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HomeMy WebLinkAboutSKYWAY PARK ESTATES #1 BLK 8 LT 7Skyway Park Estates #1 Block 8 Lot 7 #019-201-04 Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Mark Begich Anchorage, AK 99507 Mayor w .munuoro/onsite (907)343-7904 Pump Installation Log Well Drilling Permit Number: SW Date of Issue: /-30-/5-- Parcel =30-/S Parcel Identification Number: Legal Description Property Owner Name & Address: S'I / W/q Y FA F Y r - S S4ev,, X"lle-ouNy 8e. 13 y0 540"e- Pump Installation Date: %^ 3D �lS� Pump Intake Depth Below Top of Well Casing: ! / ZZ feet Pump Manufacturer's Name: Al-, 36 e(e c T Pump Model: 5O C- 3 11 9-511 Pump Size I/L hp Pitless Adapter Burial Depth: ) L feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Weil Disinfected Upon Completion?/Yes Completion?/ YesF71No Method of Disinfection: Pump Installer Name: Attention: The pump installer shall provide a pump installati1n log to the DSD within 30 days of pump installation. WELL LOG .-Date Drilledt A -S -4't Static stater Level 47 feet Draw Down N/A feet Tyre Material Drilledt 0 feet 'to 20 Crev Clav/gravel ?n Fret to 75 Sandv red clAv Shy'• Drive Gallons Per Minute 3 Total Feet of Casing 120 75 feet t0 4.4 a`xlldps/rOrk-pravpl ha �p�t to 57 rvivpl w/water S'1 fret to 1,)n rpmentprl orAvol to Perforated at 52 feet Hefty Drilling S.A.A. Box 1553 H Anchorage,Alaska 99507 tfiU" I f_ I FAL I T'T NZ, F= nr-aCF-inF:r=irE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 26.4-4720 CAr4—S I TE IJEILL F?EFtt'i I T PERMIT NO: 840029 DATE ISSUED: '01/03/84 APPLICANT: DAVID P. WOLF ADDRESS: 1340 SHORE DRIVE ANSHORAGE, AK 99515 CONTACT PHONE: 276-5152 LEGAL DESCRIP: SUBDIVISION: SKYWAY PARE: EST.ADD1 LOT: 7 SECTION: WA TOWNSHIP: NA RANGE: WA LOT SIZE: (SQ. FT. OR ACRES) BLOCK: 8 I CERTIFY THAT: 1. I AM FFIMILIAR 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 IW 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 BACs( DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. SIGNED APPLICA ISSUED DATE: NT: DAVID g, JOLF (`r �. -- ATE: js 0 j MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. _ Division of Environmental Services ME On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # o t `i - %0 / — ° y HAA # _tri C)OI W O 'Lh q 1. GENERAL INFORMATION Complete legal description Lot 9; l3tock 8; Sk•aoay Patk Eatatea #1 Location (site address or directions) 1340 Shoke Dnive Anchoaale, AK 99515 Property owner •' • • Vicki Scan,Con Day phone .: Mailing address . 1340 Shoat Drtive Anchotage, AK 99515 Lending agency Day phone Mailing address - Agent Day phone Address _ Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: 4 V 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from Stato ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. nags (R«. 1191) Fran MOA 121 S. STATEMENT_OF.INSPECTION BY ENGINEER._ As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I 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 S i S ENGINEERING Cyt -1 - X9 7 I I/UJ4 r8910 KIM Loop Road No. 204 Phone Address Eagle River, la a 377 Engineers signature Date 9/1 q / 9 ( a ROBERT G COWAN 4k- 6. 6. DHHH^S SIGNATUREf\% CE -8801 ./�`� Approved for bedroomsV` . t`�:,. Disapproved. Conditional approval for bedrooms, with the following stipulations: M- 'Additional Comments ItlTir 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. rtm (W+. un) 6.n ►qA T e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description:1-nf 7 , A'c,r8 Parcell.D.:-_O/9-Zo/��5� E•Sr,4r6S SdBdairSra,✓ l A. WELL DATA Well type P,QrvA>E If A, B, or C, attach ADEC letter. ADEC water system number Al. �. Log present49N) YfrS Date completed i Total depth AZO i Cased to 120 Casing height (above ground) Sanitary seal &N) Y�"-s Wires property protected(94) FROM WELL LOG Date of teat L� Static water level -7 Well production 3 g.p.m. WATER SAMPLE RESULTS: Coliform _- - -- - O Nitrate 0. / AT INSPECTION 9—lel -94� 1171 Y. b g.p.m. Other bacteria o Date of sample: (411, / 1 6 Collected by: S -Z _C �^�6r�✓�"�.�1�✓6 DATA Data installed Foundation cleanout (Y/N) D is of-PuMping BSQRPTI ON FIELD DATA •�- , Data ins - Effective absorption area Date of adequacy too '00v. 'W' - PORLIc YtW'A size Nu mpartments Cleanouts (Y/N) High water alarm (Y/N) Pumper N• 4. Soil rating (g.p.dJft' or f 2/bdrm) System Gravel thickness below pipe ' �oring Tube Total depth Depression over field (YM) For bedrooms Fluid depth In absorption field be (in.); Immediately gal. water added (in.): Fluid depth ns) Minutes later: Absorption rate = p.� Pe etment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 31913)' D.TION Date installed Manhole/Access(Y/N) _ High water alarm level at* _ Cycle E. SEPARATION DISTANCES "Datum Size in gallons "Pump off" level at* SEPARATION DISTANCES FROM WELL /ON�LOT TO: - Septic/holding tank on lot /y • 1J • On adjacent lots /✓ Absorption field on lot �V/• 4 On adjacent lots �• - Public sewer main ©O +F Public sewer manholetcleanout Sewer /septic service fine— e7 J �` Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation Water ZJservice Ilne SEPARATION DISTANCE FROM Property line Surface water F ENGINEER'S CERTIFICATION Property line water/drainage Driveway. Absorption field Nalll o djacent lots _ Water main/service line Nell rage area Wells on adjacent lots I certify that I have determined thru field inspections and review of Municipal in conformance with &104ta7fiin effect on this date. Signature 7L ''-� Engineer's Name _ /C B/ER T C. � L.4 -,-J ( Date Ci / I GI 47 HAA Fee $ a Lf p . C C Date of Payment L /�•Y> Receipt Number 72-026 (Rev. 3196)" Waiver Fee $ Date of Payment Receipt Number ROBUT a COWAN CE -8801 ale 09/23/1996 15:48 . ,09!23/96 CUE RoU Client Name Project NAUW# Cl wd Smmpte TD Matrix Ordered By Fwsm 9076941211 S AND S ENGINEERING 16:10 CTSE ESI IiOURACE +9076941211 ME Ento 8"Ces Inc. L9bor9tory DMdat1' PAGE 02 NO. 331 903 200 W. Fater Drive Am borago. AK 9901!•1605 Tel: 1907) 562.2343 Fax: 1007) 561.5301 964604001 • S & S Havant* .. V B11 Skywty Park SsiAw S/D V B6 3kywayTak S+aatfit it/D Ddaldaj WAter ... Ciknt rw Printed Dat*Fftm 09123196 12:11 Colkded Dat*Mme 09113/9614:10 Reed"d Date/•nme 09/131% 14:90 Technical Dirodor. S4ep111n C. Ede Ramw By C f&-- F _ (Aawfer of the io9 Group (SOC41e 0446rele do surr04(ml rNVISONMINTAL 9ACILIrl19 IN ALASKA. CAUFOINt/r'"tDA, iLL1NGlf, MMYLAND, MICHMK MISSOMI, NEW ,ICASEY, OHIO. WEST VIRGINIA ' Allowbla ?rap Anotyair paromahr aeWlt .'Iel Unite Whed Naito Oat* Dou Inuit Nitrito-It O.IOMI.>. 0.100 ap/L Smit 4500-0103r 09/16/96 ESC 111treto-4 .....0.2p ''0.100 W/L 1m10 4500•1403F 09/17/96 ETC Total Coliform 0. 0 oal/101IK Smtt 02221 09/15/94 TAV F _ (Aawfer of the io9 Group (SOC41e 0446rele do surr04(ml rNVISONMINTAL 9ACILIrl19 IN ALASKA. CAUFOINt/r'"tDA, iLL1NGlf, MMYLAND, MICHMK MISSOMI, NEW ,ICASEY, OHIO. WEST VIRGINIA MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH d HUMAN SERVICE$ 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.# olq -201—C4 1. GENERAL —INFORMATION Complete legal description LOT -7 j Location (site address or directions) - /340 S40P.c- h RI VG Do. L Property owner °CD I �AttFY Oliorsntell Day phone SY4-0819 Mailing address Lending agency Day phone Mailirig address Agent _ Day phone Address - _ _ t: Unless otherwise requested, HAA will he held for pickup - -� .. �r �.: A. i j:r JJ 1 ..:.i. '._.___. .-- a. •1':TY til J. � j 2 NUMBER OF BEDROOMS. 3 - TYPE OF WATER SUPPLY: l •. Individual well .._ _ XXx.x Communitywell ti f• �.' l i r Public water NOTE If community well system, provide written confirmation from State �i�EC. Attest- ;• ;� ,� Ing to the legality and status of system. 4. - TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank ... _ . _ Community on-site Public sewer Xy_x x - NOTE: --If community wastewater system, provide written confirmation from State 'A D__EC attesting to the legality and status of system. " - ran wIm.1Av F.oM Mw m S. STATEMENT OF INSPECTION BY'ENGINEER . As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this Inspection. Name of Firm Atj6CRSo� FNG��c�nl�G Phone Address pD Bo%. 240773 440 0a.gel� A 995'Zy Engineerssignature lt�. (..�- Date 3 1 1/z LqS The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Certificates based only upon the representations given in paragraph'5 above by an Independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes and their lending institutions in 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 engineers work. `• T2-W(Bw."1) 6Y bOAM _: _..- �' �.�.--t^st•e .•°mow O S y,Yn• • •\ 4 6.,t DHHS SIGNATURE .. - Approved for l r bedrooms —7777 Z Conditional approval for : bedrooms, with the following stipulations: ------- 1 _\.i,Additional Comments BY _.... ... _.. Date The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Certificates based only upon the representations given in paragraph'5 above by an Independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto 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 engineers work. `• T2-W(Bw."1) 6Y bOAM ® Municipality of Anchorage Ra Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lor % 13tvuc. S S11 -J rl l per- Parcel I.D. E5� ATt;t, /10. l A. Well Data Well type RzrVArC If A. B, or C, attach ADEC letter. ADEC water system number Log present (YM) y Date completed 815*/$ 3 Drifter 415-T-7 Total depth /Zo, Cased to /ZDV Casing height _ Sanitary seal (Y/N) Date of test Static water level Well flow Pump levell FROM WELL LOG S/s/8 3 4-1 Wires properly protected AT INSPECTION 3 S 3 g.p.m. /ol , 'P2oPCTZ.Ty Cp^jAi ::czc7t Septictholding tank on lot ; On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: b2ILUn/ -ro (—vgU0- SC�JAL Coliform 0 Nitrate ACXAWTri LCi Other ba'c/teria 0 3 Date of sample: .18 /95 Collected by: A• k2ALA Date installed -PIVBLIC. ScWCfZ. Tank size Compartments Cteanouts (Y/N) Foundation cleanout (Y/N) Depression (YM) High water alar (Y/N) Alarm tested (YM) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field Surface water/drainage Water main/service line n -M CM* F,ord CONTINUED ON BACK PAGE co c" Q �c Z° -ro (—vgU0- SC�JAL Coliform 0 Nitrate ACXAWTri LCi Other ba'c/teria 0 3 Date of sample: .18 /95 Collected by: A• k2ALA Date installed -PIVBLIC. ScWCfZ. Tank size Compartments Cteanouts (Y/N) Foundation cleanout (Y/N) Depression (YM) High water alar (Y/N) Alarm tested (YM) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field Surface water/drainage Water main/service line n -M CM* F,ord CONTINUED ON BACK PAGE Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at 'Pump otr Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot' - On adjacent lots Surface water 0. ABSORPTION FIELD DATA a` 7v7JLIC, S6IJETL Date installed Soil rating (GPD/Ft2) System type Length Width Gravel thickness Total depth Total absorption area Cleanout present (Y/N) Depression over field (Y/N) Date of adequacy test Results (passifail) for Bedrooms Water level in absorption field before test After test Peroxide treatment (past 12 months) (Y/N) it yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots Property line To building foundation To existing or abandoned system on On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEERS CERTIFICATION I cerfify that I have checked, verified. or conformed to all MOA and HAA guidelines in effect on thB date Qf this Inspection. .,�`, c� •.o ti' d, Signature •.. ••••� Engineer's Nameu�SIA �rOM k Date o��•�' 3 iZ�9s `�' c'• x.91 -E / 1:',j !! fp :. t••'+., ••..fir., HAA Fee $ n✓f� �� Waiver Fee $ Date of Payment —4 " 3—/3 '%5 Date of Payment Receipt Number rwee)) Receipt Number. 7228 (5'93)' Back ©3/13/95 L�E 12:18 CO MIRCIAL TESTING + 907 344 2130 CT&E Environmental Services Inc. Laboratory Division - P CtLE Ra:.# 95.0921-1 Laboratory Analysis Report Matrix RATER Client Sample ID L7 HLRS HRYWAY PARR ESTS 01 Client Name ANDERSON ENOINEBRINO Ordered by ALAN ANDERSON Project Name Project# PNSID UA Sample Remarks: ROUTINE SAMPLE COLLECTED BY: A.H. WITNESSED BY R.T. NO.933 D02 WORK Order 13161 Printed Date 02/13/95 m 11:12 ire. Collected Date 03/08/95 a 16:47 hrs. Received Date 03/09/95 m 17:00 hrs. Technical Director STEPHEN C. EDE Released OC Allowable Ext. Anal Parameter Result* Qual Unite Method Limits Date Date Init ---------------------------------•--_-------••---------_-•-----____--•--__-___-_•---_------------------------------- Nitrate-N 0.24 mg/L EPA 333.2 10. 03/10/95 CMR • • ................................................................................... .......................... • Sae Special Instructions Above VA . unavailable •• Dee Sample Remarks Above NA . Not AaalYzad a U . Vadataet•d, Reported value 1e the practical quantification limit. IT Iwse Than O . Secondary dilution. GT . Creator Than 200 W. Potter Drive, Anchorage, AK 99516.1605 — Tel: (907) 662.2343 Fax: (907) 661-6301 ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND. MICHIGAN, MISSOURI, NEW JERSEY. OHIO, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE • Department of Health &Human Services yp�, DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel l.D.#-C"k`-(.'l-fi2,- \� HAA# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) L.cF 7 St'bGC'c9 .�h;eL ctif� Pce -1, Location (address or directions) 13 YO s6on Dr% (b) Property owner Qa4le- l!h/f Telephone: (home) SY9-0 Z6 Business 276Sis'Z Mailing Address 1-1,Y0 Sino D An�!r f - 99,5-.r (c) Lending Institution 6-rf A•L Telephone S6Z-2/8/ Mailing Address Y60 W 7 -,,,Gr Raf.y fjn,A,, f rA i4wc 91'nr (d) Real Estate Company and Agent _ fid; Kux prey, er Ai w - Sidle / Ce rna» n Address 2600 Cor•dura 9j. 1r"C17arcraL� Y Telephone (e) Mail the HAA to the following address: (or check here &, if hold for pick up.) List contact person and day phone number below: 7-e"( P[oo. e 3 YS - as - 2. TYPE OF RESIDENCE Single -Family IS Number of bedrooms 3. WATER SUPPLY Individual Well 62 Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Public 9 Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/68) Page 1 of 2 Z to Z 06ed ro.e (NIL "H)Szo-u •3IJoM s,Jaaul6ua Ieuo!ssa;ad ayj ul suolsslwoJo sJoJJa Jo; o!q!suodsaJ jou s! o6eJogouy;o Aj!IedlolunW 9141 •panssl s! oleo!pliao a eJo;aq ejep ez leue Jo suolioadsul jonpuoojou op SHHO;o saaAo1dw3 -slue waJ!nbaJ alels pue 1eJ9pa; ulejJaoAjspes olJapJou! suopnj!jsul 6ulpua� Jig pue sawog;o sJasegoJnd of 6salinoo a se slgi saop SHHO 0141'eNSely10 alUIS ayj u! paJalsl6aJ Jaaul6ue leuolssa;ad juapuadapul ue Aq anoge 9 gdeJ6eJed u! uaAl6 suolleluesaJdaJ agl uodn R1uo paseq pajeol;lJao 1enoJddV AI!Jotliny gjleaH sanssl (SHHO) sao!AJaS uewnH pue glleOH;o juawjJedaO abeJogouy;oAI!led!olunyy ayj Noanvo . 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Aw woJ; pue sal!; 96eJoyouy;o A1!led!olunjry 9141 w0j; paulelgo uoljewJo;u1 9141 uo paseq jegl 4!JaA Jagvn; 1 •ulaJay pajeolpul aJnjonJjs;o adAl pue swoapaq jo Jagwnu agl Jo; ejenbape pue leuoljounj 'e;es sl walsAs lesodslp JajeMaISEM Jo/pue /Ilddns JaleM 011s-uo 0141 1eg1 SMCgS IEACJddy Al!joglny 141leaH SMI jo U0Ile6!jSaAUI Aw legl ApJaA I'Molaq uMogS ejep UCIjeplleA 814110 Se pUe C1aJa14 paxille leas lbw Aq palpjJ93 sy N0111/WHOdN1 ON1l VIVO'HOHy3S 311d'S1S31'SNOIlO3dSNl JNIOIAOUd WUlJ °JNIU33NION3 'S A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST -FEBRUARY 1984 343-4744 Legal Description: % %, 13!E C& ww;, Pink E Well Classification pyF If A, B, C, D.E.C. Approved (Y/N) NA- 7+Well Lo Present Y/N�r `!_Date Completed AI S7 ,6 ��.. nasr 7�2/ �s� 9 ( 1 p 3 Yield.a •� /o• Total Depth IZO Cased toA1 12G Depth of Grouting N -A. Static Water Level `17' Pump Set At 101' /AAA Casing Height Above Ground r 6" Sanitary Seal on Casing (Y/N) 1' Electrical Wiring in Conduit (Y/N) %' Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot N•A. ; On Adjoining Lots N• A, To Nearest Edge of Absorption Field on Lot V.A. ; On Adjoining Lots N• A• To Nearest Public Sewer Line 150' i To Nearest Public Sewer Cleanout/Manhole '-'� r c v' To Nearest Sewer Service Line on Lot > 2 S' Water Sample Collected by - r.. r • I`e•e n ; Date -7 Z 11; A9 Water Sample Test Results SefI*r rA!�^x - Qco(r!"o.r.+ /Looms Q.9o=y1.e d;ArftAe-A/ Comments* Well fea dcsr rid fds+hl!- /ef rF VOCAr, (.F it fif'cf r.. 1_706 :�'rfe /,J DNNf zKit Ceti 1 prrl; cs%d of S-2' P« t efl foo J �� 7 f 47,9 P" vitfoi .necvuerd< in 7/ 2Y/B9 B. SEPTIC/HOLDING TANK DATA N.A. C P"WIC Sewer Date Installed Size Standpipes (Y/N) Depression over Tank (Y/N) No. of Compartments Air -tight Caps (Y/N) Pumping/Maintenance Contact on File (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ;for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well To Building Foundation To Property Line To Disposal Field To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments Vewl' 'r eve- ConAGckr.^ 1600u6/rc ssawrv- w- Awli/K. 7/2-Y/89 72-026 (Ft". VN) Front Pagel of 2 C. ABSORPTION FIELD DATA N• R. Soils Rating in Absorption Strata Date Installed Width of Field ' Public Sew -e? - Type of System Design, Length of Field Depth of Field Gravel Bed Thickness Square Feet of Absortion Area Statndpipes Present (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Property Line To Building Foundation To Existing or Abandoned System on Lot ;On Adjoining Lots To Water Main/Service Line To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Commentsy0�1h,#d ea,7neCl40� 6(Oubr�c S4ewir «i /}WGf/cL 7/zy/69 D. LIFT STATION Nall. Date Installed Size In Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) —"Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. "Check Permitted Bedroom Rating Against HAA Request" certify that I have checked, verified, or conformed to all MOA and inspection. effect on the date of this Signed Ir qn*..� r ......,•y t,• . Q.. .,. • F(A40e Teebac.r v..v + 6' �1 ��a 4 AgTCompany Date MA —� 2 vt I96 / MOA No. % ' oS 2 O. .....:... 0 . THEODORE F. MOORED; 0 n ^•.• CE - 35II9 . ct�o a. as � 7,5_.361)Receipt Receipt No C11.7 -0c>6 No Date of Payment 7 _a 5-4 9 Waiver Fee: $ — Amount: $%0• Date of Payment 72-M (Rn.7/68) Back Page 2 of 2 Engineer's Seal MUNICIPALITY OF ANCHORAGE DIVISION OF ENNIRO*1ENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH A[TIHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Descriptiai (include lot, block, subdivision, section, township, range �DT-T. Rjh0(CSs SkVojj;q fah?_V- (.T1.7-aTzs_ AbD1TrcN �_O,( PL64TGG-7 SccT� s as{1y� -r zN� 2 4 wS,tA�, �tn(ado ee, 146(LC (ZL /.CfG(2 . S' L X76 St_< (b) Applicants Name D Uf h P.tooL(- Telephone 3c4q. 194 Applicants Address 13y0 ! Ft462i i pjuC t4_,c(4o2tgGC �°!5 (c) Applicant is (check one) Lending Irstitution Owner/builder ; Buyer [::� ; Other Q (explain); (d) Lending Institution F1 (2ST NATW UL 1_ 01< or 94661ephone 2E5 3 AddressPo Box (oc)7a6 AhciteP9c:er-LASGCR 99S16 _O7% (e) Real Estate Co. S Agent neu Address Telephone 2. Type of Residence Single -Family Number of Bedroom 3. Water Supply Multi -Family Q 4 - Other (chscribe) Individual Wbll Camunity � Public Note: If camurity well system, must have written confirmation frau the State Department of Environmental Conservation attesting to the legality and status. Is the well adequate for the number of bedroans specified in this HAA (Y/N) c 4. Sewage Disposal Orsite Public'- Cc munity F_j Holding Tark Is the wastewater disposal system adequate for the r=ter of bedrooms (Y/N) [Page 1 of 21 2-15-84 r'\ n 5. Ergine-ering Firm Providirg Inspections, Tests, Luta and Information I certify that I have checked, verified, or conformed to all MDA HAA Guidelines i effect on the date cf'this irsoection. Signa Date Z-Zel-84 Naw - of Firm A2CT/C cNe,iNEEJZS Telephone T&1-134!9 Address /SU6 LIL). 3(,ati AVe. OFF At 11 Signed bylih ✓� �i S T 4 .. v t N f /` P C -j .��'••?.s; l Date Z -%S'- A4 (ENGINEER SEAL) 6.DHEP Approval Approved for � bedrooms ApprcvedK71 Disapproved Terms of Conditional Approval By c _. c Date Conditional The Municipality of Anchorage Wpartment of Health and Ervirorrental Protection not guarantee the continued satisfactory performance of the water supply arfd/cr wastewater disposal system. This approval indicates that, as of the validaticr. shown above, based on the data and informaticn furnished by an ergireer register the State of Alaska, the water supply and wastewater disposal system is safe and tioral for the number of bedrooms and type of structure indicated. (CHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s (Page 2 of 21 2-15-84 A. FELL DkTA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Lot 7 BLock 8 Skyway Park Estates Subdivision Addtion #1 Well Classification 1V TC If A, B, or C, D.E.C. Approved(Y/N) Well Log Present a) Date Completed 0-5--83 Yield :> M Total Depth 120 Cased to 120 ' Depth of Grcuting (%n/cnoWyr Static Water Level T'%' Pump Set At /01/ Casing Height Above Ground ? /Z " Sanitary Seal on Casing Electrical Wiring in.Conduit ey?N) Depression Around Wellhead (Y Separation Distances from Well: To Septic/Holding Tank on Lot NIA ; On Adjoining Lots---N-/-A To Nearest Edge of Absorption Field on Lct NIA On Adjoining Lots tJJA To Nearest Public Sewer Lire 140' To Nearest Public Sewer Cleanout/Manhole ISO i To Nearest Sewer Service Line on Lot 't3O Water Sample Collected By Arcf i'c En! I - Date Z-Zf3 - 84 Water Sample Test Results ccliYovw+ macfPvic► Comments B. SEPTIC/HOLDING TANK DATA NIA Date Installed Size No. of Compartments Standpipes (YIN) Air -tight Caps (Y/N) Foundation Cleanout (YIN) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on File (Y/N) for Holding Tank High -Water Alarm (YM) Temporary Holding Tank Permit (YM) Separation Distanoss fram Septic/Holding Tank: To Water -Supply Fell To Property Lire To Water Main/Service Line r�,,,•� To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage (Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA /J /A Soils Rating in Absorption Strata Type of System Design Date Installed length of Field Width of.Field Depth of Field Gravel Bed Thickness Square Feet of Absorption Area Standpipas Present (Y/N) Depression over Field (Y/N) Late of Last Alaquacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well To Property Line To Building Foundation To Existing or Abandoned System on Lot On Adjoining Lots To Water Main/Service Line To Cutbank(if present) To Stream/Pond/Lake/c>r Major Drainage Carie To Driveway, Parking Area, or Vehicle Storage Area Cam ants D. LIFT STATION N /A Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Ramp On" level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Convents ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA FAI r. effect on the date of this inspection. ,gyp••,.•••••••..,• n 1 Signedto Z-29-84 ��n :•' �••�� s� Coapany Arrib'G E MOA No. �.''I � �•••4 G RBl/d5/S I j' j p. ; Codd S. Yan �J; % CC -5123 (Page 2 of 21 2-15-84