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Home My WebLink AboutT12N R3W SEC 27 LT 16T12N R3W SECTION 27 Lot 16 #018-092-05 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825"L" Street, Anchorage, Alaska 99502, Telephone 284-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Lot M . [ ,a Su0"iw5lon TANKS X SEPTIC ❑ HOLDING Manwacturer Capacity In gallons � Miller... No of compartments TYPE OF SYSTEM ❑ TRENCH ;< BED TANK ❑ W. DRAIN ❑ OTHER Depth to pipe b"tlom Irom WELL Total depth Irom original graoe original grade 1_6 a\ FT �,a-1O'I FT Fal aooeo alio.. rmgmal grade O' Gravel "rpm beneath pipe Ili � FT IOlt FT Graveueugar AS -BUILT DIAGRAM (Snow location of well. septic system. property Imes, lounoauon. "rwewav, wale( b""res. etc I Gravel width 4z FT ZZ t FT total absorption area (Distance between lines q2 SO FT FT Number of lines Soil ratingmaurlQ [t �lI /,;D SOFT pSTAA D 30 34 installer I Date Instaileo WELLS PRIVATE ❑ OTHER tidentlly) lAaavbuelWn JA.B.LI Total Deplll Lase"10 FT FT In51;na" _ _ N1 x ✓ Dale Inslaile" FROM ID'� TANK '" FIELD WELL WELL ce a LOT LINE S' O' Pro;1C/j e FOUNDATION 51 SOa Pro ?oJtJc AS -BUILT DIAGRAM (Snow location of well. septic system. property Imes, lounoauon. "rwewav, wale( b""res. etc I REMARKS: =6 ra a2t J SQ 'I el 4'11 m JJ ct 4 156 5-F -;� 114er L/Scale: / `10;44! sclkle� Infspb=cuo6QeAormeo by �_A�' M 73 Dale P I Ce- J' Cont -ink -it, acee III that this inspection was performed according to all Municipal and State guidelines In effect an this dale: Z( Q� g 7 nI i Health Department Approval: E'W/ Date. J A9-29-77 1ENGINEERSAEAL r; - t }j 'n .. J WELL LOG Date Drilled: 11-10-87 Static Water Level 138 feet Draw Down NSA feet Type Material Drilled: 0 feet to 20 c1 ay P. gr n, 20 feet to 23 gravel w/7 gim 23 feet 44 feet to 44 clay /:of lel Sec. 27/ VZij R3Cv 13 66I Elp, D/eRoC Dan &.Susan Church Gallons Per Minute 15+ Total Feet of Casing . LEI to 46 gravel - 46 feet to 72 cemented silty gray 1 72 feet to 71 gravel it/' Spm 73 feet to 156 (-PmPnted clap• 156 feet to 160 n1Pan gra i ;C.S^ndw./water to RECEIVED HEFTY DRILLING JVN 2Q 1996 3540 AKULA DRIVE ANCHORAGE, 93 99516 D MOIL alth &Noma Services (907) 345-0593 01129 !8 33AEI Arcnmuy VAh & 02np Sw K7_1, 30Y412 0 1 Parket IdeWiRcadw Numbi:zc: 0 18'-072-05 galDe�criptlDn Owner N-arre& Zl_dre7. I 1 0 FY 1\ 3 Vj OZ C 4 1 L, 1 1 new zass'-w1now Pump TwoHninu DaW: / I Q PUTUP -Wakl Tal) of C11 fat,570tea Pump .14, — hP Pump Size I I f'itl ss Adarqer Deptw feet 4 Pitless 'kdoptev;`,' lawtfz,cwr,,r"zi Name: Pj&ss Adywi InvaHee: V 0 0i9iUfelAVd l,`P0ikC0AGP,'Vtj0n! Almhod of INAnDcown: clanwanw: Murry In"JaHvir '�iawc: bevelopmen-r Services Department Budding Safety blvlsiun AT On -Site Water & Wastewater Pro ram t 470C E'7,.cre Pca6 40 Box 19565w MAN se"N' An ho. - a5 e, AK' 9S. ,Jr Pump Installation Log Well Di iffinp Pi;rinil N axnhtx: SW data of t3suc: Parket IdeWiRcadw Numbi:zc: 0 18'-072-05 galDe�criptlDn Owner N-arre& Zl_dre7. I 1 0 FY 1\ 3 Vj OZ C 4 1 L, 1 1 new zass'-w1now Pump TwoHninu DaW: / I Q PUTUP -Wakl Tal) of C11 fat,570tea Pump .14, — hP Pump Size I I f'itl ss Adarqer Deptw feet 4 Pitless 'kdoptev;`,' lawtfz,cwr,,r"zi Name: Pj&ss Adywi InvaHee: V 0 0i9iUfelAVd l,`P0ikC0AGP,'Vtj0n! Almhod of INAnDcown: clanwanw: Murry In"JaHvir '�iawc: J114-25-1996 1338 FLATTOP TECH. SVCS. 9073451355 P.02 :. '� STC ; .•, ? �FTti. _ .. ... .. ' � �:� i f , _ • " ' f ,OP TECHNICA S R ' L ERM, CrVM a ENVIRONMENTAL ENCINEERCVG • ENFRGY CONSERVA710N a A.NALYsrs THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 343.13SS ANCHORAGE, ALASKA 99516 June 25,1996 M.O.A. DHHS - Am.: Robbie Robinson RECEIVED - by FAX 343-4786 (2 pages) JUN 25 1996 Dear Mr. Robinson: Pt. Health & Human Seot rvices As a follow-up to our telephone conversation of this mon hg regarding the wastewater disposal system serving the 3 bedroom residence on Lot 16, Section 27, TIZN, R3W, located at 13661 Elmore Road, I am able to provide you with the following supplemental lnformation and interpretation. (1) The shed which is situated on top of the soil absorption bed does not appear to have any �emrranent foundation, and :saireld ore1didnotinterpret tt as bek in viotiof the ordinance bsurface disbe located 10 fat away from any bttIkling or sttucnne From a practical vieint, I do not view the presence of the shed as significantly impacting the perforrrranet of the absorption system On the one hand, the unheated shed could cause somewhat deeper frost peneuatioa Into the soil directly underneath it then would occur in an area with normal snow cover, but on the other hand the shed roof would reduce the amount of natural water infiltration into at least a portion of the soil absorption heti. In any case, the shed docs not appear to have caused any operational probletnc so far, so there does not seem to be any compelling reason to think that it be moved at tats time. (2) I do not know whether the portion of the waste line downstream of the septic tank which passes under the driveway is insulated, however it does have at least 3 feet of soil cover. Again, the configuration has not caused any reported operational problems so far, even in last year's cold, snowless winter, so there does not appear to be any compelling reason to second- guess the installation at this time. (3) The fluid levels you measured in the standpipes are almost identical to the fluid levels I measured at the start of my test. Three of the bed standpipes appears to be combination cleanout/monitor tubes as detailed on Corwin's design, while the fourth is an independent monitor tube. During the course of my test I added a total of 745 gallons of water into the system. Within the first 50 gallons the fluid depth in the southeast c.o./m.L which had been at 7 inches rose to 10 Inches and then remained constant throughout the remainder of the test. The fluid level In this tube fell to within 1R" of its original level within 20 minutes after the flow of water was stopped. I interpreted this to indicate that the perforations in this rou are probably partially obstructed with a slime build-up; this would allow the effluent reaching it to rapidly fill the pipe up to the level of the horizontal distribution pipe, but no further. The c.oJm.t. at the diametrically opposite corner of the bed which had been dry prior to the addition of water achieved a maximum fluid depth of 2 Inches as a result of the 745 gallon dose. Three hours later this fluid depth bad receded to 1/4 inch. In testing systems with multiple monitor tubes over many years it has been my experience that rarely do all the monitor tubes have exactly the same fluid depths. I attribute this to a number / �j� n "— � G -2 ¢-y6 TOTAL P.02 4e 44 j1�11 �K �I1— � � Com,-,�, JUN -25-1996 1337 FLATTOP TECH. SVCS. 9073451355 P.01 of factors including (1) the monitor tubes ate not set initially with a level, (2) differential settlement can occur over time. particularly when there is sand fill involved, and (3) the perforations in monitor tubes can gradually become clogged, allowing them to appear to indicate greater fluid depths than is characteristic of the absorption bed as a whole. The engineer conducting the test thus needs to exercise a degree of judgement in interpreting his raw measurements. The differential fluid levels I observed during my recent test of this system were not significant in my opinion, and I felt the test procedure demonstrated the continued ability of the System to absorb water at the required rate. Please feel fru to give me a call if you have further questions on my test procedure or observations. Sincerely. Ted Moore, P.E. cc- Rodney Davis I - --- . Mo 97 ----- ------ - ro �7—+L en-�Vv ett S 7A4tr) r") C/ 041, it r Municipality of Anchorage ' January 12, 1988 n P.O. BOA 196650 ANCHORAGE. ALASKA 99519-6650 (907)343-4200 99XRK1YatV9& Tom Fink, MAYOR DEPARTMENT OF HEALTH 6 HUMAN SERVICES Dan Church 12001 Industry Way, Bldg. B Anchorage, Alaska 99515 Subject: T12N R3W Section 27 Lo Permit 5870299, Tax 018-092-05 A permit issued by this Department or an individual well and/or on-site sewer system has expired as of December 31, 1987. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a,private engineer inspected the installation of the on-site sewer system, the original as -built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. Effective January 1, 1988, a new fee schedule is in effect. When re -applying for a new permit, the new fees are; $90.00 for an on-site sewer permit; $50.00 for a well permit; $140.00 for a combined sewer and well permit. If there are any further questions, please call this office at 343-4744. Sin ely, Robert W. Robinson Program Manager On-site Services RWR/ljw enc: Copy of Permit M U N I C I F A L I T Y O F A N C H O R A G E Department of Health & Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 O N- S I T E S E W E R & S E P T I C T A N K P E R M I T Permit Number: 870299 Date Issued: 11/05/87 Engineer Designed Owner Name: DAN CHURCH Day Phone: Owner Address: C/O 12001 INDUSTRY WAY BLDG. H Z45-4440 ANCHORAGE, AK 99515 Parepl Id: 010-092-05 Lot Legal: Subdivision: Nif!, C t. 16 fOlock: N/A bac i£-on:R07 Township: 12N--R.tngv--7_-W Lot Size 144to (sq.4. or acres) Mer.; Bedrooms: This Permit: - Total Capacity: .. SEPTIC TANK: Minimum total septic tank: capacity: 1,000 gallons. Each septic tank must have at least 2 comportments. Depth to top of septic tank(s) : 4.0 feet- requires insulation over tanl(s). INSTALL PER FNGINEERS DESIGN 18' X 37.5' BED, WITH 2' SAND FILTER. NOTIFY DHHS F'RIOR TO IST & 2ND INSPECTIONS: Af TER FMURS PHUNf_ 340-4681. 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. T. T will .-adhere to all MOA and State of Alaska requirements for the set back: distances from any existing well, wastewater disposal system or public snwerago system on this or any adjacent or nearby lot. 4. I underst:.id that this permit is valid for a maximum of 3 bedrooms. I also und:r Land th_tt the capacity of the total system is 3 bedrooms and any enla c aunt w 1 require an additional permit. Signed: DATE: (Owner ) t) iN CH' IR' If / Ised By: rr.DATE: .!�------------- ( /� p0.POE r - ((ENGINEERS SEAL) {. OE PNC RON r, •......... - �l E0. SCE Municipality of Anchorage ga� DEPARTMENT OF HEALTH & HUMAN SERVICES E 41 625 "L" Street. Anchorage, Alaska 99502-0650 ✓ / ` SOILS LOG — PERCOLATION TEST J. Corwin 4 CE -52E3 ./ PERFORMED FOR: M t. T) A AI C N veru DATE PERFOlimEO.' - z LEGAL t°pc*z�rr orya"acs 1 �w 4 6W 2 '.t3' Wellray mrtlwta� V-4* 3 `gat 9`�ror/ed sorol 4 111 ML. Si1+ v • e 5 ' C,W lit 6 ;Q Ltk tl �ruo%ritgro�c-/ wi44 7 ... 8 9 10 ` GM 13 14-1 rJ I I I N, (7 rov.j Wu 4er A— EnCvu 4erea 15- 16- 17- 18- 19- 20 51617181920 COMMENTS SLOPE r/ AM WAS GROUND WATER _ N ENCOUNTERED? S IF YES, AT WHAT L DEPTH? 0P E Depth m Water After w�n ''/�l� 11110 rinp7 11' Date: / ' Reading Date Gross Net Depth to Net Time I Time Water Drop PERCOLATION RATE (mmutesnnchl PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY:�FI�V' PASS I 4 4 CERTIFY THAT AHIS GEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELIN EFFECT THIS DATE. DATE: ��a� 7 72-008 (Rev. 4/85) ISP La -r 4 ¢5' WELL in N Lor S 3a proposeal Lor 6 _ O A6Sorp+ron • C Mc Ai tr'I (�TECT + 153' 5,0 • v ProPPDs9d 3 gd r,.. Hoose �ropOs 1L.4`r l6 Wt l l :54,4570P ik cf"f4-1 1 . ,nc 145 )JIn KOQD LoT I S No House ort I SEi7-IC Sy,TEAI OW THIS LOT I SEWER SYSTEM LOCATION PLAN j LOT eLOCX /V eDI V17ION ZW ION/ TOWNSHIP/ RANOE I ,E• , NOTE•T14E ACCURACY Of LOCATION OF EXISTING PROPERTY CORNERS, WELLS, AND SEPTIC .N BY• BYSTEMS INDICATED IS NOT EXACT. DIMENSIONS INDICATED HAVE OEEN DETERMINED OY USE OF CLOTH TAPE ARO NOT OY SURVEYING TECHNIQUES.' DATE- � Z'g"7 I SHEET or r ..::....... 1 NORTH ru 1. Corwin • ; � W t , u '•> . CL -5.37 •_; �� I Ll"C--c,.- •. t C4 LOT eLOCX /V eDI V17ION ZW ION/ TOWNSHIP/ RANOE I ,E• , NOTE•T14E ACCURACY Of LOCATION OF EXISTING PROPERTY CORNERS, WELLS, AND SEPTIC .N BY• BYSTEMS INDICATED IS NOT EXACT. DIMENSIONS INDICATED HAVE OEEN DETERMINED OY USE OF CLOTH TAPE ARO NOT OY SURVEYING TECHNIQUES.' DATE- � Z'g"7 I SHEET or Tya Dealt N.T.S. 37.ex /d . dr-'WIJ . —Slope 1011 CII � ��Bookfill, 3' minlmum or 3' Burial rninimum� ,-Prforoled 4" PVC pipe, To SIPIIC Tmk o ' ej Cloan ural 1111--`..�. �•Cle Grove, I/2-21/2" TUndisturbed Boll --- SECTIONA-A No1ee, N.T.S. 1. Grade area to divert "face water away from syetem. 2. Thred bedroom system. / 3. Imparted ural flit rated at 160 sf/br. ✓/ 4. Sep+le +ank 4o be 1,000gat. Min. �{/.QiT/GHT CAP o Municipality of Anchorage .. Development Services Department ' Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY-DWELLING— Parcel I.D. O f 8 - 09 Z - os- HAA # n�l7ri Expiration Date: 1. GENERAL INFORMATION Complete legal description 1 -of 1!6 Sezho, 0 2, T f 2 N. 13 3 f ; S. r1. Location (site address or directions) Y H 2 o EQrf 13 6" Awenu e_ Current Property owner(s) (Zodn ;y Do v4 Day phone 2 6-0 -9`/M9 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address _�,V r.S i /N S *" h"Oe. /i oQ�� ff k 99 s re ,41.wkei USA Fee! &-eo&Ac/nri,.Day phone 766 -ZS -8A �aoa ereol;f Llnan nr,vly A_ etio��,�. A -c 994713 FS t3 D Day phone Unless otherwise requested, HAA will be held by DSD for pickup. P l cart to f l p .une^ @ Z So -9 Y y9 WAin ffY}A Ctrl, u PUraIy ir.+.• r'ek- p 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-site 19 Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I 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 rlaf%/n 71ocHn; co•/ S'e•-v.c-y Phone Address i♦NS70 EcAo S'A�An c-�¢, A� S v4le' Engineer's Printed Name %f+ao:�v-r �. Mao,e Date to / to / 2ooS- 5. DSD SIGNATURE Approved for bedrooms. Disapproved. <H 'A.'��.�9TiiL'� .. 10. •� THEODORE F. R40ORE L° CC -35119 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: / \3r a . Original Certificate Date: (R•v. Ov02) Municipality of Anchorage •. • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST' Legal Description: LoF 16 Sec+r,n 27 7-11%%361X.m. Parcel ID: Orb -092-05- A. WELL DATA Well type p -t If A, B, or C provide PWSID # Date completed 11 /1/10/87 Sanitary seal (YIN) Total depth f 60 ft. Cased to l60 ft. FROM WELL LOG Date of test Ir / r& /617 Static water level 13 8 ft. Well production S+ g.p.m. WATER SAMPLE RESULTS Coliform _colonies/100 ml. Arsenic: mg./I. B. SEPTIC/HOLDING TANK DATA Nitrate 1.81 mg./l. Well Log (YIN) Wires properly protected (YIN) Y Casing height (above ground) 2 S in. AT INSPECTION 9/Z710S- 17-8 0- 1Z& ft. SS g.p.m. Other bacteria 0 colonies/100 ml. Date of sample: 2/27/40-C Collected by: Fl -/-f r, 7-ac4 Suc Tank Type/Material S e4 Fi c S fve / Date installed / z. Tank size 10V gal. Number of Compartments Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N• A•. Dateofpumping fo/,%/o.f Pumper be,2PL1i F&c,"o F," t C. ABSORPTION FIELD DATA Date installed 12 / 3 /b 7 Soil rating (g p.d./ft2 or ft2/bdrm) ►sb S._ System type 13ea/ r3vRrr Length H 2 ft. Width 27 ft. Gravel below pipe 0.83 ft. Total depth I-Cft. Eff. absorption area p Z y ftz Monitoring tube Y Depression over field _/N Date of adequacy test 9 / L 7 /US Results (Pass/Fail) Pa4f For 3 bedrooms Fluid depth in absorption field before test Z _ in. Water added fit I gal. New depth E.Cin. Elapsed Time: 30 min. Final fluid depth 3_S" in. Absorption rate >= 11 SD g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) No -c t -C , OeAo , If yes, give date N• i!. D. LIFT STATION N• A•. Date installed 'Pump on' level at_ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off" level at _ in. Cycles tested Manhole/Access (YIN) High water alarm level at Meets alarm 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1&0' 1 %n Ca) On adjacent lots 10'1 ' Absorption field on lot I N 7 r Public sewer main M. A. Sewer /septic service line —> 2S' On adjacent lots Ito, Public sewer manhole/cleanout N• .f. Holding tank N• .A. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Sr Property line go' Absorption field 34" Water main N• A. Water service line > 10Surface water '> tcGa Wells on adjacent lots > 10v ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: In Property line SS Building foundation 19' Water main N. A. Water Service line > IO' Surface water > I UCS Driveway, parking/vehicle storage a "n /� Curtain drain Mvnl S off Wells on adjacent lots > 100' F. COMMENTS CJ G. ENGINEER'S CERTIFICATION rr :.`C.' "•%�':��1 1 certify that I have determined through field inspections and ,. ;: r N : ; review of Municipal records that the above systems are in r • •............::::. conformance with MOA HAA guidelines in effect on this date. 0 Engineer's Printed Name %71gkv&16,e F Muoie T' -"Q" F. "' ':ve•; 9 Date tG/16, Z06S' �Ap� HAA Fee S it 3 0 ^^ Date of Payment Receipt Number (Rev. 12101) F.M Waiver Fee $ Date of Payment Receipt Number 12 M IR `5W -_) C Z% llD'r 16 BLM LOT 16 54,450 SQ.FT. OF AREA 4 5 6 Cn AVEL DRIVEWAY SEPTIC A av " 17I L �f!�"° . L 15 SEPTIC VENTS (TYR) WELL O GRAPHIC SCALL 1 " " 60 Feet FOR: RODNEY DAMS Date 10/26/05 scale 1"=60 L�ga1 tees Lot 16 -rip Block LanMark Grid ASBUMI r�m..rvv a a....ret. am 2936 2501029 9390 Tanguasd Drive. Suite 209Dzawn Anchorage, Alaska 99507 SUBDIVISION BLM LOT 16 by Field Hook (907g)502-6050 DIIB 217 I hereby certify that the property described hereon has been surveyed %� OF 1 by me, or at ml direction, and that the improvements situated thereon on the ,`((�.•....;;�,9��, s�,,� are within the property lines and do not overlap or encroach That .►�P,•• property lying adjacent thereto unless otherwise shown. no Improvements on the property lying adjacent thereto encroach on the MV* 4918*••�•;� f premises in question and that there are no roadways, transmission 110 !ll��V11 ,�rl lines or other easements on Bald property except as shown. 0 " ......•••••••� It is the responsibility of the owner or builder, prior to construction, P 7 �'ro. HARLE"'•"•••'••.'i"'� I. CHARLES E. FORBES o f to verity proposed building grade relative to finish grade and utility �,o ,s connections and to determine the existence of any easements, covenants, ♦ 9 LS -7326 �, ' or restrictions which do not appear on the recorded subdivision plat e., •, �� Listed distances prevail over scaling. I �1�p"stessiatTiON:�� I\\\\"NW \ Reproduction may cause distortion. MUNICIPALITY ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES. Ak Division of Environmental Services IN 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. # )^ \ Q,- cy-k A- HAA # - "A I('` Q LI � GENERAL INFORMATION Complete legal description Lo f l6. Sec /-Lon 2 7. -r I Z AI, R 3It., Location (site address or directions) 19 1!r6f EL,, v.e R _C Property owner RvdA1y Da -;J Day phone 3y9-GGS'7 Mailing address — 1366'1 E/n,oee Rcr.. Anc4 c ayz, , i4k 9,9S-16' Lending agency N. C A Day phone 2S7 - 33ao Mailing address- P. 0- Go -A fu -7o Z�, c,4uecrZ4 Atc 99sra J Agent None - R e J�*/n an ce Day phone Address Unless otherwise requested, HAA will be held for pickup. Pease-c,�/2e�f Fe a curl 2. NUMBER OF BEDROOMS: 3 \) own e- @ 3Y5'- 9riV wYe^ ready Zc,� /01ctc c./ . 3. TYPE OF WATER SUPPLY: Individual well U� Community well 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 f 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)RW.1/91) Front MOAKI 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 Tech, ni c.,/ _47ecv Phone 3 yS'-1JS-S Address f`/S ?<v �Ec/4o Src. /ice 07 C-11 f+k 9eSr6, Engineer's signature' - � qy -" Date �i 12.0 / 9� 6. DHHS SIGNATURE M -12 Approved for __n bedrooms. Disapproved. Conditional approval for Additional Comments 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. nms fin«. wn e«. Mow ni Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICER E C E I V E Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 3434" 2 0 1996 Health Authority Approval Checklist DsPL Health 6 Hu arn�ervlcea Legal Description: t o f 14 Sec 2 7 7- (Z Nr R 3 Lv parcel I.D.: U 19 -4 19 2 -0 S A. WELL DATA Well type Pr i - a Ft If A, B. or C. attach ADEC letter. ADEC water system number Log present (YIN) Yes CE,,C Iarrvt Date completed it/ to/87 Total depth 16O' Cased to 160' Casing height (above ground) 25'4 Sanitary seal (YAC Y Wires properly protected (Y" Y FROM WELL LOG Date of test it / t o /67 Static water level 1 T B Well production + r &p -M. WATER SAME RESULTS: AT INSPEMON l3l' S. o + &p -m - Coliform 0 r01Itoamz Nitrate'2�/-t OLW bacteria No -e Date of sample: S'11311,< Collected by: FW Lf 4 7W h S'c. c B. SEPTIC/1301DING TANK DATA Date installed 1213187 Tank size 1OWd? Number of Compartments 2 Cleanouts (Y" Y Foundation cleanout (Y" Y Depression (Y/N) N High water alarm (Y/M N. .4. Dam of pumping 6 / IV / 96 Pumper )q e An, Rao hr C. ABSORMON FIELD DATA Dam installed 12 / 3/ 8 7 Soil rating (g p d.M2 or fi2Podrm) ISO System type 6e o( Length H 2' Width 2 2' Gravel thiclmas below pipe 10 " Total depth Effwd a absorption ares 9 2 Y a' Monitoring Tube preseot(Y/N) Y Depression over field (Y/N) Al Dam of adegoacy test tf / 13 / 96 Results ftWFW) Pay For 3 bedrooms Fluid depth in absorption field before test (in.), C -7 " Immediately after 7trgal. water added (in.): 0-/0" Fluid depth j2.z-% " (ins.) Minutes later: 1-7 7 Absorption rate - > HSO a p.d. Petwode trea0meut (past 12 months) (Y" N on t knr wn If Ya. Sive date N. A, Qtd abtor(rerf a< an v�/t)sua/Y /nk and cc.at net $ur[Sar ter D. LIFT STATION N. A. MatthoWAccess (YIN) High water alarm Level at* m E. SEPARATION DISTANCES size in gallons "Pump on" level ate "Pump oft" level ate •Datum SEPARATION DISTANCES FROM WELL ON LAT TO: SepticRmlding tank on lot lot' t'•e+ C-0, ; On at jacent lots tole, 1v C, u ( hof rs0 Absorption field on lot l H A' •/a G o, ; On adjacent lots l 10' tri c. o ( L of is) Public sewer main N. A. Public sewer manholatcleanout N. A. Sewer /septic service line 7 2 1' Lift station N. A, SEPARATION DISTANCES FROM SEPIIC/HOIDINO TANK ON LAT TO: Building foundation SProperty line 80- Absorption field 91, Water main/setvice line t o' Surfacewatcddrainage oo' Wells on adjacem lots �> too, SEPARATION DISTANCE FROM ABSORPTION FIELD ON LAT TO: Building famdation l9' Property Line SS' Water main/service line > I o' Surface water -> iC,0, Driveway. Fuldng/vehit:le storage atea 9 d e e n f Curtain drain Ai OA t s t M Wells on adjacent lotsi uc F. ENGINEER'S CERTIFICATION +,raa•Rww # I certify that I have determined thnvgeld bupecnons and review ofMrnnicipal FeV& *ilrA s $;h9tieam in conformance with MOA HAA guidelines in effect on this date. n� - • .- 2 Signature Ve*�A�. T %t'lee-.c n`• ,� Engineer's Name Th[adore F. /`rcoo x 1 ,pilS �F .'.1 C:- c � Date d l zo /96,'•., • ...... ' ir HAA Fee S 3 oo =Q Date of Payment A,3 Receipt Number ! S l 14"2 Rev, 9/95 OSS: has wk.doc Waiver Fee $ Dam of Payment Receipt Number