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PERMIT NO.
DEPARTMENT HEALTH AND ENVIRONMENTAL - ''OTECTION
825 ' a. STREET: ANCHORAGE.- A0::. 'a_ • , J1
264-4720
810276
APPLICANT DAVID HACKNEY
LOCATION TIFFANY TERRACE
LEGAL LOT B I SHANE LEE EST.
'1320 _SUNRISE DR.
LOT SIZE 9300 _•QB,„FARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND A?'d`7 ON—'SITE SnEWPIGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY -EWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
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.
SI13NED:
APPLIC:F ,T C,A`,1IC:, HALF"NEY
ISSUED E:, _ __._ ___. _ L>F1TE_ V4. 0
i=Co:�R r #+did T I FFOW T WD
21
LOT 2 6 1 '� LEE F-;rL i3T SIZE �� '-fdxF£IeI
ti I C" U I S TRNcE 2E 11 14cuL 19 fwd" t 1Ni S I TF '530,190W O NSFIOSt t S e3TE1 IS
too FEET FoR A PRI DE } OR j -7e TI) 20
0 FST F 3ti A pfjeLIC-tEpejorm
1JVI'� TWE TYPE L-' F# f c �IELt-
t Lid Lid#3�1 DIsTA rROH A PRIVATE WELL TO €# PR(VATC 5e4ER LME IS 21 Feer -Am
TO €d r=x3MStd[ TY 'S-EWR LINE 15 ?-5 WEFT_
13F THE WELL tX% LSTI
1371-W-9 ms's` APPLY_ Des, IF ICH T I UMS 19W t: t3Ns T#2 -r i I,iri o i tjx3w� fW-
ff-MIL11OLE TO PROPOZ IM-54FTFOLLRTIOM
I?TC s T€li
i #$ FAMIl IM $-jI T IPA {fit-LTa 13 l'a` ii'
FORM ay T: �
.2: 1 14ILL MOYN- .. THE SYSTEM IN PC�WITH THE
i2------- -�--------m_--a_-__
AWMI'- SID
F
-DATE Y4-
Parcel I.D. 014-061-58
#GE BG
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date:
Shane Lee Est. Block 1, Lot 2
6740 Tiffany Ter.
Current Property owner(s) Gerry & Patricia Bering Day phone
Mailing address 6740 Tiffany Ter. Anchorage, AK 99507
Real Estate Agent
2. TYPE OF DWELLING:
Fx� Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer 0
Waiver/Variance request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ �✓ Waiver Fee $
Date of Payment ��� Date of Payment
Receipt Number 0 Receipt Number
COSA # 650,1 (,, I D6 3 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty -
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
tSystem #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Phone (907)272-8218
Date 3/1/2016
��svlgq®
r CP��t}i
Seven li. f�annoli .
—8149
Conditional approval for bedrooms, with the following stipulations:
Y111 L-1 \ 111l,
Original Certificate Date:
The 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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSAbluesheeU ..
If more than 7 septic system is on the lot:.
COSA Checklist # + of ±
Structure served by this system
Certificate of On -Site Systems Approval Checklist -
Legal Description: Shane Lee Est. Block 1, Lot 2 Parcel ID: 0 14-061 -58
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 7/20/1981 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 105 ft. Cased to 105 ft.. Casing height (above ground) 12 in.
FROM WELL LOG AT INSPECTION
Date of test 7/20/1981 2/16/2016
Static water level 65 ft 62 ft
Well production 20 g.p.m: 7.5+ g.p,m.
WATER SAMPLE RESULTS:
Coliform N69 colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 2/16/2016 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material � Date installed
Tank size gal. U er c partments Cleanouts (YIN)
Foundation cleanout (Y/N) _ epr ssTb+S over tank (Y/N) _ High water alarm (Y/N)
Date of pumpin Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./fe or ftz/bdr!�Ift.
System type
Length ft. Width Gravel below pipe ft.
Total depth ft. `Eft. absorptionre ftz Monitoring tube _ Depression over field _
Date of adequacy test Res aIts'Rass/Fail) For _ bedrooms
Fluid depth in absorption before test in. Y Water added gal New depth in.
Elapsed Time: min. Final fluid depth • in. Absorption rate >= g.p.d.
Any re' enation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Dateinstalletl 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
WELL ON LOT TO:
Septic tank/lift station on lot NIA On adjacent lots 100+ .
Absorption field on lot N/A On adjacent lots 100+
Publicsewer main 75+ Public sewer manholelcleanout 100+
Sewer /septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manurelanimal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION -
1 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 Steven Pannone . -
Date 3/1/2016
COSA canary sheet 2-6.15.doc
i SCE -8149
ASSUILT SEWARD & ASSOCIATES LAND SURVEYING 694-Q8
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE. �a:ire
FOLLOWING DESCRIBED PROPERTY: = r" F ° OF At tA:
'zr�c DATE=
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS A,
INDICATED.
'
INDICATED. IT IS THE RESPONSIBILITY OF THE B i
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID:
EASEMENTS, COVENANTS, OR RESTRICTIONS ra35' t
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- '> Duns µa,t so""l ; f
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' °� 15-6918 g =
ANY DATA HEREON BE USED FOR CONSTRIJCTI ON t }y too
OFFENCE LINES, OR FOR ESTABLISHING BOUND -
DRAWN:
ARY LINES.
V
ASSUILT SEWARD & ASSOCIATES LAND SURVEYING 694-Q8
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE. �a:ire
FOLLOWING DESCRIBED PROPERTY: = r" F ° OF At tA:
'zr�c DATE=
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS A,
INDICATED.
'
INDICATED. IT IS THE RESPONSIBILITY OF THE B i
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID:
EASEMENTS, COVENANTS, OR RESTRICTIONS ra35' t
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- '> Duns µa,t so""l ; f
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' °� 15-6918 g =
ANY DATA HEREON BE USED FOR CONSTRIJCTI ON t }y too
OFFENCE LINES, OR FOR ESTABLISHING BOUND -
DRAWN:
ARY LINES.
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services C4
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING - reissue -
Parcel I. D. # 014-061-58 HAA # HA 970338
1. GENERAL INFORMATION
Complete legal description
Lot 2; Block 1; Shane Lee Estates
Location•(sIte.address or directions) 6740 Tiffany Terrace
TTI
Property owner Dave Hackney Day phone 265
Mailing address C/O Seattle Mortgage 4300 "B" St. Anchorage, AK 99503
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
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:
Individual on-site
Holding tank
Community on-site
Public sewer xxx
NOTE' It community wastewater system, provide written confirmation from State AOEU
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 S & S ENGINEERING Phone 6 cl 4i
Eagle River Loop Road No. 204
Address Eagle River, Alaska 9.577 i
Engineer's signature
6. DHHS SIGNATURE
X Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
N0
Date 0/ )� 716l 7
bedrooms, with the following stipulations:
Date d Y- 7
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 k21
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services ik
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. # O I y " 0 6 � — S S? HAA #
1. GENERAL INFORMATION
Complete legal description Lot 2; Block 1; Shane Lee Estates
Location (site address or directions) 6740 Tiffany Terrace
, AK
Pfoperty owner Dave Hackney Day phone 265-8394
Mailing address C/Q Seattle Mortgage 4300 "B" Street Anchorage, AK 99503
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
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:
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.
S& S ENGINEERING 6 cl y_ cl 7 c�
Name of Firm 17034 FROA R'vnr I oop Road No Z04 Phone
Eagle River, Alaska 99377
Address 0.4 2f
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
Additional Comments
By:
bedrooms.
aurlr
Date �/ y/ q 7
0
ROBERT C. COWAN
CE -8801
bedrooms, with the following stipulations:
Date 'I—' / —1�7
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 orderto 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(Rw.1/91) Back MOA#21
MUNII�ALJfiY dF �N0
ENVIRCiNMENrAI, SERCHRAGE
VIC
ES 131VI51®L�
•
Municipality of Anchorage AUG 04
DEPARTMENT OF HEALTH &HUMAN SERVICES �Q
Environmental Services Division _R
� �E.
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343 -474 -4 ----
Health Authority Approval Checklist
Legal Description: LoT Z attic K i JZs-na-r>;S Parcel 1. D.:
A. WELL DATA
Well type Pgi V.WE If A, B, or C, attach ADEC letter. ADEC water system number k,
Log present ON) q&, Date completed fI
Total depth flab Cased to f Casing height (above ground) 12
Sanitary seal &N) k/ Wires properly protected (9N) Y f f
FROM WELL LOG AT INSPECTION
Date of test
Static water level (b S 5J
Well production 310 g.p.m. 2.4 9 -p.m
WATER SAMPLE RESULTS:
Coliform ® Nitrate 0, 1 Other bacteria D
Date of sample: ll //olq i `- 7/j�ti /q7 Collected by: S 8 cc E"'GINSERING
B. SEPTICIHOLDING TANK DATA /0j 4 Li c S,E &j C., 17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99377
Date installed �Tarlk size Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) C
Date of Puri#rrg ? < i > ,'`w Pumper
C. ABS-ORPTION FIELD DATA
High water alarm (Y/N)
Date installed Soil rating (g.p.d.ff or ft2/bdrm) System type
Length I`
Effective absorption area
Date of adequacy test
Gravel thickness below pipe Total depth
Tube present (Y/N) Depression over field (Y/N)
Fluid depth in absorption field before test (in.); Ir
Fluid depth ins) Minutes Inter:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
For
after_ gal. water added (in.):
If yes, give date
rooms
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at`
Cycles tested _
E. SEPARATION DISTANCES
U;
Size in gallons
level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
"Pump off" level at*
Septic/holding tank on lot AVILJ On adjacent lots 1tr\ip
Absorption field on lot On adjacent lots I t1
Public sewer main 1 Public sewer manhole/cleanout ►nn 1+
Sewer /septic service line
SEPARATION DISTANCES PREM SEP'
Lift station 160 d.
OLDING TANK ON LOTTO: /)v /3 L, c
Foundation _ Property line
Water main/service line Surface water/drainage
SEPARATION DISTANCE -.FROM ABSORPTION FIELD ON LOTTO:
Property line _ E _q foundation
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
Absorption field_
lots
5 f W,6 i2
Water main/service line
parking/vehicle storage area
Wells on
I certify that l have determined thru field inspections and review of Municipal records t e��sov�
in conformance with MY gui
Signature rues in effect on this date. �'•• ••••.
��
nature Z
a
Engineer's Name /�a��~� � � • �D u/��
ROBERT C COV
Date
CE
i
HAA Fee $5 qWaiver Fee $ _
Date of Payment _ I / 7 Date of Payment
Receipt Number_ C�3 � 75 Receipt Number
72-026 (Rev. 3/96)*
are
pj 5
CT&E Environmental Services Inc.
lL Laboratory Division ranivioiiiiiooi►.���.a�����.e'.�a�.e�'iii�'ii.,iiiieir�
Drinking Water Analysis Report for Total Coliform Bacteria Anchorage,0W- or Drive
99518-1605
READ INSTRUCTIONSONREVERSESIDE BEFORE COLLECTING SAIVPLE Tel: (907) 562-2.343
Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM I.D. 4
PRIVATE WATER SYSTEM
SendResullsSendlnvoice
S & S ENGINEERING
wae, ynemf: a River qwp- Itm W*
e River Ateska 99577
Fi�one � um <r asumiC��
Mwing Address
n tate ode
❑ Send Result ❑ Sendlnvoice
Company frame Can=w
Malmo Addrev
ry Sate Lip Lwle
SAMPLE DATE:
Month
SAMPLE TYPE:
❑ Routine
Repeat Sample (for routine sample
with lab ref. no. q7, 3 $7 3 )
❑ Special Purpose
SAMPLE LOCATION
Comments:
95 HE
Day Year
TO BE COMPLETED BY LABUKAIUKY
nalysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
❑ Sample over 30 hours old, results may
be unreliable
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via spec deliv ry iail
Date Received
Time Received y n n ,�7
Analysis Began r l�'`7 -j142-C7---)
Analytical Method: ItLMembrane Filter
❑ MMO-MUG
Number of colonies/ 100 ml.
Result* Analyst
97.4141
❑ Treated Water
PUntreated
Water
Time
Collected
Collected
By
3
Qaa C ,
New Print
Date:
1110
�
Anch Fbls
Jun ❑
Faxed
Time:
Client notified of unsatisfactory results:
❑ ❑
Phoncd Spoto with Faxcd
Date: Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MiMO-MUG Result: Total Coliform E. Coli
Membrane Filter: Direct Count �� Colonies/100 ml
Verification: LTB BGB COLIFIRp1_ -
Fecal Coliform Confirmation
Coliform/100 ml
firs
Member of the SGS Group (Soci6t6 G6n6rale de Surveillance)
r:N'rC - r..,. nmmrra¢r rat G.-nt
on - other terlaia
ASL CT&E Environmental Services Inc.
CT&E Ref.#{
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Remarks:
Parameter
Nitrate -N
Total Coliform
973719001
S & S Engineering
L 2,B 1 Shane Lee Estates
L 2, B 1 Shane Lee Estates
Drinking Water
0
Results PQL Units
0.100 U 0.100 mg/L
R�SAMA LSD
Client PO#
Printed Date/Time 07/15/97 15:55
Collected Date/Time 07/10/97 14:45
Received Date/Timed 07/11/97 N:15
Technical Director-, tde
Released By
Allowable Prep
Method Limits Date
SM18 4500-NO3F 10 max
SM18 92226
Analysis
Date Init
07/11/97 JRJ
07/11/97 TMW
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
L,or BGoc� / SN,9n/6 C �E �STATt S
Location (address or directions)
674.0 T . FFAa Y 7'c a t•.AC OF
(b) Applicant Name TD—,NAceltleY Telephone: Home 344- IC0004-Business U06 -83 -94 -
Applicant Address 6740 TiArAlAlY 7-eZ_AAG6
(c) Applicant is (check one): Lending Institution ❑ ; OwneWWA4&r RI�Buyer ❑ ; Other ❑ (explain);—
(d)
explain);-
(d) Lending Institution ALASKA 115i9 F'C1,1 Telephone ZA�r -2-5o0
Address 4eOD 6z&p/T wwloy D✓ Aoyc a e/;6i 4445k4
(e) Real Estate Company and Agent 6&r-
Address
T Address
Telephone
(f) Mail the HAA to the following address:
oLa pow ale &.11P , WO V FY S Y TE[. rvr/e-A.J
96AVY
2. TYPE OF RESIDENCE
Single -Family LN' Multi -Family ❑ Other
Number of Bedrooms T'MXea
3. WATER SUPPLY
Individual Well IId" Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ❑ Public community ❑ Holaing TaPh ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
.A
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 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 igqspection.
NLASCA J��Vr'co.�iv«ivT
Name of Firma rANYS /^f4. Telephone
Address 5313 44c-ne- 81 -VP ANe- WORA47E
Date
06
DHEPAPPROV�A*L 0130
Approved for bedrooms by �' / `—
�
Approved _--- Disapproved Conditional"_
Terms of Conditional Approval
CAUTION
Engine r' Seal
(� O .Ak
••••
••+.ase���pr�-��
•••04 •�
TH
Sfephen D. Shrader �•�
�• No. 4148-E e
�9F •••••••JN••••••
Date����
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
gpglpeer registered in the staca of Alaska The �"ER does this as a oourtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of NP d0 not condut?f WOONION Of
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALITY OF ANCHORAGE HEALTH AUTHORITY APPROVAL (HAA)
DEPT. OF HEALTH 8,
CHECKLIST -FEBRUARY 1984
ENVIRONMENTAL PROTECTION 264-4720
MAY 14 ( Legal Description: "T Z, BLd W /,
StIA/✓E LA E t'STi9TES
A. WELL4l�/l.EIVED
Well Classification PRIVATE If A, B, C, D.E.C. Approved (Y/N) AYA
Well Log Present (Y/N) Y Date Completed zo�81 Yield SEff V✓EtL COG
Total Depth 3EE l,oC Cased to Se ?-IF- Depth of Grouting &,eA /`/OWAI
Static Water Level .EC wEL4- (-O4' Pump Set At /nl EXC rS3 of (05
Casing Height Above Ground /3 mdies Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) Al
Separation Distances from Well
To Septic/Holding Tank on Lot WA — )7&aL re 50&-� On Adjoining Lots ,i%JA
To Nearest Edge of Absorption Field on Lot N A ; On Adjoining Lots
To Nearest Public Sewer Line 92 To Nearest Public Sewer
Cleanout/Manhole SDI To Nearest Sewer Service Line on Lot 4D �y SVC. C.Q.
5 . S44 914 ; Date 41z LAB&
Water Sample Collected by r j
Water Sample Test Results 54 e Dry b.,, kla1.r A*/%ss Pi Per• 4 c/id�3��is
Comments % GAL PE Ie Mldurd' AG7W)c ¢ /IaaffS 0.=
d0AJriWyoVs PVMJOINU 04/ APAIL Z2. /98&.
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
Air -tight Caps (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holiig a
To Water -Supply Well
To Property
To Water Mai
Course
Page l or e
72-026(11/84)
No. of Compartments
for
/N)
Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well —
To Building Foundation -_ �r
Lot
To Water
To Strear
To Drive
Com
D. LIFT STATION
for Major Drainage Course _
Area, or Vehicle Storage Area
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Cod ( )
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickne45
ent (Y/N)
acy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
Ma
Dimensions
Pole/Amss
fp'Dff Level at
— Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
A1� 54MrAmrS, wc-v7 ,uA
Company MOA No.
Receipt No. �OF A`�
if ,�. / �F e�. ooe aoee•ooas
Date of Payment j" (SY���
/
Amount: $ B .f;�i49TH oo• e�Engineer's Seal
.
Page 2 of 2
72-026 (11/84)
)hen D. Shrc
No. 4148 - E
14 ""ROFEWCA 4w
5. L GAL DESCRIPTION ,C��
Da _.RECEIVED �J
'
INSPECTION APPOINTMENTS
�/{2Q Qui ,
TIMI=
TIME
TIME
�oYLZC_
6. TYPE OF RESIDENCE
•,' Pm. - i
DATE
DATE
DATE
- \45'-�S� �ILson.
INSPECTOR
INSPECTOR
INSPECTOR
7. WATER SUPPLY
4o�I'INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
•
AUG 17 ;981
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720 %R E E D
I I 1
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER
Ha
PHONE
a
MAILING ADDRESS -
SO
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION A -
�edey-A_f P%/>7
HONE
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. L GAL DESCRIPTION ,C��
Zo
7�a
STREET LOCATION-
0✓t
�oYLZC_
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
❑ One ❑ Four ❑ Other
F& SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Six
7. WATER SUPPLY
4o�I'INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date,ive w"ell
PUBLIC UTILITY
ED PUBLIC
depth (attach log if available.) I� � rr-. -
L_�}�r
8. SEWAGE DISPOSAL SYSTEM
-
❑ INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
ILD
THIS SIDE FOR OFFICIAL USE ONLY „
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
_TOTAL ABSORPTION AREA
MATERIAL
h. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
11? APPROVED FOR 3 BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
8-a )-cQI
BY
`1�
72-010 (Rev. 6/79)