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HomeMy WebLinkAboutPETERS GATE BLK 3 LT 4APeters Gate Lot 4A #051-551-18 /g q�GREAR ANCHORAGE AREA BOFAGH cfl�� Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME n.s IX t' N MAILING ADDRESS 70l "r"rP/2 ,%o d C' PHONE a /4/2� LOCATION � LEGAL DESCRIPTION XO 7���OC/` SEPTIC TANK: DISTANCE/I NUMBER OF FROM WELL MANUFACTURER SiA'_St 7— /M//.MATERIAL x_44-..7� COMPARTMENTS_ INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH—LIQUID CAPACITY ! 6�__" GALLONS. SEEPAGE PIT: NUMBER OF PITS �. DIAMETER OR WIDTH, LENGTH/, DEPTH 117, LINING MATERIA �YC CRIB SIZE: DIAMETER—DEPTH 6 DISTANCE FROM: WELL � �Ofr BUILDING FOUNDATION t�v NEAREST LOT LINE _q 0 . TOTAL EFFECTIVE V ABSORPTION AREA (WALL AREA) r� D SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE /y�L ` �� CONSTRUCTION�� / DEPTH BUILDING FOUNDATION CESSPOOL DISTANCES: INSTALLED BY: PIPE MATERIAL: LOT SLOPE: REMARKS: NEAREST LOT LINE OTHER SOURCES DISAPPROVED less ' DISTANCE FROM: NEAREST SEPTIC 7 {T SEEPAGE /G o SEWER LINE -,TANK SYSTEM l REMA DATE e�l DIAGRAM OF SYSTEM �`100�_ (A P O�T peee7Wew YL r1 %�R'r/ air j X o2 % yM U "I C I F='FiI I TY ID F=i"§Z "r_0FcRGE ` DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2516 E. TUDOR RD., ANCHORAGE, AK. 35507 278-2221 WELL F=l "C• 1'--1 a—:S I TE SSEWEFR F�EFer-1 I T_ PERMIT NO. { 76801 ? APPLICANT BILL C:RAIN_ 3701 EUREKA SP#6C 272-1623 LOCATION MALCOLM LEGAL L5 B3 PETERS GATE SUBD LOT SIZE 54455 :QUARE FEET TYPE OF SOIL RSSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = -3 SOIL RATING CSQ FTr6F _ �07� THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [DhE:F:11—r F_ErA"-r = - +3FRF=iti.�L CSE°T H= S Two 7'RrNc�e S e�j ao FF'r . THE LENGTH D MENSION IS THE LENGTH CIN FEET) OF THE TREN'H OR, DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BE�aEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FE/1�f� t. THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET?. FRF=QIJ 11 FREE} :SEF'T I r_ -rF=l t -.1F<.= =. I c E_ ::L C510ia C3r=fI I IDtwF!E; '1't4CJ C: I rJS;F=•EGT I (DF`+F:H� F=IFRR: FRE7C-AU Y FREE BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. • wrt, rrR So' SrPt; c MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F=`Ef;�M I'r VFi _ I F> F= CG FR 0FME VF="F;: F= FZ01M I !E;SSUE I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF 'THE' RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED: --- -------------------- APPLICANT BILL CRAINE ISSUED BY _-- -----DATE__`_— V v /re-/{ c c/= b_-77 I •O & E GEO CHNICAL & DEVELOMENT CO. • Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Ovster 694-2774 Soils Et Foundations SOIL LOG Earl Ellis 688-2280 Land Development Performed for: Name: ""k\ -Vo `, ' .w"- Tel I. No. 27. 2.; 1 to 2q Mailing Address: Legal Description: 1 c -S `r3�x '� `�C�i�f> CSA>� .s<ar:4s Depth (feet) Soil Characteristics 0 z i 31il 'aQfl - C.\,,.io 4 5- 6- 7- 8- 9- 10 678 10 11 12 13 14 15 16 Ground Water Encountered: Yes No ✓ If yes, what depth Proposed Installation: Seepage Pit Drain Field Comments: S Maw. '1, A+ ��4Pancf_ oryr'6� Orc n \.1-e r%M tirars e v I- y » Performed by: L� U �� �r. Date: lo' �� % O ft E GEACHNI`CAL & DEVEL 'MENT CO. -• - Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 668-2280 Russell Oyster 694-2774 Soils & Foundations SOIL LOG Earl Hlis 688-2280 Land Development Performed for: Name: ' « .. A < _ '$ , Tel. No. ?'2. ,Z_ Mailing Address: Legal Description: Depth (feet) Sal Characteristics 0 1 PQ:�\� '.a••_ n ^s,o% o�-� ( "GAS c�!., _ 7r y 3 4 5 ! 6 t 7 8>_ :. 1Q ` 11 12, 13 ` 14, 15 16 Ground Water Encountered: Yes No L' If yes, what depth -Proposed_ Installation: Seepage Pity Drain Field t Comments: Perfo i�il''ls' �,� 1��� , Qate �Q,� /V. tt, Vu AJ w 1 3 6 20 9502 33 4 , E '5V ILLING REPORT DATE l I "l, 43 N, S. -0" x T Om 10 FORMATION IpoTnR. .v1; IAP NAME HRS. 4 a Eli 1-1-14 T. IL I J6 LOPE TEST ACCIDENI I GIvr "SHE, L Ft. I oto *I L BIT ANU COR kM LAD FILCOND I 4v MUD Rt.co"Ll 11ME RECORD DRILI: S t LM RFt -OR 0 it Y.$x CC", NO z blzc CoLt I WTII 1.04f;.c L III No I ILIE4 CAKE ICIILPAlkl KELLY DOWN - FT. ___COLLARS FT. AW MTL., ADDED IREMARKS) TOTAL Zsn= Irl 1.L! its SIF I 1) A To FORMATION SLOPE TEST ACCIDENT­ IGIVK NAME) ROTARY DRILLING CORING Ote. or, VISC. BIT ANO COREHEAD RECOF No. WTR, LOSS.C.C. OT14ER REPAIRS • TRIP FILTER CAKE LL No. PH. IS SUM MTL. ADDED I REMARKS) NOTARY WEIGHT PUMP SPEED ON SIT 'RAS. ix NAME HRS. RECORD DRILL STEM RECORD site D. P. SIZEOLL. % it$. D. P. Pr KELLY DOWN 'T .-I—. -7 COLLARS! Fl TOTAL III WEIGHT ROTARY DRILLING CORING VISC. NAME WTR, LOSS.C.C. OT14ER REPAIRS • TRIP FILTER CAKE ON BIT PH. ren MTL. ADDED I REMARKS) NAME HRS. RECORD DRILL STEM RECORD site D. P. SIZEOLL. % it$. D. P. Pr KELLY DOWN 'T .-I—. -7 COLLARS! Fl TOTAL III To FORMATION ROTARY WEIGHT'PUMP NAME HRS. *Ptto ON BIT ILL am LOP[ ACCIDENT,— TEST TEST ....... . 101vt NAMXI FT. Oto OFF -- ------ - DAL oil A 9.. �L(LLG1114. BIT AND COREHEA RECORD MUD RECORD TIME RECORD 11 R EIGHT DRILLING a SIZED. P. SC. CORING arm&" IN ITR LOSS.C.C. I its. . . rf R CANE VtLTl_j REPAIRS 4__ I. .�„ity-DRILLING REPORT A T IN C� 43 (,DT 76 co IiI^_ HOURS RUN MTL A DED (REMAR�Sl - RIG .0 WELL N. FROM TO - ROTARY WEIGHT PUMP TIME RECORD RECORD STATE ON SIT FEES FROM TO FORMATION ROTARY -I- WEIGHT PUMP WEIGHT IS HT Al GTIME DRILLING DRILLING S 'Z E IZE A A X E MAKE _ PEE. TEST ON SIT RES, SIZE P. I�E�.LL IT NAME OF. OF, _E CAKE 'L_�R C AR ER OTHER OTHER REPAIRS ®REPAR SIT AND COREHEAD RECORD MUD RECORD DEPTH DEPTH IN PT H IN -DEPT ni: wFA, T' LW EEAM RUN NO. -FI-HT KELLY DOWN T DRILLING SIZE CT ON m TL A ED I REMARK MTL. ADDED 11 MARKS) TRIP IF COLLARS MAKE VI.G, CORING - ----- DM II REMARKS WTR LOSS.C.0 '7 SERIAL NO. FILTER CAKE REPAIR. DEMTH IN--- HOUR RUN SLOPE TEST ACCIDENT H (.11E NAMUI MTI_. ADDEO (REMARKS) REMARKS H ET. - - --------- - DIG OFF BIT AND CORER EA RECORD _-MUD _RECORD_�=� jpp TIME RECORD RUN NO. WEIGHT DRILLING DRILL STEM RECOW SIZE SIZE D. F. VISC. CORING SIZE COLL. MAKE ! .......... - - WTR, LOSS,C, OTHER SERIAL I JTS O. A FILTER CANE REPAIRS KELLY DOWN DEPTH IN H, TRIP COLLARS TOTAL HOURS RUN MTL A DED (REMAR�Sl REMARKS., T_ FROM TO FORMATION ROTARY WEIGHT PUMP TIME RECORD RECORD SPEED ON SIT FEES DRILL STEM DRILL STEM REC -I- WEIGHT IS HT Al GTIME DRILLING DRILLING S 'Z E IZE A A X E MAKE _ SLOPE TEST ACCIDENT SIZE P. I�E�.LL IT (GIVE NAMEI OF. OF, _E CAKE 'L_�R C AR ER OTHER OTHER REPAIRS ®REPAR SIT AND COREHEAD RECORD MUD RECORD DEPTH DEPTH IN PT H IN -DEPT ni: wFA, T' LW EEAM RUN NO. -FI-HT KELLY DOWN T DRILLING SIZE CT ON m TL A ED I REMARK MTL. ADDED 11 MARKS) TRIP IF COLLARS MAKE VI.G, CORING - ----- II REMARKS WTR LOSS.C.0 OTHER SERIAL NO. FILTER CAKE REPAIR. DEMTH IN--- HOUR RUN PH. TRIP MTI_. ADDEO (REMARKS) REMARKS w NAME ?D DRILL STEM RECORT' SIZE SIZE COLL LTS R. KELLY =DOWN �-ILARS TOTAL D, OFF [RL . . ..... BIT AND COREHLAD RECORD - ']ON'- MUD RECORD TIME RECORD RECORD ­RECCr R U N RUN DRILL STEM DRILL STEM REC -I- WEIGHT IS HT Al GTIME DRILLING DRILLING S 'Z E IZE A A X E MAKE _ VIS W MIT TP LOS C C � LOSE C C CORING SIZE P. I�E�.LL E P SEPIA' I A I _E CAKE 'L_�R C AR ER OTHER OTHER REPAIRS ®REPAR "S O.P.FILTER DEPTH DEPTH IN PT H IN -DEPT ni: wFA, T' LW EEAM & KELLY DOWN NOLREWRONMENTAL PROT 'R 0 T CT ON m TL A ED I REMARK MTL. ADDED 11 MARKS) TRIP IF COLLARS II REMARKS ULM E D PRINTED IN U.5 A. APPROVED • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 �r s, �r: CERTIFICATE OF ON-SITE SYSTEMS APPROVAL F ' t Parcel I.D. 051-551-18 Expiration Date: 1. GENERAL INFORMATION Complete legal description PETERS GATE E Location (site address) 25026 MALCOLM DRIVE, CHUGIAK AK 99567 Current Property owner(s) BRUCE & ANNE FLAHAVEN Day phone Mailing address 12110 BUSINESS BLVD. STE. 6377 EAGLE RIVER AK 99577 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: 3 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 ❑ Waiver/Variance request for: Received by: "-7 t4l&41 Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5 3 f Lj o Date of Payment -3,20/5 3/ Receipt Number U ,may ll3 U J_5G "Lid COSA#_ QS C I5 1106 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 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. 1 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 3125/2015 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 iGG OF AZ\ X encroachments, deficiencies or discrepancies exist. 6. DSD SIGNATURE 5 KENNETH 31. UGMrS system #1 Approved for � bedrooms. + 'sem/,'/ System #2 Approved for bedrooms. ,Go ='' P��ssloNab i Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: l % The Municipality of Anchor 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSAbluesheet 10-10-12.d. 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: PETERS GATE BLOCK 3, LOT 4A Parcel ID: 051-551.18 A. WELL DATA Well type PRVT If A, B, or C provide PWSID # Date completed 9.23.1976 Sanitary seal (Y/N) Y Total depth 455 ft. Cased to 21 ft. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: ft. 9.p -m. Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 24+ in. AT INSPECTION 6/1712014 iIN ©.t Coliform Neg colonies/100 mL Nitrate -2-W mg/L Arsenic: ND ug/L Date of sample: 311712015 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I FIBERGLASS Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping 8129/2014 Pumper JRs C. ABSORPTION FIELD DATA Date installed 6!1611977 Cleanouts (YIN) Y High water alarm (YIN) N Date installed 6116/1977 Soil rating (g.p.d./fe or felbdrm)1Z5 System type TRENCH Length 26 & 27 ft. Width 3 ft. Gravel below pipe 5 ft. Total depth 8 ft. Eff. absorption area 530 ftz Monitoring tube Y Depression over field N Date of adequacy test 6/1812014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 47 & 55 in. Water added 570 gal. New depth 62 & 56 in. Elapsed Time: 1440 min. Final fluid depth 49 & 55 in. Absorption rate >= 450 9.p -d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off' level at _ in. Cycles tested E. SEPARATION DISTANCES WELL ON LOTTO: Septic tank/lift station on lot 100'+ Absorption field on lot 1001+ Public sewer main 76+ Sewer /septic service line 251+ Animal containment areas 501+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 51+ Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 100'+ Holding tank 1004 Manure/animal excrete storage areas 100'+ Absorption field 5'+ Water main 101+ Water service line 101+ Surface water 1001+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 104 Water Service line 101+ Surface water 1004 Driveway, parkinglvehicle storage 104 Curtain drain 504 (NONE KNOWN) Wells on adjacent lots 1001+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 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 KENNETH M. DUFFUS Date 3125115 COSA canary sheet 2.6-15.doc in. Municipality of Anchorage au, Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # OSC151106 During a recent COSA on-site inspection and test of the potable water supply well on Lot 4A of Peter's Gate Subdivision, the well's productivity was determined to be 0.9 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.31 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. a �RCTERRq x March 30, 2015 ARC 1 ERRA CONSULTING, INC 212 E. 51" Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Peters Gate Block 3, Lo 4A — OSC151106 Per your submittal comment sheet, we've conducted a site visit to address items #3&#4. MOA record documents show the absorption fields consist of 5' of effective sewer rock depth with 3' of cover. Recent measurements taken show a total depth of 8' for each trench, which is consistent with MOA record documents. This system has been in operation since 1977 with no known issues with frost. It appears that the 3' cover over the trench inverts has been adequate. Also, the second standpipe from the house is the lone septic tank cleanout. This cleanout measured 104' +/- from the well. Please see notes on the attached as - built survey. The information found in MOA record documents and per site investigation correspond to previous COSA / HAA issued by the MOA for this property. If you have any questions, please contact me at 868-3791 / FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus, P. 20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793 S'q. p ed AUSUILI SMM & ASSOCIATES LAND SDR VJMNG 694-0829 I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPEXTYt t� Of A( A o�'-.3 AMTHAT NO EwEi�� EXIST EXCEPTAS t -co DATE: INDICATED. 1T IS MRESPONSIBILItY OF T44E 0 amb, OWNER TO DETERMINE THC EXISTENCE OF ANY AUSUILI SMM & ASSOCIATES LAND SDR VJMNG 694-0829 I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPEXTYt t� Of A( A o�'-.3 AMTHAT NO EwEi�� EXIST EXCEPTAS lt" DATE: INDICATED. 1T IS MRESPONSIBILItY OF T44E 0 amb, OWNER TO DETERMINE THC EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUSDI- VISION pj.AT. UNDER No CMANSTANCF ,B SHMLD- ANY DMA HEREON K USED FOR CONSTRUCTION FS, OF FENCE LINES, OR FOP ESTABLISHING BDUND- ARY LIKES. DRAM ASBUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: AND THAT NO ENCROAJCH E(NTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THP' EtfISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI— VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OFFENCE LINES, OR FOR ESTABLISHING BOUND— ARY LINES. SERARD ASSCIGIATES I ARID SEIRVfiYIYG 65 SCALE: DATE- Q �,j o GRID- ;FS: RID FS: _ Ova a Merk Saward : - ^ •; ' . .S DRAWN: MUNICIPALITY OF ANCHORAGE • t 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.# 0:�)1- Fit -©C-o 1. GENERAL INFORMATION Complete legal description L -.D i 6;_4 B K 3 6c_16, Location (site address or directions) •25002 F-Tia��o�ive� Propertyowner -? 11y IU-iauA i'ra.-�,ne Dayphone_l6ge-9;7?(- Mailing addressI' 0, 6 � (D 70 (of 0 ri l>^q_"y , a•, Collis t Lending agency •r , � k Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well ✓ Community well Public water phone Day phone 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: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA #21 S. 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 forthe 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 O IP 107-- L1 �Y �� K� L Phone Address a �✓ / a� / Engineer's signature Date 1 6. DHHS SIGNATURE — /� Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments WTIC 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. 72-026 (Rev.1191) Back MOA 821 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L51450 Parcel l.D. A. WELL DATA Well type Re..s If A, B, or C, attach ADEC letter. water system number C�ADEC T Log present (Y/N) Date completed `'�3' � Driller o 4-c vnt•co Total depth 146.5 Cased to ILI J Casing height " P'Llud Sanitary seal (Y/N) Wires properly protected (Y/N) 1 S a kot) kmvW FROM WELL LOG AT INSPECTION Date of test III X3�%` 10 NO 43 Static water level 38 75 � - - Well flow 0+ is rm g.p.m. g.p.m. C1 N % Pump level 33 V m M c> z J co75 SEPARATION DISTANCES FROM WELL TO: y�Ul3T r ©�'' < a Septic/holding tank on lot 1011 h— ; On adjacent lots t� � z Absorption field on lot (l9 l ; On adjacent lots Public sewer main N/A Public sewer manhole/cleanout Sewer service line `S Petroleum tank 1n WATER SAMPLE RESULTS: �y Coliform Nitrate 100 /A Other bacteria 1 Date of sample: � �/ 4 3 Collected by: 770S B. SEPTIC/HOLDING TANK DATA Date installed 1014,177 Tank size 104.0 Compartments 2 Cleanouts (Y/N) V Foundation cleanout (Y/N) Depression (Y/N) N High water alarm (Y/N) // tq/J��t Alarm tested (Y/N) N/,*t Date of pumping b /f i i9 Z Pumper 9440 4t wow_ flt. A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot t o 7 On adjacentlots>> Foundation 2)to Topropertyline 7210 Absorption f laid �O� Water main/service line > b� Surface water/drainage M/1„ 72-026 (Rev. 7/91) From CONTINUED ON BACK PAGE C. LIFT STATION Date installed . Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access(Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off' level at Cycles tested Surface water _ Date installed `&/77 Soil rating System type 1 Length t— 2 � Width Gravel thickness Total depth Z Total absorption area .6 3o Cleanouts present (Y/N) Depression over field (Y/N) ^ Date of adequacy test Results (pass/fail) for bedrooms Per treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots low Property line To building foundation 3' To existing or abandoned system on lot N Vii On adjacent lots ;§! 14 Cutbank—blip KA Water main/service line ,> ro Surface water NO 0E— Driveway, parking/vehicle storage area _ ,i y Curtain drain Nio E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on to date of this inspection. 6 �A A. �^ Signature Engineer's Name Date v HAA Fee $ Date of Payment 4_24)_3 Receipt Number 27 6.12 74L7r,) 72-M (Rev. 3/81) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number