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HomeMy WebLinkAboutDALZELL-SCHNEITER BLK 1 LT 3balzefl - Schneiter Biock 1 Lot 3 #015-291-12 Jun 14 22 10:19p Anchorage Well & Pump Ser 9072430742 p.1 MUNICIPALITY OF ANCHORAGE Development Services Department-" ] Phone: 907-343-7904 On -Site Water & Wastewater Section ,\\ ) Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 015 - 291 -12 Date of Issue: - - Legal Description Block Lot Property Owner Name & Address: APPLEGATE KEVIN R & JEANNA S DALZELL-SCHNEITER 1 3 5700 MILROB AVENUE ANCHORAGE, AK 99516 Pump Installation Date: 06 10 - 2022 Pump Intake Depth Below Top of Well Casing: 35 Pump Manufacturer's Name: A.Y. MCDONALD Pump Model: 2305OV36B IPump Size: .50 hp feet Pitless Adapter Burial Depth: 12 feet Pitless Adapter Manufacturer's Name: MARTINSON [ Pitless Adapter Installer: Well Disinfected Upon Completion? )( Yes E No Method of Disinfection: PELLETS I Comments: Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE Company: 7640 KING STREET ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 City: State: Zip: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. 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 MAILING ADDRESS LEGAL DESCRIPTION IAbsorption area 'nsidelength ~ I j~ Dwelling Dwelling Material Width I Material "~ Foundation ~'~ ~ Nearest lot lin~ "~ ~ Trench width Total length of linest.~ -~ q '0 ,I inches Material beneath tile IPHONE I 34o,_ I inches NO. OF BEDROOMS Depth ~NEW [] UPGRADE PERMIT NO, No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO,, Total effective absorption area D STANCE TO' ICiL~ Manufacturer ~ [Liq. capacity in gallons ~ I~ell Top of tile to finish grade O Length Width mypeofcrib ~ C~b ieter DIBTANOE ~O: Depth DISTANCE TO Building foundation PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO. Absorpt on area(s) Sewer line Septic tank PIPE MATERIALS SOl L TEST RATING OTHER LEGAL INSTALLER REMARKS  DATE PERMIT NO. ~-ll_lr4 1 c~ I tilL i T~' IDF i--t~C:H~IZiISE DEPARTMENT OF HEALTH RND ENVIRONMENTRL PROTECTION 825 'L' STREET, ~NCHORRGE, RK. 99501 264-4720 L4ELL F-If-l[:, CIr4--S I Ti SEL4E~: 788472 ) AF'PL I CANT LOCRT I ON LEGRL JAMES BLIMGRRDNER SRR BOX 474E 9'9507 MILROB RVE L~ E:l DRLZELL-SCCHNEITER. ~_LIB LOT SIZE F'E F-: r-1 I T ¢ ,S42:=:¢1 S~.URF.'.E FEET T'T'F'E OF SOIL ' '-- '' ION SYSTEbl IS' HB_-,LEBT TRENCH blRXIMUM NUMBER OF BEDROOMS = 4 SOIL RRTING ,.'.S.c..! FT,..'BR',= ±±~--~ THE REC4UIRED, _~E OF THE SOZL RBSORPTZON SYSTEM ZS [:'EP TH= :1.1__.-1 L E r..I f-1 TH= ..7. 7 ~] F-' R'-.-' E L [:, E F" TI-I= THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DIST8NCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (:IN FEET). REK, I .... I I F-:E[:, SEPT I C: TRr-Ik; _-s I ZE: :125(-~. C-~t-RL[_C~r-.~L--~ PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS [:,EPRRTMENT ['URIf.4~S THE INSTRLLRTION INSPECTIONS OF 8NY WELLS RDJRCENT TO THIS PROPERTY 8N[:, THE NUMBER OF RESIDENCES THRT THE WELL WILL SER',,,'E. T 14 "D ( ':: ) Z I r-ISF'ECT I Or-dS ARE E:Eb--!LI I F-:E[:, -. ~' -. ,-r, c ' ' - '- BRL. KF ILL I NI.J OF RNY ---, L, TEM W I THOUT F I NRL I NSPEI-:T I ON RND 8F F F. _l ,,, HL TH I S DEPFIRTMENT WILL BE '~11B.EC':T TO PRO:,EL.L TIuN. MINIMUM DI=,TAN_.E BETWEEN R WELL AND RNY ON-SITE SEWRGE DI~F'Fr-SRL S'?'STEM T'-~ '18z4 FEET FOR R PR IVRTE WELL; OR 15~.-1 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING UPON THE T'T'PE OF PUBLIC WELL. WELL LOGS RRE REG!UIRED 8ND MUST E:E RETURNED TO THE DEPRRTMENT WITHIN Z.':~:-~ ['H.-'~"-:_, OF THE WELL COMPLETION. OTHER REG!UIREMENTS MRY RPPL'T'. SPECIFICRTIONS RND CONSTRUCTION [:,IRGF.:Rf'IS RF.:E RVRILRBLE TO INSURE PR. OPER INSTRLLRTION. F'E~:r"I I T E."4F' I E:ES [:,EC:Er'IBEF-: _-----: :.t.. :1_'__=*- 7L--3 I CERTIF'T' THRT i: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND 14ELLS RS SET FORTH B'T' THE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ].<: I UNDERST8ND THRT THE ON-SITE SEWER SYSTEM MR'T' REt]U IRE ENLRRGEMENT IF THE RES IDENC~.EMODELED TO INCLU[:,E MORE THRN 4 BEDROOMS. ..... S I GNED: ] [{IHS WELL DRILLING PHONE 34~-3792 Dec 78 DR I L L E R'S WELL L'O G CUSTOMER LOCATION SIZE Box 474-E SRA Jamee Bu~gardner dba Sun Const~.ctionAnchora A~ lot 3, Block t~ Da]~ell-Schn~ider Subdivision off Birch 6" DEPTH 45' CASING DEPTH 45" GROUTING DEPTH YIELD ~ STATIC WATER LEVEL__203_ HOW TESTED PUMP INSTALLED' !/~? ~ ]¥PE .__R~ .T~eWe~ FORMATIONS ENCOUNTERED AND APPROPRIATE DEPTHS" 44 T0.46 .46 TO 5O Gr~vo~ snd elsy~ brown Sand. ~ravel.'water 8~10 _Gra~'claY ~ TO CERTIFICATE FOR A Parcel I.D. 015-291-12 1. GENERAL INFORMATION Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O, Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 OF ON-SITE SYSTEMS SINGLE FAMILY APPROVAL DWELLING CO A# Expiration Date: ~ Complete legal description DALZELL-SCHNEITER S/D; BLOCK 1, LOT .3 Location (site address) 5700 MILROB AVENUE * ANCHORAGE, AK * 99507 Current Property owner(s) Mailing address RANDY ANDRE Day phone 5700 MILROB AVENUE * ANCHORAGE, AK * 99507 225-5710 Lending agency Day phone Mailing address Real Estate Agent SUE BURNSTIN W/ DYNAMIC PROPERTIES Day phone 830-8,387 ~ Maitir~'g address .3111 C STREET * ANCHORAGE, AK * 9950.3 Unless otherwis¢'i(equested, COSA will be held by DSD for pickup. NuMBER.(~F BEDrooMs: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well · Individual On-site · Individual Water Storage [] Individual Holding tank [] Community Class. Well [] Community On-site [] Public Water System [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF !NSPECT]ON BY ENGINEER As certified by my seal affixed herefo and as of the vafidation date shown below, I veFi~y that my investigation, based on procedures outlined in the Certificate of Qn-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 furthJr verify that based on the infom~ation obtained from the Municipality of Anchorage Nes and from my i,'~vestigation 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:Fibril' .~ "GAfRI~E~'S/' ENG NEER NG GROUP, Ltd. Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone 557-6179 Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the ~_~'_/k,t(<.. .:~' .... system under the conditions encountered at the time of the test, and separation ~ t.' '1 distances measured to readily identifiable features. The operational life of all wells and ~'~ ~ T~[~ septic systems depend on the local soils condition, groundwater levels that may /~. :'~. .~ ~ ~/. fluctuate during the year, and the water usage of the family being se~ed by the svst~m / ~ / ~ / ~ These conditibns are outside the control of the evaluator of the system. Satisfac,o~ ,~s~ ~ ~~_~. results do not guarantee future performance of the system, nor do they guarantee that ~ ,II/~fIA A. there are no hidden defects or encroachments GEG LTD can therefore not rowde any warranty or future estimate of ,~ow long the system will continue to meet the ~0~;~~. . ~. operational requirements of tho ADEC or MOA DSD: Tho content of this repo~ ~s for '~~P ~ the sole benefit of the owner listed above, Any reliance upon or use of this repo~ by any other person or pa~y is not authorized, nor will it confer any legal right whatsoeve~ ' ' . OF · ~ ~ ~* .'~ ' ,ooms ON.S TE Disapproved ~ Condibona approval for bedrooms with th ~ , ' e following stipulations:~ · ~'.. . .' Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Arsen.c AdvisoFy Maintenance Agreements Supplemental Engineer's Report Nitrate Advisor; (Rev. 11/05) Other Original Certificate Date: .-~'- / '~ ? / / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: DALZELL-SCHNEITER S/D; BLOCK 1, LOT 3 Parcel ID: 015-291-12 WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 12/5/1978 Total depth 45 ft. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Sanitary seal (Y/N) YES Cased to 45 ft. FROM WELL LOG 12/3/1978 20 .ft. g.p.m. 8-10 Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 3/31/2Oll 30 .ft. 5.63+ g.p.m. Nitrate 4.6 rog.IL. Collected by: GEG, Ltd. YES 12+ in. Arsenic: ND ug./L. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size ;1250 gal. :' Number of Compartments Date of sample: 3/18/2011 2 Date installed 8/21/1978 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of Pumping 4/20/2011 Pumper. ABSORPTION FIELD DATA I'BELOW EXISTING GRADE', Date installed 8/21~/19~8 Soil rating (g.p.d./ft2o .110 Length 43 ft. Width 4 ft. Total depth '11 ,,~ ft. Eft. absorption area 468 ft2 Monitoringitube YES Date of adequacy test 3/31/2011 Results (Pass/Fail) PAsS Fluid depth in absorptiOn field before test 0 in. Water added 720 gal. Elapsed Time: - min. Final fluid depth 0 in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE High water alarm (Y/N) N/A DENALI PUMPING System type TRENCH Gravel below pipe 6 Depression over field NO For 4 bedrooms New depth 0 in. Absorption rate >= 600+ g.p.d. KNOWN If yes, give date - D. LIFT'STATION Date installed "Pump on" level at__ E. ¸in. SEPARATION DISTANCES Size in gallons Manhole/Access ~ J "Pump off" leve..~QLa/. High water alarm level at Cycles tested. Meets alarm & circuit requirements? .in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Animal containment areas. 50'+ 100'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas N/A 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line' 5'+ Absorption field '5'+ Water main N/A Water service line 10'+ SUrface water 100'+ Wells on adjacent lots. 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation. 10'+ Water service line 10'+ Surface water 100'+ Water main N/A **UNDER Driveway, parking/vehicle storage DRIVEWAY Curtain drain COMMENTS NONE KNOWN Wells on adjacent lots 100'+ *PER 1978 INSPECTION REPORT. CLEANOUT AT BEGINNING OF TRENCH COULD NOT BE LOCATED. CLEANOUT .A-T-INSTALLED AT END OF TRENCH. **BOULDERS PLACED ON DRIVEWAY TO pREVENT VEHICLE TRAVEL OVER DRAINFIELD. SEE A'FI'ACHED PHOTO. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date ~"/~'/" COSA Fee ~; (-~¢0 --" Date of Payment ,~/~ //I Receipt Number ~,~ ~'~ ~'-~"~(-~ Waiver Fee $. Date of Payment Receipt Number (Rev. 11105) SGS Ref.# 1110980001 Client Name Garness Engineering Group, Ltd Printed Date/Time 03/25/2011 10:04 Project Name/# Dalzell Schneiter B l, L3 Collected Date/Time 03/18/2011 14:00 Client Sample ID Dalzell Schneiter B1, L3 Received Date/Time 03/18/2011 14:45 Matrix Drinking Water Technical Director Stel~hen C. Ede PWSID 0 Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 03/22/11 03/24/11 SCL Waters Department TotalNitrate/Nitrite-N 4.60 0.100 mg/L SM20 4500NO3-F B (<10) 03/21/11 AYC Microbiology Laboratory E. Coli Ne~.ative 1 100mL SM20 9223B A 03/18/11 DLC Total Coliform Negative 1 100mL SM20 9223B A 03/18/11 DLC EASEMENTS OF RECORD OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON AS,*BUILT NO CORNERS SE'~ T;~IS DATE J he.by certify that t h~ve pe~o~med a Mar~gagee's ~peCtion of the ~ilowing described p~erty ... ~; f Anchorage Recording Precinct Ai~ka. acd ~nat ~he im:prb~mems situated ti~ereon are within the prope~y ~ines and do n~ ~rfap or encroach on the proper~y lying ad~aoenl thereto that no impf~ements on pfoper~y tying adjacem thereto encrgaoh on the ¢remi~es h~ auesttor~ and that ~here roadway, transmission lines or other visible easemems on said prope~y except as h~dicafed hereon gai~d at Anchorage, Alaska th 8 ................... day of ............... L,=~.¢ ............ 19 FRED WALATKA & ASSOCIATES (9~) 2484666 Engmeer~ and Surveyors Wilco Contractors 16701 Ransom Ridge Anchorage,.Alaska 99516 345-62881345-5947 fax Invoice i DATE ~NVOICE # !411112011 257 BILL TO i SHIP TO Randy Andre 5700 Miilrob Ave. Anch., Ak, 99507 223-0220 ITEM DESCRIPTION I QTY RATE AMOUNT item Fixing monitoring tubes with the mini excavator , 1 · 525,00 Item 5 boulders two feet in diameter 1 500,00 Credit Down payment 1 -40000 Thank you for your business! Subtotal 625,00 : 0% Tax Total e25.00 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING' ' GENERAL INFORMATION ' ' '""'"': '-' ' ~' ~; '''~'" Complete,legal description ~o~'-~ :..~lk I .'~:Da~l~l~:rScb~ei'~e: Location (site address or directions) 5700 Milrob Ave '4. Property oWner Mailing address 'Lending agency ::.,Mailin:g address. .Barb~r~ Stillwater Dayphone 346-3747 5~00 Milrob Ave, Anchoraqe, AK 99516 Day phone Agent·Judy Rosenberq/Jack Address' ':'~;" White Real Estat~ Day phone 563-5500 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 \' TYPE OF WATER SUPPLY: Individual well Community welI Public water NOTE: If community well system, provide written confirmation from State ADEC attest- .. , ing to the legality and status of system. TY~E OF WAS~"EWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer xx 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 #21 STATEMENT OF INSPECTION her( the'Municipality of Anchorage files and frOm my inv_estigati°n and inspection, the on-site water and/or wastewater disP~0SaI'syst~'m is in comp!lance with.-- - ~ all Municipal and State codes, supPly ordinances, and regulations in effect on the date of this inspection~ Name of Firm Ay ~.z~ .,..~ ,,_.~ ....... Ad dress - -- :~:. ,~--_c-_~J,:. ~_r/-----., "'l~' ~' "'~ Engineer's signature / ~~~'~ Alaska Water & ~aste~ater' Consultants ThC. ,'i'o . shall be paid '~ ~Z~~''~-' at:, or prlor clos~.ng for the engineering services provided. bedrooms. DHH8 SIGNATURE X Approved for " Disapproved. Conditional approval for Phone 337-6-179 / Date //?_~/c~ ~ bedrooms, with the following stipulations: Additional Comments 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 ~ RECEIVED MuniciPalit~ of Anchorage JAN ?--~ 1999 DEPARTMENT OF HEALTH & HUMAN SERVICE~uNicm^uw oF ^NCH Environmental Services Division ENViRONIVJF. NTAt.$ERVICES 825 ~ Street, Room 502 · Aqchorage., Alaska 99501 ° (907) 343-4744 Legal Description: A. WELL DATA Well type t~e,~Y ~',1 Log present {~YN) Total depth Sanitary seal (~fN) Health Authority Approval Checklist D~. r.~.~c.~. -- ~;c~,-r.~ -~/~ ~' Parcel I.D.: If A, B, or O, a~ach ADE©leBer. ADEO wafer system number Date completed i Cased to -z'tt- Casing height (above ground) Wires properly protected (~N) ~E..% Date of test Static water level Well production FROM WELL LOG AT INSPECTION . 7.0 1 JJ --' i O g.p.m. (o. ~ g.p.m. WATER SAMPLE RESULTS: Coliform / Nitrate Date of sample: B. SEPTIC,~Iltjt!I~TANK DATA Date installed ~/'7~ Tank size Foundation cleanouti~N) Date of Pumping I : ~ -~. z~I ~t~/L. Other bacteria Collected by: /~ .~J,~. ~. t Jd i7.~0 Number of Compartments ~-- Cleanoutsi~N), Depression (V~) /kJ o High water alarm (V~t C. ABSORPTION FIELD DATA * Date installed ~/*':/~) Soil rating (~l~l=~. or ~. I10 System type Length /'J'~J _Width.. /~t (= ~ Grave[thickness below Pipe ... Total depth Effective absOrptiOn area ._~ j~.:.l~ . ~oringTube{~te~ent (~)N) "{E.5 Depression over field (Y~ Date of adequacy test J/,~ /~t~t Results (~Fai,) {)~, 5 For /~ bedrooms Fluid depth in absorption field before test [in.); O~' ~0g'f~) Immediately after_~_ gal. water added (in.): O OR,'{ Fluid depth {3" ~'Ol~f} (ins) Minutes later: ~ Absorption rate = 400''l'' .g.p.d. Peroxide treatment (past 12 months) (Y(~ ~,'~ ~t~.~/{ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole~ ~~,=~~~~ . ~i~ater a~ ' *Datum Size in gallons .---~ "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: septic/holding tank on lot i ooI'l' Absorption field on lot Public sewer main ~ /,~- Sewer/septic service line On adjacent lots On adjacent lots ~oo Public sewer manhole/cleanout Lift station ~/~' SEPARATION DISTANCES FROM SEPTIC/~ANK ON LOTTO: Foundation j;t+. Property line. Iott Absorption field 5 i~. Water main/service line tot~' Surface water/drainage tooI~''~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I0~ Building foundation ~oi~ Water main/service line lel'~ Surface water ~ __ Driveway, parking/vehicle storage area Curtain draiy i~,,~' ~-.~o~ Wells on adjacent lots ioot~ ' R ENGINEER S CERTIFICATION ,/I ~ ~ o~ ~o~ _1 · · · ' eee , ~n conforman es ~n effect on th~s date. Signature ~.~~ ~: ~, ~~~2:} Engineer's Name ~ -~ -/ ~, , HAAFee $, ',~ · ~ Dateof Payment (2//2-.~ /~' Receipt Number ~7~z~ 7 d~'-~-~ ) wai~er. Fee $:': Date of Payment Receipt Number 72-026 (Rev. 3/96)* 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 Parcel I.Do # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) ~-'7oC2 /"/,I r'o b /~,., c Property owner Mailing address Lending agency Mailing address Al ~- £u.c7 ~,.~,;~j Day phone Day phone = Agent O1~'~ ?/~.~/ ~7-¢,¢k- Address ~ ~O( "C" 5'~ /)--c~o ,,"~:~ ,,~-~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: Day phone '--z~"E - ,5-<5 2-0 If community well system, provide written confirmation from State ADEC attest~ lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1191) Front MOA #21 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 F'( ~ /.-l~r~ T~c~ ~i c~./ _~ u, c..r . Address I ~/..d'~ ~ ~--~c.~ ._C~.., t~zt(_~ o,,"~, ~/ ngineerssignature Phone Date, DHHS ? Approved for ~dL Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: IL/ 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. 72-025 (Rev. 1/91) Back MOA ~¢21 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DM$1ON Municipality of Anchorage AUG 01 1 96 ~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental ServiceS Division J ,CEIV£D 825"L"Street, Room 502 · Anchorage, Alaska 99501 · (9o7) 34 Legal Description: A. WELL DATA Well tTpe Log present Cf/N) Total depth /--/~- Sauita~ seal Cf/N) Health Authority Approval Checklist D ~ ( ~.¢ I I _C ¢ [~ ~ e ~ ~e r -q / /) Parcel I.D. : Date of test Static water level Well production If A, B, or C, attach ADEC letter. ADEC water system number Date completed t '~ [ 3 / 7t~ Cased to. ¥,C ' Casing height (above ground) Wires properly protected Cf/N) AT INSPECTION ~ -- t'o g.p.m. 5'. ~ 7 + FROM WELL LOG tx/~ / "/~ WATEE SAMPLE RESULTS: Coliform 0 cc4/(OO m -~ Nitrate Date of sample: '7 / 2. 5-/~ B. SEPTIC/HOLDING TANKDATA Date installed ~ / 7 ~ Tank size Foundation cleanout Cf/N) DateofPumping I o / l ~ [ C. ABSORPTION FIELD DATA Date installed ~ / 7a5' Length q$ ' Width Effective absorption area 5"/6~ r2 ' Date of adequacy test -7/%0'-/~ Fluid depth in absorption field before test (in.); Fluid depth O .(ins.) Minutes later: Peroxide treaUnent (past 12 months) Cf/N) ~./~ /~' / -L~'~_ Other bacteria Collected by: f:::/a, FJ=~, ~'~c/~ ~- c I ~.ft:~,n ! Number of Compat-m~ents ?._ Cleanouts Cf/lq) Depression Cf f N) N High water alarm CffN) N. /~, Pumper _.~J'~ ~ ~J' Soft rating (g.p.d./ft2 or l~2/bdrm) Immediately after 7at gal. water added (in.): Absorption rate = '> ~'OO g.p.d. /,c~o~.,~ Ifyes, give date /~. A. I/O /~_..~.' sYStemtype /$~'~-~ Gravel thickness below pipe 6'' Total depth 10.3-' Monitoring Tube presentcffN)__ Results (Pass/Fail) F~-'-~' Y Depression over field Cf/N) For ~ bedrooms (O D.~ LI~T S~FATION Date i~l~i Size in gallons Msnhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ~' I Of ; On adjacent lots Absorption field on lot ~ IO$' ; On adjacent lots Public sewer main /~/,/4. Public sewer manholedcleanout N. /~. Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTI~O~G TANK ON LOT TO: Building foundation .... ~,- Property line > ( o' Absorption field I g' ' Water main/service line .'> lo ' Surface water/drainage _-~ too ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~o ' Property Line ~> to' Water main/service line ~ t o, Surface water ~ t cd, ' Driveway, parking/vehicle storage area Curtain drain ~o~ x'de~ Wells on adjacent lots ~.> tog, Fe ENGINEER'S CERTIFICATION I certify that I have determined thru fieM inspections and review in conformance with MOA HAA guidelines in effect on this date. Engineer's Name '~eoc~,~'e.. ~. p~too~e_ of Mumctpal recor~. ~a! ~ ~ · ~ ~_~ %"~ ~,.~ *************************** HAAFee $ 3'C~.~~ Date of Payment .~ t/~/~,,,~, / Rev. 8/95 OSS: haa.wk, doc 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 AOTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~3'~'-~ 1. GENERAL INFORMATION Complete legal description Lot 3; Block 1; Dalze. F_.l-Schnicter Subdivision Location (site address or directions) 5700 Milrob, Anchorag&, Alaska w Property oWher Mailing address Lending agency Mailing address ~avid York - . . Day phone Day phone 346-3944 Agent Ka.t_h¢.rine- RE/MAX PROPERTIES Address 9_600 qor~o,,.. A.~_~_o._~,g~_. A~._~_~. ee~n~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: / Individual well ~_~_ Community well Public water NOTE: Day phone ~57-0117 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank ~Community on-site Public sewer NOTE: XXX 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 #21 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. 7034 Eagle Ri~er Loop Road Eagie ~iver, Aias~(a ~5/~ Name of Firm Address Engineer's signature DHHS SIGNATURE 7z~___ Approved for Disapproved. Phone Conditional approval for 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 paragrapll 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~-~ ~-'¢-- \ [~,~-',.,~t.4. - Parcel I.D. A. WELL DATA Well type ~,J~,~-~ If A, B, or C, attach ADEC letter. ADEC water system number NJ Date completed \?-. ~'~- '1 ~5 Driller Cased to ,~r'~ Casing height ~/ properly protected Wires FROM WELL LOG AT INSPECTION '2--o' ~.-~' '~, c::;) --' ~1~, C::, g.p.m. ~ ,~' 0¢-.,_ oV--.. Log present ~}'N) Total depth Sanitary seal (~N) Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: ; On adjacent lots ; On adjacent lots Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line Public sewer manhole/cleanout Petroleum tank yT..' t 4- WATER SAMPLE RESULTS: Coliform C:> ~'~'"'"/t ~, Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: Other bacteria $ & $ ENGINEEEING 170~4 Eagle River Loop K~aCi HO. Eagle River, Alaska ~577 Date installed Cleanouts ~)/N) High water alarm Date of pumping Tank size 1 ~,~'-C) Compartments Foundation cleanout (~/N) ~/ Depression (Y~J~ Alarm teSted J,_Y/.N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ ~ C> t ~- On adjacent lots To property line ~ f'~ ~¢ Absorption field Surface water/drainage ! c, 0 ~ ~ Foundation Water main/service line 72-0~2e (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Man ufactu rer Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes ~ SEPA~ROM LIFT STATION TO: ~W~n lot On adjacent lots Manhole/Access (Y/N) "Pump on" level at .~_~~ level at ~~'~Cycles tested Surface water D. ABSORPTION FIELD DATA Length '~' Width Total absorption area ~'-/ Depression over field (Y~ Resu Its ({;[;[~Yfail) Peroxide treatment (past 12 months) Soil rating Gravel thickness L~'~ Cleanouts present ~/N) Date of adequacy test for ~ o ~-- System type '~"~--~-~--~ Total depth bedrooms /~o v,//,j If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ICc> ~ On adjacent lots ~ c~ c:, Property line To building foundation '~....L~ ' To existing or abandoned system on lot On adjacent lots ~c::> ~' ~1~,~ Cutbank Water main/service line Surface water \ ~ ~ ~-- Driveway, parking/vehicle storage area Curtain drain ~lh~ E, ENGINEER'S (~ERTIFiCATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date S & S ENGINEERING 17034 Eagle Ri~er Loop Road No. 2{14 Eagle River, Alaska 99577 HAA Fee $ Date of Payment (~' q--?/ Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number · ~ ~ 825 L Street - Anchorage, Alaska 99501 ~C I'~'~''~NvlRONMENTAL ENGINEERING DIVISION JAN 2 9 1979 Telephone 264-4720 R E£ Ei V E D 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. I PHONE ,. P.OPE.T* OW.E. ~-' ~ ~ c ~ ~ ~ ~¢ MAILING ADDRESS PROPERTY RESIDENT (If different from above) PRONE MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE ~1 LInG ~DDRESS 5. LEGAL DESCRIPTION ~ I HEET LOCATION 8. TYPE OF RESIDENCE [[~'~1NG LE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS ~ [] One [] Four [] Other [] Two [] Five [] Three [] Six 7. WATER SUPPLY ~DIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled Prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM I~]-"-'I'N DI V I DUAL/ON-SITE** [] PUBLIC UTILITY **If individual/on-site, give installation date ~/7 ~ If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOI NTM ENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SiX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: /~,3~'''~ If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING ~ MANUFACTURER MATFRIAL Septic/Holding Tank IAbsorption Area Sewer Line Nearest Lot Line 5. COMMENTS [~I~"~APPROVED FOR ~-~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE LEGAL DESCRIPTION IBY (.~T. itle)/~ 72-010 (Rev. 3/78)