 360, Waiver Fee $ Date of Payment `J/' ��� 1 Date of Payment Receipt Number Vr lam✓ / Receipt Number 72-026 (3/93)' Back 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. # O 11 - 4221- 2.q 1. GENERAL INFORMATION HAA # �A A'I a( -'A) I Complete legal description Lo T 10 A Location (site address or directions) 93 4 I qa_e � r-4- Property owner t Day phone AYS— 55L25 Mailing address i!>gl fw:�=a&41✓ Lending agency fAGA Day phone Mailing address r, , Agent 0zV.'tCC* &e4 -4-e Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well vl� 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 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 Jo�✓�vcvr ���rki ��- Phone 9'/ Address Engineer's signature 77 6. DHHS SIGNATURE —� Approved for bedrooms. Disapproved. Conditional approval for Additional Comments 0 .S, Date bedrooms, with the following stipulations: Date �- �B - 928 - / _ 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 #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 100 13Lcne_Ic Parcel I.D. oJl- :2 -al- 29 Sea C -tom' it Slb A. WELL DATA Well type — A Log present(Y/N)_ Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. ADEC water system number �U%SIpo4 )fl Yg-s Date completed Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Nitrate — Date of sample: B. SEPTIC/HOLDING/ TANK DATA Date installed 519175- Cleanouts (Y/N) Driller Casing height Wires properly protected (Y/N) AT INSPECTION On adjacent lots On adjacent lots Public sewer manhole/cleanout eum tank Other bacteria Collected by: Tank size /�500 Compartments Foundation cleanout (Y/N) Y� Depression (Y/N) N High water alarm (Y/N) NIA Alarm tested (Y/N) / ty1A Date of pumping S�L�Z Pumper IL- eZo'emll- v � SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot � On adjacent lots NIS Foundation To property line a.0 ' Absorption field 1 Water main/service line °? Surface water/drainage I\J o 11 � - 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE 7m7 G � p Z �� zr rri o m A D rimro `o M n y 0 V' m O Z Tank size /�500 Compartments Foundation cleanout (Y/N) Y� Depression (Y/N) N High water alarm (Y/N) NIA Alarm tested (Y/N) / ty1A Date of pumping S�L�Z Pumper IL- eZo'emll- v � SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot � On adjacent lots NIS Foundation To property line a.0 ' Absorption field 1 Water main/service line °? Surface water/drainage I\J o 11 � - 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION �I Date installed — Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed Length -' A9 /% 'j Total absorption area On adjacent lots Soil rating "Pump off' level at Cycles tested Surface water _ Width '? Gravel thickness Depression over field (Y/N) System type Ic- i0 Cleanouts present (Y/N) Total depth Date of adequacy test i 6, 9 2 - Results Results (pass/fail) 7?—a.47 for Peroxide treatment (Past 12 months) (Y/N) rl� If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot——On adjacent lots N//A Property line To building foundation ',2 D To existing or abandoned system on lot IM On adjacent lots ,> aD Cutbank N U vl C Water main/service line Surface water N C N1 1.= Driveway, parking/vehicle storage area Curtain drainy t-- E. ENGINEER'S CERTIFICATION bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature_ Engineer's Name b eL-k S�D o v k lQ wS� Date 8 l�Z HAA Fee $ 176 Waiver Fee: $ Date of Payment -5- 9 -L-� Date of Payment Receipt Number 3& 7t a L) Receipt Number 72-026 (Rev. 3/91) Back MOA 21 ��94.9 r> F»~ 207"EST 15YH.AVENUE SUITE 2C6 ANCHORAGE, ALASKA YY502-JY04 (907)279-3Y16 SEPTIC SYSTEM ADEQUACY TB9T LEGAL: Lot 10A Block 3 Seiia cliff LOCATION: 9341 Jaclaire OWNER: Marvin Hathhorn RESIDENCE: Single Family, 5 Bedrooms WELL: Community Water System, PWSID # 210485 SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: 5 Bedroom System TANK: Greer Steel 1500 Gal. �ne Comparts. ABSORPTION SYSTEM: Trench ABSORPTION AREA: 500 SOIL RATING: 100 INSTALLATION DATE: 5/9/75 DATE OF LAST PUMPING: Anch. Cess Pool May 8, 11.992 DATE OF TEST: May 6, 1992 TEST PROCEDURE: System was inspected and measured. Tank was found with 5 feet of cover and with a liquid level of 51 inches" Trench sumps were 10 t deep and dry. 1150 gallons of clean water was added to the trench while the water levels in the tank and the sumps were monitored. No water accumulation were observed. TEST RESULT: This system meets the code requirements of the Health and Social Services Department of the Municipality of Anchorage. NOTE The operati.onal life of altems deends on the local soil conditions, groundwater levels that may fluctuate during the year, and the water usage of the family being served 6y the system. These condioutside the control of the evaluatoF. of this septzc system. We can therefore not give any est:;mate of how long this system will function satisfactory for current or future occupants. I ANCHORAGE DISTRIGT OFFICE 300 E. DIMOND BLVD„ SUITE 3 470 ANC;HORAOE, AK ;9` 03 May 8, 1992 FOR, Tobi -,a Spurhlarld WALTER J. HICKEL, GOVEMOR My review of the records on file in this office reveals that the Sea Calif Subdivislon tl03-5s "A° Public Water System Is in compliance with the routine coliform br,-c' rie �sr�["I ing requlren lents listed In Table C, and with the inorganic sampling listed iq Table R sof 18 AA Sincerely; Rachel Clark College Irlterr;