HomeMy WebLinkAboutMOUNTAIN AIR ESTATES BLK 2 LT 3mcawXA4a,xA A It n rA4v.) Ro+ 3 ( \6LE a w CA "�N 'Woo QL \ k qwF As to T= H F_ 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.: co Co i CvRRENr swRFAcr > IZ50 GV I a„ k SysTiM uSE ulc` /Voir ffiE��?S• A0,TACEN'r Al. T. S. L�f 3 T A444 Z04 `i )0D X01 2 Well Z04 5 72-013 A (2/91) MOA 25 89. ti -& Peri 011sf p"pe was level wiAi� 0.1 �. $f.o A/, Co S . �/% water l Col n 512 7A�( cos STI 3b''21' s,z 1/3 2y' Cot CO3 coy/ Cc6 1 36' 160' Q LQ ME DRIV✓' 1 ---- — E��'R���AL A4 10 � •'��*�, • J .• s zo*'* �6 R,Yi�Heree���ae®•j EARLe V. AUSMAN !' CE • 1393 qv^ 0, C) 0 5V0 � cn I O CG 0 0 c6 ul z U LI) rl I O CG 0 0 c6 ul z U LI) 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 $320 Check for Permit Fee 1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503 PHONE (907) 258-2420 • TELEFAX (907) 258-2419 JOB Loi 3, '31k. Z, /"/Du„-faiy' Air SID polarconsult alaska, inc. 1503 West 33rd Avenue • Suite 310 SHEET NO. ANCHORAGE, 99503 OF ALASKA CALCULATED BV (907) 258-2420 Fax (907) 258-2419 lf!� DATE CHECKED BY DATE / / L� ! Q SCALE m d^2 - es - � o • •ms//�moma� oe aoee� ♦••••••m ansa maces em •oem ooif N mn EA RLE V. AUSMAN m CE -1393 rRRA/WooD Av>E. gym• r FnRq no _ _ �T IYD S�o REPtAcEMEnT y� �� hRoPoSED ° Co _ 4q. o 0 _ TANK CO _ ill S /QQ _ Re POSED WF44 { e X1Sr/N i WELL Nor, QRaPosEo sysrE.E, wltL NO' 4Ff6c7- /1DT/tCENT 407-5 �7 (n AAID WILL NAV)5 '1/N/MVM F'UTuRE IM PAeIr. PRODUCT 204.1 (Smedo Shots) 2051(Paddedl ®m Inc., GrOM Mass.014T1. To Order PHONE TOLL FREE I @*225.6790 polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258-2419 JOB G s, LSG trure�ttln ^r SHEET NO. OF CALCULATED BY DATE CHECKED BY DATE D6- 1 GN Chi L.0 U4Ar/oN s .1 e e f V. [5 liPD �%Z y. ® Op i. oo B6ao a •o.e� 4 mdse ...... EAR6E Y. AUSPAAN CE 1393 600 G -?p C�OfID7 �)®-'e G RAVEL FROM S —rD 13 C gELow PI PF] 2 (,-RAVEL ABovE- PIPS i l6 �TZ/F7 ($ l GRAVEL rH/�KNESs DEEP 7KE/VcH 2�_3� wloE 4E11VG7N 133 4 F -r Z > g 4 FT. LON(r EsEE s rTF PzANJ 6 F� z1=r USF oNE N,�� CoNNEc-r" DIS' kbu-r/oN LIVE A -r TRCNCH MIDpp/NT. PBOOUCT 2041(Single Sheers) 2051 IPaddedl ®m In Gmton. MASA 01471 To Order PHONE TOLL FREE 1800-225 M polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258-2420 Fax (907) 258-2419 JOB L3 , B2 /yiou,4-^ ki A-,, s SHEETNO. / OF CALCULATED BY / •/� DATE CHECKED BY DATE SCALE /" = 3' (_RoSe. -SFC7-10N of PRI it, NO TUSF (FrRF. FINAL &RRDE (rtAr oVEli TRENCH) .ell - - -11%% e� F ! e ,re,'Pomoo mo oomoee�„E c..n AMP � o s�o oaoaeosa ®eoaooa•� 09®me m am moeemem ae•aae� MRIi V. AUSMN ° �i Tra CE - 1393 ° m, ZB FILTER FABRIC (SIFT FSRRRI�R)___ T r' PVC PERF PIPE (HokCs Dowty) SEWfR 2ocK (MOA -ST C.) ZFi ABovE PAPE, S � BEataW _ I I PROPOSEO (TyPICAO _ R7<PuKEn�Eiv/ 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� /. � a0000000o eod o�••' a Municipality of Anchorage 000000GGCUUo •u000 ooa eoo 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 J 0 z J Sc O E 45 I 10 WS, 1z, rd LLI s4t IL: ui w w 94 : go 00 Ile 0;� O 1z, rd LLI s4t IL: ui w w 94 : go 00 Ile 0;� 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 MOUNTAIN -AIR ESTATES naln°BwHaK00N°TncPr�R°NT"EIECD�mEDsue°"�sroxHAT.uvLFRxo CRCOMSiNICESSIgULOANY ppT0.HQ1EONBE II$®PgfOOrB1RLM.DON,PoR E8T/8l6HMG PROPERTY WES,ORFg2PLOTiWJP11RPO8ES 250HStree[ Anchorage, Alaska 9950E Pbr a Department Phone 5623291 tWCeCrl SEPrIO aiANWIPE ® Ow%Xm9'+--T`Ayrypll--' 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