HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 4 LT 17BCampbell Heights
Lot 17B
Block 4
#014-072-78
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DOC Co. GCs
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK. ALASKA 99567 • TELEPHONE 688-2759
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DRILLER'S NAME
EAGLE RIVi
ENGINEERING SERVICES INC.
P. O. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694.5195
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Municipality
Anchorage
September 16, 1986
P.O. B. X 196650
ANCHORAGE, ALASKA 99519-6650
(907) 264 -Ant 4744
TONY KNOWLES.
MAYOR
DEPARTMENT OF HEALTH 8 HUMAN SERVICES
Lou Butera, P.E.
Eagle River Engineering Service
P.O. Box 773294
Eagle River, Alaska 99577
Subject: Lot 17B Block 4 Campbell Heights Sovti Subdivision
Waiver Request, WR86-134'
Dear Mr. Butera:
Your requst for a waiver of the 25 foot separation distance required between
the existing sewer service line and a proposed water well has been granted.
This separation requirement will be waived to 15 feet subject to the following
conditions:
1. The water well must be drilled and cased to a minimum of 60 feet. The
casing must be unperforated to this minimum depth.
2. The annular space around the casing must be sealed to a depth of 20 feet
below the land surface with bentonite grout.
3. The well construction must be inspected by a registered civil engineer.
The two stipulations above must be documented in the well log or a
separate report and submitted to this department. Documentation that -the
conditions of this waiver have been met must be provided in order for
this waiver to be considered valid.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
SSM/ljw
EAGLE RIVER ENGINEERING SERVICES
Lou Buten P.E.
P.O. Box 773294
Eagle River, Alaska
99577
Telephone(907)694-5195
September 8, 1986
Mr. Steve Morris
Municipality of Anchorage
Civil Engineer, On -Site Services
P.O. Box 196650
Anchorage, Alaska 99519
REF: Lot 17B, Block 4, Campbell Heights 5pdtr
Dear Mr. Morris:
On behalf of my client, Sullivan Water Well Company, I am applying
for a waiver of separation distance with well permit, well to private
sewer line, for a well to be drilled on this referenced lot.
The well location is the only one available, as the house location
and fencing make the rear of the lot unaccessable. The sewer line is
described as a 4" ductile iron on the connect card enclosed. The well
can be drilled with a bentonite grout annulus ground the well casing to
a depth of 20' below land surface. There is little information
regarding well depths and soil logs available in this area so we have
not included this information. In our file search it was noted that
lot 18 Block 4 Campbell Heights was supposed to hook to public sewer
but has not as of this date.
If there are any questions or if additional information is
required, please feel free to contact me at 694-5195.
Thank You,
Lou Butera, P.E.
EAGLE RIVER ENGINEERING SERVICES
Lou Bulera P.E.
P.O. Box
Eagle River, Alaskalaska 9 9
9577
Telephone (907) 694-5195
September 22, 1986
Mr. Stephen Morris
Municipality of Anchorage
Civil Engineer/On-Site Services
P.O. Box 196650
Anchorage, Alaska 99519
REF: Lot 17B, Block 4, Campbell Heights South
Dear Mr. Morris:
The conditions of your waiver to 15' of the separation distance
between the well and sewer service line has been met. The well is
drilled to a cased depth of 78'-5" and the annulus of the well was
grouted with bentonite grout to 20' below land surface. The area
around the pitless adapter was also grouted after installation of the
water line. It is noted that the well was drilled thru a silty
sand layer 2-19', a clay and gravel layer 19-21' and silty sand from
21-74'. The aquifer is confined by these layers with a static pressure
of 40'.
If there are any questions or if additional information is
required, please feel free to contact me at 694-5195.
Thank You,
Lou Butera, P.E.
Encl: Well log
�CD 1es7o
8
7,-, 7;_) Municipality of Anchora:: APR 8 ��i/ L=`c
On-Site Water and Wastewater Program It
(907) 343-7904
01 6 9 gc)�
Certificate of On-Site Systems Approval
•
Parcel I.D. 014-072-78 Expiration Date: ) T- 17
1. GENERAL INFORMATION:
Complete legal description Campbell Heights; Block 4, Lot 17B
Location (site address) 3637 E.67th Ave.
Current Property owner(s) Jinnie&David Roes Day phone 229-0189
Mailing address 3637 E.67th Ave.
Real Estate Agent Katie Likkel Day phone 315-9512
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well El Community ❑
Public Water System El Public Sewer
WaiverNariance request for: l Distance:
Received by: ' Date: fi�(Q�i�
COSA to be released to the engin--' • -ss otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment cll18/ri Date of Payment
Receipt Number 6 teCa6 Receipt Number
COSA# 65Cl71/,35 Waiver#
5. STATEMEN1PECTION 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: 141 I 1j .7--
,,.0004,
o
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system 7 ,
in accordance with the guidelines and regulations established by the Municipality of Anchorage and o.' . .... ..-g c t
industry practices. The reported results describe the condition of the system/s on the date/s of the Qat'
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or .• A 9 H ..�VUj,
encroachments may exist that were not identified during the evaluation. The operational life of all wells * u
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, O".. r 0
groundwater levels (that may fluctuate during the year), quality of construction (materials and 0
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and 0,,,...-r.':..,f1 1
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the /t '•,J frfe . Gor less. 0
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of VO1'9'4'
ff I ' — 53 ' e`4Q
the well or septic system. GEG makes no representation whether an alternative well or septic system V' 't•.r c¢4
can be installed on the property in the event either of the current systems fail to perform adequately in ti,/i. V•Yi.i .� °'off
the future. The content of this report is for the sole benefit of the person/party that retained GEG to 11ea ar ofessio nay o
perform the evaluation. Reliance upon the information provided in this report by any other person or " o' •
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for 57 bedrooms
System #2 Approved for bedrooms Q���C.( OF, C4
Disapproved ..,\ O
- TE j
Conditional approval for bedrooms, with the folic /ing.sg ll iM tfi:
n WASTEWATER o
co PROGRAM �65
Ops,.r,4rT cern\11Cc.��
By: l tti--1 .G Original Certificate Date: 7 -I q -(7
l� 9
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 J` Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sneec_10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Campbell Heights; Block 4, Lot 17B Parcel ID: 014-072-78
A. WELL DATA
Well type Private If A. B. or C provide PWSID# N/A Well Log (YIN) Yes
Date completed 9/1986 Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yes
Total depth 78-4 ft. Cased to 78-4 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 9/1986 4/6/2017
Static water level 39 ft. 20.5 ft.
Well production 15 g.p.m. 3.2+ g.p.m.
WATER SAMPLE RESULTS:
Coliform ND colonies/100 ml. Nitrate 0.164 mg./L. Collected by: GEC. Ltd.
Arsenic: ND<5 ug./L. Date of sample: 4/6/2017
B. SEPTIC/HOLDING TANK DATA AWWU
Tank Type/Material Date installed
Tank size gal, Number of Compartments Cleanouts (YIN)
Foundation cleanout (Y/N) Depression over tank (YIN) High water alarm
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft`or ftIbdr System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption . -a ft' Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absor. .n field before test in. Water added gal. New depth in.
Elapsed T•- -: min. Final fluid depth in. Absorption rate >= g.p.d.
rejuvenation treatment (past 12 mo.) (YIN & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at • a er alarm level at in.
I- •• Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100.4-
Absorption
00'+Absorption field on lot N/A On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line *15' Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: AWWU
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIE IIS , OT TO:
Property line Bu •.- • oundation Water main
Water service line Surface water Driveway, parking/vehicle storage
drain Wells on adjacent lots
F. COMMENTS
*WR86-134
G. ENGINEER'S CERTIFICATION o-447OF f4,-' 1.,
I certify that 1 have determined through field inspections and 1::14.9,4' •�' •',�,��4p VA
review of Municipal records that the above systems are in ) vA
conformance with MOA COSA guidelines in effect on this Vfdate. Q .. Gar -ss.•' OEngineer's Printed Name JEFFREY A. GARNESS QQQ9• . ! — J i4
ds ' 3 • •;v0
Date4411/11 044 ro ess�o�a4o
�O�ooQ
#AECC844
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
j Building Safety Division +•
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650 .
Anchorage, AK 99519.6650
www.muni.orglons to
(907)343-7904 1,ui
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D.�(�-��-' � Cos ft ()qw
1. GENERAL INFORMATION Expiration Date: 4- -),-0-7
Complete legal description
CAMPBELL
HEIGHTS•
LOT 17B. BLOCK
4
❑
Public Water System
❑
Location (site address)
3637 E. 67th
AVENUE •
ANCHORAGE, AK
99507
Current Property owner(s) HOUSE HOLD BANK Day phone C/O AGENT
Mailing address (olio 1->1 Av6 w 5D0 SEA,-nC, 10A-
Lending agency Day phone
Mailing address
Real Estate Agent SHAYLENE ERNISSE w/ PRUDENTIAL Day phone 273-7311
Mailing address 3801 CENTERPOINT DRIVE N200 " ANCHORAGE. AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
0
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
N
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 Onsite 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. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal aliixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined In the Cer0cate 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 typo of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage rites 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 GARNESS ENGINEERING GROUP, Ltd.. Phone
Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507
337-6179
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 121 'g -10L
Engineer's Comments:
In conducting this evaluation, GEG, UD. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines d Regulations. The reported results described the performance of the
system under the conditions encountered of the lime of the fest, 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, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
otherperson orparty Is not authorized, nor will if confer any legal right whatsoever.
5. DSD SIIGGNATURE
V Approved for _—IL bedrooms.
Disapproved.
Conditional approval for bedrooms, with the Illowing
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
17P lip. .::1 ..... ...
..'
jvk�
ne:�'p.
t ey A�s
CE-795-O6�
cP4C
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
••�
\Oki)r)rr,rr
�i w( OF,gk
�. • ON-SITE ••••�c
WATER AND
WASTEWATER
PROGRAM'
By: Original Certificate Date: 1-0,-07
(Rm. 11005)
Municipality of Anchorage .
Development Services Department
Building Safety Division
On-Site water a wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-WW
www.muni.orp/onslte
(907)343.7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Descriptlon: CAMPBELL HEIGHTS; LOT 178 BLOCK 4 Parcel ID:
A. WELL DATA
Well type PRNAR If A, B, or C provide PWSID# N A Well Log (YIN) YES
Date completed 9/1986 Sanitary seat (YIN) YES Wires properly protected (YM) YES
Total depth
79 ft. Cased to 79 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 9/1986 11/29/2006
Static water level 39 ft. 24 ft.
Well production 15 g,p,m. 3.5 —
9-p.m-WATER SAM RESULTS:
Conform oolonies/100 ml. Nitrate N D mg./L, Other bacteriacolonies/100 ml.
Arsenic: ! D ugJL. Date of sample: 11/29/200 Collected by: GEG Ltd.
B. SEPTICIHOLDING TANK DATA PUBLIC SEWER
Tank Type/Material Data Installed _
Tank size gat. Number of Compartments eanouts (Y/N)
Foundation cleanout (YM)
Pumper
C. ABSORPTION FIELD DATA
tank (YIN) _ High water alarm (YIN)
Date installed Son rating (g.p.d./ft'or ft1bdrm) _ System type
Length ft. Width ft. Gravel be ft.
Total depth ft. Eff. absorption area _ ft' Monitoring t Depression over field
Date of adequacy test Resu ail) For_bedrooms
Fluid depth in absorption field before _ in. Water added _gal. New depth _in.
Elapsed Time: Final fluid depth _ in. Absorption rate >= 9•P•d•
treatment (past 12 moa (YIN & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on' level at _in. 'Pump ofP leve High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100'+
Absorption field on lot N/A On adjacent lots 100'+
Public sewer main 75'+
Sewer /septic service line '15'
Animal containment areas 50'+
Public sewer manhole/deanout 100'+
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption
Water main
Wells
Water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
Cu
F. COMMENTS
WR86-134
G. ENGINEER'S CERTIFICATION
Building foundation Water
Wells on adjacent lots
I certify that I have determined through field inspecoons and
review of Municipal records that the above systems are in
conformance with MOA COSA guidetlnes in effect on this
date.
Engineers Printed Name JEFFREY A. GARNESS
Date N zl.slo'6
COSA Fee S Y3 0. 0()
Date of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
water
PUBLIC SEWER
parking/vehide storage
Date of Payment
Receipt Number
DEC -21-2006 1507
.. a+• .NA91
••aNI Ie1eNa[
/7/T
PRUDENTIAL VISTA REAL EST
NB9'.J9'A�''E G3.OS'
EaSr 113.070
907 562 5485 P.02
[,
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/D'UT/t. EJHf.
E,vs>
67 "' %>7a<
6
•
ym%vY car"TATION
O
'o�����e•1
E,oF�, ••••
V
&Assoc.
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H
•
w
98
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i
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ANDKORAOE ALASKA •DsOa
`^"•'r��"`
M
.99
SMc
Rae Lel A.F.
Rae Pal FRO N0.
raUNIIAIM AS -WILT
POP .....
IF
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Drewe o%
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Data Orewn:
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FIRAL snuD7LIRE NL'rRIALt
EaSr 113.070
907 562 5485 P.02
[,
R IS TRE RESPONSIBILITY OF TME BUILDER OR ONNCR. PRIOR TO I ONLY TMOSE wPROrEMEwTS AROVE OROUND AND NIR9LE WALL. CE
CONSTRUCTION, To VERIFY PROPOSED GVILOINC CAADE RCLATIK DNOWN. mm r, WCLL3. SCPTIO OLCANOLIM SVEvALKS. ORiM:«ATS
TO FINISHED GRADE AND UTUTY CONNECTIONS ARD TO OCTCANMC CTC., APC SNOM1 IN TRCIR A-PROXMA719 "CATION. ONLY" �, Ow
THE crsTENCE OF ANY EASCNEVTS. COVENANTS Olt RESTRICTIONS MAY ►RCYCRT SONC IMPROVCMCMTS FROM OCINC UtM AND LOCATED.
WMIGR 00 HRT APPEAR 04 D DI PLA7
UNDER NO CRCUMSTAMCES SHOULD AM AS -MLT 1E USED FOR CONSIRUCTIOM OR^FOR ESTAWSRNO ROVNOART OR FEMC'l. u9m
THE sURVEYOR TAKES RESPOMSIBt7TY FOR THC MI'IIAL TRANSACTION ONLY AND ASSUWCS FlNANCIAL LIABU7Y ONLY FOR TME COST OF THE SI.IRVEY.. .
TOTAL P.02
ti
E,vs>
67 "' %>7a<
Prepared by
ym%vY car"TATION
'o�����e•1
E,oF�, ••••
Robert E. Johns F Jr.
&Assoc.
�,,.,,.
.�.••
�P�•^'
•
Professional Land surveyors
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w. r A..A wa wrr •..w « r ,
•
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i
1700 ~ OIL
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i
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M
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raUNIIAIM AS -WILT
POP .....
IF
Dale 3l yea:
Drewe o%
Caamod or.
�a+,t.•.AwI•'.w1.•R/wnI
.w�+.�.»ww Fw.
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••�
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6121-5
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Data Orewn:
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431
FIRAL snuD7LIRE NL'rRIALt
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.•'�
•Ar
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:
........»...
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•
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ra.
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wrw •'�• .w..w..
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04Aof
Car,T�el.l heighs ts S,d-4ivisiO
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❑ tar .w... SURV61f
TYPE
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N 'tiT
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o FDVNO REDAR ,ap..e WOOD fEwzr
1.:. 3, '.rwwm nr.. - ...-r.� .-e
CONCRETE
rii771 .nrn nr....
R IS TRE RESPONSIBILITY OF TME BUILDER OR ONNCR. PRIOR TO I ONLY TMOSE wPROrEMEwTS AROVE OROUND AND NIR9LE WALL. CE
CONSTRUCTION, To VERIFY PROPOSED GVILOINC CAADE RCLATIK DNOWN. mm r, WCLL3. SCPTIO OLCANOLIM SVEvALKS. ORiM:«ATS
TO FINISHED GRADE AND UTUTY CONNECTIONS ARD TO OCTCANMC CTC., APC SNOM1 IN TRCIR A-PROXMA719 "CATION. ONLY" �, Ow
THE crsTENCE OF ANY EASCNEVTS. COVENANTS Olt RESTRICTIONS MAY ►RCYCRT SONC IMPROVCMCMTS FROM OCINC UtM AND LOCATED.
WMIGR 00 HRT APPEAR 04 D DI PLA7
UNDER NO CRCUMSTAMCES SHOULD AM AS -MLT 1E USED FOR CONSIRUCTIOM OR^FOR ESTAWSRNO ROVNOART OR FEMC'l. u9m
THE sURVEYOR TAKES RESPOMSIBt7TY FOR THC MI'IIAL TRANSACTION ONLY AND ASSUWCS FlNANCIAL LIABU7Y ONLY FOR TME COST OF THE SI.IRVEY.. .
TOTAL P.02
75.
Municipality of Anchorage
.�� Department of Health and Human Services
Division of Environmental Services
On -Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel I.D. 0114-67:2-765-HAA#JrFf/7 ,,3_75
Expiration Date:
GENERAL INFORMATION
Complete legal description Le T 1-1 B 1L LI e A%_t1' 1311.1 t4 F_L(jEj _S
Location (site address or directions)
3 E
3 7 6 % LLi
Current Property owner(s)
k Day phone '3L46-7;; 4 35'f
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be
held by
DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
I/
Individual On-site
❑
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) 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) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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
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.
72 025 (Rev 01 00)'
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 Health Authority Approval Guidelines for the Health Authority Approval
application show 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ! o �,��«r �ey r �'�4+ ? Phone �27g
Address 17 0 3 / L Cr pap 3
Engineer's Printed Name ek Date —1 Ll — P41
`'' ENGINEERS.
.STAMP
6. DHHS SIGNATURE
I/ Approved for _ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations.
Additional Comments
Attachments:
HAA Checklist Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date: SC - / %- O o
Expiration Date: / L / -7 - o O Reissue Date:
75025(Rev 0,-001'
Municipality of Anchorage RECEIVED
Department of Health and Human Services AUG 15 Division of Environmental Services
On -Site Services Section 825 "L" Street Room WRNICWAUTY OF ANCHOMGE
P.O. Box 196650 Anchorage, AK 99519-6650v1 MAL sERvlas DIVNII
www.ci.anchorage.ak.us
(907)343-4744
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT 1-1 15 $Ky C'AMAPBELL 8Q(7HT5 Parcel I.D.: 09-6 -79'
A. WELL DATA
Well type _F If A, B, or C provide PWSID # I"/Av. Well Log
Date completed (7S'fo Sanitary seal Wires properly protected
Total depth Z_ It Cased to 7g r i ft Casing height (above ground) _ 2 L in.
FROM WELL LOG AT INSPECTION
Date of test q/t h 81710 V
Static water level 3 9 It
Well production I h g.p.m
WATER SAMPLE RESULTS:
Coliform 7�__cotonies/100 mi Nitrate PDQ mg/I
Date of sample: 81-7 16-v Collected by: S
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Date installed
Cleanouts
Date of pumping
size
cleanout
33 it
Li 5 g.p.m
Other bacteria NQ colonies/100 ml
gal Number of Compartments
Depression over tank High water alarm
Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rati g (g.p.d./1112 or ft2/bdrm) System type
Length ft Width ft Gravel below pipe ft
Total depth ft Effective orption area ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field efore 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) If yes, give date
72.026 caw. 01100•
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access
"Pump on" level at in "Pump off" level at in High water alarm level at in
Datum Cycles tested Meets alarm & circuit requirements
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot rq1A On adjacent lots
Absorption field on lot t/A On adjacent lots
N%a
Public sewer main 91 Public sewer manhole/cleanout
Sewer /septic service line Ac 4c C. O Holding tank N /V—
SEPARATION DISTANCES
Building foundation Property line
Water main
Drainage
ON LOT TO:
Absorption field
Water sero line Surface water
Wells gKadjacent lots
SEPARATION DISTANCE FROM ABSO
Property line Building
Water Service line
Curtain drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface
FIELD ON LOT TO:
Water main
Driveway, Parking/vehicle storage
Wells 96 adjacent lots
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
HAA Fee $
Date of Payment
Receipt Number D G /4;7
72.026 (Rev. 01/00)'
Waiver Fee $
Date of Payment
Receipt Number
' NGINSER'S
MUNICIPALITY ANCHORAGE
• � DEPARTMENT OF HEALTT H & HUMAN SERVICES AgEl
Division of Environmental Services zo
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. # C ) Lf 0"7a —7 S\
1. GENERAL INFORMATION
HAA # OQS S - 2in"I
Complete legal description Lot 1713, Block 4, Campbell Heights
Location (site address or directions)
Property owner
Mailing address
Lending agency
Matthew Fast
3637 East 67th Ave.
Day phone
Day phone
Mailing address
Agent Charlotte Schlosstein/Remax Day phone 257-0106
Address 2600 Cordova# Suite 100, Anchorage, AK 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XXX
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
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.
72.= IA., 1/91) Frol MOA 021
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.
S 8 S ENGINEERING
Name of Firm ENGINEERING
Phone _G t y —;L9 717
Address Eagle River, Alaska 99577
i A
Engineer's signature
6. DHHS SIGNATURE
—A— Approved for 4 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
0
Date yc / / J-/ 4 e
�7 ROBERT C. COWAN /
�t �i.'1
bedrooms, with the following stipulations:
Date /D-22 -9f3
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.
72025(R-.1/91) 8. MOA Rt
Municipality of Anchorage lC i 1993
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division """ "" II.Ei Es V
1 K UIVI
825 L Street, Room 502 • Anchorage, Alaska 99501 a (90tvxM
Health Authority Approval Checklist
Legal Description: 1- o T ) 7 13 01� k H C4 ^PA# « q a, rS Parcel I.D.: 0 1 H — 0-7 2 — .7 £�
A. WELL DATA
Well" P A �/a & If A, B, or C, attach ADEC letter. ADEC water system number
Log present &N) Ye: s Data completed 01 /8-(.
Total depth -79 Cased to 1 V S- Casing height (above ground)
Sanitary seal (9/N) YE S Wires properly protected (VN) Y t S
Date of test
Static water level
Well production
FROM WELL LOG
34
WATER SAMPLE RESULTS:
Colltorrn O
19-
WATER
S
AT INSPECTION
tol4Ki`) 8
a '
X
19. H -t
Nitrate 0. ( Other bacteria
0
Date of sample: /011y19 Collected by: S & S ENGINEERING
P� A �<<
St W4-0, 17034 Eagle River Loop Road No. 204
B. SEPTICIHOLDING TANK DATA Eagle River, Alaska 99577
Data installed
Foundation cleanout (YM)
Date of Pumping
C. ABSORPTION FIELD DATA
Data installed
Tank size Number of Compartments Cleanou/ts
Depression (Y/N) High water alarmY✓t�
Pumper
Soil rating (g.p.dJW gF*/)drm) System type
Length Width G I thicimess below pipe Total depth
Effective absorption area onitorirg Tube present (YM) Depression over field (YIN)
Data of adequacy Lest Results (Pasa/Fam For bedrooms
Fluid depth In field before test (In.); Immediately after_ gal. water added On.):
Fluid (Ins) Minutes later. Absorption rate
P to
(past 12 months) (YIN) M Yes, date
72-029 (Rev. 3MM*
i
D. LIFT STATION
Date installed
Manhole/Access (YM)
High water alarm level at*
Cyder �
E. SEPARATION DISTANCES
`Pump on"
'Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septidholding tank on lot N /4
Absorption field on lot
N l A
Size in gallons
On adjacent lots
"Pump off" level at'
N / i
On adjacent lots N 1A
Public sewer main ol J Public sewer manhole/cleanout
Sewer /septic service line 16 ' ( W"' v+® WA V46-011) Lift station A'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation
Property line
Water main/service line Surface water/drainage
SEPARATION DISTANCE FROM ABSOR ELD ON LOTTO
Property one
Surface water
foundation
Wells on adjacent kits
Water main/service one
Driveway, parldng/vehide storage area
drain Wells on adjacent lots
F. ENGINEER'S
I certify that I have determined fhru held inspecgons and review of Munkipal
In conformance wllh M/OA� guldel m in effect on M date.
Signature
Engineer's Name /Z 08 f a r C. Cv NAN
Date 10 /Pr / "t y
po
HAA Fee
nate of Pavrnouft
Wahrer Fee $
Date of Payment
Receipt Number 0,41-21743 l 612— 3 _)Receipt Number
72-028 (Rev. 3196)•
C OF
R04LRT. C. Cgw"..
,t
Li]
1
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Servlces y
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 I.D. n1 HAA k u QqC-);9C�
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
/_, --j f /76 , g//31:X ¢. 1�,Y?A-24 ell
Location (address or directions)
77-"
(b) Property owner
L
Telephone: (home)
ti Business:5:53' 333
Mailing Address U1 3e' Ave 915603
(c) Lending Institution NIS Telephone
Mailing Address A%114
(d) Real Estate Company and Agent 'OW.4
Address A/4
Telephone
(e) Mail the HAA to the following address: (or check here 2rilflhold for pick up.)
List contact person and day phone number below:
✓r22 �l� ��
2. TYPE OF RESIDE
Single -Family Number of bedrooms
3. WATER SUPPLY
Individual Well C✓/ Community 0 Public 13
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/Community
On-site 0 Public 0 Holding Tank 0
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
724251Rw. 7/88) Page 1 of 2
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NOIIVWHOdNI ONV VIVO'HOUV3S 311d'SIS31'SN01103dSNl JNIOIAOUd WHIR ONI1:133NION3 'S
MUNICIPALITY OF ANCHORAGE (MOA)
• Health Authority Approval (HAA)
MUNICIPAL ORAGE CHECKLIST -FEBRUARY 1984
ENVIRONMENT CES DIVISION .343-4744
OCT 21989 Legal Description: (�
La{' 1.70 61 IG A- lctt,c(11, 11 K`fr , 5', (11
A. WELL DATA RECEIV D 1+ , f
� `
Well Classification If A, B, C, O.E.C. Approved (Y/N)
Well Log Present (YIN) Date Completed (kV%J4,1A o,&M Yield 2 • 1 I'" Pr1 t -
Total Depth��! Cased to � Depth of Grouting
' F 1
Static Water Level Pump Set At
1
Casing Height Above Ground 3 Sanitary Seal on Casing (YIN)
Electrical Wiring in Conduit (YIN) C Depression Around Wellhead (YIN) N
SEPARATION DISTANCES FROM WELL:./ , t
To Septic/Holding Tank on Lot 0/ 8 ; On Adjoining Lots N
To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots
To Nearest Public Sewer Line 49 5 ( To Nearest Public Sewer CleanouUManhol
To Nearest Sewer ServiceLineon Lot 7 10
Water Sample Collected by V ems 1/iY4P_'!af ; Date !7Z) �E/
Water Sample Test Results
Comments
-, r
of uiellS see AV// oca .
B. SEPTIC/HOLDING TANK DATA R-eqwYeX
Date Installed Size No. of Compartments
Standpipes (YIN)
Depression over Tank (YIN)
Air -tight Caps (YIN)
Pumping/Maintenance Contact on File (YIN)
Holding Tank High -Water Alarm (YIN) _
SEPARATION DISTANCES FROM SEPTI
To Water -Supply Well
To Property Line
To Water Main/Service
To Stream, Pond, Lake or Major Drainage Course
Comments i
Date
FoundationC eal nout (YIN)
;for
Holding Tank Permit (YIN)
TAf�1F:�
To u ding Foundation
To Disposal Field
72-M (Rm. 7/88) Front Pagel of 2
C. ABSORPTION FIELD DATA
Soils Rating In Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Date
s Present(Y/N)
Adequacy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutback (if present)
To Stream, Pond, Lake, or Major Drain de Course .
To Driveway, Parking Area, or Vehi a Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes
Comments
Thole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
Receipt No. al W3 — cS 3(e O Receipt No. _ j I ii - I �i o
Date of Payment l0 " 7 fC`l Waiver Fee: $ 6' 90, Cb
Amount: $ Date of Payment 9
72-026 (A". 71U) Back Page 2 of 2
"Check Per
ed Bedro
m Rating Against HAA Request'
I certify th
I he
e , verified, or conformed to all MOA and JSAA guideli §NS ffect on the date of this
inspection
;�c
_ „�•
ti�
,
Signedr
v
Compa
r
Date _C�1%�f%
ss.`r/
Engineers Seal
MOA No.
� rY
:,_.asa :'arJ7
_
C°�;�
Receipt No. al W3 — cS 3(e O Receipt No. _ j I ii - I �i o
Date of Payment l0 " 7 fC`l Waiver Fee: $ 6' 90, Cb
Amount: $ Date of Payment 9
72-026 (A". 71U) Back Page 2 of 2
- (..N' MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH \A'
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ,A54o- `
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date September 22, 1986
1. GENERAL INFORMATION
(a) Legal Description (include lot block, subdivision, section, township, range)
Lot 17B Block 4 Campbell Hei,¢hts South
Location (address or directions)
Anchoran
(b) Applicant Name Fred 9nith Telephone: Home N/A Business 694-5490
Applicant Address Box 6613 Anchorage, Alaska 99519
(c) Applicant is (check one): Lending Institution m ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Al;aqka USA Federal CAL . Telephone 694-5190
Address P-0- Box 196613 Annhoram, Alaska 99519,6613
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
Pickup by emineer
2. TYPE OF RESIDENCE
Single -Family ® Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well ® Community ❑ Public ❑
,••'�\�� 111 li��
Note: It 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 E) Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 111 6+1
Page 1 of 2
r^ n
- 5. ENGINEERING FIRM PROVIDIWt .NSPECTIONS, TESTS, FILE SEARCH, DA... 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
Address
Date 1
6. DHEP APPROVAL
EAGLE RIVER, AK 99577
694-5195
Telephone
SOF A( z�
�u!( Engineers Seal
• fouls A. Bufara ; w
CE -6796 .• �•
Approved for '141� bedrooms by""'—"' Date /r7 -/o
Approved 41_� Disapproved Conditional
Terms of Conditional Approval
��tl III /// '•,,,,
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 engineer's work.
Page 2 of 2
72-025 (11/64)
ro•� e-1
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPAUTY OF ANCtiORAOEH AUTHORITY APPROVAL (HAA)
DEPT. OF HEALTH b CHECKLIST- FEBRUARY 1684
ENVIRONMENTAL PROTECTION 264472!)
OCT 1186 Legal Description: �pt /7 .c4 ;
Ca.. dbe// 417ti To–>L
A. WELL DATA RECEIVED
Well Classification pR/ dA TF If A. B. C. D.E.C. Approved (Y/N) A�4
Well Log Present (Y/N) —_ Date Completed 90"6 YieldG�ry-
Total Depth 79 � Cased to ZF S` Depth of Grouting f --)O 7
Static Water Level 79 I Pump Set At & 7'y -
Casing Height Above Ground tla � Sanitary Seal on Casing (Y/N) y
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) N
Separation Distances from Well:
1
To Septic/Holding Tank on Lot /N/ f'^6)•a se" ry ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot : On Adjoining Lots rico
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole —To Nearest Sewer Service Line on Lot
Water Sample Collected by C•le _r,L ; Date j�<ZS�d6
Water Sample Test Results 70"J Ater'►'
Comments
B. SEPTIC/HOLDING TANK DATA p,.6/,: Xe or q4 , e
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
_ Air -tight Caps (Y/N)
Pumping/Maintenance Contract on File (Y/N)
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
Course
Comments
Page 1 of 2
72-026(11/84)
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field —
To Stream, Pond, Lake, or Major Drainage
1 ; .
C. ABSORPTION FIELD DATA Pa 6 /, c SGcrria Au/ ti/• /t
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
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION ! /�
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
— Standpipes Present(Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
— Dimensions
Manhole/Access (Y/N)
— "Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
•' Check Permitted Bedroom Rating Against HAA Request ..
I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection
i
Signed I -
DateOF
!
/�..
Company SES
MOA S
•%
..........lo
t$.
�E
+�y.•',
No. 6�ei p n U
S
0Receipt
T49�
Date of Payment Ja=r Q42
%......
,
Amount: $ SRT O O
MLWIPAUTY
I
�� Louis A. u� aeerE
CE
/� -0MK
OF ANOiORA
.• -6736
PROTETTION
AV
—
`,"\O��
Page 2 of 2�~�
OCT 0110006
=`P
We River Engli"Ing Services
72-026 "' &' RECEIVED
P. 0. Box 773294
We River. AK 99577
BU -5195
Time
APPLK 'NT
FILLS OUT UPPER NAl ")NLY
Property Owner
1
�1 �� (3-7" z> y O
Phone
Malling Address
_ r A
-� < Zip Code y j y 1,325
2 s r
Date
Buyer
A
SS
Inspector
Address
Ji��n.L
Zip Code
Lending Institution
r
,dlA_CN fl.S/�
Phone
Address
-
Zip Code
Realty Co. d Agent
RECEIVED
Phone
Address
'CONDITIONS OF APPROVAL _ �/�
/J
��T%%%
Zip Code
Legal Description
Aol /76 Of jr `/
L-A I—✓6L1,C L. 0V rS Sfr BD
Street Location
/- A
( / I
� L/'111�tW
f
Type of Residence
Softs Ratlnp
Dat_ a Sewer Installed
�Single Family
Well To Absorption Area
❑ Multiple Family
No. of Bedrooms
❑ Other
Tank
Water Supply
!R Individual
Septic Tank Size tt
H WELL LOG. A well lop Is required for all welts drilled since June 1975.
TFt15
❑ Community
drilled prior to that date. give well depth (attach lop if available).
❑ Public Utility
Sewer Disposal
❑ Individual
_ r,
Year Individual Installed: _f
2_ Public Utility
When Connected to Public Utility: '
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
A
Inspector _
Inspector
Inspector
InspectoV\
if1
Field Notar. �
Ml1NIP OF ANCHORAGE
T, J
DEPT.T. OF ::
ENVIRO\M=NTAL PROTECTION
RECEIVED
( ) APPROVED BEDROOMS
( ) DISAPPROVED
'CONDITIONS OF APPROVAL _ �/�
/J
��T%%%
APPROVAL'
,. - A
( La -CONDITIONAL
DATE
BY: K- C Mi )
( / I
� L/'111�tW
f
Softs Ratlnp
Dat_ a Sewer Installed
Well To Absorption Area
Well Log Received
Tank
Septic Tank Size tt
72oz3 Iles
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH b ENVIRONMENTAL PROTECTION
Environmental Sanitation Division
a.r 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
CERTIFICATE OF INSPECTION
SEWER AND WATER FACILITIES
1. PROPERTY OWNER
Jerald J. Racheff
MAILING ADDRESS
PO Box 3130 Anchorage, AK 99510
2. LEGAL DESCRIPTION
Lot 17B Block 4 Campbell heights Subdivision
3. TYPE DWELLING
IN SINGLE FAMILY RESIDENCE ED OTHER (Describe)
O MULTIPLE FAMILY RESIDENCE
4. WATER SUPPLY
)0 INDIVIDUAL
C3 COMMUNITY/PUBLIC
5. SEWAGE DISPOSAL
O INDIVIDUAL/ON-SITE
O PUBLICUTILITY
O HOLDING TANK (Maintenance Required)
O APPROVED FOR BEDROOMS
O CONDITIONAL APPROVAL (See Attached) P I«
® DISAPPROVED
Results of water sample not submitted to this department
DATE
BV ITITLEI ����
12/02/81,
Jam Roberts Associated Environmental Specialist
72414 (3178)
�01
a
e,
5as3j
5. LEGAL DESCRIPTION
O C
DATE RECEIVED
INSPECTION APPOINTMENTS
STREET LOCATION
y/,/
T ME
TIME
TIME
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
'Q,
❑ One ❑ Four ❑ Other
❑ SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
DATE
DATE
DATE
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
Cs
\—
8. SEWAGE DISPOSAL SYSTEM
INSPECTOR
INSPECTQ��)7
INSPECTO
-
+/_57%LLt°z1
1 / Cli_N 0 AA 5
MUNICIPALITY OF ANCHORAGE DEPT. OF HE:L1iI &
ENVIRONMENTAL I;,L;TCL?ION
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
\ 825 L Street • Anchorage, Alaska 99501
• \I
SEP 21981
ENVIRONMENTAL SANITATION DIVISION
Telephone 2644720
RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete Munn will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER
PHONE
e"(0
1
3
MAILING A9PRESS /
O. -3/30! CtNAGP /d
PROPERTY RESIDENT (If different from above)
PHONE
i �' / L t°ti n
2. BUYER
PHONE ,
MAILING ADDRESS -
3. LENDING INSTITUTION
PHONE
13 e4 0S/�
MAILING ADDRESS �`�
jwne a -r/ J
4. REALTOR/AG NT //
lle' �
PHONE
y7G-z%!p�
e`
�A Jfn G
MAILING ADDRESS
5as3j
5. LEGAL DESCRIPTION
O C
o /
STREET LOCATION
y/,/
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
o vw✓n ;_ F C I
❑ One ❑ Four ❑ Other
❑ SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
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.)
8. SEWAGE DISPOSAL SYSTEM
❑ INDIVIDUAL/ON-SITE"
YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLICUTILITY(T 6c_
+/_57%LLt°z1
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED:
n 72-010 (Rev. 6/79)
_ THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLEFAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED -
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
❑Septic Tank or ❑Holding Tank
Size: If Tank is homemade
give dimensions:
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
❑ APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
DISAPPROVED
DATE �1 Q'
BY
.J
72010 (Rev. 6/79)