HomeMy WebLinkAboutEAGLE RIVER MID HEIGHTS BLK 4B LT 18 GRE~ER ANCHORAGE AREA BO'-UGH
Depart me nt ~3E;~irs~;:;nt a I Qua I it Y
Anchorage, Alaska 99503 /~//.>._
NAME
LOCATION
/~,~,~-,,,.1 s' F, ~.,g. LEGAL DESCR'PT'ON/
SEPTIC TANK=
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER
INSIDE WIDTH
MATERIAl
LIQUID DEPTH __
NUMBER OF
COMPARTMENTS
,LIQUID CAPACITY.
GALLONS.
SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL
BUILDING FOUNDATION.__
ADDITIONAL ABSORPTION
DIAMETER __ OR WIDTH__
CRIB SIZE: DIAMETER
NEAREST LOT LINE__
LENGTH DEPTH
DEPTH__ DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
SQ. FT.
WELL:
BU,LD,NG
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
~ ~"'/'~,~ O/'~-,~ O ~ DEPTH /~_> Z/Z" DISTANCE FROM:
NEAREST ~?_~ ~ SEPTIC ~/~_ SEEPAGE /f~//~ .
SEWER LINE TANK , SYSTEM
DISAPPROVED REMARKS
DISTANCES:.
INSTALLED BY:
pipe MATERIAL:
LOT SLOPE:
REMARKS:
DIAGRAM Of SYSTEM
Form No. EQ-031
G.A .B.
GRet -'r ANCHORAGE AREA BOF UGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
APPLICATION AND PERMIT
NAME OF APPLICANT/~ ~
INSTALLATION LOCATION
LEGAL DESCRIPTION ~/-
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
SOIL TEST RESULTS
NOTE: THIS PERMIT IS NOT VALID WITHOUT ~OIL TEST
COMPLETION DATE ANTICIPATED /~; L'~.' ~ ~'~-- ,~'¢"'/'~"> ¢ 4/
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING Of ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE TYPE _ SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCES, REOUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGe PIT
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANE ,SEEPAge PIT
TO NEAREST LOT LINE
WELL TO SEPTIC TANk
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
SEPTIC TANK, SEEPAGE PIT
TO RIVER, LAKE. STREAM.
· DRAIN FIELD
DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT
· DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP O~~
EXCAVATION 5 FEET INTO UNDISTURBED SOIL. *~
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
F~TTED WITH AIRTIGHT REMOVABLE CAPS
DIAGRAM OF SYSTEM
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588
OWNER OF LAND
ADDRESS
., ," DEPTH OF WELL
LEGAL DESCRIPTION
DATE - Started
PERMIT NUMBER
Ended
STATIC LEVEL OF WATER FT.
~ A~ 7 ',, DOWN FT
,,. ~ GALS. PER HR / "" :'
KIND OF CASING , ~
KIND OF FORMATION:
From Ft. to
From Ft. ro
From Ft. to
From Ft. to
From Ft. to
From__Ft. to
From Ft. to
Ft.
Ft
Ft.
Ft
Ft. >:'~ ' '
From Ft. to__Ft.
From__Ft. to Ft
From__Ft to Ft
From__Ft. to Ft
From Ft. to Ft
From__Ft. to__Ft
From Ft. to__Ft
From Ft. to__Ft.
From Ft. to__Ft.
From Ft. to Ft
From__Ft. to__Ft.
From__Ft. to_ Ft
From Ft. to Ft.
From Ft. to Ft
rom__Ft, to Ft
'~ ~rom Ft. to Ft
From Ft. to Ft
From Ft. to Ft.
From__.Ft. to Ft.
From__Ft. to Ft
From__Ft. to Ft
From__Ft. to Ft
From Ft. to Ft
From__Ft. to Ft
From Ft. to _Ft
From__Ft. to Ft.
From Ft. to Ft
MISCL. INFORbIATION:
DRILLER'S NAME
MUHUCI`"AU li Y OSI+ L\ HCHORL GE
Development Services Department = -J Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-271-28-000
Expiration Date:
Legal description EAGLE RIVER MID HEIGHTS BLK 4B LT 18
Site address 10052 BAFFIN ST Eagle River AK 99577
Current property owner(s) JAMES JONATHAN C & CHANTELLE N
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
131
9/13/2023
bedrooms, with the following stipulations:
Original Certificate Date: 6/13/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovaIjune 2022
MUNICIPALITY OF ANCHORAGE
o
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050-271-28
Complete legal description EAGLE RIVER MID HEIGHTS BLK 4B LOT 18
Location (site address) 10052 BAFFIN ST EAGLE RIVER, AK 99577 USA
Current property owner(s) JONATHAN & CHANTELLE JAMES Day phone
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ® Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 2 Q Waiver Fee $ _
Date of Payment 6'/223 Date of Payment
COSA # O 5C,23 1 17 y Waiver #
COSA Application.doc
COSA Checklist WELL ONLY.docx
COSA Checklist
Legal Description: Eagle River Mid Heights BLK 4B LOT 18 Parcel ID: 050-271-28
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 10/6/75 Total depth 164 ft
Cased to UKNOWN ft (40’+ ASSUMED PER MOA FILE)
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 5/23/23
Static water level at beginning of test 120 ft.
Well production at time of test 4.5 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 5/23/23
Comments
B. TANK DATA – PUBLIC SEWER
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA - PUBLIC SEWER
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist WELL ONLY.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No NA ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No NA ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
PER ROUGH SWINGTIES, ASB SURVEY & AWWU DOCS – MH IS APPROXIMATELY 100’+ & SEWER MAIN 95’+ TO WELL.
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 6/12/23
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. 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, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
6/12/23
P 141 IF
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WOOD FENCE
OF A�q�;�p
�D. 49 TH*
�� fiat
a SHANE A. HOLT
LS -6914
44a a o
\\"fessiona� Loo
survey ordered by
dar Walden
keller williams
NOTE
OH DECK W GREENHOUSE
AS -BUILT SURVEY 1" =30'
NO CORNERS SET THIS DATE
I HEREBYCERTIFY THAT l HAVEPERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOTI8 8LOCK4 3 EAGLE RIVER MID HEIGHTS
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLYTO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
ANCHORAGERECORD/NG DISTRICT, ALASKA, AND THA T THE
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WDHIN
EASEMENTS OF RECORD OR OTHER RIGHTS OF WAY, OR ANY ENTITY NOT ON THE RECORD PLAT
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
ARE NOT SHOWN HEREON, UNLESS NOTED.
EXIST OTHER THAN NOTED
NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
DA LED A T A NCHORA GE, A L A SKA THIS 3 RD DAY OF
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
JUNE 2023
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNO W AND/OR ICE.
HOL rLAND SURveYiNG
ONLY VISIBLE IMPROVEMETNS ARE SHOWN HEREON
9309 GRovER DRwE
ANCHORAGE,AK 99507
15812 231-76 223-8615
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..#
GENERAL INFORMATION
Complete legal description
Lot
18; Block 4B;~Ea.~le River Mid H~i~h~
Location (site address or directions)
Ju~nn Duf fu~
Ea~le River,
AK
Day phone
~v~.~., AK 99577
Day phone
Day phone
9~577
Property owner
Mailing address I0052 B~[ffin SC~.ec~:
Lending agency
Mailing address
Agent Frank Stevcn~/ Don McKenzie R~al Estate
Address 15135 01d Glenn Hwy. ': Ea,qle Riv~, "AK
Unless otherwise requested, HAA will be held for pickup.
696-2559
694-9055
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
.-~ ~.[.~ ....... /._~'~ .: ............
Community well
4
.......... Public Water ,,,
......
NOTE: if community Well ~ystom, provide written confirmation from sta~te ADEC attest-
lng to the legality and status of system.
'~ ; ~r'"'' ''~
"4. ~PE OF WAsTEwATER DISPOSAL:
· .' ' -} _ NOTE: ,, If communi~ waStewater system, provide wri~en confirmation from State
5. STATEMENT OF INSPECTION BY ENGINEER
As certified bymy 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 ~ Phone ~' '~ ~ ~'~ ~
Address
DHHS SIGNATURE
~ ApProved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
'/.
Additional Comments
Date
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. Employess 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-{~5(R~w. 1~31) ~ MOAi121
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Well type ~;;~{~ ~ ~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present ~'q) ',~ Date completed \ <~ - t_~ ~'35~ Driller
Total depth ~L~ t Cased to Z'~~"~'- Casing height
Sanitary seal (~'~1) ',~ Wires properly protected ~N) '-~
FROM WELL LOG AT INSPECTION
Date of test ~, o - ~ ~ '1 ~- ~-- ~--"5 ~Cl~J('
Static water level ~,'~o ~ \
Well flow "-~ c> g.p.m, tJ ,o
Pump level1 U V-----
Legal Description: ~-o.c' \~, ~ ~:) C~/_~ ~,~r,~--~Parcel I.D.
A. Well Data
SEPARATION DISTANCES FROM WI~LL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adiacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform C) Nitrate O, ~ ~
of sample: ~-2-~z/ / ~.~3~5~ Collected by:
Date
B. SEPTIC/HOLDING TANK DATA '~.~--z.~ ~ ~__,,.~ ~
Other bacteria
Compartments
~l"~;i;~;~ll(eyd/N) . Fou n dTaatinok:ic~;an out (Y/N) Depre~
High water alarm (Y/N) ~ __ __ Alarm tested (~.~
Date of pumping __ ___ ~j~r~ ~_ _
SEPARATION DISTANCES FRO~NG TANK TO: , ......
Well(s) on lot On adjacent lots __Foundation ___ _
To pi~~ Absorption field Water main/service line
S uj:faC~ water/drainage
CONTINUED ON BACK PAGE
72-026 (3/93)* Front
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at .'~
HMi~t:a~eor:l: r(~r~t i~cva~lcodes (¥/h-'~- -- --_--'~d ~_
SEPARA~ON TO:
wetr'dn lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed
Soil rating (GPD/FF)
Length Width Gravel thickness
Total absorption area
Cleanout present (Y/N)
Date of adequacy test Results (pass/fail)
Water level in absorption field before test
~; rpC~i~ tTrI~)atNmD~ ~t~PA~Stc 1E2F;~n~h~)B s(Y/oN~ PT~ ...-'~ If yes, give date
On adjacent lots _J Cutbank Water main/service line
Surface w~ter-'''''~ Driveway, parking/vehicle storage area
CErtain drain
System type
Total depth jj
Depression over fiel.~-Y~
for J Bedrooms
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed toall~M~nd HAA guidelines in
Signature $ l $ ENGINEERI
Engineer's Name Eagle R!?er, Alas~
HAA Fee $ ~-~0~)' ~z..-
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
CT&E Ref.#
Client Sample ID
Matrix
ClientName
Ordered By
Project Name
Project#
PWSID
Sample Remarks:
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~ra~'~'~-~-.ar~J~-fj~e,~e,j~er~:~:~,.arjf~jfjjjfj~j~j~
LABORATORY ANALYSIS REPORT
94.4335-1
L18 B4B EAGLE RIVER MID-ItTS
WATER
S & S ENGINEERING WORK Order 81641
R. SHAFER Printed Date 08/26/94 @ 15:57 hrs.
Collected Date 08/23/94 ~ 13:30 hrs.
Received Date 08/24/94 ~ 13:30 hrs.
UA
Technical Director
STEPHEN C. EDE
ROUTINE SAMPLE COLLECTED BY: RAY.
Parameter
Nitrate-N
QC Allowable Ext. Anal
Results Qual Units Method Limits Date Date Init
0.10 U mg/L EPA 353.2/300.0 10 08/24/94 CMR
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Rep orted value is the practical quantification limit.
D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Les s Than
GT = Greater Than
5633 B Street, Anchorage. AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department o! 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)
Lot 18~ Block 4Bi Ea~le River Mid-Hei,~hts Subdivision/
Location (address or directions)
10052 Baffin Street
(b) Property owner
Mailing Address
J~lain Duf fus
10052 B~ffin Street.
Telephone: (home) 696-2359
Ea_~16 River, Ala~k~ 99577
Business .263-4264
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
· Telephone
(e) Mail the HAA to the following address: (or check here~, if hold for pick up.)
' List contact person and day phone number below:
S & S ENGINEERING
17034 Eaqle Ri~er Loop Road
Eagle River, Alaska 9957'~.
2. TYPE OF RESIDENCE
Single-Family EX Number of bedrooms 4[
3. WATER SUPPLY
Individual Well [~ 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 end 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
Address
Date
17034 Eagta Ri~er Loop Road No. 204
_ , ... .... &[aska ~)9577
Telephone
6. DHHS APPROVAL
Approved for ~/ bedrooms by
Approved ~_ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 om issions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
(MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
u N~C~p^Lt~ I~E ~)Fd~-t~:T, r~ E B R U A R Y 1984
ENVIRONMENTAL SERVICES O~L4"~44
Legal Description:
MAY 1 0 ]990
Well Classification -~ ~N~,
Well Log Present (Y/N)
If A, B, C, D.E.C. Approved (Y/N) ~
Yield [~,~ d~N~
Total Depth
Cased to ~,o'f' Depth of Grouting ~/~
I ~- 0 / Pump Set At L) I~"
Static Water Level
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 ~7 {;~ /
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Sanitary Seal on Casing (Y/N) c/
Depression Around Wellhead (Y/N) ~J
..~ u~¢' ; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size~ No. of Compartments
Standpipes (Y/N) Air~.t Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~ Date Last Pumped _____
Pumping/Maintenance Contact on File (Y/N
Holding Tank High-Water Alarm (Y/N)~ / ~ 'l~orary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SL:~PTI'C/HOLDINGNT,~K:
To Water-Supply Well .__ To E~ Foundation
To Property Line To Disp'~Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
sqUare Feet of Absortion Area
Depression over Field (Y/N) ~ Date of Last Adequacy Test
Results of Last Adequacy Test _. ~ '~
SEPARATION DISTANCE FROM AB:~PTIO~E--'[D:
To Water-Supply Well ~ To Property Line __
To Building Foundation ~. To Existing or Abandoned System on
Lot ~; On Adjorl~ Lots ____
To Water Main/Service Line ~ To C~ack (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
inspection.
Signed
$ & S ENGINEERING
17034 Eagle River Loop Road No. 204
Company
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
72q326 (Rev 7/88) Back
HAA guidelines in
5-10 - ? o
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 ° TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT D~ SAMPLE for Work Order t 21521
Date Report Printed: ~AY $ 90 % 14:28
Client Sample ID:LIS B4'B' EAGLE RIVER }did
PW$ID :UA
Collected MY 3 90 ~ 15:00 hrs.
Received }dAY 4 90 ~ 16:00
Preserved with :AS REQUIRED
Client ~ame : S & S
Clien% Acct: SNSENG?
P.O.t NONE RECEIVED
Orde[ed By : R. S~FER
Analysis Completed :MY 8 90 Sen~l Repozte to:
Laboratory Super¥ispr ,:STE?I{EN C. EDE I)S & S ENGR
Special
Instruct:
Chemlab Re£ {: 901226 Lab Smpl ID: 9 Natzix: WATER
Allowable
Parameter Tested Result Units Method Lln~tt~
NITRATE-N ND(O.iO) ~/1 EPA 353.2 10
Sample RO[IIINE SAMPLE.
Remarks: SAMPLE COLLECTED BY RDJ.
I Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected *' See Sample Remarks Above
NA- Not Analyzed LT-Less Than, ~T-Gzeater Ttmn
UNIF?'>M RE, SIDENTIAL APPRAII$SAf"'**E. PORT
,'- ~ m ' Ccusu:; b,,cl 2..0 LENDER ~SCRETIONAflY UbE
% EA__G_~j RIVER Counl~o
~,~u.,?~q,~L~~~_A~_EAG~P. IV~ ~I~ H~.~ SZ .......... , i)at~EPT. OF HEALTH &
c e~ $ ~m~T~ Da~ o Sm~ ~Z~Q/qQIPR~'Ei{TY HIGH[5 A~D Moftga~ lype
F,l- N-.FHA 0529577
NLilSHLIIJttJ I(JI)U ANALYSIS
, ,;',UW IH fl,a, lE j-'] flap,d
~uPEflTY VALUES j ]tncmasmg
.; HAND/SUPPLY [~ SJldlt~tg~
I ) U)~ 3 Mos
MARKETING TIME I
PRESENT LAN!] USE
';,~ .gie Family 8 0
;. 4 FaJmly
)Mulh ;arllily
LAND USE CHANGE
Nk)l LW, eIy
L~ke~
In process
To:
Ovm
CUIIV{flllLqLCI~ [0 ~)[Opplilg
Adequacy Of Public T[aus~llallOfl
PIOI(:ClIUII hum OclflmeitldJ Guild
P~e & Fifc,Prulcchun
Appeal [0 Mat~ul
[-] kilT]
[-~ I×'l L-] [
)
.:JMENTS .A._~y~c, AJ~.QLDEK B~DkOOM AF. EA OF EAGLE I:LIVER BEING SITUA~D..ON...THE_
.']Y T~._Dg~ DISTk~CT.hEING ~q QLDEK A~EA, IT HAS A NUMBEK ~. O~E~. BHTI,TS_
,~C~UDI~_TH~ SUBJECT AS WELL AS SQ~ DUPLEXES.THE ~GE LOTS HA~E TN~TR
.,ELLS & THE ROAD IS GRAVEL.GIVING IT A FAIR UTTI,TTY
ri: Area ~_~~~ ..... Comet LuI HO ......... ~ TYPTCAL
'" -'J " ] FJMA' M.i,'~ ,,c
:n '., :.,' ~ A'.;,, NO , ,
. ';A ;. b;.HiI)TIUN IX ;I H:;h ;:[ h, ;:;I liON I I)DNiPAiI'.]N t~ASi MI;;I IIN~LAIIUN
A,Cd Sq. FI tQOR jfl~l U
1 ........ ,r,,.m.,~,~,, C'B/AV~ _. ~'"~ YES .... ",.t,.,sl,,~u lUO J--'-Cmh,,~
~. ~ L.,,,,.~, ,',,,,, .k~U~U~_ ':'.'~' ~'.":': ~O ....... c,.,.,,j S~/~K -'-] ~.,~
.... :'"~" R/~C~ C..t:r,', ,'. L,..:' ;~t'. A~NU~ :,,n)u Hdmp ;IQ Wail'. EJl/~ Floor
L
....... tmt,H ~ ~ ~r~ tt',~, ~]0 ....... I:iILt, I,,HOII ~ ......... DEEIGN~qD Ag A 'En~mgy
· '-[7]] ...... [ ].
.,;~rA~ES M,,Ii,,a,$~Cc,~c:I,O~ HE,~TING ,,dTCHEN EQUIP ATTIC IMPROVEME'N'{ ~LYSIS
Nel,,gt. la,o, '--- Nora [--] Clualily U'
., .... .s ,S,H / R K car P~T _ 2,A %:iT~'O" _'~.J~. J~AGASRang~/gve, ~.--" S,a,,s L__' Cu~Jil,on ol improvements
; c~o~Ls and Sro,age
,"~ ~,~ s.'o T~LD F'~ ~ COOLING .FBn/~g~O ~1 FI~ [ 'f
:~Q~_~~ Omar , j~sheh'Ory~q 'l F,msnee Elect,cai-Adequacy & Con~t~
;q STORA&E Gl~ge ~_.i l~tac~d r ld~uate ~l~se Entrt ~ ~a~ & ~ar~eta~*iAy
.',ucm,on,.)imatu,¢s _.~o._~_~]~tT]~yj%~.J~__]~ECK.GARAG~__GAS }{EATER & WOOD STOVE_
' ~ 'k ' ' ' ' ' IT
i .c~icfal markgt COnditions an0 p;evalence an~ .npdct ~n 5uO;ecIlm,dlket area regarding loan dls¢ourlts, inleres[ Duyd0wnS and concessions: ~
fN THE ,MARKET APPROACH, _
DAlE RECEIVED
TIME TIME j *
/
DATE DATE DATE
I NSPECf~R__ __~, INSPECTOR INSPECTOR
~'/~'~j~ ~, - MUNICIPALITY OF ANCHORAGE
DEPT. OF I ;ALIH
MUNICIPALITY OF ANCHORAGE ENVIRONMENT, L ~ ;~i-ECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 LStreet-Anchorage, Alaska 99501FEB 7 1980
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 gECE!.~EQ
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed. Please allow ten (10) days for processing.
1. PROPERTY OWNER J PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION PHONE
MAILING ADDRESS
4. REALTOR/AGENT J PHONE
MAI LING ADDRESS
5. LEGAL DESCRIPTION
STR E ET LOCATION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One ~ Four
/~ [] Two Five
SINGLE
FAMILY
L_J
[] MULTIPLE FAMILY [~] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
~ PUBLIC UTI LITY
* 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)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OT H~E R
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
F-1PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
ii--APPROVED FOR ~/- BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
E~] DISAPPROVED
72-010 (Rev. 6/7g)