HomeMy WebLinkAboutALYESKA #3 BLK 21 LT 13Alyeskct #3
Block 21
Lot 13
#076 - 022 - 26
JUL-17-201.3 12: 57F:_ FRrOrl:
WELL LOG
10:34'37997 P.1'1
Date Drilled: W:g4 Jack White co. WO +0 A ysfo„s
Alreska, Ak.
Static Water level 23 feet Gallons Per Minute 41/2�_____
Draw Down n/A feet Total Feet of Casing
Type
Arial Drilled:
0 feet to Deepened
to Bedrock
65 fs to Ft
to __65 ft we..11 _producing '_ to 7 _c .i o, .
to 225 ft. Producing 2 to 24 g.p.m.
to 285 ft, well prcdec:Lng 41 to 5 g.p.m.
tD
to
cC
tc
HEFTY DRILLING
3540 AKULA DAVE
ANCHORAGE, AK 99515
(007) 345-0503
Well Owner
M -VV DRILLING, Inc.
P. U. Box 4-1224 • 1310C International Airport Road
(907) 274-4611
ANCHORAGE, ALASKA 99509
Yvan Safar
DRILLING LOG
Use of Well Dom.
Location (address of: Township, Range, Section, if known; or distance main road
Lot 13 Blk 21 Alyeska Subd. ##3, Girdwood
Size of casing 6" Depth of Hole 60 feet Cased to 38. 4 feet
Static water level ft (ablt c (below) land surface. Finish of well (check one) open end ( );
Screen ( ) ; Perforated ( ),
Describe screen or perforation _IVA
Well pumping test at 1/2 gallons per (holm) (minute) for_,i --a_h ours with
of drawdown from static level.
Date of completion 8/13/79
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 TO 2
2 TO 8
8 TO 35
35 TO 60
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
Casing stickup
Organics
Silty gravel
Bedroc
throughout
•. •
fractures
//•""" `77
I':\v\'v/1 Certified Contractor
S11 & `r3
1 —CUSTOMER
•
• �-
'IV/4 I C I F it_ I tV OF !Fir -act -AL 2fIE
• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 'L' STREET, ANCHORAGE, AK. 99501
264-4720
WELL F'ERr'1 I T
PERMIT Na C 790446 )
APPLICANT YVAN SAFAR
LOCATION HIGHER TERRACE
LEGAL L13 B21 ALYESKA SAD #3
PO BOX 462 783 2876
LOT SIZE 10000 SQUARE FEET
MINIPIUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL; OP
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE I1ELL COPIPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F" 11 I T EXP I RES f>ECEMBER 3 L.. '..5 '"S+
I CERTIFY THAT
1: I API FAMILIAR WITH THE REQUIREPIEFITS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I 11ILL INSTALL THE,/ SYS M N ACCORDANCE WITH THE CODES.
SIGNED:
APPLICAFI
ISSUED BY_
AFAR
DATE
p-Aftit ttALd MAA:tj atili reeyirtAn a.itaz*
_)-€04-- Ida- IAA dull Crvt Are-
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t 7- 7}
FROM: DEPARTMENT:
INITIATED BY:
INTER -OFFICE MEMORANDUM
GREATER ANCHORAGE AREA BOROUG
TO: DEPARTMENT: ' ",4¢'/"ifi'G
RECEIVER:
FOR INFORMATION ONLY
FOR IMMEDIATE ACTION
FOR YOUR CONSIDERATION
OTHER
REQUESTED ACTION SCHEDULE
,,macc
•� .car ff'
SUBJECT:...,
,9 L ,2-7`yd .-' -" .e►
DATE OF MEMO:
DATE ANSWER
REQUESTED:
PREPARE BACK-UP INFORMATION
CALL ME BEFORE YOU ANSWER
NEED YOUR RECOMMENDATION
5
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SIGNATURE
SIGNATURE
Municipality of Anchorage }
a rte' On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I. D. 076-022-26
1. GENERAL INFORMATION:
Expiration Date: 'S - 7 -2-OV
Complete legal description ALYESKA #3: BLOCK 21. LOT 13
Location (site address) 315 HIGHER, TERRACE'GIRDVVOOD
Current Property owner(s) Jeremy J Anderson Day phone 907-529-8677
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
i Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
1
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
❑
Individual Water Storage
❑
Holding Tank
❑
Community Class_Well
❑
Community
❑
Public Water System
❑
Public Sewer
Waiver/Variance request for: Distance:
Received by: Date:
COSA to be released to the engineer. unless otherwise requested by the engineer.
COSA Fee $ 210 COV 10
Date of Payment 2--q -20
Receipt Number n X01 7 0 67
COSH :� OS CZn 166 (�
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: 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: i ?— L ; I Zu-
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
encroachrrents 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
system/s; 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 ((((((((((
\```��\QPL\�Y
OF
�%C884
`g ON-SITE
WATER AND m
52 WASTL-v !ATE:R z
o Jc�jstip��li��
i.
DSD SIGNATURE
�- System #'I Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the foll
1 �
By: ( cM i Original Certificate Date: 12- - 7- Z- b ao
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_ Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA
Checklist
Legal Description: ALYESKA #3; BLOCK 21, LOT 13 Parcel ID: 076-022-26
If more than 1 septic system on lot: COSA Checklist #
of Structure served by this system
A. WELL DATA
A Well log is filed with Onsite (or attached)
Well, production at time of test 8.9+ gpm
Date drilled '811317
Water storage tank volume N/A gallons
Total depth x285 ft
Well disinfected for coliform test? ❑ Yes FM -1 No
Cased to 38.4 ft
a Coliform bacteria is Negative
Sanitary seal is functioning correctly
Nitrate mg/LNitrate less than MRL (ND)
❑Q Wires are properly protected
Arsenic ug/L Arsenic Less than MRL (ND)
Casing height (above ground) 12+ in.
Collected by GEG LTD.
Date of flow test for COSA ' P20120
Date of Sample 1120120
Static water level at beginning of test 13.3 ft:
Comments *WELL DEEPENED ON 6/14/94 PER 7/18/94 HAA
B. TANK DATA
C. LIFT STATION
Age of tank(s) years
Required main, tenatc-8 eted
Tank type/material
ge-af-1` station years
Measured operating fluid level in septic ta��11c----"'`
_moi
Lift station material
❑ Standpipes/fou eano�ecord drawing
Comments:
c of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
Adequacy test date
❑ ALL standpipes present per record drawing
Results ❑Pass For bedrooms
Total measured depth from grade- ft (max)
Fluid depth prior to test
Measured depth to pipe invert from grade ft (min)
Water added
❑ N/A - pressurized field
w de in
❑ Monitor tubes go to bottom of effective. If not, state
Zapsed
depth into effective
time min
❑ Code -required soil cover over field
Final fluid depth in
❑System presoaked
�daysrior
Absorption rate gpd
(Required if vacant for gre an 30 to
Any rejuvenation treatment (past 12 months)
date of test)
Gallons' oduced gallons
If yes, enter date
Ccu*�ents/Deficiencies: AwWu SEWER
COSA Checklist yellow street
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
p
N/A
if ft
Community Sewer Manhole/Cleanout > 100' X50'+
❑ Yes if No
;
ft
if No ft
❑ Yes
if No
it
Water Ser ' Line > 10'
❑ Yes
if No ft
Neighboring Tank > 100'
❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No
fit
Absorption Field on Lot > 100'
❑ Yes
if No N/A
ft
Holding Tank > 100' Yes
if No
ft'
Neighboring Absorption Fields
> 100'
Animal Containment> 50' [/Yes
if No
ft
❑✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75'
F-1 Yes Yes
if No
ft
fYes
if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100' ❑ Yes
if No .
ft
Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes
if No
ft
Water Main > '10'
❑ Yes
if No
ft
Community s > 200' ❑ Yes
if No
it
Water Service Line > 10'
❑Yes
if No
ft
If septi tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distai
Building Foundation > 10'
❑ Yes
if ft
Property Line > 10'
es
if No ft
Water Main > 10'
❑ Yes
if No ft
Water Ser ' Line > 10'
❑ Yes
if No ft
rface Water>'100'
❑ Yes
if No ft
less than required)
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100' ❑ Yes if No ft
Community Wells > 200' ❑ Yes if No ft
F. ENGINEER'S COMMENTS'
*MET CODE AT TIME OF SEWER INSTALL
**NO REQUIRED SEPERATION DISTANCE AT TIME OF INSTALL
G. ENGINEER'S CERTIFICATION
I certify that l 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,
COSA Checklist yellow sheet
? Q�ill-Li co, 7 .
Jeff(�`7�
(ice E f 9 s `
X1``1,.° •��,��/��`� _.•
-AECC884
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 076-022-26
Expiration Date: / 0 -2).- / 3
1. GENERAL INFORMATION
Complete legal description Alyeska #3, Block 21, Lot 13
Location (site address) 315 Higher Terrace Girdwood, AK 99587
Current Property owner(s) Brian McGorry & Olivia Stone Day phone
Mailing address
315 Higher Terrace Girdwood, AK 99587
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
One
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well E Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Piihlic Sewer n
WaiverNariance request for: Distance:
// II,,�
Received by: �--`T•:n
COSA to be releas d to th'engineer, unless otherwise requested by the engineer.
)3 Date: <' / j,
COSA Fee $ Li 1.0 Waiver Fee $
Date of Payment 1 1 it if 3 Date of Payment
Receipt Number Q0(4 CVa- OA Receipt Number
COSA# D6G430\C\ Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Phone 522-7773
Engineer's Printed Name Michael E. Anderson, P.E. Date 7/10/2013
6. DSD SIGNATURE
_�� System #1 Approved for + bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
By:
iff stir* • 491H ,, '°
vo 4
• MICFfyr�{+3NDERSOPo : is:
8
314A•� Jf•, CE -4381 »:
•�x/0.7 i( f3 ,• .r W
t'S4PRi7rEssi00,6*
bedrooms, with the following stipulate&rTaina+
O
ON -Su E AA_
WA
Irl w&STEWATEo^
pROGRATERANS RM ))�\
)4))))))1ill1s�Sir S �'
Original Certificate Date:
7-2 2-/3
Thd-? un patty 6f 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 X Nitrate Advisory,
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet c
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: Alyeska #3, Block 21, Lot 13 Parcel ID: 076-022-47
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (YIN) Y
Date completed 6/19/94 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y
Total depth 285* ft. Cased to 38.4 ft. Casing height (above ground) >12 in.
FROM WELL LOG AT INSPECTION
Date of test 6/19/94 6/26/13
Static water level 20 ft. 37.2 ft.
Well production 4.5 g.p.m. 6.2 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate N/D mg/L
Arsenic N/D ug/L Date of sample: 6/26/13 Collected by: Anderson Eng.
B. SEPTIC/HOLDING TANK DATA AWWU Sewer
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression over tank (YIN) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA AWWU Sewer
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before 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.) (Y/N & type) If yes, give date
D. LIFT STATION AWWU Sewer
Date installed Size in gallons
"Pump on" level at in. "Pump off' level at
Datum Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots
Absorption field on lot N/A On adjacent lots N/A
Public sewer main >50'** Public sewer manhole/cleanout
Sewer /septic service line >25 Holding tank N/A
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
N/A
>50'**
None
Building foundation Property line Absorption field
Water main Water service line
Wells on adjacent lots
ABSORPTION FIELD ON LOTTO: AWWU Sewer
Property line Building foundation
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
Surface water
Water main
F. COMMENTS
*Well Deepened to 285' by Hefty Drilling on 6/14/94. Well Meets Separation
Distance Requirements in Place at Time of Original Placement.
Lot Served by AWWU Sewer.
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 Michael E. Anderson, P.E.
Date 7/10/2013
COSA brown sheet 10-10-12.doc
� ii:AEE.
MICHAEL E. ANDERSON : W
♦ �•. CE -4381 :t'r
♦0+1b; orESe4 `sls
Municipality of Anchorage
Development Services Department
Building Safety Division •
Onsite 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. 076-022-26
1. GENERAL INFORMATION
Complete legal description Alyeska #3 Blk 21 Lot 13
COSA# r)S l)Gn3
Expiration Date: it — — 0 45,
Location (site address) 315 Higher Terrace, Girdwood, Alaska
Current Property owner(s) Jason R and Karena L Stockinger
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Sam Daniell Glacier City Realty Day phone 783-1910
Mailing Address
PO Box 1048, Girdwood, AK 99587
Day phone
PO Box 550 Girdwood, Alaska 99587
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
✓❑ Individual On-site 0
❑ Individual Holding Tank 0
❑ Community On-site 0
❑ Public Sewer r❑
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 Finn Watkins Engineering, Inc.
Address
P.O. Box 110443, Anchorage, AK 99511
Engineer's Printed Name Cindy W. Ellis
6. DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone 349-1851
Date I— s-08
bedrooms, with the following stipu
• ON-SITE
WAfERAND m:
WASTEWATER
PROGRAM•
4••
�''1nn)1„,•.
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(R.v.11105)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
1— 9 —08
'Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVALCHECKLIST
Legal Description: Alyeska #3 Block 21 Lot 13 Parcel ID: 076-022-26
A. WELL DMA
Well type Private
Date completed 8-13-79'
Total depth 285 ft.
Date of test
KA, B, or C provide PWSID #
Sanitary seal (Y/N) es
Cased to 38.4 ft
FROM WELL LOG
6-14-94
bedrock
Well Log (Y/N) Yes
Wires properly protected (Y/N) Yes
Casing height (above ground) 44 in.
AT INSPECTION
11-28-07
Static water level 20 ft. 22
Well production 4.5 g.p.m. 6.0
WATER SAMPLE RESULTS::
Coliform 0 colonies/100 mL Nitrate 0 mg/L Other bacteria 0 colonies/100 mL
Arsenic: 0 mg/I Date of sample: 11/28/07 Collected by: Rocky Trainor / Watkins Engr
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material NA - public sewer Date installed
Tank size gal. Number of Compartments _ Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression over tank (Y/N) _ High water alarm (Y/N)
Date of pumping Pumper
'C. ABSORPTION FIELD DATA
Date installed NA public sewer Soil rating (g.p.d.fie or ft2/bdrm) System type
ft.
g.p.m.
Length ft. Width ft. 'Gravel below pipe ft.
Total depth ft. Eff, absorption area _ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before 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.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed NA public sewer Size in gallons
'Pump on' level at In.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA - public sewer
Absorption field on lot NA - public sewer
Public sewer main 501+*
'Pump off' level at _ in.
Cycles tested
Manhole/Access (YIN)
High water alarm level at in.
Meets alar 8 circuit requirements?
On adjacent Tots NA - public sewer
On adjacent Tots NA - public sewer
Public sewer manhole/cleanout S 0 t'
Sewer /septic service line 35' Holding tank 100+
Animal containment areas 100'+
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation NA - publicsewer
Property line
Water main Water service line
Wells on adjacent Tots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line NA - public sewer Building foundation
Water Service line
Curtain drain
Surface water
Wells on adjacent tots
Absorption field
Surface water
Water main
Driveway, parkingNehicle storage
F. COMMENTS: 'Well originally drilled to 60 ft into bedrock by MW Drilling on 8/18/79. Deepened by Hefty Drtg on 6/14/94
to 285 ft. Separation of 65' from well to sewer main met requirement when well was drilled In 1979.
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 Cindy W. Ellis
Date
COSA Fee $ H 30
Date of Payment
Receipt Number
(Rev. 11/05)
//% 5 �7Z%
Waiver Fee $
Date of Payment
Receipt Number
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U*XSS CERTAIN ASSUMPTIONS Att£ MAGE. THE
COMPUTED (C) VALUES SHOVMI ABOVE ARE OUR
BEST L7=ORT AT RECONSTRUCTING TMt WENT
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LOT .13 BLOCK 21
AL'° a►., K A SUED THIREa ADM
c'frofrieg
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
0) 4ra IA
www.clanchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.%IP—baa — a0
1. GENERAL INFORMATION
Complete legal description
HAM AO r nq N
Expiration Date: lJ /a)/get:)C1
ALYESKA :_ SUBDIVISION #3; LOT 13, BLOCK 21
Location (site address or directions)
NHN HIGHER TERRACE ROAD * GIRDWOOD, AK
Current Property owner(s) MATTHEW ALBERT
Day phone
Mailing address
Lending agency
Day phone
Mailing address
1015 E. 6TH AVENUE * ANCHORAGE, AK 99501
(AGENT) 283-0193
Real Estate Agent SAM DANIEL W/ NEXT HOME REAL ESTATE Day phone
----Mailing address
783-1910
1015_E._6T1-1 AVENUE * ANCHORAGE. AK 99501
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS`
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class 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 Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water 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 affixed hereto and as of the validation date shown below, 1 verify that my
th Authority
pproval
that based on procsuurespply
y outlined in the and/or wastewaterldisp sal system is(are) safe, funcelines tional andr this padeq ate
shows that the on-site water andply
for the number of bedrooms and type of structure indicated herein. 1 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. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AI< 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
rmance of the system, nor do
theretareonooh hidden defects or reencroachments. GEG, Ltd. can therefothatuarantee
notnt guarantee 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 reportby any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for _s:21._ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the fllowing s
Date 6 Z(, 6
�t
LkIZ
SOF Aly. yori�
•
-2. \MIER ANDA
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
`1)I»nn iiyyvv
Manitenance Agreements
Supplemental Engineer's Reort
Other
(Rev. 12/01)
Original Certificate Date: 2---
Municipality of Anchorage
Development Services Department
Building Safety Division
Ori -Site Water & Wastewater
P
r
o
ram,474.�ouT�aga
• 96c0narcchhorraagge .aAkKu9s9519-66
51
�97r�4
EALTH AUTHORI APPRO
Legal
escription
*WELL DEEP : 14 1994.
pe 'PR ATE If A, B or C provide PWSID# N A
o,z S.�M>snr ,
8/13/1979 .Sanitary seat (Y/N) YES
' ypa.rtscmu:"X".0 ..v.'k3A.s.+ax.- i rnesa".�:::
o al depth 60 ft Cased to 38.4 ft.
,.. 'd. ,. ..k^•. 1,� Chu :%'tfiu#ii�"'MC
e completed
a e'oftesf
�Rk Y C
fa is water level
e production
20 ft.
Well, Log (YM)_.. _ .YES --
Wires
_.,,Wires properly protected (Y/N) YES
Casing height (above ground)
AT INSPBi; iT1
sr
8/19/2004
70 . ,.
"8.37
Coliform
rsenic:'
x n :. •n., :;, a'hv', Y a� Y ��,,,+,. eW Asa, .r'r +w �.'!rt"t4wS '
colonies/100 ml Nitrate 0 mg /L
mg./L. Date of sample: 8/18,79;25/2004`
ac
Other Obacteria 0
... .,. colonies/1000 mt,
Collected by: GEG, Ltd.l
Date installed
"' Ce gal Number of Compartments CI
Foundation cleanout (Y/N) . • _ . er tank / .....;: alarm
(� High water lar(Y/N)
ping Pumper
is a ins aileda
Soil rating (g p d./ft or ft /bdrm
rm:) w,. Sysfem_type
ength ft. Width
.
„� 0 x -. ftGravel below
1 Eff absorption area " ft' Monitoring tube
ate o �. Results -
uiden in a isof.. ion fie d before T in
Water added
E apse • ime Final fluid'deptfi in.
efuvenation treatment (past 12 mo) (YWNtfypel"""`':.."o"
epth ft
adequacy test
xr C
Depression over field
For bedrooms
D. LIFT STATION'
Manhole/Ac
ize in gallons
Pump o
Cycles tested_ Meets alarm & circuit requirements?
in. High water alarm level at
SEPARATION DISTANCES
SEPARATION'DISTANCES FRONIWELL ON^LOT TO:
Septic tank/lift station on1ot
.Absorption field
utilic sewer' main
ewer /septic service line
EPARAtIONDISTANCES
On adjacent lots
On adjacent lots 100'+
*50+ Public sewer manhole/cleanout
-. 25±_
Holding tank 75'+
FROM'SEPTIC/HOLDING TANK ON LOT TO:
. Absorption field
Property line—
ace water
ots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
`.a
roperty line Building foundation Water main
P�----
Surface water way' parking/vehicle storage
Water service line
Wells on adjacent lots
COMMENtf f /.^S .:.@I;h vn�•.$i:.:'. .. u'a�.a?.C.+�:".h `.i Mk}M i'.i'�w �E ...ro'.:'
*WELL AND SEWER MAIN INSTALLED PRIOR TO 1982
. ENGINEER'StE
c�$.
1 ce ify that 1 have'determined throughfield inspections and
review of Municipal records that the above systems are in
. i
`conformancee With MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Dale of Payment litef `��/6
eceipt Number
Rev. 12/01)
r Fee $ Li
Date of Payment
Receipt Number 0.6P
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. # (Y-10 — HAA #
1. GENERAL INFORMATION
Complete legal description
‘,\5)`111t!2)Le
Lot 13; Back 21; Atye4fza Subdivision #3
Location (site address or directions)
NHN H.ighen Terrace pni.ve
Property owner Randy Lia ()1c\(\ 1 S L L►u ' fl Day phone
Mailing address
Lending agency Day phone
Mailing address
Agent Jack Vandenberg/ JACK WHITE CO
Day phone
762-3113
Address 3201 "C" Stnee. Swipe 100 Anehanago_, AK 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 1
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
xxx
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.
72-025 (Rev, 1/91) Front MOA N21
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
S & S ENGINEERING
17034 Eagle River Loop Road" • 2'
Engineer's signature .Ends Rival., Alaska 99 7
Phone
Date if /8/9.1
iy
!k .T"2 1, *
e
p A.
y L!l
(*.a. 1.491-8 > " "rtl
6. DHHS SIGNATURE /
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
By.
Additional Comments
I -74W
(1104
Date 2_2 -
The
-2 -
CAUTION
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Loi /3 £3C1( a( ALVESKtA
SO#3
A. Weil Data
Well type P(CJ
Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
Log presenV'N) 7) S Date completed $/ / S /9 9*
Total depth 6o ' Cased to 38, 4 ' (g1/0
Sanitary seal 6I) ` 6• S Wires properly protected &N) cl' $
Driller /V1- IA) A21LUN(a) 1NC,
Casing height 3?
- 'k L 1 EI° v6z.N To 2 S' ey HEFT I L LI N 6 o t--) 6/141 9(1
FROM WELL LOG AT INSPECTION
Date of test 6/14/q4- 6/z3/ %4
Static water level z.o/
Well flow 4,C g.p.m. 4,0
Pumplevels vK /Zo,S'
MUNICIPALITY OF ANCHORAGt
ENVIRONMENTAL SERVICkS DIVISION
6olds) /N CIA SI")
19 1994
RECEIVED
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ,./col -)6 P' 6 SL -p 1 ; On adjacent lots A-4.)/06- /AS N l
Absorption field on tot Nv N P/Ce3 JT ; On adjacent lots A.A. /'ZeS
Public sewer main S0 �� Public sewer manhole/cleanout SO 11"
Sewer service line 254' Petroleum tank/do N kwa)&)
fief— WELL Mt-L7S Seepi,t4pcN L/SINGES tom► efFecr 4% r/ aF
WATER SAMPLE RESULTS:
Coliform 0/(c24' Nitrate 0 • /0 Other bacteria e//
Date of sample: ( ro/Z3 / 9 Collected by:-S��/N.tiuG
B. SEPTIC/HOLDING TANK DATA PU/SCI C
Date installed Tank size --.
Compartments
Cleanouts (Y/N) Foundation cleanout (Y/N) Depression
High water alarm (Y/N) Alarm tested (Y/N)
Date of pumping Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TO:
Well(s) on lot On . -'. ent lots Foundation
To property line Absorption field Water main/service line
Surface wrainage
72-026 (3/93)' Front
CONTINUED ON BACK PAGE
C. LIFT STATION /703C (C S GSC— A.)4.1 `vim P''
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "' • • off" Level at
High water alarm level ycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE F
Well on 1
. ABSORPTION FIELD DATA
Date installed
UFT STATION TO:
On adjacent lots
Poerr
Soil rating (GPD/Ft2)
Surface water
Length Width Gravel thickness
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type
Total dept
Cleanout present (Y/N) Depressio ' • ver field (Y/N)
Results (pass/fail) • r Bedrooms
er test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIE - O:
Well on lot
To building foundation
On adjacent Tots
Surface wate
jacent lots Property line
To existing or abandoned system on lot
Water main/service line
Driveway, parking/vehicle storage area
Cutbank
Curt.' - drain
E. ENGINEER'S CERTIFICATION
Signature
Engineer's N
Date
, or conformed to all MOA and HM guidelines in effect of this inspection.
:0'
I certify that / have checked, verified
GINEERING
agle River, Alaska 99577
HAA Fee $ ZOO Ov
Date of Payment 1— \ek -
Receipt Number •-
72-026 (3/93)' Back
Waiver Fee $
Date of Payment
Receipt Number
RIVER, ALAS*
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
July 22, 1994
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Attention: Jim Cross
825 'L' Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Alyeska Subdivision #3, Block 21, Lot 13
Dear Mr. Cross:
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
RECEIVED
JUL 251994
Municipality Ot Anchorage
Dept. Health & Human Services
The analysis on the water sample taken on July 24, 1994, at the referenced
property, shows eight other bacteria. We believe the eight other bacteria
detected in the water sample is a result of the recent work which was performed
on the well.
Chlorination of the well and resampling of the water to show zero bacteria, will
be completed within the next ten to fourteen days.
We request you release the Health Authority Approval at this time in order that
our client may close on there home this afternoon.
If you have any questions, or require additional information for your review,
please contact us.
Sincerely,
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
obert A. Shafer, P.E.
RAS/LSF/lsf
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
INSPECTION APPOINTMENTS
DATE RECEIVED
-r)
TIME
1e Izsn ifYL0 1
TIME
TIME
DATE
I -A9 -W) frowhi),
DATE
DATE
INSPECT/9,RINSPECTOR
Y -
• PUBLIC UTILITY depth (attach log if available.)
INSPECTOR
MUNICIPALITY OF ANCHORAGE
DEPARTMENT
DEPT. OF l'ALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL i',.s.)TECTION
OF HEALTH & ENVIRONMENTAL PROTECTION
825 Street -Anchorage, Alaska 99501 1980
JAN 2 4
SANITATION DIVISION RECEIVED
Telephone 264-4720
OF INDIVIDUAL WATER AND SEWER FACILITIES
• r \
7.
ENVIRONMENTAL
REQUEST FOR APPROVAL
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER YVAItig FA
783 -2i3 ->C 2i37C
MAILING ADDRESS 60>r -1az 6;7,064,00d 4k 990-8?
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER , / Z ,�1- e
1/(/
PHONE
7e'5 —2,5> 2,8
MAILING ADDRESS 6);Q /i 9' C
3. LENDING INSTITUTION
f. L.,/,_,a' 2�-:_,_5 /
PHONEa
MAILING ADDRESS gi5"-• c-7,4 ,
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
/3 &roc .2 / A ��i1 1,1 � 4 q. 5
%V<
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS
SINGLE FAMILY One NI Four MI Other
• Two • Five
• MULTIPLE FAMILY • Three ❑ Six
7. WATER SUPPLY
XI. 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 `a
INDIVIDUAL/ON-SITE** / 1 7 , YEAR ON-SITE SYSTEM WAS INSTALLED.
'•I PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
THREE
FOUR
• SINGLE FAMILY
• ONE IN
IN FIVE
IN OTHER
❑ MULTIPLE FAMILY
E SIX
• TWO •
2. WATER SUPPLY
PERMIT NUMBER
• INDIVIDUAL
DEPTH OF WELL
IN COMMUNITY
DATE DRILLED
NI PUBLIC UTILITY
Connection Verified
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
IS INDIVIDUAL/ON -SITE
PERMIT NUMBER
DATE INSTALLED
❑PUBLIC UTILITY
Connection Verified
INSTALLER
• Septic Tank or • Holding Tank
Size: If Tank is homemade
SOILS RATING
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 1 BEDROOMS
1
ificate)
(letter must accompany
IN CONDITIONAL APPROVAL
• DISAPPROVED
DATE
,-31,--6
BY
411
72-010 (Rev. 6/79)
MUNICIPALITY OF ANCHORAGE _ DEPT. OF
EVIRONMENTAL'
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
HEALTH &,
PROTECTION
1 71979
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
• 7,r'.'"
r JUL
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1.Incomplete requests will not be processed. Please allow ten (10) days for processing.
J1.
1. PROPERTY OWNER %I
�///� IY
PHONMAILING
7 5E-28
+
/ -
ADDRESS kO L eA/'O , 6I /W0 o � At, Q' 0-87
`PHONE
8. SEWAGE DISPOSAL SYSTEM
**If individual/on-si installation date eon-II-vit./ET
PROPERTY RESIDENT (If different from above)
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION 2.6. /
/454,11-._ 6/,‘,. 2J G 0,1 / g
STREET LOCATION
C) p- r R''fx-e - oe,
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
t One • Four El Other
SINGLE FAMILY
• Two MI Five
11111 MULTIPLE FAMILY ❑ Three IN Six
7. WATER SUPPLY
IN INDIVIDUAL* * ATTACH WELL LOG. A w is required for all wells drilled
,/
V COMMUNITY eta-tc 1C since June 1975. F e Is drilled prior to that date, give well
i PUBLIC UTILITY depth (att g if available.) 1 O y- ktMf i S TO (
8. SEWAGE DISPOSAL SYSTEM
**If individual/on-si installation date eon-II-vit./ET
g INDIVIDUAL -/ON-SITE**
If syste ' ver two (2) years old an adequacy test is required
LJ PUBLIC UTILITY is Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-01013/78)
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
• SINGLE FAMILY
• ONE • THREE • FIVE • OTHER
• MULTIPLE FAMILY
IN TWO • FOUR • SIX
2. WATER SUPPLY
• INDIVIDUAL
PERMIT NUMBER
DEPTH OF WELL
❑ COMMUNITY
DATE DRILLED
• PUBLIC UTILITY
Connection Verified
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
PERMIT NUMBER
• INDIVIDUAL/ON -SITE
DATE INSTALLED
• PUBLIC UTILITY
Connection Verified
INSTALLER
IN Septic Tank or • Holding Tank
Size: If Tank is homemade
SOILS RATING
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
BEDROOMS
41
certificate)
• APPROVED FOR
El CONDITIONAL APPROVAL
(letter must accompany
MI DISAPPROVED
DATE
BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
Municipality
of
Anchorage
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M. SULLIVAN,
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
December 31, 1979
Yvan Safar
Post Office Box 462
Anchorage, Alaska 99510
Permit # 790446
Subject: Lot 13 Block 21 Alyeska Subdivision #3
A permit issued by this department for well and/or sewer
system has expired.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be sent
to this department to document the installation date.
If an engineer has inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files.
If there are any further questions, please contact this
office at 264-4720.
Sincerely,
Les N. Buchholz, R.S.
Senior Environmental Speci st
LNB/ljw
enc: Copy of Permit
July 17, 1979
TO WHOM IT MAY CONCERN:
MUNICIPALITY OF' ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
JUL 1 71979
RECEIVED
Lot 13, Block 21, Alyeska Basin #4A is in the Girdwood/Alyeska
Sanitary Sewer Lateral Improvement District #60-1, Schedule 1A.
This project has been awarded and construction is scheduled to
begin during the 1979 construction season.
The Anchorage Water & Sewer Utility, Sewer Division can in no
way guarantee that the construction of this L.I.D. will be
completed during the 1979 construction season. From time to
time, problems are encountered in construction that may delay
or even cancel portions of L.I.D.'s.
If you have any questions, please feel free to contact this
office.
JOSE VICENTE, Y.E.
Utility Sewer Engineer
Anchorage Water & Sewer Utilities
JV:mm
File: Girdwood
