HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3A BLK 4 LT 11Thund,,erbird
Heights
Block 4
11
#051-721
-37
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
LEGAL DESCRIPTION
LOCA'[
Inside length
NO. OF BEDROOMS
Liquid depth
Well
DISTANCE TO:
PERMIT NO.
Manufacturer
DISTANCE TO:
MateriaJ Liquid capacity in gallons
Foundation . Nearest lot line PERMIT
inches D istanc~tf~n lines
Tota~e~v~bsor ptio n area
inches PERMIT NO.
Top of tile to finish grade
Length Depth
Type of crib Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
Total effective absorption area
Nearest lot llne
Class Depth Driller Distance to lot line
DISTANCE TO: Buildihg foundation Sawer line Septic tank
OTHER
SOiL TEST RA~
REMARKS
APPR~,~ DATE LEGAL
72-0 l~'Rev. 3/78) ~,J -
F'ERHIT '"
FIPF:'L ! CRN-F
LOC:RT I ON
GSK C:ONS;T
L±:L E4 '['HUNDE~:BiI'~[:, H'TS;
27EiE~E~ FJ_7..._F!fE'E FEET
MFI;:-:;IMI:JM fl..J[ E,.-=r*. OF E~E[)RCIOI'd:~
THE LENGTH DZMEr",!SION ZS THE LENGTH '::IN FEE'T) OF TH, E -FRENCH (;;iR DRFIINFIELD.
]"HE I:)EF'TH O1:= F:I TRENC:H OR I::'!T :[:5 THE .,.r.."iSTRNCE BETk~E:EN THE SURI::'RCE Of: THE
GI:;'.OUND Ri'q[> THE 80'T'TOM OF THE EF-','CFA,,'RTICfN ,::IhJ FEET:).
'i'..'--IEI:~E IS; NO SET 14I[:,TH FOR TRENCHES.
THE GRR',?EL. DEPTH IfS, THI:E MINIM. UH DEP"F,'q OF GRF!',,,'EL. E~E-f'HEEN ]'HE OUTFFIL.L. PIPE
RND 'THE BOTTOt-,I OF 'THE EXCI::¢,/F';TION (IN FEET).
h'~z[d"l!T F!F'F',_irj:I::INT HF:Lc 'THE ,..E::, u,,,:,~.E,.,-L_..
I NSTRLL!::~T t l:]f',i l NSF'ECT I ElF,iS OF I=I?',?T'
i"~,UHBER I:]F RES~[:E?'.]:.I:2S THFiT THE kiELL. P.!ILL
[:' E F:'FIR ]?IE !",Fl' C, [;' r[ l'"l I]~
F'R'Z~PC=~'T"~' RND THE
HI.k!!?!Ufd DIST'R,qCE 8ETHEEF!
:~[2i9 FEET FOR F! PRIVRTE NELL OR 15C~ 'f'O 2E~el F:EET FROM B F't..!Eff.,.ZC !4E;L..L. DEPENDING
!..IP O ~.4 THE
MZNZHI:JH DZSTF!NCE FROM R F'RZ',/FITE NELL. TO
TO FI COHHUNIT'?' SEi4ER LINE iS 7~i FEET.
OTHER REQUIREHENTS I','!R'~-' RF'F'L'-¢. SPECIFZCRTION:S` FIND COF,ISTRUC-F!ON DZRGRR!"IS RRE
RVR!LFIBLE TO INSURE PROPER ZNSTRI:_LR]'!ON.
I CERT!F'?' 'TPIRT
:i,: I A.rd !:RM.ILIFiR FiITH THE RE,'.';!UIREMENT'.E; FOR ON-SiTE SEk!EF?.S AND P,!EL.LS RS SET
F'ORTH E:"? "rkiE MIJNIC]:F'RL!T'¢ C)F FINCHC)?.FiGE.
;2: I WiLL INSTF!LL THEE S'¢STEI'4 IN RCCORDF4NCE !,iITH "f'F!IE CODES.
:Z: I UNDER:E;TF!N[) THFiT THE OF,l-SiTE :5EP.IER E;"r'STEP! Mt:l? REQUIRE ENL_F!RC~EMEN'F iF 'T'HE
RESIDEhK];E IS REMODELED TO !F,ICL. UDE MORE THFit"! '~ BED?.OOMS.
~ .................................................
:S I GNED: .. RF'F'L I "~'h! T
.V9. .- ,
Russell Oyster
694-2774
Performed for:
O & E ENL.,'~EERING & DEVELC,, ~MENT CO.
!' , ,' ~X 90. Davis St., Eagle River, Alaska 9957~?
Legal Description:
694-2774 or 688-2280
Earl Ellis
688-2280
Tel. No. 4~-~. ~' ~/
SOIL LOG
Depth (feet)
Soil Characteristics
0
1__
2__
3__
4__
5__
6
7__
8__
9__
10__
11__
PLOT PLAN
12__
13__
14__
PERC. TEST
15m
Ground Water Encountered: Yes__ No / If yes, what depth
Proposed Installation: Seepage Pit
Drain Field__
Comments:
Performed by: Date' .,2,/~
•
•��t� Municipality of Anchorage
E-- B��`
o.
•
On-Site Water and Wastewater Program aF, x
(907) 343-7904 S A ETY
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-721-37 Expiration Date: D--,31
1. GENERAL INFORMATION
Complete legal description THUNDERBIRD HEIGHTS#3A B4, L11
Location (site address) 24837 TEAL LOOP,CHUGIAK,AK 99567
Current Property owner(s) GEORGE&DANNA WEAVER Day phone
Mailing address 24837 TEAL LOOP, CHUGIAK,AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ❑ Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class A Well ® Public Sewer ❑
Public Water System ❑
WaiverNariance request for: Distance:
Received by: Date: c06///q
COSA to be released to the e •' e- • less otherwise requested by the engineer.
COSA Fee $ 5a( Waiver Fee $
Date of Payment ql(Z. (� Date of Payment
Receipt Number Oct_ nb Receipt Number
COSA# 05(101 06 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 ARCTERRA CONSULTING,INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date —6/2674-6" 9/rr/1$
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen ���►\
encroachments,deficiencies or discrepancies exist. OF A T� ,
4, TH * �
6. DSD SIGNATURE _ Aram���i
System #1 Approved for bedrooms. P KENNE.� i.„
System #2 Approved for bedrooms. ¢``> ? /
Disapproved. \ Fess1010,- Air
Conditional approval for bedrooms, Pith the following stipulations:
edtr 0,-Q0( c•ee-::c r •
a S--ek (c k s QavS
•
o .
ON-SITE �vG�
WATER AND R'
tom
_ WASTEWATER z'
l ( RQ § l yr
0=
By. �.j�.,■ Original Certificate Dat% 1'(
` aSZ•":. Sd
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Appro +�� ased 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 Advisd'ry �' ` .
Septic System Advisory Arsenic Ni sorxs •
Well Flow Advisory Other "`' •
COSA blue sheet 10-10-12.doc
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: THUNDERBIRD HEIGHTS#3A B4 L11 Parcel ID: 051-721.37
A. WELL DATA
Well type A If A, B, or C provide PWSID # 211156 Well Log (Y/N)
Date completed Sanitary seal (Y/N)Y Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic: ug/L Date of sample: - Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 4/1/1982
Tank size _1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y(Inside Garage) Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 3-31 -( F Pumper Sanitary
C. ABSORPTION FIELD DATA
Date installed 4/1/1982 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type DEEP TRENCH -Length 30 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 9.75* ft. Eff. absorption area 320 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8/31/2018 _-_ _. Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 55 in.(including missing 0.4' ED)Water added 700 gal. New depth 65 in.
Elapsed Time: 110 min. Final fluid depth 55 __. in. Absorption rate >= 600+g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access(Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES -CLASS A WELL
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 6'+l• Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 200'+
F. COMMENTS
*Sump could not be located-2014 MT extends 5.6'into the 6'effective depth.
G. ENGINEER'S CERTIFICATION
1 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. ' �� OF
Engineer's Printed Name KENNETH M.DUFFUS /(S,\'' �. 1
Date 9111/2018 4.• TH #
COSA canary sheet_2-6-15.doc , ms1's\fin ®ii'!"18/D��/
-
"1 101A'
`__4".
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 'I • �f �1 907-343-7904
On-Site Water and Wastewater Section -\ 1 T j1 Fax: 343-7997
www.muni.org/onsite
Septic Tank Advisory
Certificate of On-Site Systems Approval #0SC18148O
Subdivision: ThunderBird #3A Block: 4, Lot: 11
The septic tank for this property is 36 years old. The average life for a steel septic
tank is 20 years. Typical replacement costs range from $6,000 to $9,000.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
t�- .:: - - -,i,,, ,,. raw 3, ��, - :�a, - rr�Z �?' al .
..
-• ..-1, :....,..,!„ .. 1,. . _ . . . ., ,
, , *...‘ . , .„, „1";: . .,, .: _,,.. 4 ..A. -., - 40.-„,0- --..- .
;, .. , ... „,..5. ,,, .1. -, ,_ - ,‘-----,i,:- rs it'::: - '''•-'" '- ' , -
, :.r....., '4614',e:,-.;., . - '1,1 ' ' Ar - , ..,,,,,-„..,.._,.. ., .:
, ...,....,.., - , ....-,, , _. , ,.. ,.,.... ..., 4,: '„•;-„, ,,T.--,4.a. ••,-
tAT -'-'4---.-.��N +R'ia.yj �.�F.�j
,, `1.- k At '', p. ,.• 4.,..:1%.1.. '', '.• ...,,..
, ;,. .,
. ., ...... .. ,.. .,. ... „.,..,,.. -.Z.,....:,,,4,.. ....t...,..71.'":4,..,,,_
'''s:-''..,4:4t-,,,Arl` ;,.. ' ' ,:iii , ..... ,,‘,.,Es • . .41
i. yr a` '
',;,....:,''t, h. , .' : r� `?' rte',
0 ' _ '.. .
:.► _ r; S•9 - .._'• . YS:,-
Mailing Address:P.O.Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cL anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Expiration Date:
GENERAL INFORMATION
Complete legal description ~~ ~ :~ ~5~¢;~ ~
Location (site address or directions) .~ 5~ '~A L ~ O d ~
Current Property owner(s)
Mailing address
Lending agency
VAr
Day phone ..~¥~-L. -'~[,.,~:~.~;
Day phone
Mailing address
Real Estate Agent "~,,-'" Lc. ¢¢_¼
Day phone '~ff' ~-"~,~,.~-~
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class A Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 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 Approvat 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 less than 30 days old. (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 verity that my investigation,
based on procedures outlined in the Health Authority 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
Address '~'~
Engineer's Printed Name
Phone
DSD SIGNATURE
/ Approved for ~ _
Disapproved,
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~'- / ?- ~) ]
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
www.cLanchorage.ak.us
(907) 343~7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:.__L-~_. ii
A. WELL DATA
well type A-
If A, B, or C provide PWSlD # C/~/tf ',~ Well Log (Y/N)
Date completed __
Sanitary seal (Y/N) __
Wires properly protected (Y/N)
Total depth __ ft. Cased to __ft.
Casing height (above ground)
in.
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mi. Nitrate
__ mg./I.
Other bacteria
co!onies/100 mi.
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material --.~ ~'- /
Tank size l~.~,~ gal.
Foundation cleanout (Yin)
Date of pumping ~7/
C. ABSORPTION FIELD DATA
Date installed
Length '?> ~-~ ft.
Number of Compartments
Depression over tank (Y~
Pumper
Date installed ~ /~ ~
Cleanouts (Y~ y
high water alarm (Y/N) ~x.]
Soil rating (g.p.d./f¢ or ft2/bdrm) ~'--~ System type '%,,f.~.4~/C/!
Width ~ ft. Gravel below pipe /.2 ft.
Total depth / / ft. E,ff. absorption area 3,,~g:7 f¢ Monitoring tube _~ Depression over field
Date of adequacy test ~'//~,.>/~> I _ Results (Pass/Fail) '-~ For q bedrooms
Fluid depth in abs~ion fleld before test /~ in. Water added ~C_,,?l~gal. Newdepth ~ in.
Elapsed Time:- -.min. Final fluid depth ~ in. Absorption rate >= /',~ ~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) H If yes, give date
D. LIFT STATION
Date installed Size in gallons/_ _
"Pump on" level at __ in. "Pump off" le~t
Datum Cycles t~d
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOpO:
/
Septic tank/lift station on lot, __/
/
Absorption field on lot //
/
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/~ANK ON LOT TO:
Building foundation ~ t Property line
Water main .~,,~'~) Water service line
Wells on adjacent lots ~/,~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line J'~ Building foundation
Water Service line '~ ,~.~ Surface water ~' i~
Curtain drain ~ ~ O Wells on adjacent lots
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Absorption field
Surface water
in.
Water main ~ ~
Driveway, 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 am in
conformance with MOA HAA guidelines in effect on this data.
Engineer's Printed Name "'~J~' ~f
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmenta~ Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
0 ~'/- ~/ '-~7 HAA# JI
1. GENERAL INFORMATION
Complete legal description
Lot 11; Block 4; Thund6rbird Heights #3
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
24837 Teal Loop
Chugiak~ AK
Lyn~Patzel '~ ~m~
24837 Teal Loop
John Plylar/ Greatland Realty
Day phone 688-6335
CHugiak, AK 99567
Day phone
Address 11411 0~d Glenn Hwy. Ea.qle River, AK
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
694-9125
Day phone
99577
NOTE:
Individual well
Community well
Public water
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
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 #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 ~l ~¢_
Address ~~-.-~.~. 2o4
Engineer's signatur~
DHHS SIGNATURE
/~' Approved for
bedrooms.
Disapproved.
Conditional approval for
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Em ployees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~>~ \\ ['~ ~ ~'~ 0 ~)EZ,~, ~-~-~ Parcel I.D.
A. Well Data
Well type ,~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
FROM WELL LOG
Cased to Casing height
.Wires properly p~
_~:
Static water level r, ~ ~.
Well flow .g.p.m. .g.p.m. _., ~ ~o
SEPARATION DISTANCES FROM WELL TO: ~
Septic/holding tank on lot ; On adjacent lots
Absorption field on lot '2~c, c> t ~ ; On adjacent lots
Public sewer main Public sewer manhole/cleanout ~
Sewer service line Petroleum tan~
WATER SAMPLE RESULTS: ~
Coliform ~ Nitrate Other bacteria
Date of s .'..ampt~'/ Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed \~. ~ ~
Cleanouts ~N)
High water alarm (YI~
Date of pumping ~, - '7--'~ ~ ~ ~ Pumper
Tank size / "'~--~ Compartments
Foundation cleanout (~,~) y Depression, I~Y~
Alarm tested (Y/N)''''~/
Well(s) on lot
To property line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
~,.~ ~, I -~ On adjacent lots
Absorption field
Surface water/drainage /
Foundation
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N).
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N) ~
SEPARATION DIST~TATION TO:
On adjacent lots
Manufacturer
Manhole/Access (Y/N)
Surface water
D. ABSORPTION FIELD DATA
Date installed \ c~ ~ ~
Length '"~ ~ Width
Total absorption area
Date of adequacy test ~ '~ ~ -~Cl
Water level in absorption field before test
Peroxide treatment (past 12 months)
Soil rating (GPD/FF)
"~ ~ Gravel thickness ~-~
Cleanout present ~j~l)
Results {~a[I)
.System type '-~.-~.~ r_~
Total depth t, ~
~/~,d~'J' Depression over field (Y~ ~
for ~ Bedims
~er test ~ ~
If yes, g~e date ~(~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent mots
Surface water
Cun~ain drein
On adjacent lots ~*~, Property line
To ~xisting or abandoned system on lot
Cutbank ~[ ,~ Water main/service line
Driveway. parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
Signature $ &
Date
his inspect'on.
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93}* Back
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
_ "-'~ ~,~ '~ _ ~..~ "~ NAA#
1. GENERAL INFORMATION
Complete legal description
Lot 11; Block 4;
Location (site address or directions) 24837 Teal Loop Peters Creek, Ak.
Pr~opertyowner- A.H.F,C #49405 Day phone
Mailing address 520 East 34th Avenue Anchoraqe, Ak. 99503
Lending agency Day phone
Mailing address · '
Agen~haron Minsch RE/MAX OF EAGLE RIVER Day phone
Address 16600 Ce~erficld Dr. #201 Eagle River, Ak. 99577
694-4200
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well XX
Public water
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:
NOTE:
XX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 IRev. 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 fifes and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is 'in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Engineer's signature
Phone
Date
DHHS SIGNATURE
_~'
Approved for /7/
Disapproved.
Conditional approval for
bedrooms.
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.
72~25 (Rev. 1/91) Back MOA #21
Legal Description:
A. WELL DATA
Well type ~
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter.
Parcel I.D. I
PR 1 yj 1991
ADEC water system [
Driller
Log present(Y/N)
Date completed
Total depth
Sanitary seal (Y/N)
Casedto
Casing height
Wires properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well flow
Pump level
g.p.m.
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot '~- ~ '~
Absorption field on lot -~:~I ~
; On adjacent lots
; On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Public sewer service Pine
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Nitrate
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (~/N)
High water alarm (Y/N)
Date of pumping
Tank size \ "~--~'- ~:P Compartments
Foundati/an cleanout4~ZN) ~ Depression
N//4~r Alarm tested (Y/N) IV/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /D/~
To property line J ~
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (~ evl 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
,,%*
Date installed
Size in galloos~''
,,
~n~) . ' ~ ~. Pump on' level at
Meets MO~cal codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Manufacturer ~
Manhole/Acces~~/
"Pump off" level at
Cycles tested
Well on lot
On adjacentlots
Su dace water
D. ABSORPTION FIELD DATA
Date installed \ ~ t~'~.. Soil rating ~ -v~ System type
Length ~'P<~'~ Width ~'~' Gravel thickness Total depth
Total absorption area "~L~ ~ _i
Cleanouts present (YTN)
Date of adequacy test
If yes, give date
for
Depression over field (Y~{;' r,J
Peroxide treatment (past 12 months) (Y~)
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot
To building foundation
On adjacent lots "~!
Surface water \ ~
On adjacent Pots ~ O~/l~ Property line
\ ~ ~ To existing or abandoned system on lot
Cutbank ~ ~ I~ Water main/service Fine
Curtain drain
Driveway, parking/vehicle storage area
ENGINEER'S CERTIFICATION '~c:>~_..~l~ ~-.~/~.,//.b~ ~/~
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 Nam~
Dste of Ps,merit "~/~/~ - q/
Receipt Number ~=~o~,~J~ ~.~ ~d~7/'/~
72~326 IRev. 3/91 ) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
No.
/
ANCHORAGE DISTRICT OFFIGE
~601 C STREET, SUITE 322
ANCHORAGE, A~S~ 99503
WALTER J. HIOKEL, GOVERNOR
563-6775
April10,1991
FOR: Roger
S & S Engineering
PWSID #211156 Eklutna Thunderbird Heights
My review of the records on file in this office reveals that the Thunderbird Heights S/I)
Class A Public Water System is in compliance with the provisions of 18 AAC 80.060, State
of Alaska Drinking Water Regulations.
Sincerely,
Timothy )~. Karnowski
Environmental Engineer
.~ APPLI ._C~IT FILLS OUT UPPER HAI~ONLY
Time Time Time Time
Date Date Date Date~
Inspector Inspector Inspector inspectF¢~
Field Notes: M~UNICIPALITY OF ANCHO~/',GI~
DEPT, OF H~/',LTH
FNVIRONM2NTAL P~OTECTION
RECEIVED
'~PPROVED BEDROOMS *DONDITIONS OF APPROVAl_
(
~ I D~S^PPROVED
I ICONDmONALAPPROVAL'
Soils Rating Date Sewer installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
g
Time Time
Date Date Date
Inspector Inspector Inspector
Comments Conditional Approval
Date Sewer Installed Permit No. Septic Tank Size
/--~/,~ ~ "~.~ Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner {~. S. K. Construct:ion Phone
Mailing Address SRA Box 6105-A3, Palmer, AK 99645 745-2553
Buyer
Address
Lending lnstitution Alaska Pacific Bank I Phone
Address 101 W. Benson Blvd., Anchorage, AK 99503 276-3110
Realty Co. & Agent Totem Realty, Inc./William J. Schlegel Phone
Address 724 E. 15th Avenue, Anchorage, AK 99501 272-0571
LegalDescription L0~ 11, Blk 4, Thunderbird Heights
Street Location Teal Loop Road
Type of Residence
;~ Single Family
[~ Multiple Family No. of Bedrooms
[] Other
Water Supply
~ Individual ATrACH WELL LOG. A well log is required for all wells drilled since June
;~ Community 1975. For wells drilled prier to that date, give well depth (attach ~og if
~ Public Utilit), available.)
Sewage Disposal
:~ Individual Year Individual Installed: 1982
[] Public Utility When Connected to Public Utility:
[] Holdin~l Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN SE INITIATED.