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HILLSIDE PARK PUD LT 33
Hillside Park Lot 33 #015-312-36 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241296 Work Type: SepticTank Upgrade Tax Code Number: 01531236000 Site Legal Address: HILLSIDE PARK PUD LT 33 G:2539 Site Mailing Address: 7000 CROOKED TREE DR, Anchorage Owner: LANG ROBERT J & MIRAGLIA Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 9/13/2024 9/13/2025 41071 ❑ Disposal Field Cif Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing -!3ecoi y: - CA ej Date: Issued By: kDate: 4 MUNICIPALITY Development Services Department / Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel 1. D. 015-312-36 Property owner(s) ROBERT LANG Day phone 907-350-9019 Mailing address 7000 CROOKED TREE DRIVE, ANCHORAGE, AK Site address 7000 CROOKED TREE DRIVE, ANCHORAGE, AK I ,gal �,—cripti.,., "Sub'd., a....., Q. L,+) HILLSIDE PARK: LOT 33 gal u...a�,.i iruvi tvuv u., Block . wt Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Ahcnrntinn Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade ❑X Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Priv\/ ❑ (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. (Signature of property owner or authorized agent) Permit/Rush Fees: 2 }2 S/ Waiver Fees: _ Date of Payment: 9! 2G Date of Payment: QoroiMt Altimhber Reroi�t f�I4�rnl;er: Permit No. 5 2 2 9 b Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241296, Deb Wockenfuss, 09/13/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241296, Deb Wockenfuss, 09/13/24 I 0 CL t3LO c CL > Lu 0 iV Mr II SMI y Yg dP iM nng IBJ JYk N NVA\ wNkI, �41 ci Z LU cr- fit ?* SS**- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 f o*_� ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAh1�2C ^ PHONE EW ❑ UPGRADE MAILIN DDRESS IQ• LEGAL DESCRIPTION /•�� �C�/ Gi UL LOCATION/�� l.i o 0 p NO. OF EDROOMS U DISTANCE TO: Well �(lrC�7 Absorption Drea r ( Dwelling � PERMIT �j `/77 / U 7 /� ;:z n Manufacturer �.2�— Maierief� QL J'' No. of compart is ra l' Liq. city in gallons IF HOMEMADE: Inside length Width Liquid depth 6 Y Jz DISTANCE TO: Well Dwelling PERMIT NO. _ 4c Manufacturer Material Liquid capacity in gallons O W = DISTANCE TO: Well s. CQ /i7 �? F undation Nearest lot line PEHMI /' V .Wi LLZ Z W No. of lines/ Length o3epch/ ine (9 ii Total 1F th of lines / Tren i IIs Inches Distance�eJ Jines X F <M F- O l4 Top of file finish grade Material beneath life / inches Tot Fi�1, 5- absorption area (� (�,) W Length Width Depth PERMIT NO. d f W L Type of crib Crib diameter Crib depth Total effective absorption area W DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT NO. W �+ DISTANCE T0: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS o� e , - SOILTESTRATING �S t t INSTALLER _U ,,tt c S REMARKS Aq 1067- C.ntl.C/6 TP �-n -7 e, • APPROVED n _ - -,., DATE LEGAL �•`' /016 i 72-013 (Rev. 3178) THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OP. DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). FZEG,U I REG+ SEPT I C TFir-7f� S I LE= :3- 250 GAL.LOtJS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWO C 2 ] I t ISPECT I OtaS F=iRE F?EQU I REQ BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OP.. 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER. LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS APE AVAILABLE TO INSURE PROPER INSTALLATION. PERMIT EXPIRES C)-EGEMBEF? 31r 1-L=1:0 1. I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE 14ITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER, SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED:---------------------------------------- 36,ti�- 7 APPLICANT CHUCK, y�ADDY, NEW WORLD INC. ISSUED BY�P�V',G_`�_�LC ____------DATE-Zic�-I--- V4.0 MUr4 I C I PF1L I -r *-e Op n QF<F=l C3E ?p DEPARTMENT OP -HEALTH AND ENVIRONMENTAL F'1TECTION % v 1 �1 �7 S 825 'LI STREET, ` ANCHORAGE, AK. 995at n 2E4-4720 Ortel I TE S~EIJEFZ I T a;3o PERMIT NO. < 810471 /F�="EFtrl APPLICANT CHUCK. HARDY, NEW WORLD F'O BX 10-1314 A14CH LOCATION CROOKED TREE DP... LEGAL LT.33 HILLSIDE PK. S/D LOT SIZE 45000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER. OF BEDROOMS = 4 SOIL RATING <SO FT/BR)= 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: 7 tI-/� 26 DEPTH= _ LEt-JGTH= - QRRk-@EL L-tiEPTH= S THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OP. DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). FZEG,U I REG+ SEPT I C TFir-7f� S I LE= :3- 250 GAL.LOtJS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWO C 2 ] I t ISPECT I OtaS F=iRE F?EQU I REQ BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OP.. 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER. LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS APE AVAILABLE TO INSURE PROPER INSTALLATION. PERMIT EXPIRES C)-EGEMBEF? 31r 1-L=1:0 1. I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE 14ITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER, SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED:---------------------------------------- 36,ti�- 7 APPLICANT CHUCK, y�ADDY, NEW WORLD INC. ISSUED BY�P�V',G_`�_�LC ____------DATE-Zic�-I--- V4.0 • • t•TIJtd I + f� Tit-- X 't -Y t31" h-lld+ti�1 tgf3E-�: DEPtlBTrIF11r r]F 1F1f.m rU16 FJN[f2Ut?fETITtIL PRUTECr[r]N 'L' S TPEUf v);1 Irr^lcl W- 9--Zi0 i Z64 -4?--Z"3 ID r-4 i TI. '-f= G-tE =n r-•cr<r•t i T r^�2`I[T FIt1. i vlit•t:i ) fiFfLtr7itlT p11,r,X titaDD'd. Fk�1t lJrl'J� r'1; BY t9 -t314 ft?'41 � r?77 t t dN r r]Y.FO TFEE OR_ r Lor 5 I :£ duals 5q -{x FEE T Lr. 33 HIU_StDfi x PK_ D kfE r]F '-,'UIL tafi;']RP r I0N T.S ['EM 115: TMP. -V 1 ! _� : ' rin��cr>,Jt+ FAJt•t'_'4'J2 r]F FL'pR�l]tfi3 - d 5Ut_ r.Nrtrn] Fr.�) t25 r�rJlrcEV ';[2£ +S" fid '3r]IL F1'sa1�r[Ut1 5'r3tEJ1 i5: r1L'f�T1- " 1_t=r1+3 rW j C-fx]r" PIF>?t: IAN I•i n -r- LENGTH (IN FEED LF TW Tri7}?:7i 13R. MWIF[F-1-0. .1 mE C)EPTN OF A Tr.' X:H OR Fir Is T1i_ PISrwxx E' urm, rg X: lr nlc O'1r7t1FID IlF1P T1>E rg)TTON r u Tw cjw iTtON C [N FEE r?. rt (5 NO -fir HIDTH FOR TFC? # . TT?_ + 7J+�_ D1P T] 1 [ 5 TW- MIN [ r?1M GAP TT{ 1,x,r oyvpt i. 6f - mi ! YMe UU Tt't3t l P t F'£ Rio rt-. eorrom +]t= TTtfi IDA{ n'ATtou CIN FEET). t >=1wt-[ I rzex> _•fir= T Z t=-rnr•tt�- 1 I c t Z':ff-�=1 i3t LLt_1r t a' izM i r tz:'L [ a r R -f; rT r ti'£'3t-'r3t r3 16 [ L I TY TO [ WLdZM T)t 15 DEPM TTIEN T "MG FIG TT i . ;1 (Itrir;-k ATIr]N [Fr:4-,£r]T[r)jt3 r]F 1U1r' YSfLLS tiDJfl-trr TO MIS InRIXIrcFTY MID THE rDJrt J rk F:£`i t onEs TT -DIT TPF= I -0 j- 1f n -t_ 5p�i'tr -T'LT+3 < :=_ 5 I r I t31V S 17rtG: fz>=tztJ L f1:ELti — .. 1]w -F, = TEM td t magi T F [ FUy_ t weEm ON FPIO t l]'j�'A- 5°l MIS i ani f U I t -L ec -mutE4 r TO P ZO-SC i r[ om. 11M[N[I-litt DISUVKF E LET'YrM7f A I•o_L MID MV XI -SITE 5Eltfir"r D[Sfr�}t7_ Sr�TEM ti t YsJ�3 FEr=r FOR N PF..IYATE I•TE�_L OF L59 T4 299 FEET Ffi]t1 fl i'r_k�Ltl• 1I� L D�F£11DIFr3 1 l_C'r7tt TT>: T'r'r rx Pr.r3r.[. iI�J._ 111[ffUllM DISTtiFA_'£ F>?r]M A PP[VATE i•krU_ TO A PRIVATE TIES( L[tIE [5 25 FEET FiT10 i TO H k'2WlR+I rY —3-P=- : L[riF I'. T` F££T_ A TIS S.t t)U I fio*:N r•.; Weil APPLY. ':SSC I f t raj T i r]tii mo +7]tt: TRr1G r [ r]t1 O I tirYttW3 t� 1 j:39lt+ V F TO Ifta-IRVE f'R VER [NSTAWITION. T'�rZr•1 L T f„Sty L fz:tr'= C� :jYt_r•TEaEFZ 3� . 2'x`3 L I 4-"tC9rtFV TI -0T L _ I M Ft3 I D- E NR: H I TN T11C PEQlJ I k 't9I r.3 FOR ON -SITE Sall Zk; AM FrJ,(}I t;r Tt-c- i -i- MFA-tr'r or Arm?"F F- I I WILL IIraTtlLL TFr' S''.`3TFC[ IN fp.-j-ll OtVK:E NIM TW- OXCS. 3: c rFR�.F:STVWD TMT TOC UN-•3irfi sa� ;'4 ;reit ru3•r RGr]r we Q?..r�� ]IIT IF TFiE 1 f�5t0??]Dt1£G T+] IFIL 1LF Fb]RE Ttfi]Ft d EOfb7r]Pri. ;j 2 IT 11,P1 (f� /al�lLTD�bI �k Y4. 9%i L - ----------------oars-f ------------ 1 n OR/ SOILS LOG MUNICIPALITY OF ANCHORAGE 0 PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST Pouch 6850, Anchorage, Alaska 9%02 278.2721 SOILS LOG - PERCOLATION TEST PERFORMED FOR: "" iV ;412 1 -Nr . DATE PERFORMED: VIUme 3.19XI LEGAL DESCRIPTION: LOT 3B f//LGS/OF OAQ�' P U J!/B� G/P/�%•r3�_ SLOPE SITE PLAN 1 2 ' ,( 00--1 S/GTY SA�t/oY 3 O !s.G1 -e4 W/TA' �jj� t/GT G 6.vsFS' 19 20 WAS GROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? , ,•r F� Depth to 6 ON �ob Time 7 Drop ILI e 6 s 2 a'Sic T LF.vlE fO•vliA/IIGC✓1 9 ,(MST Vot �' GGEAA/ r1� 4 .0�. 011 GiG{(/EL k12- 12 14 1413 �o b ulG 13 O1 •k Y •s, d• l 14 'o �iFOP ;OIL` 15 :G . Oxon 17 i0P0 '.d T/tAGE of S,�T 18 • 19 20 WAS GROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? L O P E Gross Net Depth to Net Reading Date Time Time Water Drop 's,J r1� 4 'i— Eci R. Bamord• if '• 754E �iFOP ;OIL` Oxon as oo it i L O P E Gross Net Depth to Net Reading Date Time Time Water Drop 's,J r1� 4 Eci R. Bamord• if '• 754E �iFOP ;OIL` Oxon PERCOLATION RATE (minutes/inch) L I TEST RUN BETWEEN FT AND FT COMMENTS Q co.Wir/ -go -C" D.1/S ' .P//�t/ Gc`"ACN Fi F.Gt� u/E.sT F•e�'�1 TAT FT�j PERFORMED 72008 (7/78) FIED BY: DATE:_&�� Municipality of Mc—fidrage • �' Deveiopmeht SONices Department' Building Safety Division - • e On -Site Water 4 Wastewater Program 4700 South Bragaw St. P.O. Box 196050 Anchorage, AK 99519.6650 www,d.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. HAA# T>50050 1. GENERAL INFORMATION Expiration Date: a, — / (o — 0 6 Complete legal description HILLSIDE PARK SUBDIVISION: LOT 33. Location (site address or directions) 7000 CROOKED TREE DRIVE 0 ANCHOARAGE. AK. 99507 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MICHELLE LAUFERDay phone (907) 929-0649 7000 CROOKED TREE DRIVE • ANCHOARAGE. AK. 99507 Day phone ruNCY BERGH—POLL= w/ PRUDENTIAL JACK W—MM Day phone 563-5500 3801 CENTERPOINi DRIVE #200 • ANCHORAGE, AK. 99503 Unless otherwise requested, HAA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class •A• Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 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 samples. (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 verify 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 type of structure Indicated herein. I further verify that based on the Information obtained from the Municipality ofAnchorage riles and from my Investigation and Inspection, the onsite water supply and/or wastewater disposal system ls(are) In compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of Installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SURE 1D1 *ANCHORAGE, AK 99507 Phone 337-6179 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thonwgh, conscientious engineering analysis of the system fin accordance with ADEC and MOA DSD Guidelines d Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identirable features. The operetlonal fife of all wells and septic systems depend on the local sops condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE Approved for _ bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory ZIt 41DS bedrooms, with the following stipulations: Maintenance Agreements Supplemental Engineer's Report Other 00 By:��� all t� Original Certificate Date: at«. 1xo1> :QP :••.....;.b0 ON-SITE WATERARD WASTEWATER PROGRAM Municipality of Anchorage • Development Services Department Building Safety Division on -SRO Water & Wastewater Program 4700 South Bregaw St. P.O. Box 196650 Anchorage, AK 995198850 www.ciAnehorage.ak.us (9M 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: HILLSIDE PARK SUBDIVISION• LOT 33. Parcel ID: 015-312-36 A. WELL DATA COMMUNITY WELL Wen type •A• If A. B, or C provide PWSID#212461 Date completed Sanity JL Cased to ft• FROM WELL LOG Date of test Static water level ;;=ft • Well production g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 MI. Nitrate Wog Wires pmpedy protected (YIN) Casing height (above ground) in. AT INSPECTION ft. g.p.m. ml. 'Date sample: Collected by: S. SEPTIC/HOLDING TANK DATA � Date Installed 6/10/1981 Tank Typ"Werial Tank size1,_ 250�Oa1. Number of Compartments ? Cleanouta (YIN) YES Foundation cleanout MN) YE5 Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 5/11— Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed 6/10/198' Soil rating (9•D djft'oOIE� 125 System type TRENCH 3 ft. Caravel below pipe 7 ft. Length .. 38 ft. WWU► – Total depth •1217 ft. Eff. absorption area 504 fe Monitoring lube 'ES DOPressbn over field NO Date of adequacy test 2/9_ /200= Results (Pass/Fall) PASS For 4 bedrooms Fluid depth in absorption field before teat 2 in. Water added620 Qct• New depth 2 in. Elapsed Time: 10 min. Final Auld depth 2 In. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 8 type) NONE KNOWN If yes, give date – D. UFT STATION Date instaned Size in gallons 'PUMP on' level at Jn. E. SEPARATION DISTANCES High water alarm level at in. Cycles tested Meets alarm S circuit requirements?. SEPARATION DISTANCES FROM WELL ON LOT TO: Septi: tankAl t station on lot Absorption field on lot Public sewer main COMMUNITY WELL On adjacent Public sewer manholeldeenout line Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells an adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 10'+ Water main 10'+ Water service line 100+ Surface water 100'+ Driveway, parkinglvehide storage 5'+ Curtain drain NONE KNOWN Wells on adjacent kits 200'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I car* that I have detemiined through field inspectlons and review o1 Municipal records that the shove systems are In """' " ...... ..... conformance with MOA HAA guidelines in effect on this date. .. . . ........ .......... Engineer's Printed Name JEFFREY A GARNESS eCE y Date Z� tz,a '�.� �lJ. •QST, Oe_ A HAA Fee $ y.30 Date of Payment Z 15 Jcf 7 Receipt Number 0(g S7� >riev. 12M) KA Walver Fee S Date of Payment Receipt Number it ae 'vv *6 v v• .a� xx l� �tlY !J 41 t r •\ Y ` . • 6961, s I i• • v Rt loon lIN onto Is fat WE 1st OF LIADIXS N"ITUltalf ertCIFICAllt To Sm ART CaMUCt7 FASENWIS Of IBC®, 011111 EMIR DISTIN IirtCUrt11 Aho KAtTs'A Lot uar tut 1Bott tzar ON TW N tAtL IMS AM Is Bol To a NO Fot 101117141111111 WCaRM KAT, AM Bm DDITICM 11YSIXTI to n famim IAolr Bt11M1 Z•d XHd 13CM3SH7 dH WdZS:Zl 0002 So Few 1• a 400 AO-DUILT RXWl (IND Im11Rlhs UT 111111 BATt) 1 hereby certify eat 1 lom perferemd a Rertpows Ilopeetlen of the follwilm described prepertyt ?1 330 ILLSM PAW 10.11.1h. ter. Amber"" Racerdles 11istrtct, Aluh" end that the lnproe—p situated thereon are within tbd pr"prty time and do rot swrtop or onereaeh an the property lying aalec.a there", that no /mprowmwtp on property. lying adjacent thereto erolweh an tho promisee in "tion and that there are in roebmp. tron mi pian tiro. or other Welble emeaments an sold property owcopt me . Indicated hereon, Osted at Archers". Ate"es this ,r_ dry N I11AY Ip -N. to yy-oo Bata AND AstoGATIS LAID wlvtlaRs . • y7r7 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH 6 HUMAN SERVICES welon of ErNirmnanw sw0cm �— onsite swAcm section P.O. B=196650 Andmice, Alm*A 98519.6650. . (907)343-4744: CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D.# 015-312-36 HAA# n 10 0 ;2-'(- 1. GENERAL INFORMATION Complete legal description Hu r SIDE PARK cr rRDnncrON• LOT 33 Location (site address or directions) 7000 CROOK n TRFF DRIVE Property owner FI AINE BURGESS Day phone (907) 346-2516 Mailing address 7OOO CROOKED TREE DRIVE ANCHORAGF. AK 99516 Lending agency Day phone Mailing address Agent BONNIE MEHN R—Dayphone(907) 762-3110 Address 3201 'C' CTREET SUITE 200 ANCHORAGE AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY. Individual well Community well xx Public water NOTE: If community well system, provide written confirmation from State ADEC attest - Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xx Holding Tank Community on-site Public sewer NOTE: ff community wastewater system, provide written confirmation from State ADEC Ing to the legality and status of system. 72-025 F". 1191) Frart MOA #21 CampAer Version PA,o W Note: Alaska Water and Wastewater Consultants, Inc. shall be paid �70D eB at, or prior to, dosing for the engineering services provided. 5. STATEMENT OF INSPECTION BY ENGINEER F-qw44 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 -este water supply and/or wastewater disposal system Is safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. l further verity 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 Munid nd State codes, ordinances, and regulations In effect on the date of this inspection. N ✓ . { % - Name of Firm ALASKA N► TE & ATER CONSULTANTS INC. Phone (907)3'-17-6179 Address 6901 DEBARR`R0AD.ASUrW2RAQE. Engineer's Signature / Date Ll Kilot In conducting fids evaluation, AWV C,I b pnovids a Uvrough, conledendous engineering analysis of the system In acaadance with ADEC and S GukWnes & Regulations. The reported mutts described Ne performance of time system under the carxlrtrarma enoountersd at the time of the tee; and separation distances measured to reaWyldsndilabte features. The operadonalft of all wa& and septic syat&ns depend on Uma boat softs condition, ground vaterlevals that mayAtrduats during the year, and time water SOFA°0� usage of the family being served by the system. These cond/tions are outside the control of o0 Me evaluator of the system. Satisfactory fast results do not guarantee future jowfornmvre (L Q of the system, nor do VWguarantee that there are no hidden defects or encroadrments rZI A %V, J= can therefore not provide any warranty for tutors ast/mats of howbng the pa system w9l continue to meet the operational requirements of ft ADEC or MOA DHHS. * : : { ... .... . ..... ... . The content of tide report Is for time sole benefit of time omwfsted above. Any rellance upon or use ofMis repot by anyotherperson or party is not au&"Lvd, 0 � . ........: nor will Itconferanylegalrightwhatsoeven n f y A. Gayness; B. DHHS SIGNATURE Approved for Disapproved Conditional approval for Additional Comments By. -7953 bedrooms, with the following stipulations: Date -1 - ;?- ('. - 0 / 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 Ulm 1/91) Beds MOA 121 CwVuter Vemion IL SEpncmLDwo TANK DATA Detq6/10/81 T"stw 1250 Nwntw lCompwWwft-2 CW8=ts(YlN)YES FOundOM Cleanout (y N) Y (Y/N) NO Mph water Bann (YIN) N/A Dateo(pumong 5/28/2000 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Dft wed 6/10/81 8011 ratimg (g pA1R2 or 421bdrm) 125 System type TRENCH 38 WkM 3' Gravel #**naaa below pipe 7' Total depth 12' Length Effective abswp&m ansa 504 Mcnitar ft Tube present (YIN) YES- Depression OwerAeld (YIN) NO Data of adogUaW test 5/26/2000 Results (PaaalFal) PASS For 4 Bedrooms Fl ld depth in absorption lleid before test (ln.X 0' lmmed * atter 950 gat. water added (kLk _2" Fluld depth 0' (fns) Mhartes later 1 D Ab wrpnon rete • 600+ GPD parm&m taotramt (past 12 nwnths) (YIIV) NONE KNOWN If yea, glee date – MM Pbv. Wr CaipARVMWM Munlclpallty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES ARM 825'V Sheet. RM 5MAncho We lB A 099501(907) 943-47" - HOM Auttwtity Approval Checklist LoON oescdpom HILLSIDE PARK SUBOMSION;_ LOT 33 Parcel IA.: 015-312-36 A.WELL DATA Well Type COMMUNITY ff A, B, or C, alfadl ADEC letter ADEC water system number 212461 Log (Y)N) Date completed Total depth Cased tD Casing how (above SwdtW seal (YIN) Whoa properly (YJN) FROM WELL LOO AT INSPECTION Date orted static water level Well production g P•m 9.Pm. WATER 8AMPLE REM Nitrale Oti1er badeAa ColUorrrr sample Collected by. IL SEpncmLDwo TANK DATA Detq6/10/81 T"stw 1250 Nwntw lCompwWwft-2 CW8=ts(YlN)YES FOundOM Cleanout (y N) Y (Y/N) NO Mph water Bann (YIN) N/A Dateo(pumong 5/28/2000 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Dft wed 6/10/81 8011 ratimg (g pA1R2 or 421bdrm) 125 System type TRENCH 38 WkM 3' Gravel #**naaa below pipe 7' Total depth 12' Length Effective abswp&m ansa 504 Mcnitar ft Tube present (YIN) YES- Depression OwerAeld (YIN) NO Data of adogUaW test 5/26/2000 Results (PaaalFal) PASS For 4 Bedrooms Fl ld depth in absorption lleid before test (ln.X 0' lmmed * atter 950 gat. water added (kLk _2" Fluld depth 0' (fns) Mhartes later 1 D Ab wrpnon rete • 600+ GPD parm&m taotramt (past 12 nwnths) (YIIV) NONE KNOWN If yea, glee date – MM Pbv. Wr CaipARVMWM D. UFT STATION aC 'Pump ort' level aC Hlpb watnraterm E SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT To. SEPARATION DISTANCES FROM SEFnCIHOLDING TANK ON LOT TO: Foundation 5'+ Properly the 5'+ Absorp8on ilaid 5' water nmYVaervlcs ON 10'+ blrrfaoe WW** ainega 100•+ wets on adjacent lots 200'+ SEPARATION DISTANCES FROM ABSORFnON FIELD ON LOT TO. spa ly Ina 100+ BdMv t wWeton 8' water n*kV*wvko One 10•+ surface water 100'+ Day, parkingArMcle stoma ares 10'+ Curtain drain. F. ENGINEER'S loortmYof n wRh A/t3A Enpineer's Ne Weds an adjacent Iota zoo'+ HAA Fee & 3 O O walver Fee $ oats of Payment c35 0 Ode of Payment Racelpt Nun bei 3 6 l _ Receipt Number maze OWV. so'oaipr"Nbn 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. # i��S— �1�- �In HAA # fail�A+1 t: 1. GENERAL INFORMATION Complete legal description Lot 33; H.ittside Pank Sub"vis:on Location (site address or directions) 7000 Caooked Tue Dai.ve Anehonago_- AK Property owner flan and ala- iihvan Day phone 561--2488 229-1103 Mailing address Lending agency Mailing address Agent Address F.VA Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 4 Day phone Day phone 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 XXX 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. 72-0251X".11911 Flom MOA821 al won wm (184' -OI) WOlu •Tom Sdaau!6ua leuo!ssajojd 0141 ui suo!ss!wo jo siona jol elq!suodsai si e6elogouV to Al!ledio!unjq eU1 pansst si eleog!liao a ajo;aq elep ozAleue jo suo!loodsut lonpuoo OP SHHO to seaAoldw3 •sluawai!nbei elels pue papal u!evao Ashes opapio u! suopnlgsu! 6wpual i!agl pue uoq to siaseyoind o; Asaunoo a se slgl saop SHHO 041 Tisely to elels ayl u! paials!6ai Jaau!6ua leuo!ssalad puadepu! ue Aq enoge 9 Udei6eied ul uaA!6 suo!leluesaidai oql uodn Aluo paseq saleolplia0 lenaddV oglnV U11eaH sanss! (SHHO) S INOS uewnH pue UlleaH to luawpLdea e6eaoyouy to Al!!ed!o!unyy a41 wopelnd!ls 6u!mollol eUl Ul!m 'swoojpaq sluawwo0 leuo!l!ppV JO) lenadde Ieuoll!puo0 •panojddes!0 •swoojpaq sol panaddV 3Hn1VNJIS SHHO '9 amleu6!s saaau!6u3 ONIM33NI9N3 S'8 S ssalppV wnd to aweN •uo!loodsui s!Ul to alep eql uo;oalla ut suo!leln6ei pue'sooueulpio aoo alelS pue led!o!unVy Ile U;!m eouelldwoo ut si walsAs lesods!p ja;emalsem jo/pue Alddns 'm el!s-uo aU;'uolloadsu! pue uo!;e6!;sanu! Auj wal pue sal!l e6ejogouV to Al!led!o!unyy aU; it poulelgo uo!lewjolu! ayl uo paseq legl AI!J8Ajayljnl l •u!aaaq paleo!pul ain;onils to odp pus oapaq lo,(agwnu eql jol a;enbope pue leuo!;ounl'ales s! Ovals (s lesods!p ialemalsem io/pue dns jalem ol!s-uo oqi leyl smogs uo!leo!ldde IenaddV Al!aoylnV WleaH s!Ul to uolle6l;sanul leUi Al!JaA I 'molaq umoys alep uolleplleA ayl to se pue 019M4 paxllle leas Aw Aq pa!l!uao sy U33NION3 AS N01103dSN1 d0 LN3W3JVJ.S 'S Municipality of Anchorage Department of Health & Human Services / HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:! I_?�-r U "Parcel I.D. A. WELL DATA Well type lAUN If A, B, or C, attach ADEC letter. AD C water system number_;//� ra`in I Log present (Y/N) />J/i4 Date completed Driller A114 Total depth Cased to Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROMWEE L LOG tv g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot � ; On adjacent lots _ 1 Absorption field on lot A66 �- —;On adjacent lots — Public sewer main 101A —Public sewer manhole/cleanout Sewer service line NA Petroleum tank 1 .o CIA WATER SAMPLE RESULTS: Scc LEnER O i= CoI^P(-/���CS�-�3� Coliform UvJ� Nitrate A)/4 Other bacteria Date of sample: Ak Collected by: B. SEPTIC/HOLDING TANK DATA _ Date installed —�t7 Tank size Chi Compartments TWO Cleanouts Y N) T i() Foundation cleanout Y N) Mc— Depression (Y/N) v� High water alarm (Y/N) /y/4 Alarm tested (Y/N) , 1J11A Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on tot �AA On adjacent lots 96, a" Foundation To property line ZS/� Absorption field S / Water main/service line y Surface water/drainage 16, 4- 72-026 72-026 (Rev. 791) Front CONTINUED ON BACK PAGE C. LIFTTION Date installed ^1 Size in gallons Vent(Y/N) High water alarm level Meets MOA electrical codes on lot _ Manufacturer _ Manhole/Access (Y/N) level at ANCE FROM LIFT STATION TO: D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested water Date Installed Soil rating ��S SF��Z type System y Length Width Gravel thickness. _L_Total depth �Z Total absorption area S ( S E Cleanouts present ©N) Depression over field (Y/G) '"c) Date of adequacy test 4-- l Results pa s/fail) ��� for T c bedrooms Peroxide treatment (past 92 months) (Y/f) NOT7 nI!XUN 1f yes, give date / A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot N�A Zoo ~ On adjacent lots r Property line— r g y To building foundation R To existing or abandoned system on lot On adjacent lots Cutbank tJ14 Water main/service line �Q A � 1 Surface water /66 Driveway, parking/vehicle storage area � Curtain drain MI tt�" E. ENGINEER'S CERTIFICATION I certify that i have or conformed to all MOA and HAA guidelines in effect on the date of this inspection, Signaturer cj ; • 4, f; .' (4 RING n �. f ! •,, .., i. Engineers4NaO34 E+yle River I =a River. Alask Road l�o�ttf;- w Date a 99577 �. ...............•• tppl�C, HAA Fee $ / 78` 00 Date of Payment Receipt Number 72-026 IR". 3191)8"k MOA 21 Waiver Fee: $ Date of Payment Receipt Number WALTER J. H/CKEL, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE ANCHORAGE DISTRICT OFFICE (907) 349-7755 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 May 6, 1993 Mr. Jim Williams S & S Engineering SUBJECT: Lot 33, Hillside Park Subdivison Class "A" Public Water System, PWSID 212461 Dear Mr. Williams: have completed a review of this office's files concerning the monitoring status of the above -referenced Class "A" Public Water System and found the following: 1. The last satisfactory Total Coliform Bacteria Sample results was submitted to this Department on April 1, 1993. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. 2. The last inorganic Chemical Contaminants Sample results were submitted to this Department on July 2, 1990. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. 3. The last Radioactive Contaminants Sample results were submitted to the Department on December 2, 1992. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. 4. The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC) were submitted to this Department on November 12, 1991. Based on analysis of the previous VOC samples results have been satisfactory. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. Issuance of this letter does not imply that the above -referenced Class "A" Public Water System is in compliance with other provisions of the State Drinking Regulations. Unless otherwise noted, this letter is valid for 30 days and is for the specified legal description noted above only. If you have any questions on the above information, please do not hesitate to contact this office at 349-7755. Sincerely, ;r Lu Environmental Eng. Asst. 11 "e STATE OF ALASKA '.SCITri' A DEPARTMENT OF ENVIRONMENTAL CONSERVATION APPROVAL OF ON-SITE RESIDENTIAL WATER AND SEWER SYSTEMS PROPERTY DESCRIPTION lock a SuWMUon or u.a buns, Lot 33, Hillside Park Subdivision 7000 Crooked Tree Drive ADEC PROJECT no. 9321 — DW -125-084 GnIPWSIDI 2�'2461a: This approval does not constitute a guarantee of any kind, explicit or Implied, as to the performance of the water supply and wastewater disposal systems. WATER SUPPLY A recent water sample was tested and found to meet Department of Environmental Conservation drink - Ing water standards for total coliform bacteria. Nema_ _ � T�I1s 1 Dere 4`—L{/ ��i�ir�ss�nt�i May 5, 199 WASTEWATER DISPOSAL The dbnestic wastewater system was: ❑ inspecte y the Department of EnvirXennsseand found to be in compliance with applicable uirements of 18 AAC 7❑ inspected by a Pr ssionai Engineesystem complies with applicable re- quirements of 18 AA ❑ Installed by a Certified Install ho ccomplies with applicable requirements of 18 AAC 72; or ❑ tested by a Professional Engine who c ifies that the performance of the system Is satisfactory and that the system complie Ith the min um separation distances specified in 18 AAC 72. This approval is valid fo ❑ single family ❑ mult mily unit with a total of bedrooms. 18M04 (Rev. M5) DISTRIBUTION: WHITE—BANKILENDING INSTITUTION; CANARY—APPLICANT. PINK—DEPARTMENT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES 1 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.# d�S- 31Z -3 to HAA# /J eL' 9a p7& GENERAL INFORMATION Complete legal description Lot 33; Hillside Park Subdivision Location (site address or directions) 7000 Crooked Tree Drive, Anchorage, Alaska Property owner Don and Elaine Girvan Day phone 5A1-74AA wk Mailing address AREA COLDWELL BANKER/4105 Tudor Center Drive, R4n�ho8ra3e'�mAlaska 9950, Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water o Day phone Day phone 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 xxx 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 IA.. 1/91) Fro l 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 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 S 8 S ENGINEERING Phone 17034 Eagle River Loop Road No. 204 Address Eacla River, Alaska 99577 Engineer's signature 6. DHHS M SIGNATURE p�, Approved for/— Disapproved.' Conditional approval for Additional Comments bedrooms. ,�IZ bedrooms, with the following stipulations: 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. 7225 (Aft. 1/91) exk MOA.21 Municipality of Anchorage Department of Health & Human Services HEALTHAUTHORITY APPROVAL CHECKLIST Legal Description: /Z Aft <rDr-PMk S/n Parcel I.D. A. WELL DATA Well typeA AAA / ,nomIf & B, or C, attach ADEC letter. ADEC water system number M r a -b l Log (Y/N) WA Date completed Driller present Total depth N�A Cased to IVCasing height Sanitary seal (Y/N) �/� Wires properly protected (Y/N) FROM LOG AT INSPECTION n _, I IA rn w /WELL YW Date of test 'A 4 < o Static water level tG m v_ 0 Well flow 9•p -m• 9 -p -m- - 0' 0 Z Pump level �� SEPARATION DISTANCES FROM WELL TO: N/� — S7✓>✓ 1��� "-2 O� �PUA� Septic/holding tank on lot ano t F ; On adjacent lots Absorption field on lot 2,60 �� ; On adjacent lots N Public sewer main MIA Public sewer manhole/cleanout N Sewer service line lVl Petroleum tank WATER SAMPLE RESULTS: N� .- S; E (Z57r&L OP e0AAPc1A- C1: Coliform A1/A Nitrate �L/& Other bacteria ^� Date of sample: NJ� Collected by: B. SEPTICAi;ZANK DATA Date installed h - Tank size Compartments (wo WjQ Foundation cleanout (VN) VBt Depression (Y/O Nb Cleanouts (9/N), High water alarm (YAI) �A Alarm tested (Y//O IJIa ( � Date of pumping �'oZ�I'01 Z Pumper / `fntiiz- _\ER-Jlcss SEPARATION DISTANCES FROM SEPTIC/ FiG TANK TO: r Well(s) on lot 0/A On adjacent lots Foundation S To property line 35,* Absorptionfield 5, Water main/service line as t Surface water/drainage too I+ - 72.026 (Rev. 75) Fm l CONTINUED ON BACK PAGE C. LIFT STATION N1/,Q Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" Meets MOA electrical codes (Y/N) SEPARATION Well on lot D. ABSORPTION FIELD DATA LIFT STATION TO: On adjacent lots Manufacturer "Pump off' level at �: GYcles tested Surface water Date installed �' (�-� 1 Soil rating IAS S.F11 ripe S stem - 2 anl Y 7, Length -` 36 Width 3 Gravel thickness -42 Total depth r - Total absorption area any Cr Cieanouts present &N) Y6C Depression over field (Y4 L6 U Date of adequacy test Results( as /fail) 11 _- f}SS for bedrooms Peroxide treatment (pasiiz months) (Y/Ib -T\�o't If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots - ci,UO Property line r -J To building foundation g ' To existing or abandoned system on lot AJ,1,4 On adjacent lots �01f Cutbank N -A r Watermain/service line- ��) f Surface water �tk1 r� Driveway, parking/vehicle storage area f Curtain drain &E bU610,J E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S 8 S ENGINEERING 17034 Eagle River Loop Road No. 204 Signature Engineer's Name Date I I- Z HAA Fee $ / 7 0 147-11 1 Date of Payment 7 -- Receipt Receipt Number Z445 -Z) r4�8'7,3 72-026(Rsv.191) Beck MOA 21 Waiver Fee: $ Date of Payment Receipt Number No. SHAFER fI WALTER J. NICKEL, GOVERNOR A1aGHORA IfGE DYSTRfGTFlG(((Eff f ���L CO\ SF RIIAT (In0 ]�i (907) 349-7755 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 November 17, 1992 Mr. Jim Williams S & S Engineering SUBJECT: Hillside Park Subdivision Class W Public Water System, PWSID 212461 Dear Mr. Williams: have completed a review of this office's files concerning the monitoring status of the above -referenced Class "A" Public Water System and found the following: 1. The last satisfactory Total Coliform Bacteria Sample results was submitted to this Department on October 5, 1992. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. 2. The last inorganic Chemical Contaminants Sample results were submitted to this Department on July 2, 1990. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. 3. The last Radioactive Contaminants Sample results were submitted to the Department on October 12, 1988. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. 4. There are no records of Organic Chemical Contaminants/Volatile Organic Chemical were submitted to this Department on November 12, 1991. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. Issuance of this letter does not imply that the above -referenced Class "A" Public Water System is in compliance with other provisions of the State Drinking Regulations. If you have any questions on the above information, please do not hesitate to contact this office at 349-7755. Sincerely, Michael Lu Environmental Eng. Asst. 11 n 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 6 /2 7 /,A<° 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) I_ - 33 !" 1 S 14 7-/,z N )C 3 W Location (address or directions) 7000 ^oekeel irez — (b) Applicant Namet5 n e 1a r, � - `i h Telephone: Home Business -sl 2�%1z Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone Telephone (f) Mail the HAAtothe following address: / l ail 'rG/ 24.13$ � �o.�nr [ ;r_ fill, 2. TYPE OF RESIDENCE Single -Family O Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well ❑ Communityx 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. 72025 (11,84) Page 1 of 2 r�) rallk 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seat 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 &YAtd � l e r l d —F, I-, Telephone Address -712-7 6 i Nth.. A. f 9 951 R Date (0 /;?,' Z 'q WATER WE L NOTE: Thi Health Ajthoriy APpro al in pection merely certlfl s tha the subject wrter 11 pro ted 0 g ons per bedro p/rday nd that/ertlfj d labo story test sho ed pr ence oif rm batter a in samplep tha water. No aran e 4�$ j E ,,....,, certif9 the/ expr ssed 6r impl} d cop ernir? the ong erm �dequacy or safety of th was supply. I 07 114 n.4 ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval gr yin Inspection merely certifies that the subject on-site sewage disposal system accepted at least 150 gallons of water per bedroom per day Q A,: NEIL IIAwTHORr= as determined by methods approved by the Municipality of Anchorage �Qa• •• CE -4369 Department of Health and Human Services. No warantee or CQ rQ. ...... S+r`` certification 15 expressed or implied concerning the long term 0 adequacy of the on-site sewage disposal system. Construction data reported on burled system components is from MOA files and was not verified during this inspection. 6. DHEP APPROVAL J,/ Approved for A2,14 bedrooms by '�" (�W2Lr Date Jy /J71 Approved Disapproved Terms of Conditional Approval Conditional CAUTION 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 engineers work. Page 2 of 2 72-0250V84) n ^ MVNICIPALJTY OF ANGIORACZ Pf?T• OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) INVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) AN 2 % F7o1J CHECKLIST - FEBRUARY 1984 2644720 ��(�/ Legal Description: A �� r � S/4/ 1-aA) Q3� A. WELL DATA Well Classification A Ito B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) * Date Completed Yield Total Depth Cased to Depth of Grouting _ Static Water Level Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot C^ J� ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 'I /Yt + ; On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole — Water Sample Collected by _ To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date Water Sample Test Results Comments Stt S4,'tt 7�EC SLS B. SEPTIC/HOLDING TANK DATA Date Installed 6 If o ZS ) Size 12 O No. of Compartments Standpipes WN) Y Air -tight Caps (Y/N) y Foundation Cleanout (Y/N) % Depression over Tank (Y/N) N Date Last Pumped �b S Pumping/Maintenance Contract on File (Y/N) 6/11A ; for Holding Tank High -Water Alarm (Y/N) —/f//A Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well ? 0 F To Building Foundation P To Property Line 'fin A+ To Disposal Field �r To Water Main/Service Line 1 To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11185) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata _ /2 T Type of System Design 7-.-e „ G Date Installed - 6 - 10 - R I Length of Field - "?6 1 Width of Field Depth of Field Gravel Bed Thickness Square Feet of Absorption Area 1D 4 Standpipes Present (Y/N) X Depression over Field (Y/N) ^/ Date of Last Adequacy Test l Results of Last Adequacy Test ax 4 �i'e�r n, Separation Distance from Absorption Field: To Water -Supply Well - tea^ f To Property Line /S + To Building Foundation R r To Existing or Abandoned System on Lot L o a 'f e al ; On Adjoining Lots -30 t To Water Main/Service Line 20 r+ To Cutbank (if present) .lJ/A To Stream/Pond/Lake/or Major Drainage Course N/A To Driveway, Parking Area, or Vehicle Storage Area ;2n '4 - Comments D. LIFT STATION Date Installed 01A Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Manhole/Access (Y/N) - "Pump Off" Levet at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA •• Check Permitted Bedroom Rating Against HAA Request •• Icertify t ntV.verif_or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date _,_,e h210/R/� Company - •' MOA No. sm¢OC ALSO Q Recei t No. r. . Dateof Payment Aw�-•Ar�+ y J Amount: $ -� 5 Page 2 of 2 72-026 (11,841 CE -43e '^'n 1 UPlC1•"'$Sty^•;;� �•+.r r r` BILL SHEFFIELD, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907) addnu: i ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 3n3 274-2533 ANCHORAGE, ALASKA 99501 DATE: June 25, 1986 PWS I.n.N 212461 To Whom it May Concern: According to records on file in this office the HILLSIDE PARK SUBDIVISION Water System is in compliance with the State Drinking Water Regulations �Sincerely, Michael P. Lewis Environmental Engineer