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HomeMy WebLinkAboutHENKINS BLK 1 LT 16Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201111 PID Number: 051-292-26 Dwelling: I•❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name ALVIN HYMES ABSORPTION FIELD Site Address El Deep Trench El Wide Trench E] Bed EJ Mound 16136 DIVISION ST, CHUGIAK AK El Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot HENKINS BLK 1 LT 16 Ft. Ft. Fill added above original grade Gravel length Township Ranae Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line Ft' Ft. Well 1004 50,+ TANK © Septic ElS.T.E.P. [0:1Holding ❑ Other �J Manufacturer Capacity SurfaceWater 100'+ I GREER TANK 1000 Gal. Material Number of compartments Lot Line 10'+ NA PLASTIC 2 Foundation 10'+ LIFT STATION Manufacturer Capacity Remarks TANK DECOM. PER UPC. Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to 3034 Installer drainfield MIKE N ANDERSON, P.E. Drainfield co/IVIT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 ft Inspection ection s 1 5/23/20 2"tl Location and description 3rd 41" GARAGE SLAB ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval:Date �p• OFQ '4�SIIr 49TH +�! /t Septic Syste MICHAEL N. ANDERSON ;� � .110 �Gl% f ✓�.•. CE 9169 Approved Date 2 `f t��'�' •. ?�c�� Note: this a proval does not include well permit requirements. �kkx OFE �S1k'j`��"'� (Rev 05/02/18) ���ti Permit No. OSP201113 Page 2 of 2 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: HENKINS BLK 1 LT 16 WELL O PID No.: 051-292-26 BENCH, GARS GE SLAB \ I b I I I I 2L CO3I „02 1 I I I h�I IIS NE ° 1000 GALLON PLASTIC TANK Lp ° MARK L c01 55 64 TC01 57 66 TCO2 62 70 CO2 63 / 72 CO3 64 74 WELL O PID No.: 051-292-26 BENCH, GARS GE SLAB \ I b I I I I 2L CO3I „02 1 I I I h�I IIS NE ° 1000 GALLON PLASTIC TANK Lp ° i i ASBUILT SCALE: 1"=30' SEPTIC SECTION N.T.S. .*��11, ��.1 114 P,,.•�• .��• .S� �i AW i ��• 4AW 9TH MICHAEL N. ANDERSON: L No. CE 9469 S°o,-30-20 •'• / o ° i i ASBUILT SCALE: 1"=30' SEPTIC SECTION N.T.S. .*��11, ��.1 114 P,,.•�• .��• .S� �i AW i ��• 4AW 9TH MICHAEL N. ANDERSON: L No. CE 9469 S°o,-30-20 •'• 5/22/20201" = 30'BFB BOBBY F. BURNETTNW 0755AS-BUILTASB2020 MUNICIPALITY OF ANCHORAGE _ On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201113 Work Type: SepticTank Upgrade Tax Code Number: 05129226000 Site Legal Address: HENKINS BLK 1 LT 16 G:0755 Site Mailing Address: 16136 DIVISION ST, Chugiak Owner: HYMES ALVIN R & MOLLY A Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft t»enr S 9 U � � ]department Total Bedrooms: 5/14/2020 5/14/2021 22651 ❑ Disposal Field 2 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: The record drawing and as -built survey, required to close out this permit, shall show the recorded MEA Easement (document 2018-020381-0). s — Received By: Date: �7 Issued By: Date: JF' l� )4"2o 3 RUS# MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-292-26 Property owner(s) ALVIN & MOLLY HYMES Day phone Mailing address 16136 DIVISION ST, CHUGIAK AK Site address SAME Legal description (Sub'd., Block & Lot) HENKINS BLK 1 LT 16 Legal description (Township, Range & Section) Lot Size 22,651 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) i Absorption Field ❑ Initial ❑ Single Family (SF) El ' (w/wo ADU) Septic Tank 0 Upgrade 0 Duplex ElHolding (D) Tank ❑ Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is' in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees:, 366 / it'6 Date of Payment: X go Receipt Number: D13LI-715 Permit No. 0.5P96%l/3 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc COVID-19 25% DISCOUNT.APPLIED May 13, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic tank permit Legal: HENKINS BLK 1 LT 16 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201113, Rebecca Carroll, 05/14/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201113, Rebecca Carroll, 05/14/20  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONE/]ENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME lPHONE '~J~IEW MAILING ADDRESS LEGAL DESCRIPTION NO. OF BEDROOM~.~ LOCAT,ON ~ DISTANCE TO: IWe) aO ~ Absorptio?~ ~, Dwelling¢~ ~ ~ Manufacturer ~ ~~ ~ ~ }~ Matorial~~ No. of compartmonts~ Liq.~a~gallons IF HOME.DE: Inside length Width Liquid depth ~ ~ DISTANCE TO: Well ~ Dwelling PERMIT NO. ~ ~ ~ Manufacturer Material ~iquid capacitg in flaHons ~earest lot I~n~ ~ ~O. ~ I~~ Top of tile to finish tirade ~ ~ Material beneath tile m ~en~th Width ~j~ Depth P~MIT ~O.  Tgpe of crib Crib diamoter Crib depth Total effectiue absorption area m ~ell BuildinO foundation ~earest lot line ~ DISTA~Cfi TO: ~ Class~ ~ D~/~ Driller Distance to lot line PfiBMIT ~O. ~ DISTANCE TO: Buildino foundation So,er line S~ptic tank Absorption area{s) Pl~fi INSTALLER REMARKS ~ TE LEGAL ~, ~ ~, ~:-:'~:~ ~hT~ ...... ~-MUNICIPALITY OF ANCHORAGE~-,, Department/ '~ Health and Environmentai lrotection 825 ~" Street, Anchorage, AK. ~9501 Permit APplicant: CCC L'bcation: ~.'~I'~)D Legal Description: 264-4720 * * * HANDWRITTEN PERMIT * * * WELL AND/OR ON-SITE SEWER PERMIT ~_~;~7. Mailing Address: Phone Number: Type of Soil Absorption System Is: Trench: ~ Drainfield: Maximum Number of Bedrooms: ~ Seepage Bed: Holding Tank: // Soil Rating(sq.ft/br) ~ ~' /~ The Required Size of the Soil Absorption System Is: / / The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(+I~-k-B-?NG) TANK SIZE = /~ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a 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 sewer line is 75 feet. Well logs are required and.must be r~turned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 1 9 $ 3 * * * 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 codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that~ bedrooms~ / ~ Signe~: c-~ Issued by: Date:~.~ SWP/024 (1/81) SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVlRONiVlENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: ~ C.~ LEGAL DESCRIPTION: "0 !" 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PERFORMED: SITE PLAN SLOPE WAS GROUND WATER N ~ ENCOUNTERED? ~) O P E IF YES, AT WHAT DEPTH? PERCOLATION RATE / ~) (minutes/inch) TEST RUN BETWEEN F/T/'A~D . FT CERTIFI Gross Net Depth to Net Reading Date Time Time Water Drop N COMMENTS WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysical Surveys LOCATION OF WELL (Pleale complete either Ia, lb or lc.) Borough Subdivilion Lot [ Block ~.J I/4 qt ri. II~.IDISTANCE AND [~IRECTION F~OM ROAD INTERSECTIONS Street Address and Area of Well Location WELL LOG Material Type Feet Below Surfcce Top ~UNiCi,,,ALCY o~ A~ DEPT. OF HEAt F~ViRONMEN I ~'L F; CHORAGE H & 986 16. WATER WELL CONTRACTOR's CERTiFICATiON: ~_ e.~H ~$ dril undo my jurisd,c i and thi' epo~t Re~Tst e recr~'u$iness Name ~ / __ ~- ~ A~{hor~ze[ Repr~llve Secflon No. Bottom Drilling Permit No. A.D.L. No. ] Town.hiPN[~ Range ED[Meridian A,d,.": S,¢ 7. 4. WELL DEPTH: (final) . 77 ,,. - s. []Cabl. tool [].o,ary []D,Iv.n []aug [] Auger r'ldeffed [] Bored [] Othlr' 7. USE:~[Oome.tle ~l Public Supply [] Induetry [] Irrigation [] Recharge [] Commerlaal [] Test Well [] Other: lB. OAS~I__G' El Threaded [] Welded d,a.. ,n. 7""/'" diam. In. to ft. Depth Stlokup__ ft. 9. FINISH OF WELL: Type: Diameter: Set belween ft. ond Backfilling Gravel peck ft. I0. STATIC WATER LEVEL: _ _ '.' 7 Date [~ Above or ~ Below land lurface Equipment II. PUMpiNG LEVEL below I~nd eurfaee and ~ fl. after ~' t~rs. pumping _,~.__ g.p.m. ft. after hre. pumping g.p.m. IE.GROUTING Well Grouted: [] Yel [] NO Material: []Neat Cement [] Other: IS. PUMP: (if available) HP Length of Drop Pipe ft. capacity __g.p.m. [] Subm. [] Jet [~ Centrifleol r~ Other is true to the best of my~ knowledge and belief; A · ~onlroct License Number D.,.: n../.,. / MUNICIPALITY OF _ F ANCHORAGE IR US Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-292-26 1. GENERAL INFORMATION Expiration Date: iC( ZCD20 Complete legal description HENKINS BLK 1 LT 16 Location (site address) 16136 DIVISION ST, CHUGIAK AK Current property owner(s) Mailing address Real estate agent ALVIN HYMES SAME 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $_ k'�) 6 O royj o Waiver Fee $ Date of Payment Shl b-0 Date of Payment Receipt Number 0 21 Z0Z Receipt Number COSA # OCG? Q 14 5 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 8-5-20 ..:"� OF• AZA 1j � fit:••,•. .•� ' j�t 6. DSD SIGNATURE ' 49",... • • . se r' System #1 Approved for 3 bedrooms • • •.• • -3 • • • • • • • • • • • • • • �J •• MICHAEL N. Ar,.D[ RSC.,.' System #2 Approved for bedrooms CE - a y Disapproved Conditional approval for bedrooms, with the following stipulationlN'� --�-,;` -,,)))))))))1),,. By: Original Certificate Date: 01Z K The Municipality of A horage 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. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: HENKINS BLK 1 LT 16 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 1124/85 Total depth 77 ft Cased to 77 ft ❑ Sanitary seal is functioning correctly Q Wires are properly protected Casing height (above ground) 25"+ in. Date of flow test for COSA 5/15120 Static water level at beginning of test 65 ft. Comments B. TANK DATA Age oftank(s) 2020 years Tank type/material Measured operating fluid level in septic tank NEW X Standpipes/foundation cleanout per record drawing Date of pumping * new plastic septic tank installed D. ABSORPTION FIELD DATA Which system tested (date installed) 8/2/83 ❑ ALL standpipes present per record drawing Total measured depth from grade 11 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 051-292-26 Structure served by this system _ Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No N Coliform bacteria is Negative Nitrate 3.1 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 0 Arsenic less than MRL (ND) Collected by MNA Date of Sample 8/12/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material _ Comments: Adequacy test date 5115/20 Results [DPass For 3 bedrooms Fluid depth prior to test 51 in Water added 500+ gal New depth 58 in Elapsed time 1440 min ❑ Code -required soil cover over field Final fluid depth 50 in ❑ System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced 0 gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Q✓ Yes Community Sewer Manhole/Cleanout > 100' 0✓ Yes if No _ ft El Yes if No _ ft Neighboring Tank > 100' Yes if No_ ft Private Sewer/Septic Line > 25' Q Yes if No_ ft Absorption Field on Lot > 100' Yes if No_ ft Holding Tank > 100' Q Yes if No _ ft Neighboring Absorption Fields > 100' ❑v Yes if No_ It Water Main > 10'❑ Animal Containment > 50' Q Yes if No ft Q Yes if No _ ft 0✓ Yes if No _ ft Water Service Line > 10' Yes if No _ Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' Q Yes if No _ ft Q Yes if No _ ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q✓ Yes if No _ ft Surface Water > 100' Q Yes if No _ ft Property Line > 5'Q Yes Yes if No _ ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No _ ft Private Wells > 100' ❑v Yes if No_ It Water Main > 10'❑ ft Yes if No _ ft Community Wells > 200' 0✓ Yes if No _ ft Water Service Line > 10' Yes if No _ ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q✓ Yes if No _ ft If absorption field is under driveway comment below Property Line > 10' ❑✓ Yes if No —ft Wells on Adjacent Lots: Water Main > 10' Yes if No _ ft Private Wells > 100' Yes if No —ft Water Service Line > 10' Yes if No_ ft Community Wells > 200' Yes if No _ ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I 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. COSA Checklist yellow sheet t7F 414x *: 49TH 9 ......:... GI MICfPAEL N. ANMRSCN ; R / �'��, ,• CEE946 ivvi 1 �'rgFo � ' �-ll• ����� .. 1 „Lifc���'J X11 �r 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 1 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) !L-(bi Applicant Name I~J~. ' ~o~,~,.,-Jg:;-~Cee- :"~? Teleph'one:. Home ~ (c) Applicant is (check one): Lend'in~ Institut[bn ~; Ownedbuilder ~; Buyer ~; Other ~ (explain); Business .,~/~1 45'73 (d) Lending Institution Lt'~''~L~e¢l'~'~ ' Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Other Number'of Bedrooms '"~P--~- WATER SUPPLY ndividual Well r~ 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 i~: Public [] Community [] Holding Tank [] Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. - '.~c~F~.:~:?~q~-~4; ':~:~??~(~-~ L.~;:~'~¢~:;~?~q/~.~'~-~U~; :~.:- ;~;~:~;J- ~ :'~::L? . ::'..~ , ~ ? -, ' '-, ' , .:': ;: ' ' :~;':'.~:~:~'~"~:]~':~AS C~ifi~d b'vm~ se~l ~ffiZ~d hek~to'nndas'Of the'v~lidnhon date shown below, I verify that my investigation of th,s Health ~??~?~¢~A6ifi:~dt~'X'h~al ~'h~g tKai't H~'0nCsitb'wat~ s~0~lgand/6r wastewater disposal system is safe, functional and adequate 'f&r the hd'~ber 0f bedrooms and typ~ of' structure indicated herein. I fu~her 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 regu ations in effect on the date of this inspection. Name of Firm ~ '~' ~oc~ Telephone Addres~'-= ~''.~ 104t~l~ ~.~ ~ Engineer's Seal Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION 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 engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or ' analyze data before a ceitificate is issued. The MunicilSality of Anchorage is not responsible for errors or omissions in the WELL DATA MUNICIPALITY OF ANCHORAGE (MO~,,x HEALTH AUTHORITY APPROVAL (HAA) /~iUi~iCI?ALIT',,, OF ANCHOR^o~ D~PT. OF HE/,L£H & CHECKLIST - FEBRUARY 1984 E. NVI~ONM~NTAL PP, OT£C?ION 264-4720 Legal Description: :,-,,') l~Jt~. Well Classification "~r',~ Well Log Present (Y/N) Total Depth ~7"2 Cased to -7"7 '/' 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 Cleanout/Manhole Water Sample Collected by CA. If A, B, C, D.E.C. Approved (Y/N) Date Completed 0 ¢, ~r,~,u~ r~ Yield Depth of Grouting .... Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ! 0'b-t- ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Test Results Comments '~o~-tl B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) ¥ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) HoLding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size ~¢,~o No. of Compartments "/ Foundation Cleanout (Y/N) Date Last Pumped -'/-If~-~E, """ ~ ; for Temporary Holding Tank Permit (Y/N) - ' To Water-Supply Well To Property Line To Water Main/Service Line Course ~ To Building Foundation '-f I To Disposal Field ~ -~ ¢ To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed E~- ~.-~ ~. Width of Field ov~ ~N4¢~ Square Feet of Absorption Area ~ctcl Depression over Field (Y/N) tkJ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field tO Gravel Bed Thickness ") ~ '-"-' Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) iO..t-j D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to ail MOA and HAA guidelines in effect on the date of this inspection. Signed'~#'vJ~ &~l-~-~j, Date ~'/-~4~-~/~ Company t~"'~o~,~('~'~ MOA No. ~m ~-z~ Receipt No. "¢OO /' O O~ '~' Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A .. FNRBANKS, ALASKA 99709 907-479-311 6957 OLD SEWARD HIGHWAY, SUITE 101 '~--i ;z~. ANCHORAGE, ALASKA 99518 907-349-8623 Drinking Water Analysis RepOrt for Total Coliform Bacteria TO BE COMPLETED BY CLIENT E3 PUBLIC WATER SYSTEM I.D. # ~J~. PRIVATE WATER SYSTEM NAME Ma lng Address City . SAMPI~E DATE: ~? ~)~ .Mo. Day SAMPLE TYPE: " ~{~ Routine [] Special Purpose State Purchase Order No. Zip Code [] TreaTed Wate't ~ [] Untreated.~t~?~r [] Check Sample (for original contaminated sample with lab reference no. Sample Time No. Location Coll~'ted Coll~:ted by Laboratory Ref. No. 10 Signature of Representative MAIL FOR LABORATORY USE ONLY CASH CHAROS PREPAID TRANSMIT[AL SPECIAL INSTRUCTIONS HOLDPICKUP FOR TO BE COMPLETED BY LABORATORY Received at: 'l~Anch. [] Fbks. Date Received "/ ": / (? Time Received_ . .~ Next Sample Due COMMENTS: SATISFACTORY S : UNSATISFACTORY "U" RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Verification Count LSB BGB IJ"IUAfIC.Ip' IRon4 Final Result* Comments *No. of~Total~,oliform Colonies per 100 mis. Reported, by /'~ d Date ~ APPLI¢ .NT FILLS OUT UPPER HAl. ONLY Property O~%"er C0C Construction Mailing Address ~),0. Box 647 Eagle River, Alaska ZipCode 99577 688-3273 Buyer Address Zip Code Lending Institution Phone Address Zip Code Realty Co. & Agent Phone Address Zip Code Legal Description Lot 16 Block I He~us Subdivision Street Location Type of Residence ~ Single Family [] Multiple Family No, of Bedrooms 3 [] Other Water Supply ..~ Individual r~,~J~ '7~ ATTACH WELL LOG. A we~l log is required for all wells drilled since June 1975. [] Community~,l-- For wells drilled prior to that date, give well depth (attach log if available). [] Public Utitity Sewer Disposal ~ Individual Year Individual Installed: [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector ~ ~ APPROVED BEDROOM8 *OONDITIONS OF APPROVAL ( ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* Soils Rating Date ~wer Installed Well To Absorption Area t Well Log Received ~ ~ ~ ~ ~ Well to Tank /~ Septic T~k Size ADEQUACY TEST WATER AND SEWER INSPECTION WELL INSPECTIONS AND FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN EXCAVATION WORK Reference: ROBERTA. SHAFER CIVIL ENGINEER 694-2979 October 19, 1983 MuN~C~P'xLJT¥ OF ANCHORAGE CCC Construction P.O. Box 647 Eagle River, Alaska 99577 ~ Lot 16; Henkins SubdiviSion A well inspection was performed on the system located on the referenced property, as you requested. The well casing was examined and found to be adequately equipped with a sanitary seal. It was necessary for you to have the wires placed into conduit and fill placed around the well casing to provide adequate sloping away from the well. This work was performed and was re-inspected and is satisfactory. A water sample was taken from the hose bib at this house and submitted to Chemical and Geological Laboratories of Alaska for an analysis for coliform bacteria. The results of this water sample were satisfactory. If we may be of further service, please do not hesitate to contact us. cc: Municipality of Anchorage Department of Health and Environmental Protection SRB 196X EAGLE RIVER, ALASKA 99577 HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria I. TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM' I Water Syste_.rn Name ~ _ . * Mailing Address SAMPLE TYPE: F1 Routine Fi Check Sample (for routine samph , With lab ref~ /~[LSpeclal Purpose SAMPLE NO. Fi,Treated-Water /,~,~ntreated Water Time Collected J I I Zip Code Collected TO 'BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: /~Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should. not be over 48 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. o.,. ....,.. I Analytical Method: D Fermentation TUbe - I~Membrane Filter - Lab Ref. No. Result* Analyst J CCI I r'T-I colonies/tOO mi. or No. of Posit,ye porlions. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE e6-122o (~) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 197a Date Collect~gl t bTe Final Membrane Filter O~slribut~.i P O. Box ,97 Eagle Riveh Alaska WELL RECOVERY TEST COM,M EN'I S: PLAT Rnq,~