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Home My WebLink AboutSEA TURN BLK 1 LT 14NAME ./~ MAILING ADDRESS ~EGAL DESCRIPTION DISTANCE TO: Manufacturer Liq. c DISTANCE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAt. TH & ENVIRONIVlENTAt. PROTECTION ENVIRONMENTAL ENGINEEIr~ING DIVISION 825 t. Street - Anchorage, Alaska 99501 Teiephonr? 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT TPH°NE ( [Absorption area length Dwelling Dwelling BEDROOMS IF ROMEMADE: Width Liquid de~ptl_~. PERMIT NO. Liquid capacity in gallons idation Nearest lot lin~___ (.~ / O i~,,f line Trench width~_, DISTANCE TO: Wel~ ~(."~ No, of Ii nF.e~.¢. I~;~-(~Lenoth of ~-~(-~- ¢..'l-'(-l~)e'ech lilne ~ Top of tile to finish grade ¢., Material beneath tile Distance between line,s Total effective absor ' Length Width Depth PERMIT NO. DISTANCE TO: [PER MIT~NO_. Absorption area(si Depth Driller Building fo~ DISTANCE TO: Sewer line // ' OTHER PI .P..E~/IAT E R I ALS SOIL TEST RATING INSTALLER Distance to lot line /0 ' Septic tank APPROVED ~ 72-013 (R~,. 3/78) / ~,' DATE LEGAL / Box :18~B9, STAR ].~OUTE A A1NCHORAGE, ALASKA 3~4-771,~ SIX INCH WATER WELL DRILLED AND CASED OUT TO ThE DEPTH OF DRILLED AT THE RATE OF _ (~ .Vo 00 PER FOOT. PROPERTY OWNER ~- & /i~ ' ~ ,/~ 2~ ] --2~ ~2 LOCATION OF WELL SITE D r I l L E R WELL LOG: 0 ..... 79' 5~t~ q~e~. 3/4 7o-f-x~ co.~ o~ i),t,~6UO;¢: [72812°00 Coo.t o~. Ne, LA. SemA.: $22.50 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. ~2834 .50 WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. DATE. BERNIE CLAU~OF RAMPART DRI].LING WORKS ~ERVICE CHARGEOF 1Va% PER MONTH WILL BE ASSESSED ON PASt DUEACGOUNTS DEF'FIRTMENT I...IERLTN RND EN',,,'IF.:CINMEI'.,IT'RL dDTEF:TION 82.5 "'L' STREET'., RNCHORRI;~E., / PERMIT NO. ,:: ,=,0~.~,, ', ~'EE% ~. FIF:'F'LICFINT RZCHRRD HUFF 2'~¢d LI=,:.:,INUT.N .... '" P LOI]:FI]" ]; ON r, - ', , ~,[~E,E, IT CREEK RD. LEGFtL ;b~? d~4 BL~K.: Z: SERTLIRN ,'g,."D' LOT T'¢F'E OF SOIL RE:SORF'TION 5'¢.STEfl I5~;: DRRINFIELD I Il.:hslMUfl H.hlBEP CF BEDROOMS = 4 THE REQUIRED SIZE OF THE SOIL FIBSORPTION SYSTEM IS: THE I_ENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENL. H OR DRFIINFIEL[:,. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETHEEN TNE SURFRCE OF THE GROUND FIND THE BOTTOM OF THE E::4CR',/RZ~ON (IN FEET'.'.,. THE ~..n,:,_ DEFTH IS THE ¢II~:~iMLiM: ~,EpTH Gte i3RRVEE; BETWEEN ~HE OUTFRLL'PIF'E RND THE BOTTOM OF THE EXCR',,,'RTION ,::IN FEET), F'ERMZT RF'F'I..ICRNT HRS THE RFSPONSIE:ILITY TO INFORM THIS DEPRRTMENT DURING THE INE;TRL. LFITZON ZNE;PECTION$ OF RN¥ HELL5 R[:'JRC:ENT TO T'H~:5 PF.:OPERT"r' FtND THE NLIME:ER.' OF RESIDENCES THRT THE HELL HILL SERVE. E,P ~.K.F IL[,.,[NU OF FINY SYSTEM I.,.IITNOLIT FINRL INSF'ECTION RND I~F'PRO'v'FtL B'¢ THIII-3 DEF:'FIF.:T'MEI'.~T 1.4TLL BE SUBJEr-:T TO FF.'._::,EuUTILIN MINIMUM DISTRNCE BETI.4EEN F~ HELL RND FtN'-r' ON-SITE SEHRGE [:,ISPOSFIL SYSTEM IS :1.00 FEET FOR R PRIVRTE HELL OR :L50 TO 200 FEET' FROM R PUBLIC HELL DEPENDING UPON T'~IE TYPE OF PLIBLIC HELL. MINIMUM DISTRNCE FROM R F'RIVRTE HELL TO R PRIVRTE SEHER LINE IS 25 FEET RND 'T'G R COMMUNIT'¢ SEHER LINE IS 75 FEET, HELL LOGS RRE REQUIRED RND MUST BE RETURNED T'O THE DEPRRTMENT HIT'H!N 20 DRYS OF THE 14ELL COMPLETION. OTHER REQUIREMENTS MRY RPF'LY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS 8RE R'¢F:IILRBLE TO INSURE PROF'ER INSTRLLRTION. I CERTIFY THRT t: I RM FRMILIFIR NITH THE REQUIREMENTS FOR ON-SITE SEHEF..'S RND HELLS FIS SET FORTH BY T'HE MUNICIPF~LITY OF FINCHORRGE. 2: I 14IL'.L INSTRLL THE S"r'STEM IN FIE:CORD~NCE HITH THE COPES. S: I UNDERSTIZlND TNFIT TNE ON-9ITE 9EHER SYSTEM MFIY REQUIRE ENLRRGEhlENT IF TNE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS, FIF F L Z CRNT R ~ E:HRRD HUFF ISSUED E:Y_ . [] SOILS LOG PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 8 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-550, Anchorage, Alaska 99502 ~76-2221 PERCOLATION TEST SOILS LOG - PERCOLATION TEST %'¢4'-t-o SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE / ~ (minutes/inch) TEST RUN BETWEEN II/'2~ FT AND 3 FT 72-008 (7/76) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0107-121-41 GENERAL INFORMATION Complete legal description Lot 14, Block 1, Sea Turn Subdivision Location (site address) 6141 Azalea Drive Anchorage, AK 99516 COSA # Expiration Date: Current Property owner(s) Kelly L. Williams Mailing address 1605 N. Raven Mesa, AZ 85207 Day phone Lending agency Mailing address Day phone Real Estate Agent Mailin'§Address .Unless otherwise/~equested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: Four (4) Day phone 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 sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. DSD SIGNATURE L/'/"~ Approved for ~ Disapproved. Conditional approval for bedrooms. Phone 522-7773 Date 9/15/10 bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements · Supplemental Engineer's Report Other. By: Original Certificate Date: (Rev. 11/05) 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/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 14, Block 1, Sea Turn Subdivision A. WELL DATA Well type Pdvate Date completed 8/14/80 Total depth 148 ff. IfA, B, or C provide PWSID # .. Sanitary seal (Y/N).....Y Cased to 148 ft. FROM WELL LOG Date of test 8/14/80 Static water level 18 Well production 15 WATER SAMPLE RESULTS: fto g.p.m. Coliform o .colonies/100 mL Arsenic: N/D mg/I B. SEPTIC/HOLDING TANK DATA Nitrate N/D mg/L Date ofsample: 8/26/._..~0 'Tank Type/Material Steel/Septic Tank size 1,250 gal. Foundation cleanout (Y/N). Y Date of pumping 7/15/2OLO ,C. ABSORPTION'FIELD DATA Number of Compartments .Two Depression over tank (Y/N) .. N Pumper Unknown*** Parcel ID: 017-121-41 Well Log (Y/N) Wires properly protected (Y/N). Casing height (above ground) AT INSPECTION 9/13/10 36.2 ft. Y Y >12 in. 5.4 g.p.m. Other bacteria 0 colonies/100 mL Collected by: M. Anderson Date installed 8/14/80 Cleanouts (Y/N) High water alarm (Y/N) N Date installed 8/14/80 Soil rating (g.p.d./fl~ or ~/bdrm) 1,90 SF/BDRM System type 5' Wide Trench Length. 109 ft: Width 5 ff. Gravel below pipe. ' 2 ff. Total depth 5.5 .ft. Eft. absorption area 779 ft2 Monitoring tube. Y Depression over field ...N Date of adequacy test 9/13/10 .Results (Pass/Fail) Pass For ~ bedrooms Fluid depth in absorption field before test 2 in. Water added 1,000 gal. New depth 9 in. Elapsed. Time:~.... 1,_440...mit~, ~- Final-fluid depth ....2 in: ......Al~6~stib-n'~site-'~:- ....... ~0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ..... If yes, give date LIFT STATION Date installed "Pump on" level at Datum in. E. SEPARATION DISTANCES Size in gallons "Pump off' level at Cycles tested SEPARATION DISTANCES FROM VVELL ON LOT TO: Septic tank/lift station on lot >1oo' Absorption field on lot >1oo' Public sewer main N/A in. No Receipt Could be Found. Manhole/Access (Y/N) High water alarm level at Meets alarm & cimuit requirements? in. On adjacent lots >1oo' On adjacent lots >1oo' Public sewer manhole/cleanout N/A Sewer/septic service line >25' Holding tank N/A Animal COntainment areas >50' Manure/animal excrete storage areas >100' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' .Property line >5' ' Absorption field >5' Water main N/A Water service line >10' Surface water >100' Wells on adjacent lots >loo' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water main * >10' Water Service line r>lO' Surface water >lOO' Driveway, parking/vehicle StOrage >25' Curtain drain None Noted Wells on adjacent lots >lOO' COMMENTS.' ***No Sludge Accumulation in the Septic Tank. The Owner States the Tank was Pumped Mid Summer of 2010. · review ~ Munic~al m~s ~at the above sy~e~ am in' . Enginee¢s Pdnted Name Mi~ael E. Ande~n, P.E. COSA Fee $ Date of Payment ........... Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment ReceiptNumber ................. SGS SGS Ret.# 1104447001 Client Name Anderson Engineering Printed Date/Time 09/01/2010 15:29 Project Name/# Lot 14 Block I SeaTurn Collected Date/Time 08/26/2010 13:00 Client Sample ID Lot 14 Block 1 Sea Turn Received Date/Time 08/26/2010 14:27 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: 4500NO3 - Total Nitrate/Nitrite - MS recovery is outside of QC criteria. Refer to the LCS for accuracy requirements. 300.0 - Anions - Sample duplicate RPD was outside of acceptance limits. The difference between sample and duplicate results is less than the LOQ. Allowable Prep Analysis Parmneter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Hardness as CaCO3 92.5 5.00 mg/L SM20 2340B C 08/26/10 08/30/10 KDC Waters Department Total Nitrate/Nitrite-N ND 0.100 mg/L SM20 4500NO3-F B 08/26/10 AYC Microbiology Laboratory E. Coli Negative I 100mL SM20 9223B A 08/26/10 SDP Total Coliform Negative 1 100mL SM20 9223B A 08/26/10 SDP Private Individual Analysis Alkalinity 92.5 10.0 mg/L SM20 2320B D 08/26/10 LP Aluminum ND 20.0 ug/L EP200.8 C 08/26/10 08/30/10 KDC Antimony ND 1.00 ug/L EP200.8 C (<6) 08/26/10 08/30/10 KDC Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/26/10 08/30/10 KDC Barium 8.13 3.00 ug/L EP200.8 C (<2000) 08/26/10 08/30/10 KDC Cadmium ND 0.500 ug/L EP200.8 C (<5) 08/26/10 08/30/10 KDC Calcium 26900 500 ug/L EP200.8 C 08/26/10 08/30/10 KDC Chloride 0.633 0.100 mg/L EPA 300.0 D (<250) 08/27/I0 08/27/10 SDP Chromium ND 2.00 ug/L EP200.8 C (<100) 08/26/10 08/30/10 KDC CO3 Alkalinity ND 10.0 mg/L SM20 2320B D 08/26/10 LP Conductivity 217 1.00 umhos/cm SM20 2510B D 08/26/10 SDP Copper 31.5 1.00 ug/L EP200.8 C (<1300) 08/26/10 08/30/10 KDC Fluoride 0.130 0.100 mgFL EPA 300.0 D (<2) 08/27/10 08/27/10 SDP MUNICIPALITY OF ,~,NCHORAGE 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 1, GENERAL INFORMATION Complete legal description Location (site address or directions) /~/4~/ Property owner Mailing address Lending agency Mailing address Day phone Day phone ¢0._~ 7- Do 7 7 Agent Add ress ~ / V ¢--~¢ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 {Rev. 1191) Ftonl MOA #21 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. NameofFirm "I~b~¢~ ..--~c,.r~.L¢_~,¢.(~ '~- ~ Phone Address ~20 _--5 ~ / 9- ,,~ ,cC ¢9--O ~ Engineer's signature ~ -~,,., ~.z ~.~_¢~.~¢~ Date I Sm DHHS SIGNATURE ~ Approved for ~-X~ fZ¢)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 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. 72-025 {Rev. 1/91 ) Back MOA #21 A. WELL DATA Well type '~ Log present (Y/N) 'Y Total depth [q~>t Sanitary seal (Y/N) ~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental SerVices Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907),~,4~4~744 Health Authority Approval Checklist If A, B. or C. attach ADEC letter. ADEC water system nmnber /'q///~ Date completed ~.-lq ' I'[[~£) Cased to I q~' Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production _ 1-% g.p.m c~ ~Zt g.p.m. WATER SAMPLE RESULTS: Coliform (25 Nitrate tt~b Other bacteria Dale of san,pie: "r~'/7/Q ~ Collected by: ~.~ B. SEPTIC/HOLDING TANK DATA Date installed ~'(q- 8(3 Tank size I,~l.50 ~ Number of Compartments c~ Cleanouts (Y/N) Foundation cleanoat (Y/N) _}/ Depression (Y/N) A/ High water alarm (Y/N) Date of Pumping _ ~/~//oQ~/'~ d. Pumper C. ABSORPTION FIELD DATA Date installed ~" Ici ' c~O Length [OCt` Width Effective absorption area "~'~ ~ Date of adequacy test {~" 3' q Soil rating ~g.p.d./ft2 or ft2/bdrm) I~O System type t Gravel thickness below pipe ~'[ ~' . Total depth Monitoring Tube present(Y/N) 7 Depression over field (Y/N) Results(Pass/Fail) '~) For q bedrooms Fluid depth iu absorption field before test (m.); Fhfid depth q ?~ (ins.) Minutes later:__4/69 hnmediately after ~p gal. water added (ii,.): ?-~ Absorption rate = ~> ~C t./O g.p.d. Peroxide treatment (past 12 months) (Y/N) fx[ If yes, give date LIFT STATION Date installed Size in gallons Mauhole/Access (Y/N) "Pump on' level at* "Pump off' level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ")' II0~ Absorptiou field on lot Public sewer main Sewer/septic service ; On adjacent lots ; On adjacent lots Public sewer manlrole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line x~ [0 ' Absorption field ~' Water main/service line >' ~.~ t Surface water/drainage ~q'/O Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ') ~ 4 Water maiiffservice line ~ ~,~L~ I Driveway, parking/vehicle storage area ~) [O ~ Wells on adjacent lots ) i(Y.)i Property line ~ lO ~ I Surface water - I O Curtain drain ~0 ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal reco~s that the above systems are in conJbrmance with MOA H~ guidelines in.~ect on this date. Signature ~ Engineer's Name HAA Fee $ Date of Payment Receipt Number ~/~ ~~ Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number ]EMENTS OF RECORD, OTHER THAN :)SE SHOWN ON THE RECORDED kT ARE NOT SHOWN HEREON, As-BUILT NO bORNERS SET THIS DATE 1 here,,y certi,y ,hat I have performed a Mertgagee's inspection of the following described property: L- o'J' /~,_ ~/~ /t Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within Ihs property lines and do not overlap or encroach on the property lying adjacent lhereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there ars no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this -7 +5 day of .A ~ ~ ~ ~ f _ 19 9~' FRED WALATKA .& ASSOCIATES (907) 248~1666 Engineers and Surveyors CT&E Environmental Services Inc. Laboratory Division 200 W. Potter Drive Anchorage, AK 99518-1605 Tel: (907) 562-2343 Fax: (907) 561-5301 CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 963630001 Tobben Spurkland P.E. Lt 14 Bkl Seaturn Ltl4 Bkl Seaturn Dri~zking Water Client PO# Printed Date/Time 08/09/96 16:37 Collected Date/Time 08/07/96 14:50 Received Date/Time 08/07/96 16:10 Technical Director 0 Released By ~ ~'. Sample Remarks: Altowable Prep Anatysis Parameter Resutts PQL Units Method Limits Date Date Init Nitrate*N 0.100U 0.100 mg/L EPA 353.2 08/08/96 EMB Total Cotiform 0 0 col/lOOmL SM18 92225 08/07/96 TAV Member of the SGS Group (Soci~t6 G6nOrale de Surveillance) ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # 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) Location (address or directions) (b) Property owner ~,, ~1~1~ H4~V~'"~elephone: (home) Mailing Address p~) 0 ~l~ldl~["~ "'~""~ t~ (c) Lending Institution Business Telephone Mailing Address (d) Real Estate Company and Agent Address ~---- -- ~ [ (e) Mail the HAA to the following address: (or check here ¢~if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Familyx' Number of bedrooms 3. WATER SUPPLY Individual Well j~ 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~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage fi]es 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. '. NameofFirm ~-.~,}t,~_~. ~.t_ ~{'~,-~l~l~.~l~-one '~7 '7-- I I~1 Address ~ ~ -~[U~ ~, Date '7- Z3- 90 6. DHHS APPROVAL Approved for bedrooms Approved ~'"'"~ ¢' Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5above 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 DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev, 7/88) Back Page 2 of 2 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) NICIPALITY QE gHEE:K[.I'ST-- FEBRUARY 1984 ONMENTAL SERViCESDl~71~J4744 JUL ~ ~ 1990 Legal Description: RECEIVED Y Date Completed 8- Depth of Grouting Well Classification Well Log Present (Y/N) _ Total Depth ~1~1~ Cased to Static Water Level '"'/'" I~ '~0 Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line J~t'~l~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved (Y/N) Yield ~ fi'~0 ' I Pump Set At I ~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ~J To Nearest Public Sewer Cleanout/Manhole ; On Adjoining Lots //~) ' ; On Adjoining Lots 99' ; Date B. SEPTIC/HOLDING TANK DATA Datelnstalled ~ ~O Size t~.~'O Standpipes (Y/N) 7 Air-tight Caps (Y/N) _ Depression over Tank (Y/N) ~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~.¢ A Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~, 0 ~ TO Property Line ~ 40' To Water Main/Service Line 3 '~ ~ No. of Compartments ~1~.. y Foundation Cleanout (Y/N) ~' Date Last Pumped J ~J~'~ '~ "~0 ~ ~ ;for ~J ~i To Stream. Pond, Lake or Major Drainage Course To Building Foundation _ 'to Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Width of Field / ~.~,/ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test ~ ~~~~L~Type of System Design Length of Field ~ ~ ~ Depth of Field ~ Gravel Bed Thickness ~.~" Statndpipes Present (Y/N) Date of Last Adequacy Test To Water-Supply Well To Building Foundation ~ 8 / Lot I~.)A To Water Main/Service Line ~"~' ~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area SEPARATION DISTANCE FROM ABSORPTION FIELD: I ~, ~ ~ To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ To Cutback (if present) Comments D. LIFT STATION~J~ Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump O~ High Water Alarm Level at ~ent (Y/N) Tested for ~ Pumping Cycles during Adequacy Test. ~~..~?~Meets MOA Electrical Codes Date of Payment Amount: $ 72-026 (Rev. 7/88) Back **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or,~7~nformed to all MOA and HAA guidelines in effe. ct,,o,n, the,date of this inspection. Company' ~,,1~ MoADate ~-- ~ '~ONo. Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 KNIEFEL ENGINEERING 8441 Miles Ct., Anchorage AK, 99504 (907) 337-1121 · Fax (907) 338-1874 HEALTH AUTHORITY RESULTS AND ANALYSIS Date of Testing: July 17, 1990 --- Presoak July 18, 1990 -- Adequacy Test Legal DescriPtion: Lot 14, Block 1, Sea Turn Subdivision Street Address: 6141 Azalea Number of Bedrooms: Four (4) Results of Well Flow Test: Average Flow Rate: > 6 gpm Passed Results of Water Quality Analysis: Passed (Samples collected by Ftt.~top Technical Services 7/13/90) Total Coliform -- 0 colonies Nitrate-N -- < 0.10 mg/1 (10 mg/1 allowable) Testing Laboratory: Chemical and Geological Testing Lab. Approval: The well and wastewater system are approved as beinq adequate for a fQur (4) bedroom house. The well and wastewater systems were tested in accordance with MOA policy and regulations ~n force at the time of this test. A water monitor tube was installed to provide end of field monitoring for both test purposes and long term monitoring. The wastewater system was pre-soaked with 1,872 gallons of ~ater on July 17, 1990. The system was then tested with 902 gallons of water on July 18, 1990. The wastewater system adequately disposed of the water introduced to the system. The well produced > 6 gpm during the test period and is capable of producing at least three gpm over a four hour period to meet the FHA minimum requirements. ";!i,' ;:% ~',I ,. A14V-}! JUL '~9 "98 1~':36 C71 PRCIFIC ItORTH 90? ~451768 ~.~~. . CHEMICAL & GEO~GICAL ~ORAT~RIES OF A~S~, INC. ~;~,~ 5~ B STREET. ~OHORAGE, A~KA 99518 TELEPHONE (907) 562-23~ FEDERAL TAX I,D. ~92-0040440 Collecto~ JDL ~3 ~0 t XI~20 ~,~eive~ 3gL L$ 90 4 .l~s, P,O,! MOII~ ~ECIIVED O~dexed ~y ~ T~DWO0~ ?~e~e~e~ ~ested - ~etult Onitm Ileth~ Ltmts HIf~YE-M ~(O,&O) W/~ ~PA 351,2 10 ~- ~OM ~teet~ *' ~ee ~le ~enazkm Abovo ~k- Rot Aml~ed LT-LeIs APPLI( NT FILLS OUT UPPER HA! ONLY Property Owner [~UFF, Richard & Renee Phone Malling Address (]'tO longer living in Anchorage) Zip Code it/a Buyer MERRILL LYNCH RELOCATION MANAGBMENT Address po O. BOX C91000, gellevue, WA ZlpCode 98009 Lending Institution none Phone Address Zip Code Realty Co. & Agent DYNAMIC RBAL~%, Perle Strang Phone 501 W. Nort~ern Lights Blvd, Anchorage 99503 Address Zip Code Legal Description Lot 142 Block 1, Seaturll Street Locat[o~ Azalea Type of Residence [~ Single Family [] Multiple Family No. of Bedrooms 4 [] Other Water Supply [~ Individual i cc~/.:~ (~'1'~ ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach log if available). Sewer Disposal ~ Individual Year Individual Installed: [] Public Utility (~,(~5~ When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNICIPALITY OF 'ANCHORAGE / ~- ,~ DFP/ C ..... .~ .... . RECEIVF. D J~j~ APPROVED"~ BEDR(~OM8 'CONDITION8 OF APPROVAL ( ( : ) DISAPPROVED ( ) CONDITIONAL APPROVAL' Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received ~r> '~ ~'"O Well to Tank Septic Tank Size / 'z)~ z-' ~ 72.023 (3/82) '~" D,~,~E RECEIVED INspEcTION APPOINTMENTS ~~: TIME TIME TIM["- DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION Telephone 264:4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts pa page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing, 1. P~0PERTYOWNER . , ~H~NE..,, MAILING ADDRESS PROPERTY RESIDENT (if different from above) PHONE 2, BUYER t PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE I MAI LING ADDRESS 4. REALTOR/AGENTf~,] ~. PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE NUMBER OF~BEDROOMS (~ One /~]" Four 8INGLE FAMILY [~] Two ' [] Five [] MULTIPLE FAMILY [] Three [] Six Other 7. WATER SUPPLY .1~'/ INDIVIDUAL* ..."' [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM INDiViDUAL/ON.SiTE~ PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) J~[~. ~,~ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [~] SINGLE FAMILY [~] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER E~]Septic_Tan~.~r [] Holding Tank Size: ( ~ If Tank is homemade SOILS RATING ~ '~-~-~ give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCESwELL TO: Septic/Holding Tank Absorption ,~rea Sewer Line [ Nearest Lot Line I Absorption Area to nearest Lot Line 5, COMMENTS PPROVEDFO. BED.OOMS [] CONDITIONAL APPROVAL {letter must accompany certificate) [~3 DISAPPROVED DATE BY ~ 72-010 (Rev. 6/79)