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HomeMy WebLinkAboutEASTERLY PORTION LOT 87 LT 1Easterly Portion Lot 87 Lot 1 #075-132-74 ~IF-_ ROM : GLRCIER VAil EY CONSTRUCTION CO FAX NO. : 987 7853178 HEFTY DRILLING 3S40 ^KUI~ DRIVE TELEPHONE: ~CHO~E, ~ASKA 99516 (~7} ~5-0593 3un. 11 1999 06:40AM P1 Permit Number~LJ q 10/i:}~,ate Of Issue __ Tax Identification Number.__ DateSt=.'ted/~ -~6~.- '7'TDateCompleted //.~L. ~) -I Is well located at approved permit iocation? ,~.Yes [] No Legal D~crlption Block Lot PrgPerty Owner Name & Ad~_ress: ' - Soil Type & Thickness & Water Strata From " Casing Type: "' , ...... Wall Thickness inches O %__ Dia&~er ~'"'ine~;~, depth ¢0 feet Liner Type: Diameter .inches, depth ...... leer ~ ~¢,~ / '~ [/ 7 ye Casing Stickup Above Ground: % feet Static Water Level (f~u.&level):~¢ c .7/' feet ~] ~ ~S D ~ 9~ Pumping Level: feet a~er hrs_ pumping .gpm ' Recove~ Rate:, / 2_ ~pm Method Of Testing:. Well Intake Opening Type: ~ Open End ~ Open Hole : ~ Screened; Sta~ feet Stopped .... feet ....... O Pedorations Stad feet Stopped feet GroutType: ~(+ ~ "Volume D~pth; -from ....... feet, to · Pump Intake Depth: feet Pump Size hp Brand Name, " well Disinfe~ed Upob Completion? ~'Yes O No Method Of Disinfe~Jon:. Comments: Company . ~//; ~ ~ Zip~9 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW970222 DESIGN ENGINeER:DUMMY COMPANY . OWNER ADDRESS:P.O. BOX 116 GIRDWOOD, AK 99587 DATE ISSUED: 7/29/97 EXPIRATION DATE: 7/29/98 PARCEL ID:07513274 LEGAL DESCRIPTION: LOT 1 EASTERLY PORTION LOT 87,USS 3042 LOT SIZE: 12012 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: WELL SYSTEM 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 (18/LAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS ISSUED BY: ~ DATE: DATE: GUNNYSACK MINi{ ROA~) .50' 1}[I(2()M. & Ill CINIC I Ag;IMINI , I 8.5' · :i ~ ::~ ) '~ ~ I PROPOSED HOUSE ~ ( ~ ~ - LOCATION ~ I ( ~' [~5~- ~)~ (~ /~ ' d F.F, = 102.0' o~ (~ (/) I 8,5' ~ <l ~'~ ~ ()/ ~ , , I()~ ~7 -~ 6/"51'00" i I , x~) ."' ~ ........... ~ , ~... ~'.~0~ ,,,,,' ~." 49Tk ~ "~ , ~.~..~ .......... ~ ...... . ~, '.. us-~a ." ~ ." "" ~':),~x xr:.~)x 't ~ .......... v~~ ~ ...................... EXCLUSION NOT[S: Ii is the o~ners' responsibility to delermlne LEGEND: SET FND ORD~RE~ BY: the exlslence of any easements..coVenants, or restrictions 5/8"RB W/CAP~ 5/8" RB O D ~ YE SI g g E ~ T which do not appear on the recorded subdivision plot. NOTE: It 3.25" AL.MaN. ~ONUMENT with GLACIER VALLEY C~STRUCTION _ is the contreclorts responsibility ~o check top at foundoUon HUB A TACK ~,~,,~,,~ ,,~,,~,,~ ~~ grade uhd b~ildin9 setbacks in relation to Iotlines and esm'ls. FENCE- ~-X x ~~"A'"~" SURVEY CERTIFICATION: SLANA has conducted o O~RHANG- ~l~:~:~ ~4 ~:'r~ Vt~' :':~ I?F//X physicoI survey of ~his property os shown on this WOOD DECKS- I ' tiro*trig ~nd Jo ~he best of our knowledge and CONCRE~- ~ '~.. ' '1 x ~ ~ J~t ~x ~ S " abilities, all dimensions have been measured true ASPHALT- :J ~LOT ~LAN OF: LEGAL DESCRIPTION: ELEV,(NO DATUM)- LAND A CONSTRUCTION SURVEYORS-PLANNERS-ENGINEERS ~40 WEST BENSON BLVD, ~ 103 A.c,o,~o:. A,~::A ~0~ ~0~) ~-~0~ LOT 1 JULY 16, 1997 1"=20'(fox) 561-6626 .oo~,-: EASIERLY PORIIO~ kOl 87 SUBDI~SION DMD. L 5012 250/28 Municipality of Anchorage �� G On -Site Water and Wastewater Program (907) 343-7904 s a F E T Y Certificate of On -Site Systems Approval Parcel I.D. 075-132-74 1. GENERAL INFORMATION: Expiration Date: ^ 2 Z Complete legal description EASTERLY PORTION; LOT 87 L.� Location (site address) 233 Gunnysack Mine Road *Girdwood Current Property owner(s) Jason Porter Mailing address Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNadance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment �l 3T.2 0.2 2 Date of Payment Receipt Number 0 H ? �26- Receipt Number COSA # 0 SC,Z2 i a l a 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: Gayness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: /S12, 2— In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or`�..• encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, �� ) groundwater levels (that may fluctuate during the year), quality of construction (materials and T I �! workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and "'"" "•".. ".j are outside the control of GEG. Satisfactory test results do not guarantee future performance of the /) system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of • • • .. • • •. • • • •� the well or septic system. GEG makes no representation whether an alternative well or septic system j .p f+. y A. Go -ss. can be installed on the property in the event either of the current systems fail to perform adequately in �!�0�. 'E- -a-- the a--the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or ��j�` .dP A party (including subsequent property purchasers) is not authorized, nor will it confer any legal right �1� r°fess °-• whatsoever. #AECC884 6. D!"IGNATURE `jTY(OF���ri� , System #1 Approved for bedrooms � \G�QP ffY OP / System #2 Approved for bedrooms Disapproved o �/ o ER A E Conditional approval for bedrooms, with the follo"E ti ������,,,,� , ND m PP P' R G ATER n_ hAU Ay JJJIII,Ls'�7TTT�l G�\\� 2/rThBy: Original Certificate Date: (0 -21 - The e Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist Legal Description: EASTERLY PORTION; LOT 87, Li R*vlsf.� �'I so) -?-Z Parcel ID: 075-132-74 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system N A. WELL DATA p MM IA/.JI 49:1—J ..:ate - N _ ar.. Date drilled "126197 J Water storage tank volume N/A gallons Total depth 90 ft t. Well disinfected for coliform test? ❑ Yes © No Cased to 90 ft /'Coliform bacteria is Negative Sanitary seal is functioning correctly L Nitrate I • b mg/L ❑ Nitrate less than MRL (ND) Q Wires are properly protected Arsenic ug/L EgArsenic less than MRL (ND) Casing height (above ground) 18+ in. Collected by GEG, LTD. Date of flow test for COSA 6/6/22 Date of Sample 6/6/22 Static water level at beginning of test 71.1 ft. Comments B. TANK DATA AWWU SEWER Age of tank(s) years Tank type/material Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (m Measured depth to pipe invert from grade ❑ N/A — pressurized field (min) ❑ Monitor tubes go to bottom o ective. If not, state depth into effective ❑ Code -required soil er over field ❑ System pres ed (Required if ant for greater than 30 days prior to date of t introduced _gallons COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station years/ Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) ❑ Yes Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' NSA Surface Water > 100' ❑ Yes if No ft 0 Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption -Field -on -L -et-> 1-00=Q Yes -if-N- N/A #t Holding Tank ->-100' 21-Yes—if-No—ft— -Yes—ifNo ft=Neighboring NeighboringAbsorption Fields > 100' Animal Containment > 50' Yes if No ft 0 Yes if No ft ❑ Yes if No Manure/Animal Excreta Storage > 100' Communi ells > 200' Community Sewer Main > 75' [DYes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) I/HVVVVU SI; tht� Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑✓ Ye�ifff ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: if No ft Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Main > 10' ❑ Yes if No ft Communi ells > 200' O✓ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If Ic tank is under driveway comment below From Absorption Field on Lot to: (Please enter dist Building Foundation > 10' ❑ Yes ft Property Line > 10' es if No ft Water Main > 10' ❑ Yes if No ft Water Se Line > 10' ❑ Yes if No ft ace Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION if less than required) If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft 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. COSA Checklist yellow sheet o ��.......... `p ,�, I .:...I�.�i. ............. f ti rness: C 795 • fe •G�l�i:s .Z�' �Ad ll0 ap�o f es siO 1 #AECCB84 q'V 97A -I ` .. 0.1 ..; 73A :1 i 96n 96A "(7.. e5(7 v+c 296. • .rSu. w'c 1 80 �. rA ° e htiga-eh Sfa yu 5411 s9A � ii >_ � a� 5c sou c U s s9n u 6 SURVGV Qom...��_�• -342 - � s9e1 rb _ 5 �r / 9Jr - e f V O` e' � e`s 5F 55.1 SR V, o m . 0 �h ssc RA R esu y'" K. GIRDW000 INDUSTRIA! Pi.RK Legend Conshuc W and Oasipn 0 Cleanout•AWWU O tory ®' 2A Maln. F&a% 75A it AWWU co McNmb, Pdvata * ^�0 1z Discharge Point AWWU 75D ]A AkRollo(AWWU ^({J 84 13 *17696 *27608 p �O\ • rn o� fi !a �i9 622 '�c' - zr Co " 1 24 GIROWOOD- . TOWNSITE.- )OD cd USS 1172. ' fi i System GIRDW000 INDUSTRIA! Pi.RK Legend Conshuc W and Oasipn 0 Cleanout•AWWU O Oeanoul,Pdvem ®' CleanoUnnManhde,AWWU Maln. F&a% A—. Too, AW WU AWWU Manholo, AWWU O McNmb, Pdvata * Dargemus Manhole ® Discharge Point AWWU ® AkRollo(AWWU ® AWawum,AWWU Ej Admini,Uadon Fadlity Memrig Station O lMStallon ® Soptago R.MW Station Wast—W,Tm tb MFadlty ® Remm Drawing LWc C3 Sewer naaln MOAGrid INFORMATION AND DATA CONTAINED ON THIS DOCUMENT IS NOT TO BE CONSIDERED ACCURATE AND THE MUNICIPALITY OF ANCHORAGE ASSUMES NO LIABILITY FOR DAMAGES OCCURING AS A RESULT OF USING THIS DOCUMENT. FOR THE LATEST AND MOST UP TO DATE INFORMATION YOU ARE URGED TO CALL THE ANCHORAGE WATER & WASTEWATER UTILITY AT (907) 564-2725 BEFORE STARTING OPERATIONS. Grid Number SE5012 Conawdad Pip. Design Pipe -.,..•"-'- Casingand Outer Pipe, All O*nms P Mel..AWWU Maln. F&a% AWWU Form Maln,AWWU nomwWU "' ® Force Main, Pew. P,M.d Pipe "- ' Abandoned In Plam,All Ow ® Remm Drawing LWc C3 Sewer naaln MOAGrid INFORMATION AND DATA CONTAINED ON THIS DOCUMENT IS NOT TO BE CONSIDERED ACCURATE AND THE MUNICIPALITY OF ANCHORAGE ASSUMES NO LIABILITY FOR DAMAGES OCCURING AS A RESULT OF USING THIS DOCUMENT. FOR THE LATEST AND MOST UP TO DATE INFORMATION YOU ARE URGED TO CALL THE ANCHORAGE WATER & WASTEWATER UTILITY AT (907) 564-2725 BEFORE STARTING OPERATIONS. Grid Number SE5012 Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 Certificate of On-Site Systems Approval Parcel I.D. 075-132-74 Expiration Date: GENERAL INFORMATION Complete legal description Easterly Portion Lot 87, Lot 1 Location (site address) 233 Gunnysack Mine Road Girdwood, AK 99587 Current Property owner(s) Donna Jefferson Day phone Mailing address P.O. BOX 313 Girdwood, AK 99587 Real Estate Agent Day phone 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) [] Duplex [] Multiple Dwellings (Single Family and/or Duplex) Three 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class. Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual [] Holding Tank [] Community [] Public Sewer [] WafverNadance request for: Distance:. COSA Fee $ Date of Payment Receipt Number COSA# Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below; I vedfy 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 flies and from my investigation and inspection, the on-site water supply and/or was(ewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.O. Box 240773 Anchorage, AK 999524 Engineer's Printed Name Michael E. Anderson, P.E. bedrooms bedrooms.~;~i?~l bedrooms, with the folldw, DSD SIGNATURE \ / System #1 Approved for __ System #2 Approved for Disapproved Conditional approval for Phone 907-522-7773 ~\kkL',:,?-(~¢((fr.: ON-SiTE- WATER AND pROGRAM 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 om~sions in the professional engineer's work. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory X Nitrate Advisory Arsenic Advisory Other If more than I septic system Is on the lot: COSA Checklist # of Structure sewed by this system __ Certificate of On-Site Systems Approval Checklist Legal Description: Eastedy Portion of Lot 87; Lot 1 A, WELL DATA we~l type Private IfA, B, or C provide PWSID # Date completed 11/26/97 Sanitary seal (Y/N) Y 71 ft. 12 g.p.m. Arsenic Parcel ID: 075-132-74 Well Log (Y/N) Y wires properly protected (Y/N) Y ;>18 in. Total depth 90 ft. Cased to 90 ft. FROM WELL LOG Date of test 11/26/97 Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 1.30 mg/L /[/ O ug/L Date of sample: 12/29/14 Casing height (above ground) AT INSPECTION 12/29/14 68 ti. 8.3 g.p.m Anderson Engrg. Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Foundation cleanout (Y/N) Date of pumping Number of Compartments __ Depression over tank (Y/N) Pumper Date installed Cleanouts (Y/N) High water atarm (Y/N) C. ABSORPTION FIELD DATA Date installed Length Total depth ft. Date of adequacy test Fluid depth in absorption field before test__ in. Elapsed Time: min. Final fluid depth Any rejuvenation treatment (past 12 mo.) (WN & type) Soil rating (g,p.d./ff2 or ff~lbdrm) ff. width ft. Eft. absorption area __~ Monitoring tube Results (Pass/Fail) Water added ill. System type Gravel below pipe ff. Depression over field __ For bedrooms gal, New depth__, in. Absorption rate >= g.p,d. If yes, give date D, LIFT STATION Date installed. "Pump on" level at Datum in. Size in gallons "Pump off' level at Cycles tested Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tan~ift station on lot Absorption field on lot >75' Public sewer main >25' Sewer/septic service line >50' Animal containment areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Wells on adjacent lots ABSORPTION FIELD ON LOT TO: Property line Water Service line Gu[lain drain Pro. perry line Water service line Building foundation Surface water Wells on adjacent lots On adjacent lots On adjacent lots Public sewer manhole/cJeanout Holding tank >100' Manure/animal excrete storage areas >100' Absorption field Surface water Water main Driveway, pa~king/vehide storage F. COMMENTS Property is served by AWWU sewer system. 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 v~th MOA CO,SA guidelines in effect on this date, Engineer's Printed Name Michael E. Anderson, P.E. 1/12/14 Date COSA brown sheet_10-10-12.doc 8408V Lo! $? I'°t I / / / / / / / .Co / / / / / o~ SCALE: 1"= 30' --"Y.""% ~co,, 49th ~ '? t. '~,,Fred Walatka,. ~ ~ .... EASEMENTS OF RECORD, OTHER THAN THOSE SHO~ ON THE RECORDED P~T AR~ NOT 8HO~ HEREON. S~NA AS-BUILT NO CORNERS SET THIS DATE I hereby certify thai I have pen'ormed a Mortgagee's inspeclion of the following described properly: LOT 1. EASTERLY PORTION LOT 87 SUBDIVISION. (USS 3042) BE Anchorage Recording Precinct, Alaska, and that the improvements situated thereon am within the properly lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the properly lying adjacent thereto encroech on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 16th dayof January .2015. FRED WALATKA & ASSOCIATES Engineers and Sun~eyors (907~248-1666) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P,O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 07q-132-74 ) 1. GENERAL INFORMATION Complete legal description ... Lot 1~ Easterly Portion of Lot 87 USS 3042 Location (site address or directions) Property owner Mailing address Lending agency Mailing address David Seifert P-O. Box 116 Day phone Girdwood~ AK 99587 783-2870 Day phone Agent Address · Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: Three (3)~' 3. TYPE OF WATER SUPPLY: NOTE: Individual well XXX Community well Public water 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. Name of Firm Anc]c,r~r~n ~.ngi n~prl ng Phone 522-7'773 Address P.O. BOX 240773 __Anc. hr~r~g~; Al< 90q24 Engineer's signature ~/~C~'~.~, ~- C/'~,_~"-'~ Date_6/21 /99~' DHHS SIGNATURE t/ Approved for F£ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date ~f-'l'llJ'Jl 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 satJsfy 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. 72q~25(Rev~l/91) Back MOA#21 Municipality of Anchorage JUN DEPARTMENT OF HEALTH & HUMAN SER~[QE~uvy OF ANCHoRAG~ Environmental Services Division ~,,,,~ 825 L Street, Room 5O2 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: Lot 1, Easterly Port±on Lot 87ParcelI.D.: 075-1 32-74 USS 3042 A. WELL DATA Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number Y Date completed 11/26/97 Cased to 90 ' Y FROM WELL LOG 11/26/97 71' 12 g.p.m. Log present (Y/N) Total depth 90 ' Sanitary seal (Y/N) Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION 6/13/99 69' >2' 8.5 g.p.m. Nitrate 1 . 1 8 mq/L Other bacteria 0 Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 6 / 1 3 / 99 Collected by: MEA B. SEPTIC/HOLDING TANK DATA - Property Served By Municipal Sewer Tank size Number of Compartments .__ Cleanouts (Y/N)__ Depression (Y/N) High water alarm (Y/N) Pumper - Property Served by Municipc~l Sewer Soil rating (g.p.d./ft2 or fF/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N)__ Results (Pass/Fail) Date installed Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed Length. Width Effective absorption area Date of adequacy test System type Total depth Depression over field (Y/N) __ For Immediately after Absorption rate = gal. water added (in.): g.p.d. If yes, give date Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* bedrooms D. LIFT STATION - None on Lot Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line __ Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: K "Pump off" level at* Date of Payment __ Receipt Number .~/ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ E. Anderson, P.E. Curtain drain Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and r in conformance with MOA HAA guidelines in effect on this date. Signature 7~/~, .'~t~ ~ Engineer's Name Michael Date 6/21 /99 Sewer Foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Surface water Absorption field Wells on adjacent lots - N/A Water main/service line Driveway, parking/vehicle storage area systems are Property Served By Municipal On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station N/A