HomeMy WebLinkAboutFETROW LT 2Fetrow
Lot 2
#051-221-58
On -Site Water System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP121185
Tax Code Number: 05122158000
Work Type: Well Upgrade
Permit Effective Dates: July 17, 2012 to July 17, 2013
Design Engineer: GARNESS ENGINEERING GROUP LTD
Subdivision: FETROW
Site Legal Address: FETROW LT 2 G:1057
Owner/Address: FETROW LESLIE F & DOROTHY F
C/O SANDRA K FRENCH PO BOX 671561 CHUGIAKAK 995671561
Site Mailing Address: 18305 OLD GLENN HWY, Chugiak Lot Size in Sq Ft:
Total Bedrooms:
This permit is for the construction of:
102694
N Disposal Field N Septic Tank N Holding Tank N Privy N Private Well Y Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received
Issued Bi
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 05
Property owner(s)Day phone �Z5
Mailing address
Site address 46��)'
Legal description (Sub'd., Block & Lot) FET9-o
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms
THIS APPLICATION IS FOR: THIS APPLICATION IS AN:
Q all that apply)
Absorption Field ❑ Initial ❑
Septic Tank 17— Upgrade)
Holding Tank Renewal ❑
Privy ❑
Private Well ❑
Water Storage _0
THIS APPLICATION INCLUDES A VARIANCE / WAIV R REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
( Ignature of property owner or authorized agent)
.
Permit/Rush y5Rush Fees: �O� ` alver Fees:
Date of Payment: -� -i a Date of Payment:
Receipt Number:_ Receipt Number:
Permit No. _OSP �ajlRS Waiver No.
G ABuildinglOn Site\Forms\Client Forms\Permit App_010411.doc (Rev. 1/11)
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_ 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
ONE
r^�
P�g
NEW
�� /V�
3J
b I.i
E__1 UPGRADE
MAILING ADDRESS
U �O K6 7oo,:�-ch `l _ c? ,5u `%
LEGAL, SCq IPTION/ �jLL 645 ;/:
!iI/lr/� !/Ole T /S )e> Gc� �71a4 s��
LOCATION
NO. OF BED5q9MS
U L
DISTANCE TO:
Well
Absorptio�y /
Dwelling �� /
PE )OW
T O. /�
yH
Manufacturer/r.1-,e f
r' I
No, of co parts
Uq.c a rt alholos
p
IF HOMEMADE:
Inside length
Width
Liquid depth -
OUZ
DISTANCE TO:
Well
D elling
PERMIT NO.
SZFQ-
Manufacturer
Material_
Liquid capacity in gallons
w2
DISTANCE
Well /� rj
FoundatiP pq
Nearest 1pt,line/ i
PE
u Z
No. of lines/
Length a ch Ijne
�
Total len of ines
�
Trench w' th ,e
Distance beoeeplanes
P ? w
o inches
7
I—
Top of tile to fini grade
Material beneath tile �� Gj
Total effy�jve�eb�orp ' n area
O
inches
G OCJ
W
Length
Width
Depth
PERMIT NO.
W
n F
w °-
Type of crib
Crib diameter
Crib depth
Total effective absorption area
y
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class//yy
via
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
i
DISTANCE TO:
Buildingfoundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
'! pp
V `.
_
SOIL TESTR ING
p
INSTALL�F�j�
/W L.L
REMARKS
171
AFX(S71tVC 6405- D BC
Od1FD
CIT"13 167
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f
OF At
............
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M'NICPALf
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r
APPROVED &109148INEt ERINC14 DATE LEGALOR13 19ep-
9riLil.% (RIVER. ALASKA '£S T#12a fis"979
4-0l5 lnev. 3//Sl
fs'
§; ' S ya�rC.Yy .1,; ja..,Yx �{ i`s �.q'WrS�ntcr h�xv.�u� S"'f
tM12Pifi °D 1 TN ,AND ENV RONMENTAL .P EC ON `
i3'EET, ANCHORAGE, AK 99501
Y yap 264-$720 -
1'�I f NCl. 840915
eT ISSUED 10/29/84
�N LtCANT: DOUBLE M., -CONST.
#)RESS'a P.O.. LOX 67005
tt CHUCaTAk, AN 99567 (JI%/LL /3E /2. FG72�G4
pNUTRCI' PHONE: 688-3113
.t �• aES7- 1& 477,44/
OAL DESCRIP: SUBDIVISION: NA LOT: 2 BLOCK. NA
17N TOWNSHIP# 15N R4166 1W
SITE: 4A (SO. FT. OR ACRES)
K BFTDO00MS • 3
` tmd below are the options available to you in designing p • Y . g � g yaur .septic
t . -Choose the option that best fits your site.
q.,, ..... - - - - - - - --- - - - - - - - -
< -' FZ F= h+B E31FlD W Tip FZ 9=k I M
H 1C7 PIPE BOTTOM (FT.) 4.0 4, 0 4.0
L"DEPTH (FT.) 5.0 0.5 3.5 (,
i{ PTH (FT.) 0 4.5 7.5: •:
L W DTH (FT.) ' 2.5 - 14.0,
L L66TH (FT. } 26.0 28.0 X8,0 { -i
NAL :VijLUME (CU. YDS,) 13.3 14.6 20.8
SIZE (QQLS) 1,000.0 * 1,000.0 1$000.0 #x
l Nt_r TN8 (SO. FT. /BR) 85 85 g5
i d MUST HAVE AT LEAST TWO COMPARTMENTS
u.t - -- - - - - - - -- - - - - - - - - - - - - - - - -
rti
'that. �
� a Ia•am familiar with, the requirements for on-site sewers andwellssett
�faith by 'the Municipality of Anchorage (MOA) and the State of Alaska.
' � , r� i �O 8rr l' n ewz tcf4e?$e rr§RrEi�tn£�r�" E if illi O�cFfii4( s and regulat'i
,,W111`adhere to all MOA and State of Alaska requirements for the -set -ba fC
4" distances from any existing well, wastewater disposal system or public
1 sewerage system an this or any adjatent or nearby lot.
rA I;UhdePstand that this permit is valid for a maximum of 3 bedrooms and
f arty.enlergement will require, an additional permit. "
L T,, STA IDN IS INSTALLED. IN AN AREA COVERED BY MOA BUILDING CODESt
494`4) ANS tLECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED;., (2) AS-BUIL.TS•.
Nd Lr APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORTf AND (3) THE
TF,ICA;, K MUST BE DONE.BY:A LICENSED ELECTRICIAN.
14
r6 t--- _
DATE= 1iws,
• - -
SLE CONST.
DATE: r.
Z,ii
PERFORMED FOR
LEGAL
1
n.
2
3 G '7
v
4 a
5 �
6
6
7 v.
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8
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10 J. G
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13-
14-
15-
16-
17-
18-
19-
20
314151617181920
PERFORMED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
L 2
G 144
iNbert A. 3hakr
No. 1437-F
N
SLOPE
el SOILS LOG
❑ PERCOLATION
TEST
fU,jDKTE PERFORMED: /O
WAS GROUND WATERS
;1
ENCOUNTERED? 'Al L
0
P
IF YES, AT WHAT E [r
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE /T
(minutes/inch)
TEST RUN BETWEEN FT AND
FT
CERTIFI
DATE:
(-ike,' _c /O fIG
cam,!/ -1l/ /�/y. C/ ai�'�✓
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.%1
i
L rrri :sa
BOX 2; 6
al -"e liver, A1asl.a
A 113
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jt.._ A
., MUNICIPALITY OF ANCHORAGE
--� A DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
FEB iu75
RECEIVED
- A 'I / �f
A A' u�
}_ A
I P A j /C
7'
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
Drilling Permit No.
A.D.L. No.
la. Borough
Subdivision
Lor
Block
Ib. 1/4gtrs. -
Section No.
TownnsshipN
Range E❑
Meridian
.ftT1C}i -..,
sj ;:
—of_of—of-
/�
1-6 S❑
S 01"
Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
3. OWNER OF WELL:
>�re Ralph Shipman
�i
Address:
SR Box 31
Street Address -and Area of Well Location
-49 .-nr
2. WELL LOG Feet Below
Sur foes
4. WELL DEPTH: (final)
5.`DATE OF COMPLETION
100 1t.
8-4442 _
Material Type - Top Bottom
D4 rt and: tf oulder$ -. 0 15
6. C] Cable tool j .Aotory C] Driven C] Dug
11 Auger ❑Jerred ❑Bored ❑Other:
Greens toile lj 70
FraCt:t:@ 70 Pio
7.USE , Domestic ❑ Public Supply ❑.Industry
E]- Irrigation ❑ Recharge ❑ Commerical
isreenstone 0 100
- -
0 Test Well ❑ Other:
S. CASING: ❑ Threaded XEkWelded -
glom. b in. to 20 ft. Depth Weight 17 Ibs./ft.
diam. in. fo_ft. Depth -Stickup fr.
-
.. 1PAL1T'f CF
9. FINISH OF WELL:
1 '. ...-
EPI r n
_ Type: �'3P. t7 TiA'f.P Dlometer: t1
Al
[i
SI ofMesh Size: Length:
set between 1r. and ft.
n
G
Backfilling - - Gravel Pack
10. STATIC WATER LEVEL: fr.
.,o
❑ Above or ❑ Below fond surface .Date
Equipment used:
I I . PUMPING LEVEL below land surface and YIELD
ft. atter -.hrs. Pumping g.p.m.-
ft. after —hrs. pumping g.p.m.
-
-
-
12.GROUTING Well Grouted: ❑ Yes ❑ No -
Material: ❑ Neat Cement ❑ Other:
13. PUMP: (if available) HP
Length of Drop Pipe ft. capacity g.p.m.
O Subm. ❑ Jet ❑ Centrificul ❑ Other
14.REMARKS:
Bail tested at 1 GYM
16. WATER WELL CONTRACTORS CERTIFICATION:
15. Water Temperature _° ❑ F ❑ C
This well was drilled under my jurisdiction and this report Is true to the best of my knowledge and belief;
Magnuson Drilling AA 530.5
Registered Business Name Contract License Number
P.O.Box 504 Eagle River, Ake
Address:
Signed L,,a ...(. r11 t.9 /�F�[.�/^C�a—.... Date:
= Authorized Representative
Form 02-WWR (11/81) - Copy Distribution: WHITE-Stoie DGGS, PINK -Driller, CANARY -Customer - -
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ei.anchorage.ak.us
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-221-- COSA# Q S
1. GENERAL INFORMATION Expiration Date:
Complete legal description FETROW S/D; LOT 2
Location (site address) 18305 OLD GLENN HIGHWAY * CHUGIAK. AK * 99567
Current Property owner(s)
Mailing address
Lending agency
Mailing address
LESLIE & DOROTHY FETROW Day phone C/O AGENT
Day phone
Real Estate Agent DIANE SHEARER W/ KELLER WILLIAMS Day phone 696-6500
Mailing address 101 W. BENSON BLVD, #503 * ANCHORAGE, AK * 99507
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
0
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 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.
Address
3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
to conducting this evaluation, GEG, LfD. 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 unde- the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational lire of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Phone
337-6179
Date ����
oo�opp
o OFA pop
O*
_H
0
................
f G ness. G
P C7 `O
U4Pd r'ro f e s si00�o�
��44000��
,%N- vg1OFA6
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist ins Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other 7
By: Original Certificate Date: —
tRe��ivosi �
ON-SITE
WATER AND
WASTEWATER
PROGRAM
Municipality of Anchorage �E ,
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: FETROW die; LOT 2
Parcel ID: 051-221- j `3
r�
A. WELL DATA *BEDROCK **SMALLONS OF WATER STORAGE INSTALLED IN HOUSE.
Well type PRIVATE If A, B, or C provide PWSID# N/A
Well Log (Y/N) YES
Date completed 1/77 Sanitary seal (Y/N) YES
Wires properly protected (Y/N) YES
Total depth 252 ft. Cased to *36 ft.
Casing height (above ground) 12+ in.
FROM WELL LOG
AT INSPECTION
Date of test 1/77
7/14/11
Static water level 22 ft.
48 ft.
Well production 0.4 g,p.m.
**0.22 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 2.02 mg./L.
Collected by: GEG, Ltd.
Arsenic: NO ug./L. Date of sample: 6/20/12
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Date installed 11 /10/84
Tank size 1000 gal. Number of Compartments E
Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO
High water alarm (Y/N) N/A
Date of pumping 7/12/11 Pumper
JR'S PUMPING
C. ABSORPTION FIELD DATA 'BELOW EXISTING GRADE
Date installed 11/10/84 Soil rating (g.p.d./ft`or /bdrm 85
System type DEEP TRENCH
Length 26 ft. Width 2.5 ft.
Gravel below pipe 5 ft.
Total depth *8.5 ft. Eff. absorption area 260 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 7/14/11 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 785 gal. New depth 2 in.
Elapsed Time: 110 min. Final fluid depth 0 in.
Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE
KNOWN If yes, give date —
D. LIFT STATION
Date installed
"Pump on" level at in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off"
Manhole/Access
water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/I'rft station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main
Sewer /septic service line 25'+
Public sewer manhole/cleanout N/A
Holding tank
Animal containment areas 50'+ Manurelanimal excrete storage areas 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 main N/A
Water service line 10'+ Surface water 100'+ Driveway, parkingtvehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
l codify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSH guidelines in effect on this
date.
Engineers Printed Name JEFFREY A. GARNESS
Date -719(/2
COSA Fee S L `1 U
Date of PaymentG!%l �
Receipt Number G -7-a7c�C//
7
(Rev. 11/05)
Waiver Fee
Date of Payment
Receipt Number
JUL-9-2012 13;28 FROM:K&L PLUMBING & NEPTI 1-997-694-2441
G
PRODUCT 211
K & L PLUMBING &. HEATING, INC.
P.O. Box 774792,,.
T0:6966505
C.
V L.y
JOB INVOICE
33054
i
P.2/2
2
S.F.
OLD GLENN HIGHWAY
N 50039'43"E 454.88'
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POLE
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5' DRAINAGE ESMT.
N 50"38'48"E 463.55'
UM,
TED. �
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TO
ENl'S, AV•
JOT Tk. 49TH t *��
'LAT. .................. "JO
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DATA ...........
FOR m Jeffery A Gaslaldi /
iO� :� A.
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FETROW 5
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102,1
b
GASTALDI LAND
SURVEYING, LLC
JEFF A. GASTALDI, R.L.S.
t000 E. DOWLING RD., SUITE 8
ANCHORAGE, ALASKA 99507
PHONE 248-5454
GRID
NW 1057
DATE
6/29/2012
I HEREBY CERTIFY THAT I HAVE SURVI
PROPERTY DEPICTED ABOVE AND THA
ENCROACHMENTS EXIST EXCEPT AS It
IT IS THE RESPONSIBILITY OF THE OW
DETERMINE THE EXISTENCE OF ANY E
COVENANTS OR RESTRICTIONS WHICH
APPEAR ON THE RECORDED SUBDIVIS
UNDER NO CIRCUMSTANCES SHOULD
HEREON BE USED FOR CONSTRUCTIO1
ESTABLISHING BOUNDARY OR FENCE
ANCNnRAnF RrrnRniNn ❑I_RT irr
*MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
•� ' APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
(a) Legal
Location (address or directions)
(b) Applicants
Applicants Address 7z) a a
(c) Applicant is (check one) Lendiot3
Buyer = ; Other Q (explain);
Application Date /— v O — 9 S
ision, segtioq, tgwnsAip, range)
699-1-3113, -
phone - Home Business
Owner/builder ;
(d) Lending Institution /frpi.J 0' Telephone
AdcTrgss
(e) Real Estate Co. & Agent
Address
IM 11/7
Telephone
L
(f) the HAA to the following address:
2. Type of Residence
Single -Family Tszr
Number of Bedrooms
3. Water Supply
Multi -Family
3
Other (describe)
Individual Well Community Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite I '�-' Public Community Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[:Page 1 of 2]
5. Engineering Firm Providing Inspections Tests File Search, Data and
As certified by my seal affixed hereto and as of the validation date shown below 1
verify that my investigation of this Health Authority Approval shows that the on-site
water sapply and/or wastewater disposal system is safe, functional and adequate for
the nunber of bedrooms and type of structure indicated herein.- I further verify that,
based sa 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 regula-
tions !a effect on the date of this inspection.
Name of Firm
M
Address
Date /-
Telephone
n�'•,� 1457 -L -
6.
457.i/
6. DHEP Aporoval
Approved for bedrooms �av: ,� ate CXJ
Approved -- Disapproved Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS- 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2] 7-19-84
MUNICIPALITY OF ANCHORAGE
U°PT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA) ENVIROiVPhENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A_ WELL DATA
Legal
f
FEB n5
T/_SN iC ! w
Well Classificatio GZ _ If A, B, or C, D.YE.C. Approved(Y/N)
Well Log Present (Yk Date,Complete�l J.gl.� %%% Yield
Total Depth " cased to 36 Be�r� Depth of Grouting
Static Water Level Z 1 Pump Set At
It -
Casing Height Above Ground C Z " Sanitary Seal on Casing ( )
Electrical Wiring in Conduit (Y Depression Around Wellhead (st
Separation Distances from Well:
To Septic/HTank on Lot ��a S r ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot '78 On Adjoining Lots L1 Af0/_"O
To Nearest Public Sewer Line —10,U//4 To Nearest Public Sewer '
Cleanout/Manhole A}A To t4arest Sewer Service Line on Lot 'ZS 7A -
Water
Water Sample Collected By -75. 5; Date �z
Water Sample Test Results c
Comments 111�0 A-11
B. SEPTIC/ TANK DATA
Date Instalie C3 _ Size No. of Canpartments
Standpipes (Y Air -tight Caps (Y hN Foundat,io�j Cleanou (Y )
Depression over Tank {JZ Date Last /$Pumped Z P /�
Pumping/Maintenance Contract on File
,{Y 111P ; for 1
Holding Tank High -Water Alarm (Y/[ ,� Temporary Holding Tank Permit (YA1,W
Separation Distances fran Septics Tank:
To Water -Supply Well /j�f To Building Foundation
To Property Line 'Lo To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course "Pu O fit=
Receipt #
Date Paid: U
Amount:
(Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Abscrpti n Strata kS_i�6i Type of System Design en_C [9
Date Installed l� �' ngth of Field
Width of Field `j�� Depth of Field
Gravel Bed Thickness a b
Square Feet of Absorption Nea Z �® Standpipes Present (Y
Depression over Field (71 Da of Last Adequacy Test h1 C�
Results of Last Adequacy st %✓ !� ®�
Separation Distance from Absorption Field:
To Water -Supply Well % 7e To Property Lire zo
To Building Foundation Z & r Terror Abandoned System on
Lot 3.0 4- ; On Adjoining Lots 4V N '0 F c%
To Water N&WService Line %C7 1F To Cutbank( if present) Ai YJ AJC
To Stream/Pond/Lake/or Major Drainage Course AJ 0 N Offr
To Driveway, Parking Area, or Vehicle Storage Area ZO f
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons Manhole/Access (YIN)
"Pump On" Level at p f" Level at
High Water Alarm Level at Vent (yLN)
Tested for Pumping Cyc s ing Adequacy Test. gets MOA
Electrical Codes(Y/N)
Convents
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all M.A. HAA Guidelines in effect
on the date of this inspection.
Signed Date
Company SRB 1 SK& CUT MOA No.
PF9, 6
KBl/d5/s
(Page 2 of 21
2-15-84
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date �kf VLL''
Z-),-
(a)
'
(a) Legal Description (include lot, block, subdivision, section, township, range)
AA, 47'1�%Z a / 7 T/ 5 V IFD//cJ
Location (address or directions)
L- � GL€nJ
(b) Applicants Name
Applicants Address_
2-72-
lephone - Home Rnnina.,
(c) Applicant is (check one) Lending Institution Owner/builder
Buyer � ; Other [-:::I (explain); ;
(d) Lending Institution /l.1 0 moi/ Telephone
Address
(e) Real Estate Co. & Agenty_"n /L.t F
Address
Telephone
AIL0
(f) Ma.44-the HAA to the following /address:
J! _S t Z mlAE'E:'/i2
C
2. Type of Residence
Single -Family
Number of Bedrooms
3. Water Supply
Individual Well
Multi -Family
Z_
Other (describe)
Community M Public M
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite Public Community Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. Engineering Firm Providing Inspections, Tests. File Search. nor. —A r..c,._._
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 regula-
tions in effect on the date of this inspection.
Name of Firm53o 1157 Telephone i'
Addreas ��. �i �' > T 22
Date AF ®r�� Ok- At It
'•4 ttt
(ENGINEER SEAL)
6. DHEP Approval a sr,«ior ec`
'n •. No. 1457-E ,
Approved .for `� bedrooms By + j(" It `j' ' 4 £ °'
Approved Disapproved Conditional
Terms of Conditional Approval C, C), o) %r/o9p /zO/?j/1JC TZCQ� F22G1 /.3E
//v 5 7x, t.�
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT—
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE—
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE ISNOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 21
7-19-34
........... ...........
MUNICIPALITY OF ANCHORAGE (MOA)
i
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA Legal Description:
!1J /43 l GI.J I S" /.tet
Well Classification Prc j[JC k If A, B, or C, D.E.C. Approved(Y/N) %�—
Well Log Presen ( Date Completed ;R''k � Yield s
Total Depth %e70' Cased to 26 � 13 % Depth of Grouting
Static Water Level .00 Pump Set At 4
Casing Height Above Ground .30 " Sanitary Seal on Casing (Y
Electrical Wiring in Conduit (Y/ j Depression Around Wellhead W
Separation Distances from 411:
To Septic/`Hc� Tank on Lot /00 On Adjoining Lots /CSC
To Nearest Edge of Absorption Field on On Adjoining Lots /00
To Nearest Pubis Sewer Line /0 Zr-l- To Nearest Public Sewer
Cleancut/Manhole Al To Nearest Sewer Service Line on Lot c'SO
Water Sample Collected By �/?Py/%�l Date //�Z �9Z
Water Sample Test Results -7-15 L19C7'-1/0
Comments /Q 0 P
B. SEPTIC/%'TANK DATA JV
Date Installg4 GLt< Size / CT�o No. of Ccrnpartments u
Standpipes (Y Air -tight Caps (Y'Foundation Cleanout 'g/ )
Depression over Tank (§7 Date Last P l/ Z7 9�
Pumping/Maintenance Contract on File (Y//N) for
Holding Tank High -Water Alarm (Y/N)L" 'i? Temporary Holding Tank Permit (Y/N)4
Separation. Distances from Septiclf Tank:
!
To Water -Supply I,bll To Building Foundation c5_0
To Property Lire /CJ To Disposal Field CL 4 -
To
To Water 4ervice Line P7"—, To Stream, Pond, Lake, car Major Drainage
Course 'kf 0
Comments f1�2 Tim/�s�
Receipt #
Date Paid:
Amount:
[Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in
Absorption Strata
Type of
System resign
7�61C Aj
Date Installed
LA 4c
Length of Field
/..C -
Width of Field
go "
Depth of Field
6t L -C_
Gravel Bed Thickness _ U VL
Square Feet of Absorption/ �A1rea LL 6-C Standpipes Present (WI)
Depression over Field (ZPDate of Last Adequacy Test // 2
Results of Last Adequacy L_A1Z.vk
. 7�✓ BE'
Separation Distance from Absorption Field:
To touter -Supply TAb ll /L; � �� To Property Line /0 C�
To Building Foundation cSL� �tL To Existing or Abandoned System on
Lot 4' -�' h J F On Adjoining Lots 30 i,4
To Water Mar?/Service Line 5 1f To Cutbank(if
To Stream/Pond/Lake/or Major Drainage Course A-' 0 AJ
To Driveway, Parking Area, or vehicle Storage Area (,tCoicmients ��C� CQ e-,, s�cv¢Wa✓ /-Le n /Xi -a 7eld
4aIFA-,rlbF�-z 1"1TS„r NL'w 04JA.'c� Ceti
D. LIFT STATION / eec<'L E.eL,
Date installed
Dimensions
-rd ®:J
�irvx
Size in Gallons Manhole/Access (Y/N) _
"Ptunp On” Level at ifXesirVienq
evel at _
High Water Alarm Level at nt (YM) _
Tested for i Cy Adequacy Test. Meets MOA
Electrical Codes(YM)
Comments
** Check Perm
I certify that
on the da of
Signe
Conga
KBl/d5/s
(Page 2 of 21
Bedroom Rating Against HAA Request **
I )fave checked, verified, or conformed to all MOA HAA Guidelines in. effect
Date .
MOA No.
x ,
2-15-84