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HomeMy WebLinkAboutKNIK HEIGHTS BLK G LT 7 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO'FECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL D, ESCR I.~PTI O N . .... ~ ' We ~ .... ~ Absorpti~na[ea D~lling ~ Manufacture' ~5 Materi~. Liq. capacityin aallonsl nsde ength /O~)0 F HOMEMADE ~ ~ DISTANCE TO: Dwelii~g Well ~ I I Well~ ~ Foundation ~ ~ ~ I No. of lines Z I Length of e~ch line Total length of lines Trench ~fi~th ~ _T°P of tiloto finish grade ~ / ..... Material beneotb tile I Length Width Depth < ~ I Type of crib -- ~~- ~ DISTANCE TO Nearest ]et line " ~ [Class Depth Drille~ Distance to lot hne ~ DISTANCE TO Building fou~datio~ Sewer lin~ Septic tank NO, OF BEDROOMS NO. of c~,~altments Liquid depth PERMIT NO. Liquid capacity in gallons Total effective absorption area PERMIT NO. Total effective absorption area PERMIT NO. Absorpt on area(si OTHER PIPE M AT E R/II A.~.L:S .I ~ ~ ' c_ SOl L TEST ~,~ RATING ~) ~ REMARKS ZJ 07- © DATE LEGAL U Apr 27 20 061 7p Anchor a (-j a Well & P u r1-1 p Set- 907/2430742) p.1 4'.710"o Elmor-�. �4,,�xd Mark Seg;ch ,K 9V'50-7 A F E G-4 Pump Installation Log Well DrillingPermit Number. SW Z� Date of Issue: ParM Identification N, urqber: egal Descrip on "Property Owner -Name & Address: Punipinstalla(ion Date: 4 Ab Pump Intake Depth Helov% 'Fop of Weft C.j.jjjjg: et psi feet Pump'Manufacturer's N2me: Pump -Model: Pump Size P ss Pitleis Ad3pterBuriai Depth. 1�ef Pillesi Adapter Manufacrurves j%amv: AA,",T1 CA,.,, Pitleis Adapter installer; Well Disinfected Upon ComplMon? rn �Yll [.-] No orDisiDfection. Comments: pelel-"�S Pjrnp install -es- Name: Attention: 1 fie Pur inotatl-eAhall pr,,:, -,'de a purnp im;YaIlation )ng to the DSD «!thin 30 days o -1 - pump installation. [:,EF'FIRTMENT HE:FIL. TH FIf',,ID Ei'.,I',,,' I RONHENTF:It .... ..OTE.::CT]: O1'.,t ,"-3;L:'5 '"E... '" STF::EET., FI1",ICFIORFIGE., FIE:::. ;~.'G 4-',':1. 72 El It...tl EE IL.. It .... ~ I'..,4t tE:, E:) ~..~ .... ."~; Z: T' ~: ~Z:_:; E: L-.if EE: IF;;:L' ,~, 5:':t. Er::~"25 8G2EI J'FI[.',E '.?1". LOT SIZE I"'IF~::.:',~HUM NUMBER OF' DE[:,ROOMS = ]: SOIl... RFI'FINI3 ,::S(;:! FT,.."BR) .... 85 ]'HE 19. E[.:!LJII~:EI} SIZE OF' TFtE SOIL. FIBSORF'TION S"r'.STEH IS: :'HE. LE]NGTFI DIMENSION ]:S THE LE1"~GTFI (IN FEET) OF 'T'HE TRENCH OR [:,RFIINF]:E:L.D. THE DEPTH OF' FI TRE:NE:::H OR PIT IS THE DI':;TFff.,ICE BETI.,.IEE1'.,I THE SI...IRFFIE:E:. ElF THE E3ROU1"~[:, FI1",I[:, THE E:OTTOM ElF' THE EXCFI',,,'FITION ,:: IH FEET). THERE] IS NE: SET I.,.II[:'TFt F:OR TREI",ICHE~;. THE GRFI',,,'EL [:,EF'TH I'-:; TNE MINIHUH [:,EPTH CIE-- GRFP,,'EL. DE:TI.,.IEi:EN THE OEJ'rFFILL. F'IPE FIN[:, THE BOTTOM OF' THE E:XCF¢,,,'FITIOI'.,I (IN FE:ET). F'ERHI T FIF'F:'L.I E:FINT FIFIS 'I"HE RESF'ONS IE:I L I T'¢ TCl INFORM TH I S [:,EF"FIRTMENT E)I..IRIi'.,I6 "f'HE I N'.:~;]'F:IL.L.E::F['i ON :!: hlSF'E:CT 101",1S OF' FIN¥ t.4ELI_S R[:,JFICE1",IT TO TH 1% E':'ROF'ER]"¢ Fff',l[:, THE NLIME:ER OF' RESI[:,EEI'-,ICES THFIT THE: 14ELL HILL ..................... ]"' l...fl C~ ,:: :.:'~ ::, .'ir: t"-,,~ :]-3; IF:-' E C: "'ir' ::1: L], f'-.l ~_:; FI1 I::;;':i: E: If.',~: EE ~:]:~ LJ % E:;:: IfEE IE: ....................... 8FICKF' I L.L I NG OF' FIN"r' S"r'STEM I'.11 I"N(7)LIT F I [',IRL INSPECT t ON FIN[:' RF'PRO',,,'FIL E?'¢ TH ! S E}E:F'RRTMENT I.,.tIL.L BE ::-.',LIBJECT ]'O F'ROSECLITION. I','IINIMLIH DIS'FRi'.,ICE E:ET[,.IE:EI'.,I FI I.,.IELL R1'.,ID Fli'.,Ih.' 131'.,I-L-Z, ITE SEklRGE [:,ISPOSRL. S"r'STEM :l. lE~l FEET FOR FI F'RI',,,'FITE P~EL.L OR :L50 TO ;.:.?EIt.'3 F'EE]' FROH R F'I...IE',!... :[ E: I.'.IEL. L [:'EF'EN[:,INE3 EJPOI",t 'THE: T"r'PE OF PEJSL I C I.,.IEI_L. I"IINIMEJH DISTFff',ICE FRCfi"I FI PI:;.:I',,,'FITE NELL TO FI PRIVRTE SEF-~E:R LI1",IE; IS 25 FEE:T FIN[) TO FI C:OHHUNIT'¢ SE:MER LINE IS 75 FEET. HEL..L.L. OEi':'~; FIRE REg.!IJIRE[:, FIND MI...IL:;]' BE F::ETLIRNE[:, TO OF THE HELL C:OMF'LETION. OTHER RE[.:!LIIRE:MENTS MFI"r' RPPL'¢. L:;,F'ECIFICFrf'IONS Fff4D CONSTI;~:UCTION DIFIGRFff,IS FIRE I::1',,,'I::! I L..i::tE,'LE TO INSURE PF.:OPER I HSTFIL. LFITI I CERTIF:'h.' THFtT :1.: I RM FFIHILIFIR t.,.IITFI :'HE REg!UIREMEI'.~TS FOR O1'.~-SITE :SEI.,.IE'RS FIND, 1.4ELL.'.::; R'.'*~; SE:T F'ORTFI Bb.' TFIE MEJNICIF'FIL. I T'¢ OF RNCFIORFIGE. ;2: I t.,~IL.L. INSTFILL. :'FIE: '.:]"r'.STEM ]:1"4 FICCOR[:,FINC:E: I.,.tITH THE CODES. ]:: I UI".![:,ER'.'5'T'FIN[:, THFIT :'FIE O1",t-'::3ITE :SEI.,.IER 5'T'S'I"EM I'"IF:I'T' REL.]L.IiRE E1",II...FIE;.'.GEME1",H" IF' THEE RE::SI[:'ENCE IS REMO[:'EL.E[:' TEl INCLU[:'E MOF.:E 'THh3N ~: E:EDF.:OOHS. F:tPF'L.. I~T C ~,.1' EXC. SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-850, Anchorage, Alaska 99602 276-222f SOILS LOG- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: R.F. Voughn Construction (C & J Excavating) DATE'PERFORMED: April, 25, 1981 LEGAL DESCRIPTION: Lot 7, Block ~6f, Knik Heights Subdivision 9 lO 11 ,~-.~ 2 13 14 15 17 18 19 20 Roots, sandy-silt, residual soilr iSLO~E reddis h-browI. Sandy-gravel (GW) Gray, well graded, well rounded,I contains some cobbles, low I ] ] I J moisture. ~___~ i, slight dip west, low moisture Sandy-gravel with some silt (GW-GM) low moisture. Sandy-gravel and gravelly-sand (GW-SW) gray, well rounded, low moisture. SITE PLAN WAS GROUND WATER NO S ENCOUNTERED? L ~ O IF YES, AT WHAT E i DEPTH? ..... ~ ........ ~ *' Bottom of Excavation Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BEI~NEEN We recommend the GW-GM soils be assigned a rating of 155 COMMENTS PERFORMED BY: Howard Grey & Assoc., Inc. 5 10 15 MUNICIPALITY OF ANCHORAGE CD716. 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. 017-372-25 Expiration Date: ((0 _1 (7-I 1. GENERAL INFORMATION Complete legal description Knik Heights, Block G, Lot 7 Location (site address) 13040 Ridgewood Road, Anchorage, AK 99516 Current property owner(s) William & Jennifer Hobbins Day phone (907) 350-8395 Mailing address 13040 Ridgewood Road, Anchorage, AK 99516 Real estate agent _ Day phone 2. TYPE OF DWELLING: X Single Family (w/wo ADU) ❑ Duplex [ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well n Private Septic U Water Storage (l Holding Tank ❑ Community Well n Community ❑ Public Water System ❑ Public Sewer �f Waiver request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ SSO. 00 Waiver Fee $ Date of Payment IN poll Date of Payment Receipt Number 0 S l 03 Q Receipt Number COSA# CSC I6t`a9 5 Waiver# • an 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 Forge Engineering Phone 907-522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date July 10, 2019 I• ••� P• •••• 49thx �� 6. DSD SIGNATURE • 1'C_ System #1 Approved for bedrooms . ••••••••••••ICHAEL E ANDERSON SVA%'� No. CE-4381 •'' System #2 Approved for bedrooms % ��'••...7-10-1s •• Disapproved •�•416.RF[SS\.'44 �ti•us•� Conditional approval for bedrooms, with the following stipulations: \`??,LITYf0A f(f(,( �E-.S/TC R WAS?-pe Nn - 10 50.0 �' °Gi', 6-' >VI J . �))11111I1)1�111��1 By-= w�( � Original Certificate Date: —7 I(p~l T The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval(COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Cbeckl st blue shee' • COSA Checklist Legal Description: Knik Heights, Block G, Lot 7 Parcel ID: 017-372-25 If more than 1 septic system on lot: COSA Checklist#__of Structure served by this system A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Well production at time of test 1.6 gpm Date drilled 7/15/81 Water storage tank volume 0 gallons Total depth 332 ft Well disinfected for coliform test? 9 Yes II No Cased to 142 ft Coliform bacteria is Negative Sanitary seal is functioning correctly Nitrate 2.12 mg/L 9 Nitrate less than MRL (ND) Q Wires are properly protected Arsenic ug/L Q Arsenic less than MRL(ND) Casing height (above ground) 24 in. Collected by FORGE ENGINEERING Date of flow test for COSA 7/2/19 Date of Sample 6/19/19 Static water level at beginning of test 158 ft. Comments B. TANK DATA C. LIFT STATION Age of tank(s) 4 years ❑ Required maintenance completed Tank type/material SEPTIC/STEEL Age of lift station years Measured operating fluid level in septic tank 49" Lift station material j Standpipes/foundation cleanout per record drawing Comments: Date of pumping 10/03/18 -A+ Home Services D. ABSORPTION FIELD DATA 5' Wide Trench Which system tested (date installed) 12/23/15 Adequacy test date 7/2/19 ❑� ALL standpipes present per record drawing Results Q Pass For 4 bedrooms Total measured depth from grade 13.7113 ft(max) Fluid depth prior to test 8/7 in Measured depth to pipe invert from grade 9.8/9 ft(min) Water added 706 gal 9 N/A—pressurized field New depth 9/8 in Q Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective ❑■ Code-required soil cover over field Final fluid depth 8/7 in Absorption rate 600+ gpd 9 System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) None date of test) Gallons introduced 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' Community Sewer Manhole/Cleanout> 100' 0 Yes if No ft 0 Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line >25' 0 Yes if No ft Absorption Field on Lot> 100' 0 Yes if No ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields_> 100' Animal Containment> 50' 0 Yes if No ft 0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' Q Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells >200' 0 Yes if No ft Water Service Line > 10' 0 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' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells> 100' 0 Yes if No ft Water Service Line > 10' Q Yes if No ft Community Wells > 200' Q Yes if No ft Surface Water> 100' Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 400,\\\miii,R I certify that I have determined through field inspections and review • '� ..•• '••.�1p of Municipal records that the above systems are in conformance with j �.•,• `I vj MOA COSA guidelines in effect on this date. a '• 49th �� = �t r r ** •MICHAEL E. ANDERSON % 116' • r ♦ -J s No. cE-4381 ,•a• •v fCn%••••••................. ... 7/11/19_,.. <,',, ii COSA Checklistyellow sheet ♦.1 F�pp��,,••••.••.• P� 4� •+'PRt1\\O°i, SGS Ref.# 1193209001 Client Name Forge Engineering Inc. Project Name/# Knik Heights L7 BG Client Sample ID Knik Heights L7 BG ✓Iatric Drinking Water Printed Date/Time 07/12/2019 11:16 Collected Date/Time 06/19/2019 14:10 Received Date/Time 06/19/2019 15:07 Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter ReSWlts LOQ Units Method Container ID Limits Date Date (nit Total Dissolved Solids 195 10.0 mg/L SM21 2540C D (<500) 06/26/19 EW\V Metals by ICP/MS Hardness as CaCO3 147 5.00 mg/L SM21 2340B B 07/01/19 07/01/19 DSII Waters Department Total Nitrate/Nitrite-N 2.12 0.200 mg/L SM21 450ONO3-F C (<10) 06/21/19 EWW Microbiology Laboratory E. Coli Negative 1 100mL SM21 9223B A 06/19/19 A.I., Total Coliform Negative 1 100mL SM21 9223B A 06/19/19 A.L Private Individual Analysis Chloride 9.09 0.200 mg/L EPA 300.0 D (<250) 07/01/19 07/02/19 DM IM Conductivity 318 1.00 umhos/cm SM21 2510B D 06/25/19 EWW Fluoride ND 0.200 mg/L EPA 300.0 D (<2) 07/01/19 07/02/19 DMM Sulfate 17.2 0.200 mg/L EPA 300.0 D (<250) 07/01/19 07/02/19 DMM Alkalinity 124 10.0 mg/L SM21 2320B D 06/25/19 EWW Aluminum ND 20.0 ug/L EP200.8 B 07/01/19 07/01/19 DSH Antimony ND 1.00 ug/L EP200.8 B (<6) 07/01/19 07/01/19 DSH Arsenic ND 5.00 ug/L EP200.8 B (<10) 07/01/19 07/01/19 DSH Barium 47.3 3.00 ug/L EP200.8 B (<2000) 07/01/19 07/01/19 DSII Cadmium ND 0.500 ug/L EP200.8 B (<5) 07/01/19 07/01/19 DSI -I Calcium 40700 500 ug/L EP200.8 B 07/01/19 07/01/19 DSI -1 Chromium ND 2.00 ug/L EP200.8 B (<100) 07/01/19 07/01/19 DSH CO3 Alkalinity ND 10.0 mg/L SM21 2320B D 06/25/19 EWW 2 of 6 SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1193209001 Forge Engineering Inc. Knik Heights L7 BG Knik Heights L7 BG Drinking Water Printed Date/Time Collected Date/Time Received Date/Time Technical Director 07/12/2019 11:16 06/19/2019 14:10 06/19/2019 15:07 Stephen C. Ede Parameter Results LOQ Units Method Container ID Allowable Limits Prep Analysis Date Date Init Private Individual Analysis (Provisional Cert —Cu) Copper 14.9 1.00 ug/L EP200.8 B (<1000) 07/01/19 07/01/19 DSH HCO3 Alkalinity 124 10.0 mg/L SM21 2320B D 06/25/19 EWW Iron ND 250 ug/L E13200.8 B (<300) 07/01/19 07/01/19 DSI -I Lead 3.72 0.200 ug/L EP200.8 B (<15) 07/01/19 07/01/19 DSI -I Magnesium 10900 50.0 ug/L EP200.8 B 07/01/19 07/01/19 DSH Manganese 2.51 1.00 ug/L EP200.8 B (<50) 07101119 07101/19 DSH Nickel ND 2.00 ug/L EP200.8 B (<100) 07/01/19 07/01/19 DSH 01-1 Alkalinity ND 10.0 mg/L SN121 2320B D 06/25/19 EWW pl I 8.0 0.100 pH units SM21 4500-1-1 B D (6.5-8.5) 06/25/19 EWW Potassium 1030 500 ug/L EP200.8 B 07/01/19 07/01/19 DSH Selenium ND 5.00 ug/L, EP200.8 B (<50) 07/01/19 07/01/19 DSH Silver ND 1.00 ug/L EP200.8 B (<100) 07/01/19 07/01/19 DSI -I Sodium 4380 500 ug/L EP200.8 B 07/01/19 07/01/19 DSI -I Thallium ND 1.00 ug/L EP200.8 B (<2) 07/01/19 07/01/19 DSH Zinc 246 10.0 ug/L EP200.8 B (<5000) 07/01/19 07/01/19 DSI -I 3 of 6 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer if community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA ~21 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 verifythat 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. NameofFirm -'~0~1 ~:~u¢~-~-t~'t~' '"'~-~- Phone ~7~- ~ Address ~¢~ ~ /,~ ~ ~ ~¢ % EngineeYs signature DHHS SIGNATURE Approved for J~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: / - Date //~_//~__~_¢~7,~ Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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. 72~25 (Rev. 1/91 ) Back MOA ~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) Legal Description: A, WELL DATA Well type ~.. Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER sAMF;EE RESULTS: Coliform ,~ Date of sample: ! 0/~7/~'~ Health Authority Approval Checklist ~, t,~ ~-~ ~¢~ ~"-\ t I~ ~' t~' f,G 1{4% Parcel I.D.: If A, B. or C, attach ADEC letter. ADEC water system number Date completed ~/~/~:~/~' / Cased to ]/¢,-~- Casing height (above ground) Wires properly protected (Y/N) _ /N/ FROM WELL LOG / AT INSPEC'I'ION // g.p.m. ]; ~-~ g.p.m. Nitrate (~. /~I¢~'/ ~4~f/~ Other bacteria_ ~ Collected by: "-~,-' ¢- B. SEPTIC/HOLDING TANK DATA Date installed ~/~/ I Tank size Foundation cteanout (WN) Date of Pumping /~:~-) Number of Compartments ~ cleanouts (Y/N)~ Depression (Y/N) ~ High water alarm (Y/N) . Pumper /~..,~ ~./,.5 C. ABSORPTION FIELD DATA Date installed J'~ ~/,~' / Length r~-- Width Soil rating (~,f~l,/4Cor fF/bdrm) ~ ! .~ Gravel thickness below pipe System type Effective absorption area ~ ,~-% Monitoring Tube present (Y/N) "-// Date of adequacy test I O/~'9~/~r Results (Pass/Fail) '~ Fluid depth in absorption field before test (in.); Fluid depth / ~ (ins) Minutes later: /'7/~ ~,~',5 Peroxide treatment (past 12 months) (Y/N) ~ Total depth · DepressiOn over field (Y/N) For ~ Immediately after/~ gal. water added (in.): __ Absorption rate = ~ /?Z¢? E~ _g.p.d. If yes, give date v// bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION r'-//,~_ Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line lO:Z, On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HEIE--DII~I~i~TANK ON LOT TO: Foundation J,~ '~ Property line '~ / O ~ Absorption field t Water main/service line ~ '~ Surface water/drainage i'-l/O SEPARATION DISTANCE FROM ABSORPTION FIEL~D ON LOT TO: Property line ~,.~ / ~ Surface water ~ lO Curtain drain Wells on adjacent lots Building foundation ,.~) ~ Water main/service line Driveway, parking/vehicle storage area ~> Wells on adjacent lots ~'~ l o-O I ENGINEER'S CERTIFICATION , C-,~: ,: ':., I certify that I have determined thru field inspections and review of Municipal recur, ds that the ~bove'~ys,.tems are in conformance with MOA HAA guidelines in effect on this date. ~' ' .... ' ' :' "~,~ Signature '~ ~~ Engineer's Name Date /I/1 7.~/ HAA Fee $ Date of Paymen, /////~,,/~:~ Receipt Number /-7/ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 1. GENERAL INFORMATION ...... · '"Complete legal description MUNICIPALITY OF ANCHORAGE ~ ' DEPARTMENT OF HEALTH & HUMAN SERVICES ':~ 'I~ : Division of Environmental Services .,.., ,~ :. On-Site Services Section . P.O. Box 196650 Anchorage A aska .99519-6650 343-4744 CERTIFICATE OF HE, ALTH AUTHORITY · APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or directions~ ~ ~~ ~:~ ~~ Lending agency ~~ ~~ ~ Day phone ~~ -./~ Unless othe~ise requested; H~ 'will be held for pickup. :~,~ ', ..' . ,,~:.,m 2. NUMBER OF BEDROOMS: ,-~ TYPE OF WATER SUPPLY: Individual well ..... Community well - - Public water .... . ...... "NOTE: ing to the legality and status of system..: .... 4, TYPE OF WASTEWATER DISPOSAL: ,'.! ---..v,:, : ...: -' Individual on'site ..... _ If community well system, provide written..confirmation fro,m?'state ADE, C attest- : ....... ;; ' Holding tank , -.,.. . ~ ',. " ' ,.. Community on-site .... .",;,' ..... " t'-; '; '. I ' :'"'" ,~:'::"-' '- :~ .'"g'~. ':: ':.',~/ : .. . ' .'," -; - ~i'::'- ;',:?," ' ~! ..... ,,.. NOTE: If community wastewatersystem, provide written confirmation from State ADEC attesting to the legality and status of system. ', ..' ~ , '_.., -,. ...... " 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown bi!OW, ! verify that my investigation of this Health :Authority,Approval application shows that the on-site water supply and/or wastewater disl3osal system is safe, functional and adequate for the num oar 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 inves!i_gation and inspection, the On-site water supply and/or wastewater disposal system is in corn pliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. ~ Name of Firm ~ Phone ~-----.~ ,.'~ ,P ..... .r ................... ; ...... = , ..*-.', ..... .~. ~., ....... ~ ~.,~,.',,....~. .., ..-.: Conditional 'approval for ' ~b~rooms, with ~the following.stipulations: Tl~e MuniciPality Of Anchorage Department (~f Health and Human Services (DHHS) issues Health Auth0'rityLL?~!:: Approval Certificates based only upon the representations giv, e,n ,(p pa?eg ,raph 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 n order to sat sfy certain federa and State requ rements Emp oyees of DHHS do not .';,': '":" co, ndu,ct Inspect, ions or analyze' data· before a Certificate is issued. The Munici pality of Anchorage ,is not ,':;;, .... res onsible for errors or om ss ons nthe rofessona engneer'swork . ~., ¥ ,.,~. , ,,,,. ~,~ .... 4.,, _, · p ........... P ........ ., . - ,,,.~, . ~.: .,,,, ,~ .... Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /, ¢'7' 7 ,~/_~Ol,<~ ~ -/~AJ,'t.~Parcel I.D. ' / ' A. Well Data Well type ~ ¢ ~ ~f A, B, or C, attach ADEC letter. ADEC water system number ,eoo .,et d - Tota depth Sanitary seal GN) Date of test Static water level Well flow Pump level1 Cased to FROM WELL LOG / //'¢,'~-- ./~:7'. ~ Casing height ~__..'A_~,-ed~=r' ~',~.. Wires properly protected (I~N) g.p.m. AT INSPECTION /,2¢/ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ,/'~.~ Absorption field on lot ./",~--~ Public sewer main /'~///~ Sewer service line ; On adjacent lots . ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~(~ ~t_~ t~:~.q'/~x~.. Nitrate Date of sample: Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed /~/~. /~;',,-¢~/ Tank size ,,,/~20 _,~?.,4../_.. Compartments v / Cleanouts(~N) V;~'~ _Foundation cleanoutt~N) V ~ '~ Depression (Y/N) High water alarm (Y~ ,/~ Alarm tested (Y/N) Date of pu m ping ,/V~//¢¢ P u m per To property line ~' ~'0 Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~(:~¢_,~ / On adjacent lots /'~//~ ! /, Absorption field ,,/~ Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) / "Pump on" level at / Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ¢;~h On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /~'~---I /--- / (~./Soil rating (GPD/Ft2) ~,~_~-'~ System type ~ ! / Length .~--.~./ Width ..~ ~¢:.~_~__Gravel thickness ~ ~' ,~-7~¢_.~-~--~Tctal depth //~ Total absorption area ~.~;~!~.,~anout present¢/N) ( 1 ~ Depression over field (yin) / Date of adequacy test ,,,,~, L_ /_r~//¢~¢,~'Result~fail) ~ -~ .~ ¢'/'~'~/ for ,~ Bedrooms Water level in absorption field before test ~--~ o ~r~ After test ~.dS> ~ Peroxide treatment (past 12 months) (Y/~ ,)~0 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /.~.~ ! On adjacent lots /'~'/,-~ Property line To bu ding foundation ~ ,~¢ To existing or abandoned system on lot On adjacent lots ,/~,///~ Cutbank Y//~ Water main/service line Surface water ,-,. ,~f¢.,~ ~, ("~¢_br_Driveway, parking/vehicle storage area Curtain drain ,/t-"//~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) (c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name %'//,,*¢ ~ /~¢ ~ Applicant Address ~ Oo ¢¢ Applicant is (check one): ~enOin~ Institution ~: Owner/budOe~; Buyer ~; Olher ~ (explain): Telephone: Home -~'~//~"5~.~ Business (d) Lending Institution , ,-:)~%, ¢k,~5~ ~(* ~ \\*.:~.ll ~'~ Telephone Address (e) Real Estate Company and Agent zv~-~ Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family/~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite'~" 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. Page 1 of 2 72 02511184) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my sea[ affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address '--/ / ,2-. -~ Date _ -~ WATER WELL NOTE: This ltealth Authority Approval inspection merely certifies that the subject water well produced 150 gallons per bedroom per day and that certified laboratory tests showed no presence of coliform bacteria in a sample of that water. No warantee or certification is expressed or implied concerning the long term adequacy or safety of the water supply, ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval inspection merely certifies that the subject on-site sewage disposal system accepted at least ]50 gallons of water per bedroom per day as determined by methods approved by the Municipality of Anchorage Department of Health and Human Services. No warantee or certification is expressed or implied concerning the long term adequacy of the on-site sewage disposal system, Construction data reported on buried system components is from MOA files and was not verified during this inspection. DHEP APPROVAL Approved for Approved bedrooms by _ 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 certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY OF ANC~G~.I AUTHORITY APPROVAL (HAA) DEPT. OF HEAL'I'H ',~' ..... ENVIRONMENTAL PROTECTK]~,,~'IECKLIST- FEBRUARY 1984 264-4720 APR & 2 1986 Legal Description: L -7 R, ECEIVED Well Classification Well Log Present (Y/N) _ ~/ Total Depth ..~,;L _ Cased to Static Water Level 1 3 2-. - Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ~/--) 3 / To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole _ /k.) Water Sample Collected by _ Water Sample Test Results If A, [3, C, D.E.C. Approved (Y/N) Date Completed '"~ / cc~'( Yield Depth of Grouting /b,'/,~ Pump Set At . Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots .,C/./// /~..o + ; On Adjoining Lots -/V///~ To Nearest Public Sewer To Nearest Sewer Service Line on' Lot ~c'2 '+- Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) 7 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: To Water-Supply Well / 0 '-'5 r To Property Line _ ~' 2_~ ~ To Water Main/Service Line ~' ~'~O' Course Size t C)~-O No. of Compartments Air-tight Caps (Y/N) _~ Foundation Cleanout/(Y/N) Date Last Purr, pad ; for Temporary Holding Tank Perrnit (Y/N) _ /t../~z¢ __ / To Building Foundation .2 4) ~ To Disposal Field / r~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~-..-/~ / Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ("'/ /'/"+- Type of System Design Length of Field ~ P- Depth of Field ~-/~ '~ Gravel Bed Thickness -2 ;:;z_ ?o¢- {-~c( Standpipes Present (Y/N) Date of Last Adequacy Test ~,. ,/,, ¢~//~o~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line /~ ~- To Existing or Abandoned System on ; On Adjoining Lots ~/,4 To Cutbank (if present) /J//4 Comments D. LIFT STATION ~/,,,Z~__ 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 t h~¢h?/~d~e~d.~_.~r conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed // ~vf //~/~.~-~ Date Company A/~v,~ -~,,~w~''-'~- MOA No. ,ece,pt No. ¢1. 5g' ¢k Date of Payment ~i-~'~ Amount: $ Page 2 of 2 72-026 (11/84} [.)'" - D. d RECEIVED INSPECTION APPOINTMENTS ¥1ME TIME TIME DATE DATE - DATe INSPECTOR INSPECTOR INSPECTOF ~UNIOIPALITY OF ANOHO~AGE DEPT. OF HEALTH &  DEPA~T~EN~ OD HEALTH · ENVIHON~ENTAL PHOTEOTIo~NVIRONMENTAL PROTECTION 82~ L 8treat - A~oh0rnge, Al~sk~ Dg~0~ ENVIRONMENTALSANITATION DIVISION JUL 3 :t 19~1 Telephone 264-4720 R E C REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing. PROPERTY RESIDENT (If different from ~bove) I PHONE MAILING ADDRESS MAILING ADDRESS 4. ~EALTO~/AGEN'r ' ~PHONE / MAILING ADD~ED8 LEGAL DESCRIPTION ;TREET LOCAT, ON 0:(~, TYPE OF RESIDENCE NUMBER OF ~EDROOMS ~ One ~ Four E~ Other ~INGLE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~¢' Three ~] Six 7, WATER SUP~_LY (~ INDIVIDUAL' * ATTACH WELL LOG. A well Icg is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILII'Y depth (attach Icg if available.) 8. SEWAGE DISPOSAL SY,~TEM [~N DI VI DUAL/ON-SITE** lq~/ '~ YEAF{ ON-SITE SYSTEM WAS INSTALLED. E~ PUBLIC UTILITY NOTE', THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 I Rev, G/7D) THIS SIDE FOR OFFICIAL USE ONLY I. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH ~OF WELL~. [] COMMUNITY BATI~ DRILLED [] PUBLIC UTILITY / Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED . []PUBLIC UTILITY Connection Verified INSTALLER ~(~t []Septic Tank or []Holding Tank Size: //~),¢z) 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 1 WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~APPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ~~~_. DATE BY