HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 3 LT 14A2-1BOnsite File
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SULLIVAN WATER WELU.-rl) PS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 o TELEPHONE 688.2759
OWNER OF LANA'_ 14�` r0 ,j DEPTH OF WELL A /
ADDRESS_L3__ _OAC �_-J �� a�• ST.ATIC LE t' OF MATER FT.
LEGAL DESCRIPTION __�1--�-_�f- _1_3fk E(7(a h ^ DRAt4 DO1YN FT.--
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MISCL. INFORMATION:
Municipality ui 0,ijcnorage
Dept. Health & Human Services
DRILLER'S NAME � — -
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM PERMIT
PERMIT NUMBER:SW950177 DATE ISSUED: 7/24/95
DESIGN ENGINEER:DUMMY COMPANY EXPIRATION DATE: 7/24/96
OWNER NAME:SERSHEN DON & DARLENE
OWNER ADDRESS:P.O. BOX 771505
EAGLE RIVER, ALASKA 99577
PARCEL ID:05027147
LEGAL DESCRIPTION: D ^``
EAGLE RIVER HEIGHTS BLK 3 LT 14A 964 `y OJ.
LOT SIZE: 48993 (SQ_ FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY :
DATE: 7 ,e 2 V - ,
DATE: /- 24 - 7-:5
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R r GRENIrR ANCHORAGE AREA BORG,,GH
• �C�r�� Department of Environmental Quality
- 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM /
NAME S �(�/ 61 '�
`!!� MAILING ADDRESS �x • I �'v-e`er PHONE (294601"12
LOCATION -QAA'' a&A,� LEGAL DESCRIPTION L v 3 �-^ Q NE -
SEPTIC TANK:
DISTANCE NUMBER OF /
FROM WELL MANUFACTURER /UA -A -A-- MATERIAL COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY% L' GALLONS.
TILE DRAIN FIELD:
TOTAL LENGTH —) r -
DISTANCE FROM WELL
FOUNDATION
NEAREST LOT LINE
OF LINES
NUMBER OF LINES I
DISTANCE BETWEEN LINES
TRENCH WIDTH_
IN. TOTAL EFFECTIVE
ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER If
DEPTH:
IN. ABOVE TILE
DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE
WELL:
IN.
TYPE CONSTRUCTION DEPTH DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC
FOUNDATION_. LOT LINE • SEWER LINE , TANK.
CESSPOOL • OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL
LOT SLOPE:
REMARKS:
Form EQ -032
SEEPAGE
SYSTEM_
DIAGRAM OF SYSTEM
z -7Co
MJJN I C I PFiL I TY OF' F=l r-4 01RFIGE ,Qp,
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 E. TUDOR RD., ANCHORAGE, RK. 99507 An L
276-2221
ON—SITE SEWER PERMIT ct�� �D/'�J�l-7iD
PERMIT NO. C 76209 ) / a� 4 .
APPLICANT KEN TRY LOE BOX 100 EAGLE RIVER 694-2296
LOCATION CHAIN OF ROCK RD
LEGAL L14 83 EAGLE RIVER HGTS LOT SIZE 43725 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS - 3 SOIL RATING CSO FT/BR)= 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
17EPTH= 7 LENGTH= 7G GRFiVEL_ DEPTH= 2
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
REGU I REQ SEPTI C Tl=l"K S I ZE= 1 OQ13 GFIILLOPIS
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION �A/ND APPROVAL BY
THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION. a `i � IvD!k-E OA-) IA"�bo
MINIMUM DISTANCE BET14EEN A 4JELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
PERM I T VnL- I 0 FOR ONE YEFIR F= ROM I SSUE
I CERTIFY THAT
1: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IPJ ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED
APPLICANT KEN TAYLOR
ISSUED BY
r
X O NEED . 1=� svmp AT �-
EA -0
o.►� UU
U �J 0
•
0 ft E GEOT-CHNICAL & DEVELG,'MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577 _-
694-2774 or 688 -2280.. -
fad Ellis
Russell Oyster SOIL LOG 688.2280
69 4'2774 ---"- Land Development
Soils Et Foundations
Performed for: Name: 2"M Ayw--AQ- Tel. No.
Melling Address: 32:9 �x \��
Legal Description:t. �`•r t'L ���4v'�•'aP
Depth (feet) Soil Characteristics
0 ,-
1 '
.2-
3 3
4
r'
6
8
9
10 GP- 6m
11
12
13
14
15
16
Ss'any C t,_
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z 1 b •rn..� / , a ami
T`'`>tsa
t
)Cs�a/i3
1�LT''im2. 1 it L�z�6s'
Ground Water Encountered: Yes No If yest wnat oeptn
Proposed Installation: Seepage Pit Drain Fiend
Comments:�-
�vs��
Performed by:\�� � '' Date: N 9, Max ��'
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Parcel I.D. 050 271 69
Certificate of On -Site Systems Approva
Expiration Date: to- 6 ZdZ0
1. GENERAL INFORMATION
Complete legal description EAGLE RIVER HEIGHTS BLOCK 3 LOT 14A2 -B1
Location (site address) 10312 CHAIN OF ROCK
Current property owner(s) KRAFT
Mailing address
Real estate agent
2. TYPE OF DWELLING:
Fx� Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
0
Waiver request for: NONE
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
t
COSA Fee $ 33 b
Waiver Fee $
Date of Payment -7&1a00
Date of Payment
Receipt Number D 517 DD
Receipt Number
COSA # 05c a01 21
Waiver #
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, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation.
Name of Firm C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 6/30/2020
Aw
,� of a/-qs���
6. DSD SIGNATURE 0
System #1 Approved for bedrooms ' /�% ' L—�"
HARLES G BALZARIFII�
System #2 Approved for bedrooms �� F� . CE -13854 • �� v'
Disapproved ����FOPROFESstoNP�.
Conditional approval for bedrooms, with the following stipulations:
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tes Original Certificate Date:_7 - 7''--2020
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
Legal Description: EAGLE RIVER HEIGHTS LOT 14A2-113 B3 Parcel ID: 050 271 69
If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1996
Total depth 142 ft
Cased to 141 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) +12 in.
Date of flow test for COSA 6/16/20
Static water level at beginning of test 128 ft.
Comments
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies: PROPERTY IS ON PUBLIC SEWER
COSA Checklist yellow sheet
Well production at time of test +5.5 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ❑ No
FOR Coliform bacteria is Negative
Nitrate 4.06 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by C.Balzarini
Date of Sample 6/16/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: PROPERTY IS ON PUBLIC SEWER
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
M Yes
if No
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑✓ Yes
if No
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No
Neighboring Absorption Fields > 100'
Animal Containment > 50' ❑✓ Yes
if No
❑✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑✓ Yes
if No
ft
0 Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
❑ Yes if No ft
Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No.
Water Main > 10' ❑ Yes if No ft Community Wells > 200' []Yes if No.
Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below
Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No
Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No
Surface Water > 100' ❑ Yes if No ft
F. ENGINEER'S COMMENTS
property is connected to public sewer
G. ENGINEER'S CERTIFICATION
l certify that / have determined through field inspections and review
of Municipal records that the above systems are in conformance with ��Q'� • ' ' • • • S�
MOA COSH guidelines in effect on this date. 6/30/20 ®� co - .-�!
49 TH
.... ..
CHARLES G BALZAR191
COSA Checklist yellow sheet FC/', • CE -13854
Rs
PROFESS10NP
ft
ft
ft
ft
CERTIFICATE
FOR A
Parcel I.D. 050-271 ,,8'/
1. GENERALINFORMATION
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
OF 0N-SITE SYSTEHS
SINGLE FAHILY
APPROVAL
DWELLING
Expiration Date:
Complete legal description
EAGLE RIVER HEIGHTS S/D; BLOCK 3, LOT 14A2-1B
Location (site address) 10512 CHAIN OF ROCK STREET * EAGLE RIVER, AK * 99577
Current Property owner(s) SHAD & JOANN MILLER
Day phone
Mailing address 10312 CHAIN OF ROCK STREET * EAGLE RIVER, AK * 99577
Lending agency
Day phone
Mailing address
Real Estate Agent VIKI KAAS W/ HOMES UNLIMITED Day phone 346-4111
Mailing address 517 W 12TH AVENUE * ANCHORAGE, AK * 99501
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
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 On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEI~ENT OF !NSPECT!ON BY ENG]NEER
As certified by my seal affixed hereto and as of the vafidation date shown below, I verify ,,~"~-' my
investigat!?n based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
sho'~zs that the on-site water SL,~ply 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 Mun~c;pafity of Anchor~,ge files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compfiance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone 557-6179
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, L TD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MQA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
t,~ Approved for ~5~
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations: ~"~
t.,4 ~eL;F, IIS ~
Septic System Advisory
Well Flow Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Repo~
Other
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: EAGLE RIVER HEIGHTS S/D; BLOCK 3, LOT 14A2-1B Parcel ID: 050-271-67
Ao
WELL DATA
Well type PRIVATE
Date completed
Total depth 142
If A, B, or C provide PWSID# N/A Well Log (Y/N)
5/1996 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
~.ft. Cased to 141 ft. Casing height (above ground) 12+ in.
YES
Date of test
FROM WELL LOG
5/1996
AT INSPECTION
5/5/2011
Static water level
124 f. 127 ft.
Well production
7 g.p.m. 6.0+ g.p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 mi. Nitrate ~. ~ I mg./L.
Collected by:
GEG, Ltd.
Arsenic:/~or'~ ug./L.
Date of sample: 5/4/2011
B. SEPTIC/HOLDING TANK DATA
PUBLIC SEWERI
Tank Type/Material
Tank size__ gal.
Foundation cleanout (Y/N)
Number of Compartments
Depression over tank (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date installe'd ~"
Length .ft.
Total depth ft. Eft. absorp~ ft2 Monitoring tube
Date of adequacy test / Results (Pass/Fail)
Fluid depth in~ before test in. Water added
Elapse~m~: ___ min. Final fluid depth in.
A~y rejuvenation treatment (past 12 mo.) (YIN & type)
Date installed
Cleanouts (Y/N)
High wat~
Pumper
Soil rating (g.p.d./ft2or ft2/bdr~-'"'""'"'"" System !y, pe
Width .~ ft. Graft. Gravel belOw pipe
ft.
gal.
Depression over field.__
Absorption rate >=
If yes, give date
For__bedrooms
New depth ~in.
g.p.d.
D. LIFT STATION
Date installed
"Pump on" level at
Size in gallons Manhole/Access ~ ~
in. "Pump off" leveLa.L~ High water alarm level at
.in.
E. SEPARATION DISTANCES
Cycles tested.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75'+
Sewer/septic service line
Animal containment areas
25'+
Meets alarm & circuit requirements?
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout 100'+
Holding tank N/A
50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: iPUBLiC SEWERi
Building foundation Property line Absorption field
Water main Water service I ne Surface water ~
on adjacent lots ~
Wells
SEPARATION DISTANCE FROM ABSORPTION FlEeT TO:
Property line B~ation. Water main.
Water service lin..~...~-"~ Surface water Driveway, parking/vehicle storage
~ Wells on adjacent lots,
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
COSA Fee
Date of Payment
Receipt Number
(Rev. 11/05)
o5 q70
Waiver Fee $
Date of Payment
Receipt Number
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
(9O7) 343-79O4
CERTIFICATE OF HEALTH AUTHORITY APPROVA. L
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050- Z'T/- 0/'7
t. GENERALINFORMATION:,
Complete legal ,description '
Location (site address or directions)
Current P~'operty owner(s)
Mailing address ' ]O.3 IZ
Lending agency '"
HAA# 0~'0 5- ~
Expiration Date:
t475., L,3T/H A 'Z -
Day phone
~-~ : ~
Day phone
Mailing address
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
[]
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
Individual Holding tank ·
Community On-site ~
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site Wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the v~'lidation date shown below, I verity 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 Ihe 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 E~
Address /OV. 21
Engineer's Printed Name £ ~/t'2.Zs'Tc~-/L /2.
DSD SIGNATURE
Approved for L/_ bedrooms.
Disapproved.
Conditional approval for
Phone. ~?q-~ ~)~-"
Date /J /c~//~'-
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bregaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Legal Description:
A. WELL DATA
Date completed
Total depth 14t ! ff.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
HEALTH AUTHORITY APPROVAL CHECKLIST
~,~CTL~ ~.iVE-~ HE/CTHT5, LIq,'4'=3"'-I~ Parcel ID:
I ga
IfA, B, or C provide PWSID #
Sanitary seal (~)
Cased to I q I ft.
FROM WELL LOG
I ~. ,.I ft.
-~ g.p.m.
Coliform J~' colonies/100 mi.
Arsenic: m~ rog./1.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material "~[4{~/.-J ~.
Tank size __ gal.
Foundation cleanout(Y/N)
Well Log (~/N)
Wires properly pr6tected (~/N)
Casing height (above ground)
AT INSPECTION
I ~ ft.
(~ ..-~- ' g.p.m.
Nitrate ~.o~ mg./l.
Date of sample:
Number of Compartments
Depression over tank (Y/N)
Other bacteria ~ coloniesll00 mi.
Collected by: ~
Date of pumping
ABSORPTION FIELD DATA .~ Syste~m
Soil rating (g.p.d./ft2 or ft2/bdrm)~ type
Width J ft. Gravel below pipe
High water a~
Pumper
Depression over field
gal.
in. Absorption rate >=
Date installed
Length ff.
Total depth ft. Eft. absorpti~
ft2
Monitoring
tube
Date of adequacy test f Results (Pass/Fail)
a~before test in. Water added
Fluid
depth
in
Elaps~ Ti~3~e~-. min. Final fluid depth
~rejuvenation treatrnent (past 12 mo.) (YIN & type)
For bedrooms
New depth in.
g.p.d.
ft.
If yes, give date
D. LIFT STATION
Date installed Size in gallons. Manhole/Acce~--------~
'Pump on' level at in--arm
level
at
in.
Datum ~ Cycles tested
~ Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
Absorption field on lot
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
On adjacent lots -~' I O0 '
On adjacent lots '/'/'0(~ ~
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
~ I00 '
Building foundation Property line ~ Absorption field
Water main Waler service line Surface waler
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSO~LOT TO:
Property line ~ndation _ Wa~er main
dveway, parking/vehicle storage
In drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date II/ ~ I O~
Dale of Payment I I / q/E)~
Receipt Number ~ .~
(Rev. 1~01)
Waiver Fee $
Date of Payment
Receipt Number
ASBUI LT
SEWARD & ASSOCIATES LAND SURVEYING 694-0829
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWIN6 DESCRIBED PROPERTY:
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS~ OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES,
SCALE:
DATE: .
GRID:
DRAWN:
J.33W.LS ~I30W -I0 NIYH3
L 6"1,~ t M.6[',ZO. OOS
O~
40.0
40,0
3.90,00.00N
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date August 14, 1986
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
. Lot 14A; Sock 3; Eagle R.Lveit HeEgh.tb Subdiv.ieion
Location (address or directions)
95 Chain o6 Rocks
(b) Applicant Name Homequi,ty Telephone: Home 694-5500 Business
Applicant Address c/o Connie Bates/Jack White Realty/Eagle R.iveA
(c) Applicant is (check one): Lending Institution 0 ; Owner/builder 6 ; Buyer 0 ; Other 0 (explain);
(d) Lending Institution Nortthtand Mohtgage Telephone
Address Eagle Rim, ATTENTION: Kunt Sheppard
(e) Real Estate Company and Agent Jack White Realty/Connie Bates
Address Eaqte River Alaska
Tele?
ele hone 694-5500
HOL$
(f) W the HAA to the following address:
S 9 S Engineexinq
SRS 196X
Eagle Rim Afa6ka 99577
ordeAed by Connie Bates
2. TYPE OF RESIDENCE
Single -Family jR Multi-Family[3 Other
Number of Bedrooms 4 '
3. WATER SUPPLY
Individual Well Community 0 Public D `
Note: If community well system, must have written confirmation from the State Department of Env'ronm,eptal Conservation
attesting to the legality and status.
4.'. SEWAGE DISPOSAL
OnsiteE3 Public W CommunityE3 Holding Tank 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11.84(
Page 1 of 2
n flm�'
5. ENGINEERING FIRM PROVIDII,� INSPECTIONS, TESTS, FILE SEARCH, Dn.A AND INFORMATION
As certified by my seat affixed hereto and as of the validation date shown below. I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S S S ENGINEERING Telephone
Address SR B 196X
Date
EAGLE RIVER, AK 99577
6. DHEP APPROVAL
Approved fort�C1!�2_ bedrooms by Date
Approved _d Disapproved
Terms of Conditional Approval
Conditional
F
CAUTION
1044� . . . . .....
a&Lwf A. Saler
No. fug{
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 p 1M1
MUNICIPALITY OF ANCHORAGE (MOA)
171 HEALTH AUTHORITY APPROVAL (HAA)
E�•/I;_G�•;,C,1il.l F;; :-- CHECKLIST -FEBRUARY 1984
2843720
AUG L 1 19M LoT 1 SFA SNX- 3
Legal Description:
RECEIV ED =Lo' yl'-�
A. WELL DATA
Well Classification S•C• If A. B. C. D.E.C. Approved (Y/N) rA)p
Well Log Present (YA® Date Completed PIWA** te• MSr Yield Ie 6 4Y►a i L•
Total Depth V•Y• Cased to Lky>r'r Depth of Grouting —�
Static Water Level 5-2. A Pump Set At K—
M
Casing Height Above Ground i2 Sanitary Seal on Casing (2iN)
Electrical Wiring in Conduit &N)
Depression Around Wellhead (Y®
Separation Distances from Well: rI
To Septic/Holding Tank on Lot �JO On Adjoining Lots a/P
To Nearest Edge of Absorption Field on Lot N P ; On Adjoining Lots AAA
To Nearest Public Sewer Line ECWoli' To Nearest Public Sewer I
Cleanout/Manhole too I •h To Nearest Sewer Service Line on Lot 7_Q'}
Water Sample Collected by S S C;a"ANWI�.Z6 ; Date 8 iCk .56 t�
Water Sample Test Results G'dI1S•Fbt:�Ce
Comments Ujcz. trt.o%,ni
« AF
B. SEPTIC/HOLDING TANK DATA
Date Installed
Size
No. of Compartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well
To Property Line
To Water Main/Service Line
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course
Comments l �'`� ��r -ipt]TstiL 5?dnb,) A
Page 1 of 2
72-026111164)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
--N
Type of System Design
Length of Field
_ Depth of Field
Gravel Bed Thickness
Standpipes Present(Y/N)
Ir Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
On Adjoining Lots
• ���L Llr
D. LIFT STATION
Date Installed -
Size in Gallons
To Existing or Abandoned System on
To Cutbank (if present)
Dimensions
Manhole/Access (Y/N)
-Pump On" Level at"Pump Off' Level at
High Water Alarm Level at T� Vent (Y/N) .
Tested for
Electrical Codes (Y/N)
Comments
Check Permitted Bedroom Rating Against HAA Request '•
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed 5 & S -ENGINEERING Date �2 ° �Y 6
Compa*, B 196X MOA No. 3
EAGLE RIVER, AK 995?
Receipt No. — y 6 r / 6:� n a
Date of PaymentJr
_ �� l� `p�,.••'
Amount: $ 5� U lilEl ••ti
Page 2 of 2
72-026 n 1,84)
Fw
r
-
DATE RECEIVED
INSPECTION APPOINTMENTS
-T,�1.iE _ TIME
TIME
6. TYPE OF RESIDENCE
c
DATE
DATE
DATE
❑ Two ❑ Five
❑ MULTIPLE FAMILY
la
INSPECTOR
INSPECTOR
INSPECT R
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
Y
MUNICIPALITY OF AN
MUNICIPALITY OF ANCHORAGE DEPT- OF t1EALTH S
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI"NIRONMENTAL PROTECTION
825 L Street • Anchorage, Alaska 99601
1 NOV 3 O 1981
ENVIRONMENTAL SANITATION DIVISION
Telephone 2644720 I V E D
I (TIES
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE A
DIRECTIONS: Complete all parts on Page 1. Incomplete requests will not be processed. Please allow ten (101 days for processing.
1. PROPERTY OWNER
�^^
PHHON
[E�
MAILING ADD SS
/1
CiJ 4/.t O aK
PROPERTY RESIDENT (If dil fere_[ fro bove) PHONE
T. BUYER
a ,4 6&o
PHONE O
MAILI G DRESS
.2BY//o /�// s s /rte., Gl/Qs li.; .1 6a 3/
3. LENDING IN TITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT PHONE
74_
MAILING ADDRESS -
o
7
6- LEGAL DESCRIPTION
Got
.
STREET LOCATION
i7er/h O
6. TYPE OF RESIDENCE
NUMBER OF,SEDROOMS
SINGLE FAMILY
❑ One Lk Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
.00 INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
i 7 INDIVIDUAL/ON-SITE"
'_`' YEAR ON-SITE SYSTEM WAS INSTALLED.
Ar PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING C=INITIATEDL
72-010 (Rev. 8/79) (}(w
�,, 1 �L
72010 (Rev. 6/79)
or
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
❑ ONE ❑ THREE Cl
FIVE ❑ OTHER
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
❑ TWO ❑ FOUR ❑
SIX
2. WATER SUPPLY
PERMITNUMBER
❑ INDIVIDUAL
DEPTH OF WELL
❑ COMMUNITY
GATE DRILLED
❑ PUBLICUTILITY
Connection Verified
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
PERMIT NUMBER
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified •—
(Tank
DATE INSTALLED
e7—,F
INSTALLLH
❑Septic Tank or ❑Holding
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
Septic/Holding Tank
Absorpbon Area
Sewer Line
Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
/
r
ROVEDFOR
BEDROOMS
CD----CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE '
By
p ('
72010 (Rev. 6/79)
or