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HomeMy WebLinkAboutT12N R3W SEC 33 LT 157 S2T12N R3W SEC 33 Lot 157 #018-281-15 Municipality of Anchorage Page 1 of 3 Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (907)343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SWO20164 PID Number. 018.281.15 R.na Dan and Roberta Zipay Wastewater System: New Aaoniss: 14950 Loc Loman Lane Anchors a AK 99516 ABSORPTION FIELD PNana �g�992aim lwnev of eatropna Deep Trench LEGAL DESCRIPTION ` Ta 1Diptrilr °"°""'°'°` .8 GPDrFF 9 Ft. eiorx S112 Lot 157 sWbwam. DOPIN b tpe eettan from Ix" paW. Gra.a eapN taraa� p" 2 Ft. 7.5 Ft Teanaap' Rands: 12N 3W 154 w 33 FA aba0 aeo.a a,prW grana. Grael LanpN. 1.4 Ft. 88 Ft. Well: Existing i w0" Numaratab*. aaaou«..« aa.. 3 Ft. 2 >70 Ft Cwar,utm IPrnas, A B. CI: Toa Depn: Gust b' sial arwrgm rsa pa MaaW. 1,320 Fe ASTM 3034 PVC Q'iller Dae Drab¢ Sbrc Waar Lever. e FL Owner 5130.6/212003 T wnvSet a Cas-V Hgra A TANK—EXISTING GPM Ft. Ft SEPARATION DISTANCES ® Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption Lift Holding lubticnftata . From Tank Field Station Tank sewerune Anchorage Tank 1500 vow >100, >100, WA WA >25'Steel Two (2) s.f.wa« >100' >100' WA WA LIFT STATION — NONE ON LOT Lana >5' 4' WA WA Gar FeMtar.n >5' >10' WA WA °n - ww A a "' in k G.mnoran I None Noted .a'b"" la "w`"p°°'°"'p'tanadby Ren,a s BENCH MARK 5" Lot Line waiver. Existing c Tank Reftcatetlli!Jut-oie Concrete Slab Near North Ground Level Entrance. 100.0 Ft Engineer's Stamp • Inspections performed by: MEADates: 11t 513012003 ° 4 to ° •i Department of Health Zee 61212003 and Human Services approval N ; L 1 MiCNACL E. aNDEF50N { Reviewed and approved by r Date: �{ «— 0-5,ar 1• Jr� No. CE-alar jpf� � • �f r :� czar. Cowl •4s, :, ESSIa��••• is til �� ..,�...o.. •••• �v;���i LO co co ~ I IMIO 09'191 M ,SS. LA O O N I ..•„ \�4\ O \\\\� �• tV 2 ;t�yy 7355y�� 3NVI NVNOI OOl tm CL -- --T— 7��---- or 0 CL C 1 1 .>w f' I 1 •. Ji If)cl O Zm� 1 yy1 I 0) Lf) OWY� Y ` rc I L88S I �In UJ O)w w mW m \\W ---- , I `r < 6 (n a N COrL 'Oil LLJ o m CY ('n 47 M wCU � � Z 1 ..�, �.4�!K� —.•nvl%�:,..'..:.Sf.1��).`A ;tel{�'>: � 4, L. —) (t 31ON 335) (N) a•mt 3 ,00,00-00 N F— o 3 U � 99l 301 � ��W .moi ,€ 0 J CL N N Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 page 3 of 3 On -Site Wastewater Disposal System or Well Inspection Report Permit Number. SW020164 TBM = CD U S U PID No.: 018-281-15 m M V F E U PROFILE AS -BUILT ;^' '...Mc .,N -I Apr. 6. 2005 10:03AM 9015226119 MUNICIPALITY OFANCHORAGE Development Services Department OnSlte Water & Wasle"ter AiVram 4700 South Brdgaw Street P.O. Box 19600, Anchorage, AK 99519-550 (907) 343.7904 ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number. SWO20164 Legal Description: T1 2N R3W SEC 33 LT 157 S2 Design Engineer. 0014 Anderson Engineering Owner Name: Dan E Roberta Zpay Owner Address: 14950 LOC LOMAN LANE MCHORAGE , AK 09516.4029 No.9158 P. 1/10 Date Issued: Jun.12, 2002 Expiration Date: Jun 12, 2003 Parcel ID: 018-281-15 Site Address: 014950 LOC LOMAN LN Lot Size: 64450 SO. FT. Total Bedrooms: 5 Permit Bedrooms: 5 This permit is for the construction of: Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.65 and 15.65 and the State of Alaska Wastewater Disposal Regulations (1 BAAC72 ) and Drinking Water Regulations (18AACSO ). 3, The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and dosed on the same day}- r B. Covered, sealed, and heated to prevent freezing. Received 13y: Issued By: Date: 0/// 2Lo Z ADr. 6. 2005 10:03AM 9015226119 Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK W519-6650 www.ci.anchorage.akus (907) 343-7904 No -9158 P. 2/10 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 016.281.15 Permit Number SW Property owner(s)_ Dan and Roberta Zipay Day phone 3484M Mailing address (1)14950 Loc loman Lane Anchorage, AK 99516 Malting address (2) Zip Code Legal description (Lot, Block & Sub'd.) _S112 of BLM W157, Section 33.712N R3W Legal description (Section, Township & Range) Lot Size 54,450 SF Acres/Sq.FL Number of Bedrooms Six (6) THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub ❑ Jacttzzi ❑ Swimming Pool ❑ r Water Softening Unit r ❑ Therapy Pool ❑ certify that the above Information is correct. I further certify that this application Is being made for a Single Family Dwelling and is In accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: Date of Payment Receipt Number: (Rev. 12100) Waiver Fees: Date of Payment Receipt Number. Apr. 6. 2005 10:03AM 9015226119 No -9758 P. 3/10 June 4, 2002 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: S1/2 of BLM Lot 157, Section 33, T12N, R3W Septic System Design and Permit Application Impacts to Adjacent Properties 1 Dear Onsite Services Engineer. The owners of the S1/2 of BLM Lot 157 intend to construct a six -bedroom home on the lot at some point in the future. We are therefore requesting a permit be Issued for the upgrade of the existing septic system to serve the new home. The attached Site Plan and backup documentation identify the location and configuration of the new septic system and the parameters used In the design. Also. Identified on the plans are the location of the well on the lot, lest hole locations and the locations of existing wells and septic systems in the area. Drainage contours are also shown and current drainage Fattems will be maintained after construction. The existing septic tank will be relocated from Its current position to that shown on the Site Pian. The test hole placed near the location of the proposed absorption trenches ilndicated silty sandy gravel with -a percolation rate of 12 minute per Inch. No groundwater was found during the placement of the test hole and none was noted during the high water period. We are therefore proposing to place 2 - 3' wide by 40' long by 7.5' effective depth absorption trenches on the property. The total depth of the trench will be 9.5'. The distribution pipe will be placed at 2' below the ground surface. A flow splitter valve will be placed to insure an even distribution of septic effluent from the tank. The ground surface on the lot slopes as shown on the attached Site Plan with moderate to slight slopes from east to west and south to north. The new absorption trench will be constructed in conformance with Municipal requirements and parallel to ground contours where possible. All components of the new septic system will be constructed a minimum of 100' from the well on the lot and those in the area and 10' from the service line from the well to the house. If the system Is constructed in accordance with our design the following statements apply. 1. The system, if constructed as designed, will have no adverse Impact on the wells Apr. 6. 2005 10:04AM 9075226119 No -9758 P. 4/10 S11/2 of BLAH Lot 157 June 4, 2002 Page Two In the area or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on exisUng septic systems in the area or those to be constructed In the future. 3. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located In the area. 4. The system, If constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, YY) C-c4j ems, Michael E. Anderson, P.E. Attachments AAf. 6. 2005 10:04AM 9015226119 un.975A P..5/10 Mr. 6. 2005 10:04AM' 9075226779 No.9158 P. 6/10 S112 BLM LOT 157, SECTION 33, T12N, R3W DESIGN FACTORS: Six Bedroom Home Perc. Rate: 14.1 Min.Anch Avg. Application Rate: .8 GPDISF SYSTEM REQUIREMENTS: Deep Trench System 1,5 Gallon Septic Tank (Existing) 7.5' Drain Fleid Rock 6 Bedrooms X 150 GPD 1.8 GPDISF ■ 1,125 SF of Absorption Area 1,125 SF115 SFA_F n 75 LF Trench Length Therefore: Construct Two Absorption Trenches Each 40' in Length by 3' Wide With 7.5' of Drainfleld Rock Beneath the Distribution Lateral. Splitter Valve Placed Between Trenches to Assure Even Flow to Each Trench. Distribution Lateral to Be Placed 2' Below Existing Ground . Total Depth of Trench to Be 9.5' Below Existing Surface. Cover Over Septic Tank a Minimum of 4' or 2" of Insulation and 2' of Cover .5' 7.5' U _r 3' i ) Geotextile Fabric 4" Perfora�ted PVC Schedule 10 Drainfield Rock TYPICAL DEEP TRENCH SECTION (NO 3CALE) NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. Minimum 10' From Lot Line. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Wells in the Area. Minimum 10' Separation From Water Service Line. Apr. 6. 2005 10:05AM 9075226779 No -9758 P. 1/10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES 825 L STREET, ANCHORAGE, AK 99502-0605 SOILS LOG - PERCOLATION TEST PROJECT #: M0216 PERFORMED FOR: DAN ZIPAY DATE PERFORMED: s/3/07 LEGAL DESCRIPTION: I OT tqj S 1/7 RIM SECTION 33 TI?N. RlW TEST HOLE # 1 SLOPE OG / TOPSOIL MEDIUM DENSITY / SILTY -SANDY - GRAVELS SOME COBBLES TO 16' WAS GROUNDWATER TEST GROSS TIME ENCOUNTERED? NQ S NET DROP L IF YES, WHAT DEPTH? 0 DEPTH OF WATER P AFTER MONITORING: E ATE: DATE.- 5.2S" SITE PLAN © C 3r UTl EASDKMn NO SCALE/SEESCALE/SEE ASBUILT READING DATE GROSS TIME NET TIME DEPTH OF WATER NET DROP Start 5/3/02 12:36 8' 1 13:06 30 5.2S" 2.25' Recharge 13:07 8. 2 13:37 30 S.25" 2.25' Recharge 13:38 B. 3 14:08 30 S11S' 2.12S' PERC RATE: 14.1 MIN./INCH PERC. HOLE DIAMETER: 6' TEST RUN BETWEEN L.5 FT. AND 5.5 T. COMMENTS: NO IMPERMEABLE$ ENCOUNTERED / HOLE PRESOAKED PRIOR TO TEST TEST PERFcRmED BY: T.L. KIMBRDUGH I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH All STATE AND MUNICIPAL GUIDELINES ON THIS DATE: MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 SOUTH BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION`S1/2, Lot 157, Section 33, T12N, R3W PERFORMED FOR: Dan Zipay DATE: 5/30/2003 PROJECT No' PARCEL ID,(j TECHNICIAN: M. Anderson DEPTH TEST HOLE Ti] (feet) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 SILTY ORGANICS/OB SLOPE Silty Sandy Gravel GM NMI SITE PLAN SEE SITE RAN Y a WAS GROUND NATER ENCOUNTERED? NO IF YES g, WHAT DEPTH! 0% _ 2%DEPTH OF NATER AFTER MONITORING: NONE DATE OF IdONMRING: U W M' DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH of WATER (INCHES) NET DROP (INCHES) 5/30/03 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 10:26 12.0" CHARGE 2 10:56 30 9.75" 2.25" 3 10:56 12.25" RECHARGE 4 11:26 30 10.125" 2.125" 5 11:26 12.0" RECHARGE 6 11:56 30 1 9.87511 2.125" PERCOLATION RATE11, 4.1 (MCJ/INCi1) FERC. HOLE DIA. 8 ([NCIIES) TEST RUN BETWEEN.• 4.5 FT. and 5.5 FT. COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY VETECII ENGINEERING TECHNICAL SERVICE. 1, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE-: 4/1/2005 t MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ��� ENVIRONMENTAL ENGINEERING DIVISION 825 L Street • Anchorage, Alaska 99501 Telephone 264-4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAMEPHONE ❑ NEW Carl Thompson 345-1078 WUPGRADE MAILING ADDRESS Loc Loman Road LEGAL DESCRIPTION S11 Lot 157 T12N, R3W, Sec 33, SM LOCATION NO. OF BEDROOMS Anchorage, Alaska 3 Well Absorption area Dwelling PERMIT NO. uy DISTANCE TO: 1 s 1 r Or Existing ;:z Manufacturer Material No, of compartments W< NA Conc. 2 to Liq, capacity in gallons IF HOMEMADE: Inside length Width Liquid depth 13 le DISTANCE TO: Well Dwelling PERMIT NO. —iDZ _? F Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well 1 s Foundation s Nearest lot line PERMIT NO. 1 10, . of fines Length of each line Total length of lines Trench width Distance between lines r t Inches R cc tile to finish Material beneath rile Total K�Z p of grade effective absorption area 7)= 2! 6' 72 inches 864 sf ngth Width Depth PERMIT NO. pe of crib Crib tliameter Crib depth Total effective absorption area in DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot fine PERMIT NO. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER ro' ' 1 PIPE MATERIALS PVC 0. ` W rLL SOIL TEST RATING 150 sf br A.1--u INSTALLER 7T7jLHED ` wner REMARKS The owner upgraded his existing system as shown. The permit ti showed a bed system 3 feet wide 00 r ( 0 • Ir and 1.5 feet deep by 72 feet Jang, at the location of the graVel. /a ._. . Soils changed to Sand (150 sf r Cps .....•, ,,, ,•, as indicated above. See new ' APPROVED DATE LEGAL as Kinney R. Baxter 9/19/84 Slij Lot 157, T12N, R3W, Sec 33, SM 72-013 (Rev. 3/78) MIJN I C I P AL I TY OF ANCHORAGE �, f DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK, 99501 264-4720 O N— S I T E S E W E R P E R M I T PERMIT NO: 840635 UPGRADE DATE ISSUED: 07/27/84 APPLICANT: W. C. THOMPSON (3 ADDRESS: SRA BOX 5484 ANCHORAGE, AK 99516 CONTAft PHONE: 345-1078 LEGAL DESCRIP: SUBDIVISION: N/A LOT: 157 S.5 BLOCK: N/A SECTION: 33 TOWNSHIP: 12N RANGE: 3W LOT SIZE: 1.25A (SQ.FT. OR ACRES) I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations; and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system oripublic sewerage system on this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK, MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED r @. ---------- DATE: �7 2 / APPLICANT: W. C. THHOOM�PSON ISSUED BY �---------------- DATE: 7r,�L � = 3a ft . 5'�10� /1 /1 SOILS LOG MUNICIPALITY OF ANCHORAGE f ' i� f DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION ( ^ 1_ 825 L. Street, Anchorage, Alaska 99501 2643720 ST SOILS LOG — PERCOLATION TEST PERFORMED FOR: Carl Thompson DATE PERFORMED: Augttct Q 1984 LEGAL DESCRIPTION: S� Lot 157, T12N, R3W, Sec 33. SM DEPTH SLOPE SITE PLAN EE VV V Overburden 1V VVVV 2 // C 3// Brown Silt 4 (ML) 5 6 7 Grey Sand 10- w/ Silt it .'t (SP) 150 sf/br i. 12 �.: 13 ; 15- 16-- 5 16 �. BO T OF A1_ 17- 18-1 1k 14e�TH 19 1 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? NO S L "O P E Reading W Date Gross Time Net Time Depth to Water Net Drop t KlnneY R. BGKW .� t 20J'J,'•e� 7636.E j�1�pPROPE$$}�Ha�� PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS This soils log supersedes the log dated 7/19/84 due to chance in soils after trench was dug. ( See Inspection Report ) PERFORMED BY: KRB CERTIFIED BY: KRB DATE: 8/18/84 72-008 (6/79) (-. n I% SOILS LOG MUNICIPALITY OF ANCHORAGE ° 1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Strwt, Anchorage, Alaska 99501 2644720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: Carl Thmmpann DATEPERFORMED; Ti,!y iq,19R4 ® ■N■■ ■■NM■■■M■■ MIEN■ ■■■■■NEIN■■ ■■N■ ■■■■■■■■■M ■� ■■ I c a MN■■ ■� no ■■■NN■■■■ ■1■■ ISIMMONUMME ■■■N ■■w■NNNN■■ 8 � o • .9 06. 15 -V z 1 16 1 �P(F•OV 44 17 14.x 16 19 I ^C ; Klnn* . Boater e/l aj'l "• 7636.! c 20 Ftp...«....°•p\ �11,DOOF�S�0�6�4 s PERCOLATION RATEi (minutes/inch) TEST RUN BETWEEN , FT AND FT COMMENTS Recommend a bed sXstem since it is expected that the gravel layer may henome narrower as the trench is lengthened. PERFORMED BY: X2 CERTIFIED 72-008 (6/79) TE:7 /� /* R d- Q a a U a .4 4 10 °p 'Q Gray Gravel (GW) b 85 sf /br ' ' S 11 0 WAS GROUND WATER ENCOUNTERED? NO 0 12 P E / / IF YES, AT WHAT 13 DEPTH? Brown Silt (ML) 14 / 300+ sf/br 15 -V z 1 16 1 �P(F•OV 44 17 14.x 16 19 I ^C ; Klnn* . Boater e/l aj'l "• 7636.! c 20 Ftp...«....°•p\ �11,DOOF�S�0�6�4 s PERCOLATION RATEi (minutes/inch) TEST RUN BETWEEN , FT AND FT COMMENTS Recommend a bed sXstem since it is expected that the gravel layer may henome narrower as the trench is lengthened. PERFORMED BY: X2 CERTIFIED 72-008 (6/79) TE:7 /� /* R d- Q a a U a f Cerfified Well -,,,4 oo �5 0 o Viocatio/6 r— 4 Ce, C, Date completed Dep Y Depth of well 15 v 6 1,, 1 c/C Mai 4— Size of casing— Distance to water Distance to water while eymping at rate -Ix V 'SOLlo a gal ons per lour. Description of Formation from to re7 / el /' C7 25 i rvc/,; 5 4 r6 &-'t:, / B-1 X2467 4- �-Pckr IV 0 6 -1 --- Sri "Id 57t? '7& C, q: • .f I . ..• I MUN i I ;AL17i OF ANCHO Ge . I certify the above true and correct. C -FT CF HEALTH & KAINITAL PROTECQ. it Driller a a "RaAit Cre, N32 — 0610607. 2. RECE1VW--'.-'.-. 171d.5 k, d We Advise you to attach this certificate to your deed. 4, LAS -3590' cc DGGS . ML4"*# i9pi TO P,6/,'� �(/n✓�! f/Jn i ✓�riirr F R lJ.s/iS�S ✓ U7//t/ SUBJECT .?7 T /> f/ d 4 Iw/ DATE i //.4_ Ael, MESSAGE REPLY .4S472 J. SIGNED 1/; SIGNED SEND PARTS I AND 3 INTACT - PART 3 WILL RE RETURNED WITH REPLY. DETACH AND FILE FOR FOLLOW-UP carbon/ess POLY PAK (SO SETS) 4P472 . I Municipality of Anchorage Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 August 15, 1989 Mark Pearson, P.E. Mountain Engineering 10251 Crestview East Eagle River, Alaska 99577 Subject: T12N R3W Section 33 N2 Lot 157 PID #018-281-14 Dear Mr. Pearson: The proposed plan you submitted to the On-site Services section this morning has been reviewed and our comments are as follows: 1. The method you propose to fill the low lying area outside of the required 100 foot well setback distance will provide an acceptable site for an on-site wastewater disposal system. 2. The proposed installation of a 15 inch culvert to provide seasonal surface drainage away from the intended site at the subsurface disposal field is not acceptable. An acceptable alternative is to divert the seasonal surface drainage well away from the proposed drainfield site. Filling the low lying area will no doubt change the surface drainage pattern to the extent that diversion away from the proposed drainfield site should not pose too great of a problem. If I can be of further assistance on this matter, please feel free to contact me at any time at 343-4744. Vn ly, Robert W. Robinson Civil Engineer On-site Services RWR/ljw:157 w..ti-...uwJ.ru....v...�....�.w.`:.. ✓.....v r%a1..... �.. '..n w\a. an...�Itaw..r..rrv..'si.w.n.nr..}..u.....n... ..n+.�.i siLl�...n.n .r w. � r 1 ... 441 .'�'' [• .1047 y 0 o_ r 1 � r 1 y 0 o_ r 1 3 � � OD �. O Q O — 3 O L4 0W N N ♦,Z N 3 0 CD o ►-+. vii T 0 o Depth Varies Ile -g w 0 0 6 7 1 +�Z�� •'' N ♦,Z u Ile -g w 0 0 6 7 Municipality of Anchorage Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage, AK 9951916650 www.ci.anchorage.sk.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018.281.15 HAA# 015--o 1-30 Expiration Date: 7 - It ` 0.5� 1. GENERAL INFORMATION Complete legal description S112 Lot 157 Section 33 T12N R3W Location (site address or directions) 14950 Loc Loman Lane Anchorage AK 99516 Current Property owner(s) Dan and Roberta Zioay Day phone 2296992 Mailing address 14950 Loc Loman Lane Anchorage AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Five 5 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 5 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 less than 30 days old. (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 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 Anderson Engineering Phone 522-7773 Address P 0 Box 240773 Anchorage AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 4!312005 5. DSD SIGNATURE C/ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By; 42f, „/ !w Original Certificate Date: !�' il —0 b– rR«. coot Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 198650 Anchorage, AK 99519-W50 www.cl.anchomge.ak.us (907) 3437904 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type P, 1�tv a If A, B, or C provide PWSID Date completed',jMR Sanitary seal (Y/N) Y Total depth –ti -ft. Cased to >40 fL FROM WELL LOG Date of test 5nn964 Static water level 30 ft Well production 5 g.p.m. WATER SAMPLE RESULTS: Well Log (Y/N) Y Wires property protected (YIN) Y Casing height (above ground) >24 _in. AT INSPECTION 55.2 ft 3.25 9— p.m- Coliform ,_Q_coloniesl100 mL Nitrate _,L mg.A. Other bacteria _jL ooloniesl100 ml. Date of sample: 3n512005 Collected by: A. Harals B. SEPTICIHOLDING TANK DATA Tank Type/Material SepticiSteel Date installed &"3012003 Tank size 1.500 gal. Number of Compartments j Cleanouts (YIN) Y Foundation cleanout (Y/N) I Depression over tank (YIN) N High water alarm (YM) N Date of pumping 41412005 Pumper A Pius Home Sen rim C. ABSORPTION FIELD DATA Date installed 5812003 Soil rating (g.p.dA? or fe/bdrn) .6 GPIAF System type Deep Trench Length 88 ft. Width 3 ft Gravel below pipe T.5 R Total depth u ft Eff. absorption area 1.320 fe Monitoring tube y Depression over field N Date of adequacy test Results (Pass/Fall) For _ bedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in. Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date D. LIFT STATION Date installed 'Pump on' level at _ in. Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (Y/N) 'Pump otr level at _ in. High water alarm level at in. Cycles tested Meets alarm & ckoult requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/Uft station on lot >IW Absorption field on lot MW Public sewer main WA Sewer /septic service line >2S On adjacent lots >100' On adjacent lots MW Public sewer manholelcleanout NIA Holding tank WA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >F Property line>f' Absorption field >S Water main >10' Water service line >10' Surface water MW Wells on adjacent lots >IW SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 4' Building foundation >10' Water main >10' Water Service line >10' Surface water MW Driveway. perkingtvehide amrage >S Curtain drain None Noted Wells on adjacent lots >1W F. COMMENTS G. ENGINEER'S CERTIFICATION I cer* that 1 have determined through field inspections and y;' review of Municipal records that the above systems are in 49t conformance with MOA HAA guidelines m effect on this date. • Engineers Printed Name Michael E P.E.nderson. P.`�� �ti •no. a-4= Data 112f2005 •elf St� HAA Fee E S7 Date of Payment Receipt Number (Rev. 12(M `J Waiver Fee E X75 N Date of Payment Receipt Number 3-28-05:12:23 :CT and E Anderson Enoln. :56.5301 • 2/ 2 200 W. POTTER DRIVE SGS/CTBE ENVIRONMENTAL SERVICES ANCHORAGE, ALASKA 99518 Tetg07.562_y3g3 -SiG$- Fax: 907-561 5301 Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST BE COMPLETED BY WATER SUPPLIER . ❑PUBLIC WATER SYSTEM We ❑ PRIVATE WATER SYSTEM ❑ Send Results SAMPLE COLLECTION ❑ sand b"Ice Irl.�.erwy. w.rw M.wr Mr.rrr.rw� Deft: LL YwM 0q Yv AM PM Nwr ewl Locctlon: STS !�T /C'7 f C� .s � 0 Send Results SAMPLE TYPE: 11 Routine I eI. R.. - r 1051585IpII�1IIppIlIppuugg��''(%'� I�IIWdNNYllll 13 Treated Water E3 Repeat Sample Untreated Water (refer to lab no. t 13 special Purpose Transported to tae Or ❑ Same as collector Other. . TO BE COMPLETED BY LABORATORY. Sample Receiving: ��[[ Date: �L'["� 0Samplemmr30hotesdd. 0 RUSH SAMPLE Time: 2, Results may be unnwws Temp: ❑ �e Now W Phone 0: DepveryMethod: G F ems. Pa%e: o► Confirmation Received Bv: 1 i � .............................................................................................................................................. Bacterioloaical Water Analysis Record - i MMOdAUG (PIA) RESULTS: Sem b ADEC: j Analyst* Beam: 'j� y�, ;� ANC FBK NN Total CoGorm; DaWli w Analyst _ 'r- E Ccp: I Analytical McMod: - Sent to Client MEMBRANE FILTER RESULTS: Phoned Q FastedQ t owaCewR 9 o a CobnlswoonL DstUrns: Membrane Filter MMO-MUG (P/A) Vef cation: �I.,01 se wan: {BGBA,w- C .&*a Satisfactory , rrc.r„e { EC"AAL ❑ Unsatisfactory _ Reported By: % DateMme: �-.2�' '+'j - /e ] r o TM-T°'N'. fte. 00 •on.s. I \beValpubpclDOCUMENTIFORMS1MIcrolCop Form 121703.x1s � � Form f FW- 0053 12/17/03 ... I 04-01-05 II:07Al1 sns FROM -CUE ESI, SCS ENV SERVICES GS Rcf.# 1051392001 lieot Name Anderson Engineering 'rolect Name/N BLM Sec 33 Subd T12N R3W SW 71ent Sample ID BLM Sec33 Subd T12N R3W SW latrls Drinking Water ample Remarks 9075615301 T -34T P.02/04 F-192 All Dates/Times are Alaska Standard Time Printed Datef ime 0323/1005 738 Collected Datefrlme 03/152005 19:40 Received Datefrlme 03/162005 11:10 Technical Director Stephen C. Ede Released By ammeter Results PQL Units Method Container ID Allowable PrepDale An,1, Dna is Init Ar latera Department Nitratc-N 0.100 0.100 ttrg/L EPA 300.0 D (<=10) 03/16/05 CAM Licrobiology Laboratory Total Coliform 25 OB, No Coli cot/IDOmL SM20 92228 A (<-I) 03/16/05 TLF p u F~ �{ r.<oq0 �_ S' r Q O o q . +a P •{ . i. v.: n ^ 0- VI m irk ° O N 0 0 co r rr. 0 0 o °a :° Pep � N fpa� h G Z p � p A O �. F I g n n c> 'tea °F'o viTo^ DDr n A on. m �nyo Ct �p � C P Q, tj ry4 Obi CD m n n a t03 u Nl O Z r^ Z m m F 'W`lk LOT 156 E 181.50 I I I I � I I NOTE 1 8� cm O o OEC 1 0. tO _ v 16.0 N o 24.0 c I I N A TWO STORY N _ J I or,' HOUSE o �8 .or p� r Ar �W r:• ' O �ooi �ml 'S �v v ' .r • •{ . i. v.: .; ; ::GRAVEL 0RIV1 O N 0 r Til M �M mg m S I I I I � I I NOTE 1 8� cm O o OEC 1 0. tO _ v 16.0 N o 24.0 c I I N A TWO STORY N _ J I or,' HOUSE o �8 .or p� r Ar �W T�- r:• ' O �ooi �ml 'S �v v L O C O N 0 r Til M �M mg m S I Ln �b O `'r••? I r `r. 1�.. •~ (,� urn Furn Z m F T�- r:• ' O �ooi �ml 'S �v v L O C O N 0 r Til M �M mg m S ------- - - - - -- - -- I - V�33' PUBLIC ACCESS T I EASEMENT I;j.l r LOC LOMAN LANE N 00 Kro 'umy u r -< SO y0= �g mvm 0;00 '{c (nO �� mo oz O0 Z 0 p Z m c Agog . Z O c C y camp rrnzm� om Z �U)_� M'O,m 19oz zg0 mc:s m LOT 158 m �ooi �ml 'S �v v L O C O N 0 r Til M �M mg m S 17 m W 0 0 0 C Z m 0 r O Z c z I m a c Fop Z M-0 z _ fav �LOz .g co CD O 4 Z O m(x� .il 9 O Z ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 April 1, 2005 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: S1/2 of Lot 157, Section 33, T12N, R3W Separation Distance Waiver Absorption Trench to Lot Line Dear On Site Services Engineer: The north leg of the new absorption trench for the S1/2 of Lot 157, Section 33, T12N, R3W is located approximately 4' from the north property line. This area was determined to have the best soil conditions on the lot for an absorption trench. In addition, the house was moved further to the north than originally planned causing the absorption trench to shift to the north. The second leg of the absorption trench was constructed more than 10' from the property line. Placement of the absorption trench at the location shown will not impact wells or adjacent septic systems. We therefore recommend a waiver be issued allowing the new trench to be constructed at 4' from the north property line. Sincerely, mtz- � dt.", Michael E. Anderson, P.E. WHAEL E ANDERSON l No DE -4181 . Municipality of Anchorage Development Services Department v Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519.6650 www.ci.ancborage.ak.us (907)343-7904 Waiver Review Worksheet WR#: 060017 PID#:018.281-15 HA#:050130 Permit#: 020164 Date Received: 04104/05 Legal Description: T12N 83W Sec 33, S 1/2 of lot 157 Engineer. Anderson EngineerIng P.O. Box 240773. Anchorage AK 99524 Applicant: Daniel Zioav Waiver Requested: SevaraHon distance4 Feet Absootion Field to Property Line Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ............................................................................... Waiver is Granted: tl_� Waiver is not Granted: List Conditions or Reasons for above: Date: Ll — (. O S� By: Rec#: 65608 Amount: $175.00 Date Paid: 4/6/2006 AZuniclpality of.Anchorage J ICO. IA'X 1!X6710 • Anehmi re, Aha.ka !X Ai if) (67II • ! r 6 Telephone (X171 iSi:4�Kit1I •Pax 1.X17) Yia�F!LIXI J \' 471X1 [Int %% timet • Anchamge, Ahiska !k6517 .tlayor Jlark Bggich aimmumLorg I3uilding Safety Dl%isioit 6 April 05 Anderson Engineering P.O. Box 240773 Anchorage, AK 99524 Subject: Waiver Request for T12N R3W Section 33 SI/2 of Lot 157 Waiver Request #WR050017 Parcel ID #018-281-15 Dear Mr. Anderson: Your request for a waiver of the required 10 feet from the Absorption Field to the Property Line is approved. The approved separation distance is 4 feet. This waiver approval applies to the existing Absorption Field to Property Line separations only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, 6;�Vol�o;r Jeff Poet Engineering Tech On -Site Water &: Wastewater Program Community, Security, Prosperity Municipality of Anchorage Department of Health and Human Services Tom Fink. 825 "L" Street Mayor P.O. Box 196650 Anchorage. Alaska 99519-6650 August 15, 1989 Mark Pearson, P.E. Mountain Engineering 10251 Crestview East Eagle River, Alaska 99577 Subject: T12N R3W Section 33 N2 Lot 157 PID 4018-281-14 Dear Mr. Pearson: The proposed plan you submitted to the On-site Services section this morning has been reviewed and our comments are as follows: 1. The method you propose to fill the low lying area outside of the required 100 foot well setback distance will provide an acceptable site for an on-site wastewater disposal system. 2. The proposed installation of a 15 inch culvert to provide seasonal surface drainage away from the intended site at the subsurface disposal field is not acceptable. An acceptable alternative is to divert the seasonal surface drainage well away from the proposed drainfield site. Filling the low lying area will no doubt change the surface drainage pattern to the extent that diversion away from the proposed drainfield site should not pose too great of a problem. If I can be of further assistance on this matter, please feel free to contact me at any time at 343-4744. Sinly, Robert W. Robinson Civil Engineer On-site Services RWR/ljw:157 ( IUNICIPALITY 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 2644720 1. GENERAL INFORMATION (a) Legal Descri tion (include dc'7 d Location (address or Application Date f G subdivision, section, township, range) ( 2,%Z `- 7— (b) (b) Applicant Name��Ir._i �::rr/7f�'t� Telephone: Home �� �t7f' Business Applicant Address / ,«/– /r ��l= (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderr ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Mp one (1 Mail & HAA to the following — /0:7C 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Telephone Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Public ❑ Community ❑ Holding Tank ❑ No 1 community well system, must have written confirmation from the Stale Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72.025 (11,94) I eo�" 5. ENGINEERING FIRM PROVIDING II.: ECTIONS, TESTS, FILE SEARCH, DATA'...0 INFORMATION As certified by myseal affixed hereto and as of thevalidation dale shown below, I verifythat 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.) 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 h�JnspeFlion. r Name of Firm 5 �` i��/zs s' _Z` S e lephonee Address l// Date �) 6. DHEPAPPROVA J �y Approved for bedrooms by Approved Disapproved Terms of Conditional Approval nal CAUTION or At 14 rt�Tli ti •,tit' .,.,...... -•----. .. Meyer Date e E,6 The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an Independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending Institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72 025 (11,84) MUNICIPAUTy OF ANCHORAGE n DIPT. OF HEALTH 6 MUNICIPALITY OF ANCHORAGE (MO.,, FNVIWNWNTAL PItOTECTION HEALTH AUTHORITY APPROVAL (HAA) MAR 61986 CHECKLIST - FEBRUARY 1984 264-4720 �; `' c ^ Legal Description: �� r^ >, wL cu Y C �1 A. WELL DATA Well Classification iv rye If A, B, C, D.E.C. Approved (Y/N) Well Log Preserd�5kl) Date Completed v X96` Yield `2Ze G.2�// Total Depth /��lr rt �- p Cased to Depth of Grouting Static Water Level 7, / Pump Set At Casing Height Above Ground _% /J Sanitary Seal on Casing((Y f) Electrical Wiring in Condu&) Depression Around Wellhead (Y vim. Separation Distances from Well: To Septic/Holding Tank on Lot ����' /'`— ; On Adjoining Lots To Nearest Edge of Absorption Field on To Nearest Public Sewer Line Cleanout/Manhole �! Water Sample Collected by Water Sample Test Results ;On Adjoining Lots /40 _ To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date - H Comments 1222 t -'An 4 U1 LL IN IR' DSP ty,4r_r_V7 VA2Lr Id le UNC Uv'H ACOUNI) VAULT p-eLLVAU(T IS IN GAir . B. SEPTIC/HOLDING TANK DATA Date InstalledSiz�No. of Compartments Z Standpipeti J) Air -tight Caps/ 1) Foundation Cleano Q l) Depression over Tank (1A� Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/HOldin,q,Tank: To Water -Supply Well To Building Foundation �S To Property Line �� /f To Disposal Field To Water Main/Service ine Course 'e-�- Comments Sed Pwip f6NEP7' RNP lij"Az=m rjerokR" To Stream, Pond, Lake, or Major Drainage Pagel 012 �e 72-026(11184) L C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata P�rty'pe of System Design Date Installed Length of Field Width of Field 36 Depth of Field Gravel Bed Thickness Square Feet of Absorption Area ��� S F Standpipes Presen(&N) Depression over Field (Y _ Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well /G c -74— To Property Linef— To Building Foundation �� To Existing or Abandoned System on Lot /oc / 7` 7— To Water Main/Service Line f 71— To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments 5GTV A>7AC A-12 PSC -75;' D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments On Adjoining Lots c To Cutbank (if Dresont) ✓'o"F .sfs�_,_%r Dimensions Manhole/Access (Y/N) 'Pump Off' Level at " Check Permitted Bedroom Rating Against HAA Request " Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA Icertify that Pavechecked, verified. or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed M� Q DateT11 B& Company Q / MOA No. Receipt No Date of Payment Amount:$ (oS� Page 2 of 2 rz-azc 0 1,B42 ,-n Client's Name: Address: BESSE, FOPS S POrrs 2220 PAST 88 AVE:JE ANCHORAGE, AK 99507 (907) 349-45451 Date: it -b�D Subdivision: Lot: 7 - Block: Block• Tester: Initial Reading on Meter: TIME GPM GALII.US A VOLUME GALL(XLS TOTAL VOLUME /"ArG/C iteA0oda q_3 NOTES: r,�f/G �A�i�iifnf�7Pzc�1 l sr�i0!>E[T Production Rate: C GPM 24-1four Capacity Gallons BESSE, TIPS & POTTS June 11, 1986 John Kennedy DHEP 825 "L" Street Anchorage, Alaska Re: Health Authority Approval S 1/2, Lot 1571 T12N, R111 S33 Owner - Carl Thompson Dear John: r-. This letter is to document our evaluation of the size of the septic tank on the above -referenced lot. Since no as -built information was available to establish tank size, we have exposed the top of the vertical type steel tank and measured actual dimensions of the tank. The tank is cylindrical in shape, 5 feet in diameter, and nine feet long which provides 1,320 gallons of capacity. We hope this will allow for the on-site septic system to be approved for four bedrooms per your discussions with Mr. Thompson. Very truly yours, � Ir(1,�11i1 Carey S. ye r E smh ` OF A AW r�TN 00 Tt Carey e F ENGINEERING, PLANNING, SURVEYING 2220 E. 88th Ave. /Anchorage, Alaska 995071 Telephone 907-349-64511344-1352 "Providing a quality personalized service to those building Alaska's future" am for n 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 1. GENERAL INFORMATION (a) Legal Descri (include I on Location (address or Application Date —3, — � <e- subdivision, section, township, range) �C_ 32L 41,11 /- Inti (b) Applicant Name,•/- 12v-,r//i-1'4' Telephone: Home Applicant Address /'�%�r� 7ef Business ..e (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderd; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address pJone (f Mail he HAA to theJollowing address: /G 2 e 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsitetcommunity Public [3 Community 13 Holding Tank ❑ Nol . well system, must have written confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 1r1/04) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and Inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and Stale codes, ordinances, and regulations in effect on the date of thisjnspeclion. el Name of Firm��-T� S`` /Cir/r % / ��x S TP)PnhnnP Address Date ,or L M1la<. Meyer CJ2� 6. DHEP APPROVA Approved for bedrooms by, Date Approved Disapproved Conditional Terms of Conditional Approval 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 72.025(11104)