HomeMy WebLinkAboutSOUTHPARK #2 BLK 2 LT 85outhpark
Block
Lot 8
#020-501-31
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PERMIT NUMBER:
OSP241087
NOTE: PfPE LOCATIONS ARE
SHOWN PER GEG SHOTS
TAKEN WITH LEICA DISTO
5910 LASER DISTANCE
METER. SWING -TIES TO
HOUSE CORNERS WERE
GENERATED IN AUTOCAD.
LOT 9
PARCEL ID NUMBER:
020-501-31
NOTE: ALL PROPERTIES
SHOWN ARE SERVED
BY AWWU WATER.
LOT 13
N \
��• � �n�...
moo.
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
MICHAEL & GENEVIEVE DANIELS
907-227-1112
2 OF 4
LEGAL DESCRIPTION:
DRAWN BY:
SOUTHPARK #2; BLOCK 2, LOT 8
D.J.G.
TYPE OF WORK:
DATE:
,._ SEPTIC TANK RECORD DRAWINGS
6/21/2024
WATER LINE LOCATION
�• .,,••.;. • •,:r.,.;,..
PER GEG DISTO SHOTS.
t•.`.i.•.<•;
PROFESSIONALLY
LOCATED BY ARCTIC
EFFLUENT
\6'+ SEE WAIVER AMENDMEN
o a
REQUEST WITH DESIGN
°a
1250 GALLON HDPE GREER TANK
LOT 7
ENGINEERING,,SALES-CONSULTING
��• � �n�...
3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 • PHONE (907)337-6179- FAX (907)33&3246 WEBSITE: www gamesseng neer ng com
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
MICHAEL & GENEVIEVE DANIELS
907-227-1112
2 OF 4
LEGAL DESCRIPTION:
DRAWN BY:
SOUTHPARK #2; BLOCK 2, LOT 8
D.J.G.
TYPE OF WORK:
DATE:
,._ SEPTIC TANK RECORD DRAWINGS
6/21/2024
LOT 14
SCALE:
mommow
1"=40'
��,'�,,'►n\\C1\111
AV
. .
............ ........................r
0♦ ey A. Gar • •ss
1#�� G -7 53 = _:
LICENS414 "'� �5��
PERMIT,NUMBER: PARCEL ID NUMBER:
OSP241087 RECORD DRAWING 020-501-31
TOP OF MANHOLE = 99.02
FINAL GRADE = 98.52-98.64
MH1 STI
2" INSULATION PER CONTRACTOR
TOP OF TANK AT INTLET = 96.26 TOP OF TANK AT OUTLET = 96.23
INVERT OF PIPE AT INLET = 95.59 INVERT OF BUNG AT OUTLET = 95.35
NEW 1250 GALLON H.D.P.E.
SEPTIC TANK
J .......
AV
., �♦
t. �AV
� ,r_ .�_ v_. k .. . �. �,ar_ sx . ,� ,""r""., .,w
011TP td
........... .. ....................'......�
x ENGINEERING SALES- CONSULTING
3701E TUDOR ROAD, SUITE 101 ANCHORAGE, AK 99507PHONE (907) 3373179' FAX (907) 338-3246' WEBSITE. —.9 n—prI..n g — �. ..... ............
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: • effrey A"Garness 141
MICHAEL DANIELS 907-227-1112 3 OF 4 0 6,
CE-7953 Z V
LEGAL DESCRIPTION: DRAWN BY:,, ( \
SOUTHPARK #2; BLOCK 2, LOT 8 D.J.G. •## � ..2, ! '���•� �
TYPE OF WORK: DATE: LICENSE
♦♦ FQ p'••,•• • ' Q`� ••
SEPTIC TANK PROFILE 6/21/2024 #AECC88+',�\S\��••
BOTTOM OF FOOTER ELEVATION = 96.08 -
EXPOSED BY ARM SEPTIC SERVICES
6.5+ FEET TO EDGE OF TANK
45* ANGLE OF REPOSE)
-TOP OF TANK ELEVATION PER GEG
FIELD MEASUREMENTS = 96.23-96.26
'ELEVATION PER GEG FIELD
MEASUREMENTS = 90.58
451/,
11 T
GARNESS ENIG INEERING' (31 RO u PLtd
ENGINEERING SALESq,-, CONSULTING mmmm�
3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 -PHONE (907) 337-6179' FAX (907) 336-3246 - WEBSITE v i.ge essengineeting.c
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
MICHAEL DANIELS 907-227-1112 4 OF 4
PROJECT/LEGAL DESCRIPTION: DRAWN BY:
SOUTHPARK #2; BLOCK 2, LOT 8 D.J.G.
TYPE OF WORK: DATE:
,._ PROFILE OF TANK DRAWING TO FOUNDATION 6/18/2024
L'a'sawli
OF A.
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��ESS
LICENSE 11 vi
#AECC884(ol I 11/ 1 2�
MUNICIPALITY OF ANCHORAGE»cn�
On -Site Water & Wastewater Program
"'ON
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
Ucpartn��nt
On -Site Wastewater Disposal System Permit
Permit Number: OSP241087 Effective Date: 5/28/2024
Work Type: SepticTank Upgrade Expiration Date: 5/28/2025
Tax Code Number: 02050131000
Site Legal Address: SOUTHPARK #2 BLK 2 LT 8 G:3236
Site Mailing Address: 15711 SOUTHPARK LOOP, Anchorage
Owner: DANIELS A MICHAEL & GENEVIEVE Lot Size in Sq Ft: 21789
Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Remve4*: -
Issued By:
Date:
Date:
tea-
Mun*dpabty of Anchorage
I)rportin ant
P.O. Box 196650 0 4700 Elmore Road
Anchorage, Alaska 99519-6650 a (907) 343-7904 0 Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
Cin -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * *
Waiver#: COSA#:
PID#: 020-501-31
Permit#: OSP241087
Legal Description: SOUTHPARK #2 BILK 2 LT 8
Engineer: Garness Engineering Group
Your request for a waiver of the required 10 feet horizontal separation from the absorption field to
the water line has been approved. The approved separation distance is 6.0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
Waiver is Granted: X Waiver is not Granted:
Date: 'Z 'Z -L Approved by: f� -----
Name of Reviewe
............................................................ ■...............i
**** VARIAN C E/WAIVER REVIEW ****
MUNICIPALITY OF ANCHORAGE
}
Development Services Department Phone 907-3A3-7904
Ort -Sire Water & Wastewa', Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 020-501-31
Property owner(s) MICHAEL & GENEVIEVE DANIELS Day phone
Mailing address 15711 SOUTHPARK LOOP, ANCHORAGE, AK 99516
Site address `{5711 SOUTHPARK LOOP, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) SOUTHPARK 42; BLOCK 2, LOT 8
Legal description (Township, Range & Section)
Lot Size
Sq. Ft. Number of Bedrooms 4
907-227-1112
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF F DWELLING_ :
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) R
(w/wo AD U)
Septic Tank
❑X
Upgrade ❑X
(D) El
Holding Tank
El
Renewal
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
63iKush Fees: 22 5 Waiver Fees:
Date of Payment: Date of Payment:
Receipt Number: C���{�G Receipt Number:
Permit No. bS f g4 t O g" —1 Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241087, Deb Wockenfuss, 05/28/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241087, Deb Wockenfuss, 05/28/24
MUNICIPALITY OF ANCHORAGE
° DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE //~ NE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Liq. ca a Ions IF HOME,DE:
~O Wetl DwelHng PERMIT NO.
DISTANCE
TO:
O Z < Manufacturer Material Liquid capacity in
-- ~ N . of lines Length ol es h line Total lengt ol lines Trench width Distance ~3~en
~ Top of l,le to finish Material ~neath tile
Length W~dth ~pth PERMIT NO.
~ k Type of crib Crib ~iameter Crib depth Total eff~ti~ absorption area
~ Well Building foundation Nearer lot line
~ DISTANCE TO:
~ 31ass Depth Driller O;stance to lot line PERMIT NO.
m Building foundation Sawer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PiPE MATERIALS
SOILTESTRATING~ ~~ ~
INSTALLER ~ ~ ~
.'., CE-8316 ,,'...~.-
· , .......,...
APPROVED DATE LEGAL
72-013 (Rev. 3178) ~
DEPARTMENT OF HERLTH FIND ENVIRONMENTAL PROTECTIOf~
825 L STREET, A~CHORAGE} AK 99501
264-4720
m_-m~'-4--~ I TE SEWER PERI~'i I T
PERMIT IlO: 840177
DATE ISSUE[): 04/12:/84
RPPLICAf4T:
ADDRESS:
C~NTACT PI4OfIE:
LANDMARK-VENTURE LTD
P 0 BOX 111654
ANCHORAGE, At{ 99511
345-4S07
LEGRL DESCRIP:
LOT SIZE:
MAX BEDROOIflS:
SUBDIVISIOH: SOUTH PRRK #2
SECTION: ~ TOl.lftSHIP:'iifl
2i789 .<SO. FT. OR FlCRES>
4
LOT: 8 BLOCK: 2
RANGE: ~Pl
LISTED BELOW RRE THE OPTIONS A"/AILAE:LE TO YOLI IN DESIGNIt~G YOUR SEPTIC
SYSTEM. CHOOSE THE OPTIOf~ THaT BEST FITS YOUR SITE.
T il: E l-.I K3 H BED
DEPTH TO PIPE BOTTOM (FT.) 3. 0 =+"+= 4.
GRAVEL DEPTH (FT.) 7. 0 O.
TOTAL [.'EPTH (FT.) ICi. 0 4.
GRAVEL 14IDTH <FT. ) 2. 5 25.
GAR'm/EL LEHGTH (FT.) 77. 0' ** 56.
GRAVEL VOLUME (CU. YDS. ) 53. 4 58.
TANk' SIZE (GALS) 2., 250. 0 ** .1,250.
SI]IL RATING (SQ. PT. /'BE:) 268 257
DI~: m----I I I'-.I
4.0
7.5
5.0
129. 0
95. 5
250. 0
29~
DEPTH TO PIPE BOTTOM.{ ~. 5 FT. REQUIRES INSULRTION .,
DEPTH TO PIPE BOTTOM ~ 4. 0 FT. MAY REQUIRE Ft LIFT STATIOH
GRAVEL LENGTH } 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEE~)ING 75 FT.
TAf~K MUST HAVE AT LEAST Thio COMPARTMENTS
EACH)
I CERTIFY THAT:
1. I Afl FAI:IlLIAR WITH THE REQUIREMEHTS FOR O~I-SITE SEWERS RflD WELLS FlS SET
FORTH BY THE MUNICIPALITY OF RHCHORAGE (MOA) AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH FILL MOA CODES RHD REOULATIOHS,
AND IN COMPLIANCE 1.4ITH THE DESIGN CRITERIA OF THIS PERI'lIT.
~. I .14ILL RDHERE TO ALL MOA FIHD STFlTE OF RLRSKA REOUIREMEHTS FOR THE SET BACK
DISTAf~CES FROM ANY EXISTIf~G WELL, ~4ASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM OH THIS OR RNY ADJACENT OR NEARBY LOT.
4.' I UHDERSTAND THAT THIS PERMIT IS VALID FOR A MFiXIMUM OF 4 BEDROOMS FIND
ANY ENLAROEMENT WILL REOUIRE RH FIDDITIONAL F'ERMIT.
IF R LIFT STATION IS INSTFlLLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEH Ii) AN ELECTRICAL PERMIT AND I)4$PECTION MUST BE OBTAIIqED; (2) A$-BUILTS
WILL NOT BE APPROVED WITHOUT A~4 ELECTR. ICAL INSPECTIOfl REPORT; AHD (~) THE
ELECTRICAL I.IORI:,' MUST BE DO)4E BY A LICENSED ELECTRICIAH.
RPPL ICAfI'T~y//LAN, DMRRK-~..ENTURE LTD
ISSUED BY ~ ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION /~
PERCOLATION
TEST
825 L. Street. Anchorage. Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: p~( /~.1},~ e~- DATE PERFORMED:
LEGAL DESCRIPTION: ~o~ ~ ~/~ ~ Z~ ~ ~ , ~=
SLOPE SITE PLAN
1
4
5
6
7
8
9
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11
12
13
14.
16-
20-
/
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
&',, ,~-~ p.,-~.
Reading Date Gross Net Depth to Net
Time Time Water Drop
/oz 3 ,rr
toyz. tS ,~-5" ,/0
4'11
72-008 (6/79)
PERCOLATION RATE .~ ~-
TEST RUN BETWEEN ~//'~' FT AND
· ',,¢-..,t v,'r~//. _~ 6>5.0'
CERTIFIED BY:
(minutes/inch)
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Legal Description: SOUTHPARK #2; BLOCK 2, LOT 8
Parcel ID: 020-501-31
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
PUBLIC WATER
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 00
Date of flow test for COS
Static water Dinning of test ft.
nts
B. TANK DATA
Measured operating fluid level in septic tank NEW
Date of pumping N/A
❑ Required maintenance completed, if AWWTS
Comments: SEE ATTACHED RECORD DRAWINGS
D. ABSORPTION FIELD DATA
Which system tested (date installed) 4/21/1984
0 ALL standpipes present per record drawing
Total measured depth from grade 9.1 ft (max)
Measured depth to pipe invert from grade * ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
r
❑ Monitor tubes go to bottom of effect.x� 7
If not, state depth into effecti 7.11
e .')
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced - gallons date
Any rejuvenation treatment (past 12 months) -
If yes, enter date -
Well production at time of test
Water storage tank volu gallons
Well disinfe r coliform test? ❑ Yes Q No
iform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date
C. LIFT STATION
❑ Required maintenance compl
Age of lift station ars
Lift station al
Adequacy test date 4/23/24
Results 0 Pass
Fluid depth prior to test 35 in
Water added 787 gal
New fluid depth 59.75 in
Elapsed time 120 min
Final fluid depth 54.25 in
Absorption rate 600+ gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 108 in
Effective depth used 77 in
Effective depth remaining 31 in
Comments/Deficiencies: `1.4 TO & OF SOIL COVER. CLEANOUT ON FAR END IS SHY ON COVER - SOME OF THE TRENCH HAS ADEQUATE COVER.
DRAINFIELD AREA WILL BE SUBJECT TO SNOW COVER - SEE ATTACHED EMAIL FROM HOMEOWNER REGARDING NO FREEZING ISSUES.
1984 RECORD DRAWING INDICATES 18" FROM TOP OF TILE (DRAINPPE) TO FINISH GRADE IS 18 INCHES
COSA Checklist June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Ma Cleanout > 100'
FlYes if No ft ❑Yes if No ft
Neighboring Tank > 100' Yes if No ::::ft P ' Sewer/Septic Line > 25' ❑Yes if No ft
Absorption Field on Lot > 100' ❑ Yes if No Holding Tank > 100' Yes if No ft
Neighboring Absorption Fields > 100'
es if No ft
Community Sew In > 75' ❑ Yes if No ft
Animal Containment > 50' [:] Yes if No ft
Manure/Animal Excreta Storage > 100'
Q Yes if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No *6.5+ ft Surface Water > 100' Q Yes if No ft
Tank to Property Line > 5'
[E Yes if No ft
Field to Property Line > 10'
Q Yes if No ft
Water Main > 10'
[E Yes if No ft
Water Service Line > 10'
❑ Yes if No 6 ft
Wells on Adjacent Lots:
Private Wells > 100'
Community Wells > 200'
Yes if No ft
n Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*6.5 FEET FROM EDGE OF TANK TO FOUNDATION - SEE ATTACHED PROFILE DRAWING
"WAIVER APPROVED BY MOA
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Garness Engineering Group, LTD. (GEG) Phone 907-337-6179
Engineer's Printed Name Jeffrey A. Garness Date
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in
accordance with the guidelines and regulations established by the Municipality of Anchorage and industry
practices. The reported results describe the condition of the system/s on the date/s of the evaluation.
Separation distances were measured to readily identifiable features. Hidden defects or encroachments may
exist that were not identified during the evaluation. The operational life of all wells and septic systems depend
upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate
during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing
the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not
guarantee future performance of the systems; therefore, GEG makes no warranty (express or implied) regarding
the future performance of the well or septic system. GEG makes no representation whether an alternative well
or septic system can be installed on the property in the event either of the current systems fail to perform
adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG
to perform the evaluation. Reliance upon the information provided in this report by any other person or party
(including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever.
COSA Checklist—June 2022
F A
0� J:
49 TTH
PO
el i .4. Gomess.
41- CE
LICENSE Frofessio�oo�
#AECC884
David Garness
From: Genevieve Daniels <gdanielsrn@gmail.com>
Sent: Friday, lune 21, 2024 2:37 PM
To: David Garness X7-1
Cc: Jeff Garness; Sonja Blewett; Jody Maus
Subject: Re: Freezing issues - Southpark Loop #2; Block 2, Lot 81577 Southpark Loop
*Anchorage, AK 99516
Never had any freezing issues
On Jun 21, 2024, at 14:32, David Garness <David@garnessengineering.com> wrote:
Micheal,
I am working to finalize the COSA paperwork on your property and it was noted that the far cleanout
is shy on soil cover. Would you please respond to this email and confirm that you have not had any
freezing issues associated with your drainfield. Thank you
Sincerely,
David Garness, P.E., M.S.
Civil Engineer
Garness Engineering Group, Ltd.
3701 E. Tudor Road, Suite 101
Anchorage, Alaska 99507
Phone: (907) 337-6179
Mobile: (907) 632-4528
Website: www.garnessengineering.com
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1 25
GRAPHIC SCALE
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. ............
GA GERVELIS
S-14823
,l1 PROFES80NA��P�
L(C G ��rh! Inc
a,ic&eecE«-te - e,,96,,eez&Lq • Jc�2�Aec�u,�
ORDERED BY: GENEVIEVE DANIELS
LOT 9
NV Jo 15�\C P151E: SHED
ELECT
�_'\Vvo
NE jRETAINING
WALL
SECOND�
...STORY ...<. u, TING HOUSE 7
i EXISTING w
DECK 3
^. 3.2'
2 ...... . ✓�� ;.. � 220 � ,� //� //
`moo
Q> , �1. 't 2.0' w
n /
%Q$Q CLEAN OUT (5) ;. "' Tb
CLEAN OUT (2) I r
o b /
s
SEPTIC MANHOLE s
250 H Street
LEGAL DESCRIPTION:
Anchorage, Alaska 99501
LOT 8, BLOCK 2,
Survey Department
SOUTHPARK SUBDIVISION
Phone 562-5291
Mainline
Phone 243-8985
ADDITION NO.2
DRAWN DATE: 6/19/2024 WORK ORDER:
24020
DRAWN BY: AP PLAT:
83-213
AECC 668
CHECKED BY: ADS GRID:
SW3236
SCALE: 1 " = 30' FB/PG:825/44
REF: 071_84
LOT 8
LOT 7
AS -BUILT
- Asphalt.
SEWER MANHOLE
O1 4 Concrete
CLEAN OUT OP HjfjjLjVt1 i idi ig
FENCE-�1VOOd Deck
LOT 13
NOTE:
1) THIS MORTGAGE LOCATION SURVEY (AS -BUILT) WAS PREPARED
FOR GENEVIEVE DANIELS IT SHOULD ONLY BE USED FOR A
SINGLE PROPERTY TRANSACTION. RE -USE OF THIS DRAWING
BY THE ORIGINAL CLIENT OR BY OTHERS FOR ADDITIONAL
USES LATER WITHOUT THE EXPRESS WRITTEN CONSENT OF
LCG LANTECH, INC. IS A VIOLATION OF FEDERAL COPYRIGHT
LAW.
2) THE LIABILITY EXTENT OF LCG LANTECH, INC. SHALL BE
LIMITED TO THE AMOUNT OF FEES COLLECTED FOR SERVICES
IN PREPARATION FOR THIS PRODUCT, UNLESS GROSS
NEGLIGENCE IS DISCOVERED.
3) THIS MORTGAGE LOCATION SURVEY (AS -BUILT) IS A
REPRESENTATION OF THE CONDITIONS THAT WERE FOUND AT
THE TIME THIS SURVEY WAS PERFORMED. THIS AS -BUILT DOES
NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECTTO
ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY
MAY DISCLOSE.
4) THE INFORMATION CONTAINED ON THIS DRAWING SHOULD
NOT BE USED IN SUPPORT OF ANY NEW CONSTRUCTION.
5) THIS AS -BUILT ONLY SHOWS EASEMENTS THAT WERE ON THE
ORIGINAL PLAT. IT IS THE PROPERTY OWNER'S RESPONSIBILITY
TO DETERMINE IF THERE ARE OTHER EASEMENTS, COVENANTS,
RESTRICTIONS, OR RIGHT OF WAY TAKINGS OF RECORD NOT
SHOWN ON THE ORIGINAL PLAT.
n
,'\UUKt55:15/11 SOUTHPARK LOOP PARCEL#: 020-501-31-000
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020-501-31
GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date: _//- ~(~- / /
SOUTHPARK #2, BLOCK 2, LOT 8
15711 SOUTHPARK LOOP, ANCHORAGE, AK 99516
Current Property owner(s) JOHN & KRISTA ]~OHNSON
Mailing address
Lending agency
Mailing address
Day phone
15711 SOUTHPARK LOOP, ANCHORAGE, AK 99516
Day phone
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well [] Individual On-site []
Individual Water Storage [] Individual Holding Tank []
Community Class A 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 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 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 1//02/2010
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assesSment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface COnditions that may nOt be observed from the surface;
changes inland use, local soil characteristics, groundwater levels that may fluctuate dUring the year and the
water usage of the family being served by the system. The operational life of all well an d septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations-
~: WATER AND
~ : WASTEWATER
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
By:
(Rev. 11/05)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
M Hty of Anchorage
Oevelopmertt sewices Department
Building Safety Division
On-Site water& Wa~tewater 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: SO--ARK #2, BLOC~ 2, LOT 8
A. WELL :~TA
Parcel'lD: (120,581-31
Wires
TOtal depth __ff.
Cased to __ff.
FROM WELL LOG
Casing height (above ground) in~
AT INSPECTION
Date oftest
Static water level
Well= .prodUction
WATER SAMPLE RESULTS:
ff. fl;
g:p.m, g:p~m. '
Coliform colonies/100mL Nitrate mg/L
Arsenic: . mg/I Date of sample: Collected by:
SEPTiC/HOLDING TANK DATA.
Tank Type/Material Septie./stee! Date installed ..6/21/84 Tank Size 1250 gaI.
Number of Compartments 22 cleanou.ts (Y/N) Y Foundation CleanOut (Y/N) -Y Depression over tank (Y/N)
High water alarm (Y/N) N Date of pumping .;t0/27/20;t0 Pumper ISAACS
C. ABSORPTION FIELD DATA
Date installed ~984 Soil rating (g.p.d./ft2 or ft2/bdrm) 268 System type Tzench
Length 60 ft. Width --3 ft. Gravel below pipe 9___ff. Total depth ;tO ft.
Eft. absorption area ;t080 ft2 Monitoring tube Y Depression over field N
Date of adequacy test ;t0/28/q_0 Results (Pass/Fail) Pass For 4__ bedrooms
Fluid depth in absorption field before test 3_0_0 in. Water added ;t000 gal. New depth 58 in.
Elapsed Time: 1430. min. Final fluid depth 3;t in. AbSorptiOn rate >=600+g.p,d.
Anyr reju~enati~ treatmer'~ (-pa~ 12 mo.)N_.(YIN &type) :ff yes,-give date ~
LIFT STATION
Date installed
"Pump on" level at
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off" leVel at
Cycles tested
in.
Manhole/Access (Y/N),
High water alarm level at in.
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer,main
Sewer/septic .service line
Animaii~n~ihment,~.~as ,, - '~.~' ,'
SEPARATIONDISTANCES FROM SEPTIC/HOLDING TANK ON' LOT TO:
Building foundation 5'+ Property line 5'+
Water main :tO'+ Water service line 10'+
Wells on adjacent lots 200'+
SEPARATI'oNDISTANCE FRoM ABSORPTION FIELD ON LOT TO!
PropertYline :tO'+ Building foundation 10'+
Water Service line 10'+ Surface water 100'+
Curtain drain 50'+ (None Known)
COMMENTS
On adjacent lots
On adjacent lots
PubliC sewer manhole/cleanout
Absorption field .~'+
Surface water 100'+
Water rnain 8~ (OK- S~ MOA ~;,:FS)
Driveway, parking/vehicle storage
Wells on adjacent lots 200'+
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 KENNF.~-[ M. DUFt~S
Date 11/02/2010
COSA Fee $490.00
Date of Payment
~Receipt Number
(Rev. 11/05)
Waiver Fee $ ....
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater prOgram
4700 Bragaw Street
P.O. Box 196650
Anchorage. AK 99519-6650
www. muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0;)0-501-31
1. GENERAL INFORMATION
Complete legal description
COSA#
Expiration Date:
ROLITHPARK #2: BLOCK ~: LOT B
Location (site address) 1 571 1 ~otrrHPARK LOOP: ANCHORAGF: AK 99S1 ~
Current Property owner(s) KRL~'rFN & TIM MARTINEAll
Day phone 34S-5759
Mailing address
15711 ~OtITHPARK LOOP: ANC. HOP, AGE: AK _q9~1 ~;
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class A Well
Public Water System
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 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 pdvate or Class C well
and may be reissued with new water sample results. (Certificates may be reissued for a pedod 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 cf the validation date shown below, I' vedfy 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 vedfy
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 ArcTerra Engineefin_a & Surveying: Inc.
Phone 696-6111
Address 2~3441 Ptarmigan Rival.: Eagle River: AK 9-q~;77
Engineer's Printed Name Kenneth M. Duffus
Date
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations.
The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from
the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during
the year and the water usage of the family being served by the system. The operational life of all well and
septic systems are subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
KND can not give any estimate of how long a
system will function safisfacto~ for current or future
occupants or can KND guarantee that no unseen ~'~,-~,;,'
encroachments, deficiencies or discrepancies exist. ~"~'~.~)TH ~' ~"~ ~.--.
~. '".~ ..... ".;
~ Approved for bedrooms.
Disapproved. '~,~.'~'~.~-'~
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Fiow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: i - / ')-,-o 7
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewafer 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: SOUTHPARK #2 BLOCK Z. LOT S
A. WELL DATA
We, type Ciasa 'A'
Date completed
Total depth
Parcel
If A, B, or C provide PWSID # 21~475 Well Log (Y/N)
Sanitary seal (Y/N) __ Wires properly protected (Y/N)
ff. Cased to lt. Casing height (above ground)
FROM WELL LOG AT INSPECTION
Date of test
Static water level It. It.
Well production g.p.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100mL Nilmte mg/L Other bacteria
Arsenic: mg/I Date of sample: Collected by:
B, SEPTIC/NOLDING TANK DATA
.in.
colonies/100 mL
Depression over field N
Results (Pass/Fail) pass
Water adaed 910 gal.
Elapsed Time: 1395 min. Final fluid depth ~.6 in. Absorption rate >= 600+
Any rejuvenation treatment (pest 12 mo.) (Y/N 8, type) N If yes, give date .....
For a~ bedrooms
New dean.
g.p.d.
Eft. absorption area 1080 ~ Monitoring tube Y
Date of adequacy test 8/8/06
Fluid depth in absorption field before test 30 in.
C. ABSORPTION FIELD DATA
Date instefled 6/21/84 Soil rating (g.p.d./~ or ~/bdrm) 268 System type
Length 60 'it.* * Width 3 It. Gravel below pipe .~_ft. Total depth 1 0 It.
Tank Type/Material_~,d~ Date installed ~ Tank size 1250 gal.
Number of Comper~nents 2 Cleanouts (Y/N)Y Foundation cleanout (Y/N) ~ Depression over tank (Y/N) N
High water alarm (Y/N) N Date of pumping 8/7/06 Pumper ~
D. UFT STATION
Date installed
'Pump on" level at in.
Datum
E. SEPARATION DISTANCES
Size in gallons
'Pump off level at
Cycles tested.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
in.
Manhole/Access (Y/N).
High water alarm level at in.
Meets alarm & circuit requirements?.
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~;'+ Property line ~ ' -I-
Water main 1 0' Water senace line 1 0 ' +
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'.1- Building foundation 10'+ Water main {}' *
Water Service line 1 0'+
Curtain drain
F. COMMENTS
*See MOA files
G. ENGINEER'S CERTIFICATION
Absorption field 5 ' +
Surface water 1 0 0' +
Surface water 100 ' ~- Driveway, parldnghmhicie storage 10 ' +
Wells on adjacem lots 200'+
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 KENNETH M. DUFFU~
Date 01/16/2007
COSA Fee $430.00
Date o, P.yment
Receipt Number 4:~)
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH'AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # . 020-052-82,
1, GENERAL INFORMATION
Complete legal description
Lot 8; Biock~2; South Park Subdivision
Location (site address or directions)
Property owner
· . M,~iling address
15711 South Park Loop
Anchoraget AK
Dennis Cook
Day pgone
15711 South Park Loop Anchorage, AK
345-5161
Lending 'agency
Mai!in.g address.
Day phone
Agent
Address
Clair Ramsey/ Dynamic Properties
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4'~
NOTE:
Individual well
Community well XX
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
XX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 was~ewater 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 ' f __Phone
Address
Engineer's signature
Alaska Water
Wastewater Consulta nts,
Shall be PAID
or prior to, closing for the
Engine~rinsI ,3¢rvi¢cs Prov~
DHHS SIGNATURE
I.-'"" A.p.proved for F'0/-,/~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
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 requlroments. 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.
RECEIYE0 _
Municipality o! Anchorage ' ~U! 1999 ~
DEPARTMENT OF HEALTH & HUMAN SERVICES "0 8
Environmental Services Division ~*JN~PAU~ O~
825 L Street, Room 502 · Anchorage, Alaska 99501 o~[/~/~y~:r~s orvl3ic~
Legal Description: '~"~[ L"~'~'~
A, WELL DATA
Health Authority Approval Checkllet
Well typeCr~,Y~,,~ Ca ~/"/-~// If A. B. or C. attach ADEC letter. ADEC water system number ~.~ I _~ L~ 7_~
~.~/N) Date completed
Total depth -~ Cased to Casing height (above
Sanitary seal (Y/N) ~~Wires properly p~/N)
Date of testFROM ~.~
Static water level
Well production J
WATER SA~
..: Nitrate
Date of sample:
g.p.m. ~ g.p.m.
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~ Tank $'.tze ! ~ Number Of Compartments ~ Cleano~ts (Y/N)._(..~t~./~,.
Foundation cteanout (y/N) ~ Dapressiort~(Y.-~N) J~...? High water alarm (y/N) ~
Date of Pumping ~/L~") /~_ Pumper /~'/"
C. ABSORPTION FIELD DATA
Effective absorption area J(:::)od{~ Mo~itering Tube present (y/N)~ Depression ever field (y/N) ~
Date of adequacy test (,p/~/c:~c~ Results(Pass/Fail) r4"Y~<;_4::; For ZT/ bedrooms
Fluid depth in abeoq~tion field before test (in.); I (~ '/ Immediately after t ~gal. water added (in.): 4.~, ~/~
Peroxide treatnmm (past 12 monttm) (Y/N) Z:]~::L~~If yes, give date --
72-026 (Rev. 3/96)*
/~'"~m~e_vel at' 'Pump of~ level et'
Manhole/Access
(~/N)
High water al~- ~'Datum -~ ~
E. SEPARATION DISTANCES
~ WELL ON LOT TO
SEPARATION-DISTANCES FROM :
Septic/holding ten~ ~
Absorption field on lot
Public sewer main Public s~'e~hOle/cleanOut
ce line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Absorption field
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
P.~p~.y,ne /~' ~ Bu,d~ng ~nda, o. /~ '+ Water.~.~se~v~
s,,~e=, wate, / 4:)O ' 'f- D~.~y, pa.~nC.,h~=e
Curteindrain //'~J,3~, ~::~')~__,}/~r'} Wells on adJacentlote
Waiver Fee $
Date of Payment
Receipt Number
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2B ~ Anchorage ~ Alaska 99504
Phone (907) 337-6179 ~ Fax (907) 338-3246
Consulting Engineers
July 20, 1999
Municipality of Anchorage
Department ofHealth & Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Attn: JeffPoet
Reft Lot 8; Block 2; South Park Subdivision 02
Water line location
o ~o,,, ~t/~ ~01.
c ~$
Dear Mr. Poet,
Per your request, the water service line has been located on the referenced property (see attached
photos). The separation distance between the center of the trench cleanout and the locate is 9.5
feet. Given the fact that the trench is 3 feet wide, the water line is only about 8 feet from the
sidewalls of the trench.
If you have any quT/~ons, please call me a 337-6179. Thank you for your assistance.
.MUNICIPALITYOFANCHORAGE. -
· DEPARTMENT OF HEALTH &'HUMAN SERVICES
" Divisl0n of EnVironmer~tal Services '
.... ' On-SiteSe~icesSection '
:. - . ~ ,. P,O. Box196650 Anchorage, Alaska:99519-6650 "~ "343~744 ' '
CERTIFICATE OF HEALTH AUTHORITY
' :~ ~ ' '- ~ " '~p~nr~VALFOR
A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION' .
complete legal description LO~
· ' Locati'on (site address or directions) ~ 5 '~ t t .~o o~-,~. '-:'*'~,--V, ~-~p
Mailing add'ress - ~ ~ {;, J
Lending agency
Mailing address
Y-~-~%~'--~ ~" ~- Day phono
Day phone
Agent ' Day phone
Address
e
Unless otherwise requested, HAA will be held for pic~up.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
4. TYPE OFWASTEWATER DISPOSAL:
RECEIVED
1 19 7
Municipality of Anchorage
· Dept. Health & Huma~ Sen/Ices
Community well
NOTE: If community well system, provide Written confirmation from State ADEC attest-
: lng to th~l~Jitya ~d~tat s ofsystem'· "i'i,:, ............ · -.
Holding tank
Community -site ~ ~" -,
NOTE:· 'If community wastewat~r System, *p~ovide ~[tten C6nfir~atidn* from st~t~ ADEC
attesting to the legality ~nd s}~tus*of*S~St~. '
5.STATEMENT, OF. · INSPECTION BY ENGINEER
AS certified by ~Y seal ~ffi'xe;t heret~ and as of the validation date shown below, I verify that my
in, vestigation of this Health Authority Approval appli~:ati0n shows that the on-site water supply
' and/or w,a, .stewater 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 Mun_icipality of Anchorage ~es and from my investigation and inspection, the on-site water
' sU, p, pi}; a~ld/o'r wastewater disposal system is in compliance with all Municipal and State codes,
~ ~ brdinances and regulations in effect on the date of this inspection.
. Narne~fFirm ~"c>l~--~ S~o~-~.~:~.~c~. '-~.'~ · Phone ~-~c~_ ~qlL~
Address. ~o_~
Engineer's signature
6. - DHHS SIGNATURE ....
~" Approved .for
bedrooms.
Disapproved,
Conditional approval for
bedrooms, with the following stipulations:
· '- Additioh~il Corhmen{~ '
By:'~.'~ ' . Date ~'-
:~'l'he M~ni~ality of ~,n'"~h~rage Department of Health'and Human Services (DHH~) issues Heaith Authority
Approva Cert f cates based on y upon the representabons given n paragraph 5 above by an ndependent
professional engin, .~er ~egistered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
a~d't~eir lendi~ institutions in order to satisty ~ertain 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 professior~al engineer's ~vork.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
Legal Description:
A. WELL DATA
Health Authority Approval Checklist
~V.. ~. iCooo'T~ YA~'g.~Z- Parcel I.D.:
Dale of test
S~tic water level
Well production
WATER SAMPLE RESULTS:
Coliform
Dat~ of sample:
IfA. B. or C. altech ADEC letter. ADEC water system number
Dale completed
Casnd lo
FROM WELL LOG
C~sing beighl (abovc ground)
Wircs properly prolectcd (Y/N)
AT INSPECTION
g.p.m. . g.p.m
O~ber beeteria
Collected b~:
Number of Compa~me,qs __
SEI~IC/IlOLDING TANK DATA
F~on cl~ (Y~) ~ ~r~ion ~
A~OR~ON ~'~D DATA
~ ~O Widm
E~ive ~n ~ tO~o
High water alarm (Y/N)
Soil raing (g:p~ or ft'-/bdrm)~-~' ~ System ~pc. '-i'VE N
Gravel thickness below pipe q Toaddcpth tO¢
Monitoring Tube present(Y/N) "/ Depression over fie. id (Y/N)
Results (Pass/Fail) ~ For ~ bedrooms
lmmod!ntely after &OOgal. wamr ~da~ (in.):
Absoq~tion tale ~ ~ ~,~-0 gpd.
If yes, give
Fe
LIFY STATION
Dale inslalled
Manhole/Access (Y/N)
Size in gallons
"Pump on" level al*
"Pump off" lin'el at*
High waler alarm Icvel al* *Datum
Cycle~ tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
S~pfie/holding ta~k on
; On adjacent lots
RECEIVED
MAY 2. 1 1997
Muni~ipalily o[ Aft~horago
Health & Human 8ervt~
Abaorplion field on Iol
; On adjacent lois
Public sewer main
Public se~r maahole/cleaaoal
Sewer/septic service line
Lift station
I
D~ 4/~.~ ~1,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation /~ I l~ny line ~. j'~ / Absorption field L~ t
w~ m~se.~i~ ~i~ >, 0 s~,~,,~/~ N/~ w.~ o. ad.a, lots r//~
SEPARATION DISTANCI~ FROM ABSORFFION FIELD ON LOTTO:
Buildins foundation t/o / Walm' mnin/s~xiee line
Surface walar ~ / o Driveway, parking/vehicle storage area ~ I O /
Cmlain drain l'"~/O Wells on adjacent lots t~//~ Property li,~c
ENGINEER'S CERTIFICATION ...... ~, - · "-.
/ certify that I have determined thtnt field inspection~ and review of Municipal records:
in conformance with MOA HAA guidelines in effect on this date.
HAA Fee $ ,~ .- ~
Date of Payment
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
R~:eipl Nnmher
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # C'~..'~C',_ C3~.~ - .~,.-~,~ HAA # t,.~ ~"A"~ .Q,-?~ ~"~
1. GENERAL INFORMATION
Complete legal description Lot 8; Block 2; South Park Subdivision, ~2
Location (site address or directions) 15711 South Park Loop
Property owner
Mailing address
Lending agency
Mailing address.
'Bill Kramer Day phone 349-7272
8361Peterebur~ Street , Anchoraqet Alaska 99507
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
x
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 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
Engineer's signature
ENGINEERING
DHHS SIGNATURE
./~_ Approved for ~
Disapproved,
Conditional approval for
17034 Eagle R ver Loop Road Ne. 204
~n~l. ;1vAr: Alas~a 99577
Phone
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a 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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ ~ ~:;'~¥-- '?-- ~o.'~,~...~-~,;> ~LZ- Parcel I.D. /2~)
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter, ADEC water system number '~'l~'J ~"
Log present(Y/N)
Date completed Driller
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well fl°.w .
Pump ~evel/--''''~ ~ . .
S PAEX~RATION DISTANCES I~R~M WELL TO:
Cased to __Casing height
Wires properl? p~otected (Y/N)~
FRO,,, WELL LOG ,ON
Septic/holding tank on lot ~.oO ~ 4-
Absorption field on lot
Public sewer main
Sewer service line
g,p.m,
; On adjacent lots
; on adjacent lots
· Pub~
· ..~"~etroleum tank
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts ~Y~N)
High water alarm (Y~
Date of pumping
Tank Size ~ '/..~'o Compartments
Foundation cleanout(~/N) ¥ Depression ~'/N)
Alarm tested (Y/N)
Io-. .~o- ? ?_. Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~*oo *~'
To property line /o ~ +'
Surface water/drainage
On adjacent lots
Absorption field
/o ~ "'""
Foundation
,5- ''* - Watermain/service line
72-026 (Rev. 7/91) From · CONTINUED ON BACK PAGE
C. LIFT STATION
r~
Date installed ' Manufacturer
Size In gallons ' . Manhole/Access (Y/N) ~..-----~'*
Vent (Y/N) L ~ ."Pump on" level at ' ' '-' ~._' ~ a-t
High water alarm level f .-~'""~Cycles tested ~.
Meets MQA electrica~~ ; ,
.S. ~~ANCE FROM,LIFT STATION TO: '
We'll on lot - On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date i;lstalled -7- ~
Length ~'ot: ' Width
Total*absorption'area
Depression over field (Y.~)
R e s ult s ~F'a3'~fa il) ;' ¢~S,~ for
Peroxide treatment (past12 months) (y~:~) ,~o~J~. ~/Jo~//,J -. Ifyes, givedate
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ",
Well on lot ~o o, +' On adjacent lots Property line
To building foundation ~.'Z.. ' To existing or abandoned system on lot
On adjacent lots ~ ~e- , .
Cutbank ~,o Water mare/service line
o p/a
Surface
water
Drive rkjng/vehicle S, torage area
Curtain drain ' /'J/'~* ~:¢ ~ '~* "/'~
Cleanouts present~/N) ~/
Date of adequacy test /~ - Z. ~ - ~.
bedrooms
E. ENGINEER'S CERTIFICATION
~ 17034 Eagle Rlver Loop Road No. 2~ ' ~'~..- ~.
H~ Fee $ I ~ ~. ~ Waiver Fee: $
Date of Payment I( /Z/~ , Date of Payment
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
~ - I~.~k -~.'~ HAA if k\ C'~c~ ¢~ \L\
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lo~ ~; St. oc~ ~; Sou.,t. hpcuth. No. ~
Location (address or directions)
15711 Sou~hpa~k Loop
(b) Property owner
Mailing Address
Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address ?i~fl!
Telephone
100
(e) Mail the HAA to the following address: (or check here,~, if hold for pick up.)
List contact person and day phon6 number below:
$ & $ ENGINEERING
17034 Eaa. le R;ver Lo~? Road N~ 9n4
E~gle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family,~ Number of bedrooms 4TM
3. WATER SUPPLY
Individual Well rn Community ~( Public i-I
Note: If community well system, must have written confirmation from. the State Department of Environmental
Conservation 'attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site~ Public rn Community rn Holding Tank rn
Note: If Community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
AS certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
17034 Eagle Rtver Loop Road J~o. ~(:~4
Telephone
6. DHHS APPROVAL
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
'v'~CHECKL~"~,I~I~Y 1984
FE~ 2 ]9~gegalDescription: ~ 8: ~1o~ 2~ '
A. WELL DATA
Well Classification ~__./f~ 5 ~.
Well Log Present (Y/N) /J/R
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ~ 02
To Nearest Edge of Absorption Field on'Lot
To Nearest Public Sewer Line
RECEIVED
Date Completed
Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
/3'- ; On Adjoining Lots
p, oo 'f' ; On Adjoining Lots'
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments -~,~
; Date
B. SEPTIC/HOLDING ,'l',~c~ .K
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ,.~ O0 /'f-
DATA
Size ~ No. of Compartments ~--
Air-tight Caps (Y/N) t./ Foundation Cleanout (Y/N)
Date Last Pumped [/ ~
;for
Tempora~ Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
T.o Property Line: ! 0 /"
To Water Main~Service Line
To Stream, Pond, Lake ~)r Major Drainage Course
1/2-0~ (Rev. 1/S8) Fr~,~ Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~/~;~/~
Width of Field ~..5"' ~
Square Feet of Absortion Area
DePression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field I
Gravel Bed Thickness
Statndpipes Presentd~/N)
Date of Last Adequacy Test
iv...
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Property Line ! ~' t-
To Existing or Abandoned System on
; On Adjoining Lots _~O ' 3'-
To Cutback (if present) ~ '
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, c~r Vehicle Sto?ge Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons ',
"Pump On" Level at
High Water Alarm Level at N
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions.
Manhole/Access (WN)
"Pump off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
*'Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on
inspection.
Signed
Company
Date
MOA No.
S & S ENGINEERING
17034 Eagle River Loop I(oad No. 204
I-'...lnRlver. Alaska 99577 ~-~ t/~ ~'~'
t~ d,a. te of this
Receipt No.
Date of Payment
Amount: $
1'-7 o.
'~ Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
~ineer~l
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
I ~-'~ I I
(b) Property Owner~,,
Mailing Address
(c) Lending Institution
Mailing Address
(d)
(e)
~,.~; (1'~.,~' Telephone: Home ~W~'- I~,~G Business
Telephone
Real Estate Company and Agent "~'.~ LI~ u~ ~. ( T ~ . '~. L~.~?~;~ ,~
Address ~ ~ I ~ ~~
Telephone ~ ~ ' ~
Mail the HAA to the followina address: or: Check here~ if hold for pick up.
List contact pemon and day phone number below.
TYPE OF RESIDENCE
Singlo-Family~
Number of Bedrooms
WATER SUPPLY
Individual Well[] Community~ Public
Note: If community well system must have written confirmation from the State Department of Enviro.,nmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite.~ Public[] Community[] Holding Tank []
Note: I~community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-o2s tRe~ 6/861
I~UO!1!puoo
le^o~dd¥ leUO!ppuoo lo SLUJal
pa^o~ddes!C] '~/ pa^ruddy
Xq scuoo~paq ~ ~o! pa^ruddy
*IYAOUdd¥ SHHO
'9
MUNICIPALITY OF ANCHORAGE (MOA)
,MUN~CIPA/tTy OF ANOfo~A~L?H AUTHORITY APPROVAL (HAA)
ENYtI~ON~ENTAL SER¥1CE$ D ~, ~.~CHECKLIST - FEBRUARY 1984
','~ION 264-4720
APR 6 ]987 Legal Description: J_O'~'
WELL.ATA RECEIVED
Well Classification ~.. L/~.~.~
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot .~
To Nearest Edge of Absorption Field on Eot ~'
If A, B, C, D.E-C. Approved (Y/N)
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
To Nearest Public sewer
To Nearest sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed °//~ ~'/
Standpipes (Y/N)
Depression over Tank (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 '~ / O
Course
Size /~-BO NO. of Compartments 7'
Air-tight Caps (Y/N) Y Foundation Clean0ut {Y/N)
~ Date Last Pumped ~r~/~/~' 7
- :for
Tempora~ Holding Tank Permit (Y/N}
*To Building Foundation ~
To Disposal Field ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-0260 1,84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed "7/9 ~/
Width of Field ,~.
Square Feet of Absorption Area
Depression over Field (Y/N) I'~
Resutts of Last Adequacy Test
Separation Distance from Absorption Fietd;
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
I O S ID ~ Standpipes Present (Y/N)
Date of Last Adequacy Test
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
To Property Line ~ ,r O
To Existing or Abandoned System on
; On Adjoining Lots ~. ~ ~53
To Cutbank (if present) ..o~) ~
r,/orV/.E
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
*' Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified..or conformed to all MOA and
Signed /"--~"~ ~ ~' ~-~'/~;'~/ Date
/
Company MOA No.
ReceiptNo. /~O/ ~O ~ ~
Date of Payment ~/$/; ~
Amount: $ LO a ~
Page 2 of 2
HAA guidelines in effect on the date of this inspection,
Engineer's Seal
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
GENERAL INFORMATION
(a)
Application
(b)
(c)
Date
Legal~ Description ~;~ (include~.~_ lot. block.....~,., subdivision. ~'-~-- section..~.~ -!1~? township, range)^ J~
Location (address or directions)
Applicant Name~--~-- ~Te,ephone: Home ~~s
Applicant Address ~ ~* ~ t ~ -- [ ~-~- ~~
Applicant is (check one): Lending Institution ~; Owner/build,Buyer ~; Other
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ulti-Family r'l Other
Number of Be(drooms --.~
WATER SUPPLY
Individual Well I-~ Community,S)Public D
Note: If community well system, must have written confirmation from the State Deparlment of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~ Publicr9 Communityr-I Holding Tank r-I
Note.(" ---If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legali'ty and status.
Page 1 of 2 7=.~,5 {, ~4}
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of lhe 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 Ihe 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 ~-.~ TE:L..~'~I',~."~E ~ C~' ~-~,'-,ri' Telephone ~'~,'-,'~ -- ~ ~ ~.
Address ~ ~ , ~~ ~ '~~; ~ ~ ~ ~]G
Date ~~ ~
Engineer's Seal
DHEP APPROVAL . , ..
APproved for, Pr~, ,c ! c~,) 'bedrooms by
Approved ~ "'~' Disapproved
Terms of ~ndit dna Approval
Conditional
CAU~ON
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based ~olely upon the representations given in paragraph $ 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 tn 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
HUNICIPALITY OF ANCEORA~
DIVISION OF Et~IKO~AL ~TE
DEP~ OF ~T~ ~ E~IKO~ PKOTECTION
APPLIC&TION ~0K ~LTE ~HOKI~Y ~PKOV~ CEKTIFICATE
1. General Info~a~ion Applica~ion Da~e ~
(a) Legal Desc~p=ion (include 1~, block, subdivision, section, to.ship, ra~e)
Location (address or directions)
Applicants adress ~. '--~, ~_~. I ~- I 5'4 ~~
(c) Applicant is (check one) Lending Ins~lCution { ~ ; ~er/builder~;
Buyer ~ ; Other ~ (explain);
(d) Lending Instil, ': Telephone
Address
(e) Real Estate Co. & Agent
(f)
Address
Mail the HAA ~o the following address: .,~ .~
2. Type of Residence,
Stngle-Family~
Number of Bedrooms
Multi-Family ~--~
Other (describe)
3. Water Supply
Individual Well ~-~ CommuniCy~ Public ~-~
Note: If community wall system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Se__wage Disposal.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
®
En~ineerin~ Firm Providin~ Inspections~ Tests~ File Seareh~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval'shows that the on-site
water supply and/or was~ewater disposal system is safe, function~ and ~equate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtain~ from'the Municipality of Anchorag~"files and from my
investigation'and inspection, the on-site water supply and/or wast,water disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm ~'] ~--~:~'i~ I~C- Telephone ~-7,~--?~;f
~. ;.....f/.l
DHEP Approval ~ ·
. , · c- .s0,6
Approved ~_ Disapproved.
Date '5//~'t'-
Terms of Conditional Approval
CAIfflON
THE MUNICIPALITY OF A~NCHORAGE DEPARTMENT OF HEALTH AND ENVIRO~fl~NTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IM PARAGRAPtl 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER KEGISTERED
IN THE STATE OF ALASKA. THE DHEP DOSS THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
M/ENTS. I~.IPLOYEES OF DHEP DO NOT CONDUCT INSPECTION~ 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.
(DHEP SEAL)
RE~/ej/D~'8
[~ase 2 of 2]
7-19-84
MUNICIPALITY OF A%~HO~GE (MOa)
HEkLTH AUTHORITY APPROVAL (HAA)
C~ECKLIST - FEBRUARY 1984
?AL , C? .... MO:.,~.
~rpT. O? Hi:L?.; ~,
.,D ........ ~.
RECEIVED
ae
Well Classification
Well Log P~esent (Y/N)
Total Depth
Static Water level
Casing Hsight Abo~ Ground
Elect.~ical Wiring in Cold, it (Y/N)
Separation Distancss f~cm Wall:
To Septic/Holding Ta~k on Lot
To Nsa~est Edge of Absc~ption Field on
To Nearest Public Se~r Line
C leanout/Manhole
Water Sample Collected By
Water Sample Test.B~sults
C~,,~nts
If A, B, cr C, D.E.C. A~p~oved(Y/N)
Date C~,91e ted
Depth of
Set At
Seal on Casing (Y/N)
A~ound Wellhead (Y/N)
To Nearest
; On Adjoining Lots
~ On Adjoining Lots
To Nearest Public Sewer
Service Line on Lot
B. SEPTIC/HOLDING ~ DATA
Date Installed .'~-~t.~ IF~,? Size I?--,~'.,~-~ No. ~ ~nts ~
S~i~s ..(Y~) ~ Ai~-ti~t ~ (Y~) ~ F~n~ti~ C~an~t (Y~)~
~essi~ ~ Ta~ (Y~) ~O ~te ~st ~d ~ /~
Holdi~ Ta~ Hi~-~te~ ~a~ (Y~) h% [ ~ ~a~ ~ldz~ Ta~ ~t (Y~)
~ati~ Dista~s ~ ~ptic~ldi~ Ta~:
To ~te~ly ~11 ~,~ ~, TO ~ildi~ F~n~ti~ ~ F
To ~ty Li~ ~ /~' To Dis~al Field ~ /
To ~ter ~i~vi~ Li~ ~To S~, ~, ~e, ~ ~j~
C. ABSORPTION FIELD DATA
Soils Ratin~ in Abscrp=ic~. Strata
Date Irstalled .~ ~,v % ~ gq--
Width of Field ~go"
Squa=e F~et of Abscrptice. Area
Depressic~. over Field (Y/N)~..~po Date of [mst Adequacy Test
Results of Last Adequacy ~st
Separation Distanc~ fr~cm Absorption Field:
To Wat~=-$upply Wall ~_~-Cb-~- To Property Line
To Building Fcundation ~_~ ~ To Existing or Abandcmed System cn
Lot ~.~ [~ ; On Adjoining. Lots
To Water Main/Service Line ~M~-~X~.~'~W6To Cutback(if Frese~.t)
To St-'e~/Po~d/Lake/or Majo~ DraiP~je Ccu~se
To D=i~way, Pa~king Area, cr Vehicle Storage Area
D. LIFT STATION
Date In~tallea ~
Size in Gallo~ /-' Ms~cle/A/~ess (Y/N) .
"l%mp On' Da~l at / "Pump Of/f" Level at / /" '
High Water Alarm Lavel ~t / / Vent (Y/N)
** Check Permitted ~edrccm Rating Against HAA l~quest
I certify that I have d%ecked, verified, or confc~,=d tn all MOA FAA Guidelines in effect
Signed -- ~_ Date _
Ccmpany --~ ~c~ MOA NO.
KB1/dS/s
[Page 2 of 2]
2-15-84