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Municipality of Anchorage Page I of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: 57t' 74a .Oz PID Number: 0/7 — 211 - 2 3
Name: Paw/ Zoew
Wastewater System: XNew ❑ Upgrade
Address: 156 �t(o4on, Roadi ??50AI
ABSORPTION FIELD
Phone: '338-27-15
No. of Bedrooms:
Deep Trench ED Shallow Trench 11 Bed 11 Mound EJ Other
LEGAL DESCRIPTION
Soil Rating: //C
C>.7 7
Total Depth from original grade:
13-3
FTLot.
GPD/Sq. Ft.
Block: SubdivisiMon:
Depth to pipe bottom from nal grade:
5•ori fi
Gravel depth beneath pipe
9
10t4n�in
Ft.
• Ft.
Township: � � A'
Range. 3 _ �
W
Section:
Fill added above original grade:
2-3
Gravel length:
86
V
FL
Ft.
WELL: ❑ Upgrade
Gravel width: Z-3
Number of lines:
I
Distance between lines:
I
,New
Ft.
Ft.
Classification (Private, A,B,C):
Y7 VA,
Total Depth:
119/0 0 Ft.
I CasedTo:
I /o Ft.
Total absorption area: ^�
3 J S SG, Ft.
Pipe material: F- O ERS
CAST I VG
Driller ,
5 S Dt'i'111� CO,
Date%nlled:
�
Static Water Level:
Installer py n t
I l • "IAC "2 e—
Date installed: �/� /��
g
9
d Ft.
!/
Yield:
5 GPM
Pu p Set at Casing Height Above Ground:
o. (� Ft 3 Ft.
TANK
SEPARATION DISTANCES
XSeptic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Litt
holding
Public/Private
Manufacturer
Manufacturer: �-
544
Capacity in gallons: 125oCT./
From
Tank
Field
Station
Tank
Sewer Lines
Well
128'
It 2'
n%
4,
fir,
Material: S1_ C l
JC
Number of Compartments:
Surface
Water
AM
Aii
44"
LIFT STATION
+5v /
f`o,
�(J
A/O
Size jn g is:
Manufacturer_
LLotine
j
/VUnt
Foundation
77,��
. /�
/,,V/
• /
.fesPuNp
�A(�/
on" level at:
"Pump off" level at:
High water alarm at:
Curtain
Drain
,,,�//
/Vg11.A.
Norut
/hent
/
/cm2
/Vvvne
Pump Make &Model
Electrical Inspections performed by:
BENCH MARK
Remarks:
Location and Description: i�
Nou'/ wI F/a 'o k /2
5 P ruse. - - sou• /t A F line . (See s, ye f Qrl
Assumed Elevation: /00
ENGINEER'S SEAL
to
ry}.� l
` a✓wns"� 1st -7�50?f
°4q
Inspections performed by: , Dates:
aAAQ®mai ,®a @Rc!
2nd
¢ MW Ve AUSMAN
Department of Heal and liuman Services approval
�) °°g° CE 393
`,•
h7xr^i CO9.PC®OPt
/ - _ _
Reviewed and approved by: Date: 2-28- 7,1
�1, "c ...y,*
'"�
72-013 (Rev- 9/91) MOA 25
Permit No.
Page Z of Z
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: 2-04 31 Bicck Z) Aol.1n�''n '4'r S/D PID No.:
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PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE 0.c -c\
DEPARTMENT OF HEALTH AND HUMAN SERVICES O -C) LA
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW940202 DATE ISSUED: 6/24/94
DESIGN ENGINEER:POLARCONSULT ALASKA, INC. EXPIRATION DATE: 6/24/95
OWNER NAME:LOEW PAUL & ELAINE J
OWNER ADDRESS:14820 SIERRA WAY
ANCHORAGE, ALASKA 99516
PARCEL ID:01721123
LEGAL DESCRIPTION: MOUNTAIN AIR ESTATES BLK 2 L
T 3
LOT SIZE: 54044 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS) .
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONSS����
RECEIVED BY:
ISSUED BY:
DATE: Sr A
DATE: (O`2 4-/
polarconsult alaska, inc.
ENGINEERS • SURVEYORS • ENERGY CONSULTANTS
June 13, 1994
DHHS, Environmental Services, On-site Services
P.O. Box 196650
Anchorage, Alaska 99519
Attn: Permit Review Officer
Re: Design and Construction Approval for On-site
Sewer System at Lot 3, Block 2, Mountain Air
S/D.
Dear Sir or Madam:
Please accept the following design for review and permitting. The proposed system
does not affect the current use of the adjacent properties and will have minimum future
impact. If you have any questions, please give me a call.
Sincerely,
Matthew Korshin
POLARCONSULT
Attachments:
On-site Sewer/Well Permit Application
Site Plan, Sheet 1 of 5
System Design Calculations, Sheet 2 of 5
System Cross -Section, Sheet 3 of 5
Percolation Test, Sheet 4 of 5
Percolation Test, Sheet 5 of 5
$320 Check for Permit Fee
1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503
PHONE (907) 258-2420 • TELEFAX (907) 258-2419
JOB Loi
3, '31k. Z, /"/Du„-faiy' Air SID
polarconsult alaska, inc.
1503 West 33rd Avenue • Suite 310 SHEET NO.
ANCHORAGE, 99503
OF
ALASKA CALCULATED BV
(907) 258-2420 Fax (907) 258-2419
lf!� DATE
CHECKED BY
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1503 West 33rd Avenue • Suite 310
ANCHORAGE, ALASKA 99503
(907) 258.2420 Fax (907) 258-2419
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polarconsult alaska, Inc.
1503 West 33rd Avenue • Suite 310
ANCHORAGE, ALASKA 99503
(907) 258-2420 Fax (907) 258-2419
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CALCULATED BY / •/� DATE
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Disclaimer: The attached onsite septic system design was developed in accordance with generally accepted engineering practices and
current Municipality of '.Anchorage design requirements. Polarconsult offers no warranty, express or implied, of performance or
longevity of the system and is not responsible for damages associated with its performance or longevity. This design has been based on
the results of the attached soils percolation tests which are assumed to be representative of the soil conditions in which the system is to
be built. If during construction the soils are found to be less -favorable than assumedfromthese tests, the system may require redesign
or not be able to be constructed at all. The locations of the soils tests, monitoring wells, and leachfields are approximate and have been
based on the assumed locations of the lot lines which may be subject to significant error. As such, we recommend that these locations
be, verified by a registered land surveyor prior to site planning and system construction. Polarconsult will not be_ responsible -for
damages associated with errors relating to the location assumptions.
PRODUCT 204 1(Sln9le Sheets) 205-1(Paddetl) ®® Inc.. GrO106. Mass. 01471 To Order PHONE TOLL FREE 1 000 225 6360
Via; �911 '•.� A�
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a Municipality of Anchorage
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DEPARTMENT OF HEALTH & HUMAN SERVICES 1111111119 V. AtrSOM o A
825 "L" Street, Anchorage, Alaska 99502-0650 'm CE - 1393
Qtlhti °• V q, YY'
SOILS LOG — PERCOLATION TEST®�'e•®•,•••a" a
PERFORMED FOR:
JeAn LArISaaT:C�r DATE PERFORMED: 5128173
LEGAL DESCRIPTION: Elk. Z 4o -f_ Township, Range, Section: IA4Th• Air Saba
1-1 SLOPE SITE PLAN
1
ON
`�0
2 0
3 O `` SP
4
N,D ,
Depth to
Water
Net
Drop
O � �
5
`
2
��
6
101.2-7- I m
is
8 r'
t? �
10:z
7
`«
!D: ! r*
NI
SM
6
!0; 53 h,
y rc
9-
10
to -
11
11
O
0
12
13
14
D
15
. D
0
16--,
17
t)
18
.0'
19
20
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
U
gepth to Water After 0 R`(
Monitoring? N p Oate: /a / 4.7,
S
L
O
P
E
+I
Reading Date
Gross Net
Time Time
Depth to
Water
Net
Drop
2
3
101.2-7- I m
is
8 r'
H
10:z
/6
`«
!D: ! r*
"/G
6
!0; 53 h,
y rc
PERCOLATION RATE. Z3 (minutes/inch))PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 7 FT
PERFORMED BY: v t b A OS" YJ I :1.2eL - CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: (O r H ` R -J
72-008 IRev 4/R51
" `�5110
.x:49_. *0
A006606490 90*00000
Municipality of Anchorage P�"" &coo .:9 .00 0"p
DEPARTMENT OF HEALTH &HUMAN SERVICES I!I1fitE V.CE - AUsruald �
825 "L" Street, Anchorage, Alaska 99502-06501
1393
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: "e^n L-a"sotmkv- DATE PERFORMED:. S/�8b
LEGAL DESCRIPTIO Rik• Z Le3 Township, Range, Section: 417 u
• Ar Sb 4'
(FEET)
1 �
1 1
'
2 0
3 01b
b t I
4
5 O
6-
7
7 Io
8 6'0
9-
10-
11 10 11 t
"6
12 t
13-
14-
15-
16-
17
3 14 151617
,D•o
18
' 0•
19
20
COMMENTS
rol
SP
-r#fes
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
N
S
L
O
P
V E
Depth to Water After D�R�t
Menflorfno? '_1L- Hate: v
491,1,3
SITE PLAN
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PRESOAK
4Reading
l/: y2
—
�.
a /(
5
12:18
0 V"
PERCOLATION RATE 5.3 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN Al FT AND 5 FT
PERFORMED BY: YQ.V i Al -6 4N� I �A CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE. (O - Ll r Q
70 Ann ,o.... ...c'
8
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PPE 841
• '� Municipality of Anchorage
On -Site Water and Wastewater Program a
(907)343-7904 s: Ery
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 017-211-23 Expiration Date: ' 2,Co -
1. GENERAL INFORMATION
Complete legal description MOUNTAIN AIR ESTATES BLOCK 2 LOT 3
Location (site address) 14820 SIERRA WAY, ANCHORAGE, AK 99516
Current Property owner(s) WILLIAM PAUL & ELAINE J. LOEW Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
PO BOX 111888 ANCHORAGE, AK 99511
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class _ Well
Public Water System
4
Day phone
TYPE OF WASTEWATER DISPOSAL:
El
El
❑
Individual
Holding Tank ❑
ElCommunity
Public Sewer
WaiverNariance request for: Distance:
Received by: � / Date: ��z!(o
COSA to be released to the engineer, unless ot, i requested by the engineer.
COSA Fee $ b"a1o, 0
Date of Payment Y./23/6Receipt Number 6.2 ?,CIL)
COSA# 660 Ql37p
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
®
Individual
Holding Tank ❑
ElCommunity
Public Sewer
WaiverNariance request for: Distance:
Received by: � / Date: ��z!(o
COSA to be released to the engineer, unless ot, i requested by the engineer.
COSA Fee $ b"a1o, 0
Date of Payment Y./23/6Receipt Number 6.2 ?,CIL)
COSA# 660 Ql37p
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. 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 ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 8/18/2016
Engineers 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 6 O T� \
encroachments, deficiencies or discrepancies exist. V "L �
Af -. , T,
6. DSD SIGNATURE
M
—)Q- System #1 Approved for —�L bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the
I EWIET ?�DIU,
i '�'G •r -
P - S 1
01
''fY
ON-SITE
Original Certificate Date: ^�l9
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of Onsite 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 engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other _
COSA blue sheet_10-10-12.dw
If more than 1 septic system is on the lot:
COSA Checklist # of _
Structure served by this sys—tem _
Certificate of On -Site Systems Approval Checklist
Legal Description: MOUNTAIN AIR ESTATES BLOCK 2 LOT 3 Parcel ID: 017.211.23
A. WELL DATA
Well type PRVT If A. B, or C provide PWSID #
Date completed 7/11/1994 Sanitary seal (Y/N) Y
Total depth 140 ft. Cased to 140 ft.
FROM WELL LOG
Date of test 7.11.1994
Static water level 70 ft.
Well production 5 g.p,m.
WATER SAMPLE RESULTS: `
Coliform colonies/100 mL Nitrate 4-(�-)_mg/L
Arsenic:_ug/L Date of sample: 81912016
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTICISTEEL
Tank size 1250 gal. Number of Compartments 2
Foundation cleanout (YIN) Y Depression over tank (YIN) N
Date of pumping 411912016Pumper A+
C. ABSORPTION FIELD DATA
Well Log (YIN) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
8/9/2016
ft.
Collected by: ARCTERRA
Date installed 7/611994 .
Cleanouts (YIN)
High water alarm (YIN) N
Date installed 7.6.1994 Soil rating g.p.d. r ftz/bdrm) 0.45 System type DEEP TRENCH
Length 86 ft. Width 2.3 ft. Gravel below pipe 7.9 ft.
135
Total depth 15 ft. (Measured 8/9116) Eff. absorption area #onitoring tube Y Depression over field N
Date of adequacy test 819016 Results (Pass/Fail) PASS For 4bedrooms
Fluid depth in absorption field before test 55 in, Water added 600 gal. New depth 64 in.
Elapsed Time: 1440 . min. Final fluid depth 54 in. Absorption rate >=.,,600 g..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 LOT TO:
Septic tankAift station on lot 100'+
Absorption field on lot 1001+
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 501+
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N)
High water alarm level
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manurelanimal excrete storage areas 1004
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 101+ Surface water -100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO: rt
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water. 106'+ Driveway, parkingivehicle storage -10'+r
Curtain drain 50'+(NONEKNOlWN) Wells on adjacent lots 1001+
F. COMMENTS
in.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systemsiare in conformance
with MOA COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 8118/2016
COSA canary sheet,2-646.ddc
Adventures In Wood
e.�. ufvq
:...........................
STEVEN CALAGHAN, o
L3-12034
FERN WOOD AVENUE
N899 50' 19"W 229.02
10' UTILITY EASEMENT
LOT 3
2389'58'10T
2
9073454464 P.1
RETAINING WALL
TYR
NOTE:
THIS DRAWING SHALL NOT BE MODIFIED FOR USE ASA PLOT PLAN
WITHOUT THE EXPRESSED WRITTEN CONSENT OF LCG LANTECH.
ADDRESS 14820 SIERRA WAY PARCEL- 017-211-23.000
ORDEREDBY: PAULLOEW
suRVEv cFRrE%anoH:Lm IPA'rECH, INcxns conoucTFOAPHrswusua.EroF
TIE MOMMAS sHOWN ON RIS pRA\ING MDC FE3MH ME
'aPR°i�'^EI+Ts mTOnTEnTMaieon w+E wTMw msPROPERrr WFs amXo
EACR00.CMEHBEXSTOTER HPHN019.
LEGAL DESCRIPTION
AS -BUILT
LOT 3, BLOCK 2
EJa;LU810NNYV NATE: R E R1E 0 WNERS' RESPDXSial T' TO DETERMINE TIE
EUSIFlICEOFHIY E/SFIEMS. COVENRNTS RFATPoCTpXB pI RIGHiAFWPY
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E8T/8l6HMG PROPERTY WES,ORFg2PLOTiWJP11RPO8ES
250HStree[
Anchorage, Alaska 9950E
Pbr a Department
Phone 5623291
tWCeCrl
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wATERWBI
FENCE—X—%—.'Concretei;:;%
DRAWN DATE: 07/08776 WORK ORDER: 18047
DRAWN BY: ADS PLAT: 70-378
Il'IC Malnitne
Phone 243-8985
GHEGKEDBY: MJH GRID: 3738
SCPJT• 7'=q0' FB7PG: 353.20
MUNICIPALITY OF ANCHORAGE
N\
• 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 FORA SINGLE FAMILY DWELLING
Parcel I.D. # X11— - HAA # iA Q5 'Ln S S 1
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
ing to the legality and status of system.
.
i 1;11/
4. TYPE OF WASTEWATER DISPOSAL:
�,
I
Individual on site--
Holding tank
Community on-site.
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-M(R#v.1/91) Front MOAN21
_,.._.
...... :......
S.
6.
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 �/ ����`� Phones
Address
Engineer'
Date z_/�2y /Z ) c
�YB y Date -5- - 30 - >s
,el
The Wn cipality of(AA horage 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 eng1neer 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.
7225 (Rw. 1/91) Sack MOA a21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L 3, 2-, 14e) 14�r,Parcel I.D.
A. Well Data �r
Well type f�f o if A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) y Date completed —Driller `7sr 15;%
r y� I r
Total depth l `x Cased to / Casing height - �" 0v
Sanitary seal (Y/N)
FROM WELL LOG
Date of test 7_
Static water level 7 r
Wires properly protected (Y/N)
Well flow 5 9•P•m•
l
Pump levell
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION n,
r
Septic/holding tank on lot / 2,9 ; On adjacent lots
Absorption field on lot ; On adjacent lots �--)
Public sewer main `� Public sewer manhole/cleanout
C
Sewer service line L Petroleum tank /V c7f�,
WATER SAMPLE RESULTS:
Coliform r Nitrate ' r 1 Other bacteria
0
Date of sample: %l -&w Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/�l Z4 Tank size
ZJ2 Compartments
Cleanouts (Y/N) C/ Fou/ndation cleanout (Y/N) _
High water alarm (Y/N) ��1) Alarm tested
Date of pumping^ ' New�Co�l � Pumper
SEPARATION DtS1'ANCBS FROM SEPTIC/HOLDING TANK TO:
Depression (Y/N)
(Y/N)
Z_
Well(s) on I b • ,, On adjacent lots —k' lC Foundation J
To property line% Absorption field 2 �� Water main/service line
Surface water/drainage h% d`�)
72-026(3M)•Front CONTINUED ON BACK PAGE
�k Z,
56
t�
g.p.mr,)
i7
in
tit
X)
m
c
n:i
rri
cert
O
r
0
Absorption field on lot ; On adjacent lots �--)
Public sewer main `� Public sewer manhole/cleanout
C
Sewer service line L Petroleum tank /V c7f�,
WATER SAMPLE RESULTS:
Coliform r Nitrate ' r 1 Other bacteria
0
Date of sample: %l -&w Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/�l Z4 Tank size
ZJ2 Compartments
Cleanouts (Y/N) C/ Fou/ndation cleanout (Y/N) _
High water alarm (Y/N) ��1) Alarm tested
Date of pumping^ ' New�Co�l � Pumper
SEPARATION DtS1'ANCBS FROM SEPTIC/HOLDING TANK TO:
Depression (Y/N)
(Y/N)
Z_
Well(s) on I b • ,, On adjacent lots —k' lC Foundation J
To property line% Absorption field 2 �� Water main/service line
Surface water/drainage h% d`�)
72-026(3M)•Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent(Y/N)
High water alarm level
"Pump on" levgl at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FRf1M-L'tFT STATION TO:
"Pump off" Level at
Cycles tested
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed _ ��� Soil rating
Length
(GPD/Ft2)Q>'/� G7 System type
�9 Width - Gravel thickness
`/
Total depth / -1�1 . 5
Total absorption area vI �' Cleanout present (Y/N) X Depression over field (Y/N)
Date of adequacy test lVc��W rfC=1Cf Results (pass/fail) c7 `--� for Bedrooms
Water level in absorption field before test After test
Peroxide treatment (past 12 months) (Y/N) If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / / On adjacent lots -� Property line c�
To building foundation To existing or abandoned system on lot
On adjacent lots /00 Cutbank Al il/% t'' Water main/service line
Surface water / �2 Driveway, parking/vehicle storage area L2
Curtain drain 04 r --
E. ENGINEER'S CERTIFICATION
/ certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date
5— Z, Z--, � r�
HAA Fee $ 7 e)o ° ` D
Date of Payment t "l/Y- —:l S`r
Receipt Number fel %0%47�
1nn. Ma %- 0-6
Waiver Fee $
Date of Payment
Receipt Number
OF
Y
Jameu F. Sizemore
# faff e
CT&E Environmental Services Inc.
ZiL Laboratory Division ►i®iiiiiisiiiisa�swiiii�
CT&E Ref.# 95.1449-1 Laboratory Analysis Report
Matrix WATER
Client Sample ID L3 BLK2 MOUNTAIN AIR S/D
Client Name
JAMES SIZEMORE & ASSOCIATES
WORK Order
13944
Ordered By
Printed Date
04/20/95
@ 11:58
hrs.
Project Name
Collected Date
04/17/95
@ 16:00
hrs.
Project#
Received Date
04/17/95
@ 16:25
hrs.
PWSID
UA
Technical Director
STEPHEN C.
EDE
Released By...3�T �_�,,_,,,-.�,�,..._.,,_
►-,a...'yf�.w.*....,�
Sample Remarks:
SAMPLE COLLECTED BY: J. SIZEMORE.
QC
Allowable
Ext.
Anal
Parameter
Results Qual Units
Method Limits
Date
Date
Tnit
--------------------------------------------------------------------------------------------------------------------
Nitrate-N
0.10 U mg/L
EPA 353.2 10.
04/17/95
CMR
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less Than
I = Secondary dilution. GT = Greater Than
200 W. Potter Drive, Anchorage, AK 99518-1605 — Tel: (907) 562-2343 Fax: (907) 561-5301