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HomeMy WebLinkAboutSHANE LEE ESTATES BLK 1 LT 8 u'I © PEF..:H ]] T lqO. FIF'F'L I E:FINT L '/.: iT.' FIT 'J: Oiq I_E(~FIL EDH I N R.]: NNER L8 B% SHFINE LEE ESTFITE:5 z q :] ~.':.-I H EL.L..z,I .... C'1" LOT z,_~E. E E E C.~ :SQUf:IRE FEET Ft:ENZ[PtUI"I DZS"FRNCE BETHEEN FI HELL FIND FINk' ON-E;tTE :SEklRGE D.'[.:~POEE;FIL. :t. OEEt FEET FOR Fl F'RI',/FITE HELL. OR 2C~O FEET FOR Fl PUBLIC !4ELL. HELL. LOGS FIRE REX;!LIIREE:, Rf'.,ID HLtST BE RETURNED TO THE I::,EPFIR'TI"IEi'q-f' 1.4]:THIN OF THE HELL COHPL.ETION. SF'ECIFICFIT]:ONS FIND CONSTRUCTION [:,IRGRFII'"IS FIRE F~VRtL_RBL.E "FO INSURE PROPER I NS"r FIL.LFIT I ON. 'J: E:ERTIF'.r' THFIT :i.: I Ri"1 FRi',IZLIFIF-: HI'TH )'FIE REf.qU]:F-:Ef'iENTS FOR ON--SITE :E;EI.,.IER!-2J FINE:, t.,.!EL..I_"~; Fi:.zl SET f:'ORTH E',"r' THE HUIq :[ C :£ F'FlL. i T"r' OF FINCHOF. tRGE. 2: ): 14]:LL iN:'~;TFILL. 'f'HE S'T'STEH,.:i:N I=ICC:OF.:DRNCE HITH THE CF.ff::,E~;. :1: :'iii"4EC: ' ~ .................................................................. FIPF'L~ I CFlNT E[Z:,H I N F.: i hlNER 1:5:~:iI.JED B'¢. ...................... DRTE i Municipality of Anchorage On -Site Water and Wastewater Program <u (907).343-7904 s F Et7 Y CERTIFICATE OF ON-SITE SYSTEMSAPPROVAL w I Parcel I.D. 014-061-64Expiration Date: (7 —�-26;Z!O 1. GENERAL INFORMATION Complete legal description Shane Lee Est. Block 'I Lot 8 I Location (site address) 6650 Tiffany Terrace Anchorage, AK 99507 ! i Current Property owner(s) Melvin Flynn Day phone Mailing address 6650 Tiffany Terrace Anchorage, AK 99507 Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 . TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual ❑ Individual Well ® Holding Tank ❑ Individual Water Storage ❑ Community ❑ Community Class _ Well ❑ Public Sewer Public Water System ❑ WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ F6 21y. W Waiver Fee $ Date of Payment 6-191A&.26 Date of Payment Receipt Number (J�q�J KoZ� Receipt Number COSA#. '5 6 2 1 Waiver # COVID-19 25% DISCOUNT APPLIED 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 'Engineer's Printed Name KENNETH M. DUFFUS Date 5/29/2020 Engineers Comments: This investigation Was completed in compliance with ADEC and MOA regulations. The assessment of the condition or the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen �F �L., encroachments, deficiencies or discrepancies exist. ,� c�� �f DSD SIGNATURE •J System #1 Approved for System #2 Approved for Conditional approval for bedrooms, with the fol *`/�9TIJ Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of Onsite Systems Approval (COSA). based only upon the representations given in.paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue 0zet 10-10-12.doc Legal Description: COSA Checklist Shane Lee .0 St. $tock 1 Lot 8 Parcel ID: Structure served by this system 1 If more than 1 septic system on tot: COSA Checklist # of A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 1/23/78 Total depth 91 ft Cased to 91 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (abode ground) 40 in. Date of flow test for COSA 5/19/20 Static water level at beginning of test 24 ft. Comments B. TANK DATA Age o a _ ears Tank type/material Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Is, stem tested (date installed) ❑ ALL star- resent per record drawing Total measured depth rade ft (max) Measured depth to pipe invert fro de ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective71fnot, s depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons. introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet MA 114.1 4A Well production at time of test 4.2 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes No Coliform bacteria is Negative Nitrate mg/L N Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by ArcTerra Date of Sample 5/19/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min 'L lid depth in Absorptiongpd Any rejuvenation trea past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No Community Sewer Manhole/Cleanout.> 100' ❑ Yes if No NA ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No NA ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment? 50'] Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 10 Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Prop 'ne > 5' ❑ Yes if No ft Wells on Adjacent Lots: ft Absorption Field > ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Main > 10' es if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ Yes it ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances Building Foundation > 10' ® Yes if.No ft Property Line > 10' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Water Service Line =10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS required) If absorp eid is under driveway comment below Wells on Adjacent Lo Private Wells > 100' if No ft Community W7ells 200' ❑ Yes if No ft G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet d� J a� I 6 i 1 o 7-,,,,0 F2AM� k1 Z3 z Q 1 i0' U-`ILI TV 123 .Sl 2.1 ; REVISED 5-5-92 I HEREBY CERTIFY THAT I HAVE SURVEYED THE AS - BUILT " SURVEY FOLLOWING DESCRIBED PROPERTY: LOT 8 BLOCK 1 LOT S BLOCK 1 SHANE LEE SUB. SHANE LEE SUBDIVISION AS RECORDED IN THE ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE IMPROVEMENTS SITUATED THEREON ARE AS SHOWN ON THIS PLAT AND THAT THERE ARE NO ROADWAYS, TRANSMISSION Beltaine C. Kozlowski LINES OR OTHER VISIBLE EASEMENTS EXCEPT AS INDICATED HEREON. Registered Land Surveyor 4620 Emerald Court DATED AT ANCHORAGE, ALASKA THIS Anchorage, AK 99502-5120 (907) 243-5550 27 DAY OF APRIL 1992 DATE: 4127192 SCALE: 1" =20' -Municipality of Anchorage Development Services Department .. . Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 " www. ci.anchorage.ak, us .' (907) 343-7904 ... "UTHORITY APPROVAL. FOR A SINGEE FAMILY D ELLiNG ' Parcel I:D. ,_-_0 try .--~.~'! - e GENERAL INFORMATION Complete legal descriptio'n Loca. tio.n,(site address'or directions) Current Property °wner(s). Mailing address Lending agency 'Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: ' Individual Well Individual Water Storage Community Class Public Water System TYPE OF WASTEWATER DISPOSAL: I~} Individual On-site r-] I-i !ndividual Holding tank I--I' Well .. [3 Community On-site I--I D Public Sewer I--~ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served bY a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties'served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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. # 0 Iq '~ O~/~,~ 1, GENERAL INFORMATION Complete legal description HAA # Location (site address or directions) Property owner ~)~v' Mailing address Lending agency Mailing address Day phone Day phone Agent Ad dress Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide wrlffen conf~rmat~on from g~a~e 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 ail Municipal and State codes, Phone ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Fngineer's signature / bedrooms. DHHS SIGNATURE ~' Approved for Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 Alasl~a. 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 ~F21 Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type '~ Log present (Y/N) Total depth If A, B, or C, attach ADEC letter. y Date completed (~ 1 Cased to c~ [ Sanitary seal (Y/N) ADEC water system n~mber Il ~'3/7t~ Dritler '-""'~-_v~ vi Casing height Wires properly protected (Y/N) / FROM WELL LOG Date of test Static water level I '7 Well flow ¢~ 0 Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main I~.O '/' Sewer service line ~.-~ g.p.m. AT INSPECTION . _. ; On adjacent lots ~//'~ ; On adjacent Jots public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTSi Coliform /Il// Date of sample: ~/~' 7-- B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Nitrate (~, / L/ Other bacteria Collected by: Tank size Compartments Date of pumping Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot TO properly Iirl Surface water/drainage On adjacent lots f l OOrpliorl fiOl Foundation 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA ~"~ Date installed Soil rating Length. Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water bedrooms System type Gravel thickness Total depth Cleanouts present (Y/N) Date of adequacy test for If yes, give date Well on lot To building foundation On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area 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 Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number · MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION~ 825 L Street - Anchorage, Alaska 99501 ~ /1~/~ ' ENVIRONMENTAL ENGINEERING DiViSiON Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing, 1. PROPERTYOWNER ~'5 PHONE MAILING ADDRESS ' PROPERTY R ESI DENT (If different from above) PHONE E~ .PHONE ,~. 2. BUY MAILING ADDRESS 3. ~NDING INSTITUTION r' I PHONE STREET LOCATION [] One [] Four [] Other~ /J~ SINGLE FAMILY ~1~ Two [] Five ~ MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** PUBLIC UTILITY **If individual/on-site, give installation date .~.0,.,,'- ~,,-,. If system is over two (2) years old an adequacy test ~s required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY : DATE RECEIVED " INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [~SING LE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [~'/TWO [] FOUR [] SlX PERMIT NUMBER 2. WATER SUPPLY [~"'"~IN DIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVI DUAL/ON -SITE DATE INSTALLED (~'~L I C UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions; TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~0VED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL~S~RIPTION 72-010 (Rev, 3/78) 203 WEST 15TH. AVENUE SUITE 206 ANCHQRAGE, ALASKA 99502-~904 4907) 2794916 RESIDENTIAL WELL INSPECTION LEGAL: I--(:~':. ','."J Block :1. Shane L..e~:, E.:.d'-ate . ... TYF'E OF WEI_L: F'r'iwat.*+:,~ Singl*:-~, Fami].y WELL YIELD FROM WELL LOG: 20 [¢alioris per PUMP YIELD FROM TEST: Gallons per' Minute DATE OF INSPECTION: A!::)r"i! 6,~ J. 992 TEST PROCEDURE: We:l. 1 was pumped at a c:oristarit rate whi:l.¢z the dl"a~'JdOB~fl was fl'lCil] J. t. or ed ~:[ th afl a(:::ous'L J. c probe. A'I:. '~the beginriing of the 'b:~.~st water ].~vei was fourx] at less thal'] 24 feet below top of casing. At a pumping I'"a'l':.i.:e of 6 ga].lons I:)er m;i. nute the war. er ].ewx!. fluctuated between ].ess than 24 and 25 feet. A total of 720 gallons were pumped. TEST FOR E.COLI AND TOTAL NITROGEN: War. er" was -l:.~.~s'l'.'.ed for' and '::oral n~'l:r-(::,gen on April 8,~ i992 E. Col. 'i n , L ,.a]. Ni t:r"o(p*n 0. lz~ mq/1. Max. allmaabIe 'i"otal Nitrogen :LO mg/1.. TEST RESULTS: Th:i.s well meet'.s'(ihe r..equir'ement~ ~::If the l',lursic:tpa!i'hy of Aruzhor-age. THIS WELL ~ILL PRODUCE ~ORE THA____~N .~ GALLONS PER MINUTE F~R ~ORE THAN FOUR HOURS The Mun:i.c:ipal r. eClLd, r. emerlt for well flow is 15() gaiIons (:~f water' p6?r bedr'o,,::,m per (:la,/,, Th:i. s ~.xal ]. exceed .l:hi s r"equ:i r'emer¥~: ,, 'l"J'-~e a,~;~;¢s~.~m,~mt o¥ 't:'.h~:-:;, cor'M:i..1: .i. I:)r",, o.,',: the con(::i:it:ioris as c:,f the (:]ay te.--:.d:sad,, The .i:l(::,~*,~ rate may char~ge due 't:o '.-:iiLtb!~!.t..(r-[ace (:::orld:i.t:LoFJs:.:, t. hat may rio'l:, bE, obser'ved and chan(~F,2¢s :Ln the ].arid us(.'.:: arx:J o'(:hcm factors t:ha't: may impact 't:.he aqu:i, f,er' -l:;¢_~ed:i. n(;I the ~,.~el 1, Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 ~.wv. ci. anchorage.ak, us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel i.D. Of ^/ ~ ~o"l - dh// 1. GENERAL INFORMATION Complete legal description ~.,¢,/- ~ /Y/a,c l.- Location (site address or directions) Current Property owner(s) ~ {-¢, / ee,-~ Mailing address Lending agency Mailing address Real Estate Agent /~o~ ~ Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: Expiration Date: Day phone __zy_~,! Day phone Day phone J TYPE OF WATER SUPPLY: ' Individual Well [] Individual Water Storage [] Community Class ~ Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and ~pe 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(are) in compliance with all applicable Municipal and State cOdes, ordinances, and regulations in effect at the time of installation. Name of Firm F=(~ t-¢.o? 7"ec/~ ,~-a! ~,*~, ;c~J Phone Address Engineer's Printed Name DSD SIGNATURE / Approved for ~ Disapproved. Conditional approval for bedrooms. ~' ~ ~:'' ~ '- ~'~ ~ bedrooms, with the foflowing stipulations: Additional Comments By: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original certificate Date: '7 - / 0 - ~) .~ (Rev. D1/02) Legal Description: A. WELL DATA Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Well type . ~%,'f Date completed ¢ / 23/~'~ Total depth .. ¢! ft. Sanitary seal (Y/N) . Cased to ?1 ft. FROM WELL LOG Date of test t / 'Z 3 / '7 ~ Static water level · 17 fl. Weld production ~Q g.p.m. WATER SAMPLE RESULTS: Coliform . (~. colonies/lOOmL Arsenic: -- mg.tL SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size __ gal. Foundation cleanout (Y/N) Date of pumping ABSORPTION FIELD DATA Date installed Length ft. Width Total depth ~ ft. Eft. absorption area ~ Date of adequacy test Fluid depth in absorption field before test __ in. Elapsed Time: __ min. Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ e ¥ - Cd'/-6'5' IfA, B, or C provide PWSID # .. ,M_, 4, Well Log (Y/N) 'K Wires properly prOtected (Y/N) .. Casing height (above ground). AT INSPECTION 2/ ft. q, 9 ¢ g.p.m. _in. Nitrate 0, t97 mg./I. Other bacteria 0 colonies/lO0 mi. Date of sample: ~'/~c/¢,~ Collected by: FI~ Date installed Cleanouts (Y/N) _ High water alarm (Y/N) bedrooms in. g,p.d. Number of Compartments ~ Depression over tank (Y/N) . . Pumper Soil rating (g.p.d./ft2 or ff~/bdrm) ft. fi2 Monitoring tube Results (Pass/Fail) water added in. System type. , Gravel below pipe Depression over field For __ gal. New depth Absorption rate >= If yes, give date D. LIFT STATION ~/. ~, Date installed "Pump on" level at Size in gallons __ "Pump off' level at in. Manhole/Access (Y/N) : High water a/arm level at in. Datum Cycles tested : Meets:alarm & circai~ requitem~ht~'~ E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot fJ. /~. . . Absorption field on lot Public sewer main On adjacent lots On adjacent lots Public sewer manholelcleanout Sewer/septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ,t/. ~,. Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main __ Water Service line. Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through fie/d inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date, Engineer's Printed Name~ --r-J~o ~z,~> ~ F. I~/~o,-~ Date, ,_ ,.-r'~ [,y HAA Fee $ Date of'Payment Receipt Number (Rev. 1~01) Waiver Fee $ Date of Payment Receipt Number