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HomeMy WebLinkAboutKRAMP BLK 3 LT 1Kromp Block Lot ! #016-171-10 Parcel I.D. L i 1, GENERAL INFORMATION ~ I 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/onsit8 - (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEHS APPROVAL FOR A SINGLE FAHILY DWELLING COSA# O~- Expiration Date: /O Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address KRAMP S/D; BLOCK 3~ LOTS 1 & 2 11800 NORTHERN RAVEN DR * ANCHORAG~ AK * 99516 MT. ROBERTS DEVELOPMENT, LLC. Day phone 7945 PORT OXFORD *ANCHORAGE , AK 99507 Day phone BRIAN BRODERICK W/ PRUDENTIAL Day phone 748-~900 5801 CENTERPOINT DR #200* ANCHORAGE, AK * 99505 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 [] 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 ~ (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. Phone' 357-6179 Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS. P.E. Date '~/1~/I0 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 perfon~ance 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 so/le 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 iisted above. Any reliance upon or use of this report by any other person or party is not authorized, nor will tt confer any legal right whatsoever. $, DSD SIGNATURE ~_~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev. 11105} Arsenic Advisory Maidtenance Agreements Supplemental Engineer's Report' Other ///~-'2~ 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/onsJte (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEHS ,PPROVAL CHECKLIST Legal Description: KRAMP S/D; BLOCK 3, LOT 1 &: 2 Parcel ID: A. WELL DATA Well type PRIVATE Date completed ,,,1964 Total depth *65'+ ff. *PER GEG INSPECTION 12/4/2009. **PER SURROUNDING WELL LOGS. SEE ATTACHED. If A, B, or C provide PWSID# N/A Sanitary seal (Y/N). YES Cased to **40% ft. Well Log (Y/N)~ NO Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. Date of test Static water level Well production FROM WELL LOG ~ g.p.m. AT INSPECTION 12/4/2009 45 ff. 7.8 g.p.m. WATER SAMPLE RESULTS: Coliform (~ colonies/100 mi. Arsenic: ~1~ ugJL. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size__ gal. Foundation cleanout (Y/N)__ Date of pumping C. ABSORPTION FIELD DATA Date installed NitrateO, ii {Omg./L. Other bacteria (~ .colonies/100 mi. Date of sample: 7/9/2010 Collected by: GEG Ltd. [PUBLIC SEWERI Date installed Number of Compartments __ Cleanouts (Y/N) J Depression over tank (Y/N)__ High water alarm~.,(,Y~. Pumper Soil rating (g.p.d./ft2or em type Width ../- ft. Gravel below pipe ft. Length ft. Total depth .ft. Eft. absorptio~ ft2 Monitoring tube Depression over field__ Date of adequacy test / Results (Pass/Fail) Fluid depth in~ before test in. For bedrooms Water added __gal. New depth in. in. Absorption rote >= g.p.d. If yes, give date D. LIFT STATION Date installed. "Pump on" level at Da__~tum ...-------------'--- Cycles tested. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons ~ ..-----~~ ~ High water alarm level at in. Meets alarm & circuit requiremente~ *PER 1696 CODE. Septic tank/lift station on lot Absorption field on lot Public sewer main *50'+ Sewer/septic service line 25% Animal containment areas. 50'+ On adjacent lots N/A On adjacent lots N/A Public sewer manhole/cleanout *50'+ Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO: [PUBLIC SEWER] Building foundation Property line. Absorption field Water main Water service line Surface water ~ on adjacent lots ~ WeJls SEPARATION DISTANCE FROM ABSOR~LOT TO: Property line ~ziJ~ir~foundation__ Water main~ w~ay, perking/vehicle storage F. COMMENTS 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 N?me JEFFREY A. GARNESS Date ~ /11~ / I 0 COSA Fee Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment. Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Wa[er & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.m unLorg/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEHS APPROVAL FOR A SINGLE FAMILY DWELLING 1, GENERAL INFORMATION COSA# © ff O /¢'.¢'/ Expiration Date:_ ~ "~ ~-- / O Complete legal description KRAMP S/D; BLOCK ,5, LOTS 1 &: 2 Location (site address) 11800 NORTHERN RAVEN DR * ANCHORAG, AK * 99516 Current Property owner(s) Mailing address Lending agency Mailing address MT. ROBERTS DEVELOPMENT~ LLC. 7945 PORT OXFORD *ANCHORAGE Day phone _ ~ AK 99507 Day phone_. Real Estate Agent Mailing address BRIAN BRODERICK W/ PRUDENTIAL Day phone 748-.4900 5801 CENTERPOINT DR #200* ANCHORAGE~ AK * 99505 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 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 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 sea/affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of Qn-Site Systems Approval Guidelines for this application, shews 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. Phone 357-6179 Date Engineer's Comments: In conducting this evaluation, G£G, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The repotted results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable featurea. The operational life of all wells and septic systems depend on the local softs condition, groundwater levels that may fluctuate during the year, and the water usage of the family being Sealed 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 MQA DSD. The content of this report is for the sole beneN 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 fighl whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for __ bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev. 11/05) Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reporf Other ' Original Certificate Date: / ~_~ . .~_ L/._ ~)~/~ Municipality of Anchorage Dovelopmont 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 O CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type PRIVATE Date completed --, 1964 Total depth '65'+ ft. KRAMP S/D; BLOCK 3, LOT 1 & 2 ParcellD: O/(-¢-- /"'7[--/L.,~ *PER GEG INSPECTION 12/4/2009. **PER SURROUNDING WELL LOGS. SEE ATTACHED. IfA, B, or C provide PWSID# N/A Sanitary seal (Y/N) YES Cased to **40% ft. Well Log (Y/N) NO Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. Date of test Static water level Well production FROM WELL LOG AT INSPECTION 12/4/2009 45 .ft. ,,--~' g.p.m. 7.8 g.p.m. WATER SAMPLE RESULTS: Coliform {~) colonies/100 mi. ArseniC: I~. ~ uo.tL. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size__ gal. Foundation cleanout (Y/N)__ Date of pumping C. ABSORPTION FIELD DATA Date installed Length ft. Total depth .ff. NitrateO, i f I mg./L. Other bacteria ~ colonies/100 mi. Date of sample: 12/4-/2009 Collected by: GEG Ltd. IPUBLIC SEWERI Date installed Number of Compartments __ Cleanouts (Y/N) J Depression over tank (Y/N) __ High water alarm_~,YJ~ Pumper Soil rating (g.p.d./ft2or ~tem type Width J ff. Gravel below pipe ft. Eft. abs ft Momtormg tube Depression over field__ ,~' Results (Pass/Fail) Date of adequacy test Fluid depth in~ before test in. VV~ater added gal. Elapsed~: . min. Final fluid depth in. Absorption rate >= A-rr'y rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date For bedrooms New depth in. g.p.d. D. LIFT STATION Date installed Size in gallons ~ ~ "Pump on" I~ High water alarm level at__ .in. Da.__~j.g_tum ~ Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main '50'+ Sewer/septic service line 25'+ Animal containment areas. 50'+ *PER 1696 CODE. On adjacent lots N/A On adjacent lots N/A Public sewer manhole/cleanout '50'+ Holding tank N/A Manure/animal excrete storage areas 100% SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: iPUBLiC SEWERi Building foundation Property line Absorption field Water main Water service line Surface water ~ on adjacent lots. ~ Wells SEPARATION DISTANCE FROM ABSOR~LOT TO: Property line ~oundation Water maln~ W~w y, parking/vehicle storage F. COMMENTS 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 $ ~ ~ O Date of Payment *~ ~, ] c~ ~ I ~c'~ Receipt Number 01¢1~[~ ~9 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On-Site Systems Approval # 090451 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 1 & 2 of Kramp Subdivision. This inspection revealed an arsenic concentration of 14.4 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On-Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. CHINOOK AVENUE N 89'57'2t3" E '~5' UTIL ESMT $ 7'20' W ---" 160.17' Z m 30' Prepared by Robert E~ dohns, 3r. & Assoc. Professional Land Surveyors D,~,, r,~.~ 9-30-09 J~,4: 2733 ~,o. 9230 Lot 1 & 2 Block 3 SYMBOLS ~._o,~: MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Telephone: (home) Business Location (addre&s or diiectiqns) (b) Property. owner,,,¢ ,~/~ ~ Mailing Address -' . (c) Lending Institutibn Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: (e) 2. TYPE OF RESIDENCE Single-Family'[~. Number of bedrooms 3. WATER SUPPLY Individual Wel I"~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Pub[ic'~¢ Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev 7/88) Page 1 of 2 leAoJdd¥ IeUO!l!puoo Jo suJJej. leUOpjpuoo pe^oJddes!c] ,~. p@AoJddv ~, Jo~ pe^oJdd¥ lVAO~Id~t¥ SHHa '9 e~eO /v[UNJClPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES Dr~$1~iONI~ CiPALiTY OF ANCHORAGE (MOA) jU! (/~_ Health Authority Approval (HAA) R E C E I V E D Legal Description: A. WELL DATA Well Classification Well Log Present (YL~ Y Total Depth >' (~,,5' 'Cased to ~)~//'//~/'-~'~ If A, B, C, D.E.C. Approved (Y/N) Date Completed ~/~v"~/~/,,Jx/ Yield '~ Depth of Grouting ~,'/,4 Static Water Level ¢r'tf f Pump Set At -'~J/~ Sanitary Seal on Casing (~N) Depression Around Wellhead (Y~') Casing Height Above Ground Electrical Wiring in Conduitj~/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line-" To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments /,~E'Z~P ,¢'/.¢~ -;z~-'3"7- ; On Adjoining Lots /)/~ ; On Adjoining Lots ,d/,~ To Nearest Public Sewer Cleanout/Manhole ; Date ¢/ B. SEPTIC/HOLDING TANK DATA ~#~f/..t& ,5'E~J~ ~alled Size No. of Compartments Standpip~ Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tan-'k~__ __ Date Last Pumped __ PCmtenance Contact~L.~e (Y/N) __; for ~ Holding Tank. Hi'g .h-' 'W~r. W~ -~.A~-Iarm (Y/N)~'".-.,_ Temporary Ho d ng Tank Permit (Y/N) SEPARATIO~I:D~I~]'AI{I~,'.I:~OM SEPTIC/HO'"~"L'~G TANK: To Watbr::Sa'pply~l~[1,1~,I~ t~ To~'"~"'B~ding Foundation __ To ProPerty~L,i. ne~~_ To Dispos-"~eld __ TO war? Mai n/SCr~4? Ei~ ,:':,, ' ~ TO Streaml Po'~id., Lake o~ I~aJb'r'Drainage Course ~ Comments : ' ' :'. ~ 72-026 {Rev. 7/88) Front Page 1 of 2 ~--~,~-~. Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test C. ABSORPTION FIELD DATA '~.ls Rating in Absorption Strata Dat~4~lled __ __ Width of Results of Last Adequacy Test SEPARATION DISTANCE FROM ABsORP~ FIELD:~ To Water-Supply Well ~ To Property Line To Building Foundation ~ To Existing or Abandoned System on Lot ; On Adjoin~ To Water Main/Service Line T Cutback~t) To Stream, Pond, Lake, or Major Drainage Course CommentsTo Driveway, Parking Area, or Vehicle Storage Area D. LIFT STATION "Pump On" Level at ~ "High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~ Vent (Y/N) ~ ~Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines inspection. Signed Company Date MOA No. Receipt No O: c~/c~4 7 ~'~¢.~0 ~ Date of Payment Amount: $ 72-026 (Rev. 7/88} Back on the date of this Receipt Waiver Fee: $ Date of Payment Page 2 of 2 General Information MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH ~ ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE (a) Legal Description (include lot, block, subdivision, section, towmship, range) Location (~ddress or direction) - nome Business (c) Applicant is (check one) Lending Institution Buyer ~ ; Other~--~ (explain); Ad~A~ss (e) Real Estate Co. & Agent ~ ; Owner/builder~ ; Telephone Address 2~ T~pe of Residence Single-Family~ Number of Bedrooms (f) Mail the HAA to the following address: Water Supply Individual Well~ Multi-Family ~--~ Other (describe) 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 Note: If community well system, must have w~itten confirmation from ~he State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] En~ineerin~ Firm Providing Inspections~ Testst File Search~ Data and Informatiou 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 tho om-site water supply and/or wastewater disposal system is safe, functional and adequate for the n~mbor of bedrooms and type of structure indicated herein.. I further verify that, based on the information obtained from the M~nicipality of Anchorage files and from my investigation and inspection, the o~-site w~ter supply and/or wastowater disposal system is in compliance with all Municipal and Stato codes, ordinances, amd regula- tions in effect on the date of this inspection. Name of Firm~ Telephone D~P Approved Toms of Co~ieion~ Approv~ CAUTION TM MUNICIPALITY OF ANCHORAGE DEPARTMENT OF R~LTH AND ENVIRONMENTAL PROTECTION (Dw~P) ISSUES HEALTH AUTHORIT~f APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPI{ 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN '1%1~ STATE OF ALASKA° THE D~EP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES 0F DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS 0R OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RRd/eJ/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ,~Lvi~HORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITy OF ANCHORAGe. DEPT. OF HEALTH & rNVIRONMENTAL PROTECTION Well Classification /~ ~! ~/ll3,~j,,~ I_ Well Log Present (Y/N) /%/ Date Completed Total Depth / ~ {~ / Cased to ? ~ ~ Static Water Level., _/ ~3~ / __ Pump Set At Casing Height Above Ground ~ /, Electrical Wiring in Conduit (Y/N) Separation Distances frc~ Well: To Septic/Holding Ta~k on Lot-- To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ? ~ ?~ If Ar B, c~ Cr DoE.C. Approved(Y/N) ~x~ / ~f'~ ~' Yield~ Depth of Grouting /t),//9 Sanit~y ~al on ~si~ (Y~) ~essicn ~nd ~l~ead (Y~)~ ; On AdjoiniJg Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole /~ /~ To Nearest Sewe~ Service Line on Lot ~/6) z Water Sample Collected By ~r .~//~/.'~/~ (.'~' ~ ~te ~- ~ ~ - ~.~ ~ .... Water S~fe Test ~sults _ ~/.%~C ~ ~ C~nts S IC/HOLDZ S DATA c t c_ Date Installed ~Size No. cf CQtTa~tmsnts Standpipes (Y/N__) .Airtight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) __ ,~te Last Pumped Pumping/~4aintenance Contract on Fil% (Y/N) ; for Holding Tank 'High-Water Alarm (Y/N) ~ Tempora~ Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply %~11 ', To Building Foundation To Property Line Tox Disposal Field To ~ter Main/Service Line To S,,~eam, Pond, Lake, c~ Major D~ainage Course '· Corm~nts , [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Ratin~ in Absorptxion Strata \ Date Installed Width of Field Results of Last Adequacy Test Separation Distance f~om Absc~pt~n To Water-Supply Well Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes P2esent (Y/N) Date of Last Adequacy Test ' To BuildiP~3 Foundation ~ Lot ; On Adjoin~g Lots To Water Main/Service Line To Cutbank( if present) To St~eam/P°nd/Lake/c~ Major D~ainsge stC~o~a~ To D~iveway, Pa~kin9 Aatea, c~ Vehicle A~ea Ccx~rents ~ Field: To P~operty Line To Existing or AbandoEed System cn D. LIFT S~TION Date Installed Size in Gallons "Ptlmp On" Level at High Water Alarm Level at Tested fo~ Electrical Codes(Y/N) Comments Di~eneions Manhole/Access (Y/N) "Pum~ Off" Level at Vent (Y/N) Cycles cknting Adequacy Test. ~eets ~DA ** Check Permitted Bed~ocxa Rating Against HAA Bequest ** certify that I have checked, verified, or confo~.,L~d to all MOA HAA on the date of this i~pe.~. Signed.,~~ Date ~-~2 ~ - ~-~ in effect [Page 2 of 2] 2-15-84