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HomeMy WebLinkAboutMCKINLEY HEIGHTS #1 BLK 5 LT 3On -Site Water and/or Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP161110 Tax Code Number: 05121312000 Work Type: SepticTank Upgrade Permit Effective Dates: May 19, 2016 to May 19, 2017 Design Engineer: C & M Engineering Subdivision: MCKINLEY HEIGHTS #1 Site Legal Address: MCKINLEY HEIGHTS #1 BLK 5 LT 3 G:1058 Owner/Address: GIRARD SCOTT L & KIMBERLY GWYNN PO BOX 671721 CHUGIAK AK 995671721 Site Mailing Address: 18206 AMONSON RD, Chugiak Lot Size in Sq Ft: 43560 Total Bedrooms: 4 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By. MUNICIPALITY OF ANCHORAGE ti; -, ft a MAY t 'S Community Development Department Phone: 937 Development Services Division Fax: 90 98 5" �� 9 On -Site Water & Wastewater Program 6 8 L ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051 213 12 Property owner(s) SCOtt Girard Day phone 440-4562 Mailing address 18206 Amonson Road Site address 18206 Amonson Road Legal description (Sub'd., Block & Lot) Mekinley Heights #1 Block 5 Lot 3 Legal description (Township, Range & Section) Lot Size 43560 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) FE (w/wo ADU) Septic Tank x❑ Upgrade x❑ Duplex (D) ❑ Holding Tank ❑ Renewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. nature of property owner or authorized Permit/Rush Fees: al�J Date of Payment: Receipt Number: n 2Z3� Permit No. C% 101 Io 1110 Permit App_;;- Waiver Fees: _ Date of Payment: Receipt Number: Waiver No. C&M ENGINEERING SERVICES Ph: 907-8545558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: RE: Proposed Septic System Repairs for McKinley Heights Block 5 Lot 3. Dear Reviewer, The above referenced property is currently served by a 4 bedroom septic system. The existing tank is showing signs of advanced corrosion, and the baffle has failed. We are requesting approval to replace the existing tank with a new moa approved 1250 gallon steel septic tank, as soon as possible. All work shall be completed in accordance with MOA standards and the following Specifications: The existing tank will be pumped and disposed of properly, in accordance with moa requirements. The new 1250 gallon tank shall be of MOA approved construction with two 4" cleanouts. The tank shall be installed level, and within the excavation created by removing the old tank. The bottom of the excavation shall be leveled and compacted sufficiently to prevent settling of the tank. The new tank shall be insulated with no less than 4' of cover, and the manufacturer's maximum burial depth shall not be exceeded. The ground surface shall be sloped to prevent ponding. The line from the foundation deanout to the tank shall be replaced with 4" pvc pipe meeting ASTM 3034 standards. Dual after tank cleanouts shall be installed within 5' of the new tank, between the tank and leachfield. The new tank shall be installed in accordance with the separation distances required by 15.85.050A. The tank will be installed: Greater than 5' from the property line, building foundation, and drain field. Greater than 10' from any water main or service line. Greater than 100' from any surface water. Greater than 1 00'from any private well, and greater than 200' from any public or community well. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cobaizarini( gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE / MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW ❑ UPGRADE MAILING ADDRESS y�e LEGAL DESCRIPTION Cir, 3 LOCATION NO. OF BEDROOMS U L. DISTANCE TO: Well ✓ I / e' L �L Absorption area p 6 Dwelling j _� PERMIT NO. iT E • i� t F— z Manufacturer y Material No. of compartments to Liq. rapacity in gallons Inside length Width Liquid depth IF HOMEMADE: — -----'— Jaz DISTANCE TO: Well Dwelling PERMIT NO. _ = h Manufacturer Material Liquid capacity in gallons W ell yp. / Foundati'cn _7 ✓ Nearest lot line.Ce PERMIT NO. x DISTANCE TO: / / 5 ZNo. of lines / Length of each ligqe, j Total length of lilts Trench widt Distance between lines w 5 31 .} C' inches /`i P Top of tile to finish grade i Material beneath tile Total effective absorryiion area ..+ V4? inches `D `'�'% /P�' Length Width D pth PERMIT NO. LU 0 Q h Type of crib Crib diameter IV f depth Total effective absorption area a4 LU LU y Well Building foundation Nearest lot line DISTANCE TO: Class -- ) e th {� / Driller Distance to lot line PERMIT NO. J 1 f � I✓ A ( W Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER PIPE MATERIALS V SOIL TEST RATING f INSTALLER 7 we REMARKS d�.I>1 IT 0),6 0, 1 t; L � i 1 r, r k 4Z s•, N a.- APPR'O ED DATE LEGAL / //jyp((9f��.•j"/''% q �Jd 3r � d //( NA: 72'01) (Rev. 3/78) ✓"x'_ - MUNICIPALITY•OF ANCHORAGE Department Health and Environmental rotection 825 Street, Anchorage, AK. ,_/501 264-4720 r # # HANDWRITTEN PERMIT # # Permit # Z"��� WELL AND/OR ON-SITE SEWER PERMIT Applicant • /� c� lea-td� Mailing Address: Location: Phone Number: Legal Description: LT 3 (91, _ )WSL1Nl_ Lot Size: Type of Soil Absorption System Is: Trench: _ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br)� The Required Size of the Soil Absorption System Is: DEPTH LENGTHS_ GRAVEL DEPTH �� WIDTH 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(HOLDING) TANK SIZE _ MOO 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 returned 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 31, 1 9 u 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 esidenc is emodeled to include more that 3 bedrooms. Signed: Issued by: Applicant lq Date. SWP/024(1/81) l MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST DATE PERFORMED: c.4 ) , //,., —7D . d' P—SOILS LOG EJ PERCOLATION TEST pc , --f C PERFORMED FOR:"`- &4 .,9 - I Le"i— Is- dkjesb��Lc LEGAL DESCRIPTION: Net Time Depth to Water DEPTH IF 2 - 3 - 4 - 5✓ - 6- 61 ye ec' 7 - 9- 10- �-A —J,rk SLOPE ec I WAS GROUND WATER S 11 ENCOUNTERED? L 0 P 12 E IF YES, AT WHAT DEPTH? 13- 14-- 15 16 17 - 18- 19 N P Reading Date Gross Time Net Time Depth to Water Net Drop 20 Na, 421 (minutes/inch) ",.PERCOLATION RATE_ ST RU( )BETWEEN FT AND FT COMMENTS 1-V ee- Al - PERFORMED B CERTIFIED BY: DATE: -dli--?3 r•1 } Y cr Lo O Q CL N W O LOLU J w ¢ w Y w w 3 ® > a U 3 A x a EA- A H d ai 3 A vi Cd.7 Y w w w w w w�rH.w w w w w w iZ :O o as r) i Lr) LLJ : z J:O C H H V, w F w H w F w H&4—,Z w u `�. ww F w H w O UA O O O O O O O O O O O O x x x x x x x x x x x x w w w w u4 w u4 w w w w w Tpraffirb llwg by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started Ended PERMIT NUMBER KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From_ Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft. From From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DEPTH OF WELL STATIC LEVEL OF WATER FT DRAW DOWN FT. GALS. PER HR KIND OF CASING _ From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft From Ft. to Ft. From Ft. ) pAUf4.pp ANICHOoere DEPT. OF HEALTH & From Ft. V&aOp Mft From Ft. to----MA)rt. From Ft. to -Ft. From Ft. toRECEIVED From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft DRILLER'S NAME MUNICIPALITY OF ANCHORAGE ,f Development Services Department �' 7 Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051 213 12 1. GENERAL INFORMATION Expiration Date: t Q — `19 Complete legal description McKinley Heights#1 Block 5 Lot 3 Location (site address) 18206 Amonson Current property owner(s) Mailing address Real estate agent Scott Girard 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic Fx_1 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550-6110 �1 Waiver Fee $ Date of Payment -I l < a b( I Date of Payment Receipt Number O 109—+ l/ Receipt Number COSA # 05CI q 1 C'�'t + Waiver # Ain 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 7/11/2019 '5\ '5 TriTrrrr Original Certificate Date: i -ZZ —� 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 Checklist blue sheet ��A. A Q�� �O'iN •.* 6. DSD SIGNATURE 4—C System #1 Approved for bedrooms CHARLES G BALZARIHI System #2 Approved for bedrooms �tr``6, % • CE -13854 • •. ��� Disapproved 0PR0FESSIONP���~ Conditional approval for bedrooms, with the following stipulations: '5\ '5 TriTrrrr Original Certificate Date: i -ZZ —� 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 Checklist blue sheet *� 1 Legal Description: McKinley View Heights#1 Block 5 Lot 3 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 5/83 Total depth 120 ft Cased to 33* ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 44 in. Date of flow test for COSA 6/25/19 Static water level at beginning of test 36 Comments well casing into bedrock ft. B. TANK DATA Age of tank(s) 3 years Tank type/material steel ❑ Standpipes/foundation cleanout per record drawing Date of pumping 8/18/18 D. ABSORPTION FIELD DATA trench Which system tested (date installed) 1983 ❑ ALL standpipes present per record drawing Total measured depth from grade 11.4 ft (max) Measured depth to pipe invert from grade 6.16 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of drainfield. If not, state depth into effective 63" ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced na gallons Comments/Deficiencies: looks goad COSA Checklist yellow sheet Parcel ID: 05$ 213 12 Structure served by this system Well production at time of test 1.67 gpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes ❑ IN ❑ Coliform bacteria is Negative Nitrate 11.3 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by C&M Engineering Date of Sample 6/25/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station na years Lift station material na Comments: septic tank cleanouts under bench Adequacy test date 6/25/19 Results �❑✓ Pass For 4 bedrooms Fluid depth prior,to test 4 in Water added 600 gal New depth 6 in Elapsed time 1440 min Final fluid depth 4 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) If yes, enter date na no 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' Yes if No Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft 21 Yes if No ft Neighboring Tank > 100' QYes 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' ✓O Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ✓❑ Yes if No ft Q Yes if No ft ft Community Wells > 200'✓Q Yes if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0✓ 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' O✓ Yes if No ft Property Line > 5' ✓❑Yes if No ft Driveway/Parking > 0' Yes if No, comment Absorption Field > 5' Q,/ Yes if No ft Wells on Adjacent Lots: ❑✓ Yes if No ft Water Main > 10' F,7� Yes if No ft Private Wells > 100' FV-� Yes if No ft Water Service Line > 10' ✓❑ Yes if No ft Community Wells > 200'✓Q Yes if No ft From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ✓❑ Yes if No ft Driveway/Parking > 0'✓Q Yes if No, comment Property Line > 10' ,/0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' ✓0 Yes if No ft Community Wells > 200'✓Q Yes if No ft Surface Water > 100' ./0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that l 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. 7/10/2019 COSA Checklist yellow sheet OF A`.s��� Q; ��• 'fes �i CHARLES G 13ALZARIUI ���'���•. CE -13854 . ® AW- MUNICIPALITY 0-FANCHORAGE 1 DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 On -Site Water and wastewater Section : ; ? Fax: 343-7997 www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC191297 Subdivision: McKinley Heights #1, Block: 5, Lot: 3 A water sample revealed a nitrate concentration of 11.3 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Nfa��i ss P 0mw 5650 o a es 9951 0 �i� o g a �� . ACRI III T anllxtu� n ASJULdK116 LAND SURVEYING 694-0829 I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE` FOLLOWING DESCRIBED PROPERTY= A AND THAT NO ENCROACHMENTS EXIST DATE-,..... � EXCEPT AS INDICATED. IT f5 THE RESPONSIi3ILI7Y OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS „ •.4,2FTH •O,� sly GRID: OR RES RICTIONS /✓ �z ... �..... WHICH DO NOT APPEAR ON THE RECORDED SUBDI- � � � '. o�e�e ...Mt,Sa v .. �� VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION fig° � / LS -5 13 tz' B 4 OFFENCE LINES, OR FOR ESTABLISHING -A -WN 2� -or BOUND- ARY LINES. D' Q Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: McKinley Heights #1 Block 5 Lot 3 Mr. Ecklund, Per your request, I inspected the well at the above referenced property with a down hole camera. The entire length of casing and into bedrock was inspected. No perforations, cracks, holes, or other defects that would allow water intrusion through or around the casing were observed. The casing length is consistent with the length indicated on the well log. The below photos show representative images of the well casing and the bedrock below. Note that the casing appears wet because the well was drawn down for inspection. Sincerely, Charles Balzarini, PE 411 7/18/19 ;, r "CHARLES G BALZARINi4 �F .o CE13854w 0 A��AWFr �la'FDnt... �r\qw-�. �o 3 -A MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES. i Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# 05-1HAA# 4 P 9L- 4-$4 1. GENERAL INFORMATION / #/ Complete legal description Location. (site address or directions) Property owner Day phone Mailing address Lending agency Day phone Mailing address Agent' Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. 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. I 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site L Holding tank Community on-site i Public sewer NOTE: 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 X21. 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 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 !, f y Phone Address Engineer's signature 6. DHHS SIGNATURE ox &o Approved for - bedrooms. Disapproved. Conditional approval for Additional Comments Date 1: 7 - OF .4 4.1 - OF.44.1 r E T. �;.. DO LAS T. KENLEY, CE 8176 ••� � i � 1��40FESSIONP��'� bedrooms, with the following stipulations: Date Z� —61 `'¢ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto 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. 72-M (AW. 1/91) Back MOA 921 Municipality of Anchorage Department of Health and Human Services 44 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: , i" ,,� ,; " A ,, '. Y;� '/ ..I- %2".-i Parcel I.D. A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed _Driller Total depth Cased to jr� A, —Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 0 Date of test (P Static water level e Well flow g.p.m. 9.p -m. Pump levell 0 C) 0 T11 S� SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot On adjacent lots Absorption field on lot Z On adjacent lots Public sewer main —Public sewer manhole/cleanout— Sewer service line Petroleum tank /I /!-/ WATER SAMPLE RESULTS: Coliform li Nitrate Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed /// �L, 'I- Tank size Other bacteria e) Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) -Depression (Y/N) High water alarm (Y/N) ¢ Alarm tested (Y/N) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot It' On adjacent lots /` "', V / / Foundation ""./ o/ To property line —Absorption field �,/) —Water main/service line Z"C yl.PAli. I ' I I Surface water/drainage 72-026 (3=)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed ---Manufacturer Size in gallons —Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump olff.Level at High water alarm level -.Cycles-tetted Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water-----" 0) J D. ABSORPTION FIELD DATA C Date installed 1 Soil rating (GPD/Ft2) _-System type Length Width Jv Gravel thickness Total depth Total absorption area —Cleanout present (Y/N) Depression over field (Y/N) Date of adequacy test —Results (pass/fail) for "I —Bedrooms Water level in absorption field before test —After test Peroxide treatment (past 12 months) (Y/N) a It yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ? On adjacent lots Property line To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water —Driveway, parking/vehicle storage area Curtain drain 4 E. ENGINEER'S CERTIFICATION certify that I have checked, verified, or conformed to all MOA and HAA guideline ern tt* ff this inspection. TH e// 1 11 Signature X :X 0Z:il Engineers Name__6y 0 GF P, I Date HAA Fee $ Waiver Fee $ rc Date of Payment Date of Payment Receipt Number Receipt Number 72-026 (3/93)* Back Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 HUSTON.XLS SEPTIC SYSTEM ADEQUACY TEST Legal Description Applicant Date of Test r SYSTEM DATA Tank Volume Number of Bedrooms y� Absorption system Number of Bedrooms Absorption required (1.5 daily flow) �o TIME FLOW (gpm) VOL. (gals) TEST DATA J � TANK LEVEL TUBE LEVEL� COMMENTS 'e-yoo I 39'' ".f-© Z -f "eD �0j'� z9�•'f I ii .2/30 97�7 2 >w N9`✓b .2��0 Y,* x •f9' Z.B. .��9� r�s .3 3' �+'f� �.�� �=`•8' ,Z•�/G • � 3?fes � % � / .� .o ,gra..e Z 996 -9/ 6� •� • • Srfv.•� System Passed Comments 4rl. Sysytem Failed r a m s 70-.v, Page 1 CT&E Ref.# Client Sample ID Matrix Client Name Ordered By Project Name Project# PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services " - ",". , ,/ ; LABORATORY ANALYSIS REPORT 94.4530-1 LOT 3 BK 5 MCKINLEY HTS WATER DOUGLAS KENLEYP.E. DOUGLAS KENLEY UA Sample Remarks: ROUTINE SAMPLE COLLECTED BY: FRED KENLEY. WORK Order 81954 Allowable Method Limits PrintedDate 09/08/94 @ 10:15 hrs. Collected Date 09/05/94 @ 13:40 hrs. Received Date 09/06/94 @09:35 hrs. Technical Director STEPHEN C. EDE Released By: QC Parameter Results Qual Units Allowable Method Limits Ext. Anal Date Date Init ----------------------------------------------------------------------------------------------------- Nitrate-N 2.9 mg/L EPA 353.2/300.0 10 09/07/94 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 D = Secondary dilution. Gf = Greater Than 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES �J�aa�/ DIVISION OF ENVIRONMENTAL SERVICES LSg i CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date I (V, 0 /&8f(f 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Ownerda4— - 9 v Telephone: Home Ild'St' 4(J341 Business -=:l`( Mailing Address (c) z Lending Institution 2666T3 Telephone Mailing A ' Real Estat Address Telephone 62 A% Y 77Y 7 (e) Mail the HAA to the following address: or: Check hereif hold for pick up. List contact person and day phone number below. S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family Number of Bedrooms - 3. WATER SUPPLY Individual Well K 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 x 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 72-025 (Rev e/86) Front 77 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional 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 — 5 Telephone e4 qZ11c— 2 Address Eagle River, Alaska 99577 1! r th � ..:._ Of A !i 6. DHHS APPROVAL Approved for 'et bedrooms by 'e Date _ LGl fl Approved 424�__ Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. 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. Page 2 of 2 n-oas (Rev e?asi Rack MUNICIPALITY CF ANCHORAGE �� � � 213 ENVIRONMENTAL SERVICES DMUIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) J)JN 13 1988 CHECKLIST -FEBRUARY 1984 RECEIVED % ry 284-4'744 !® 1 V Legal Des ription. A. WELL DATA t % Well Classification C �9 V Liv �' �= If A, B, C, D.E.0 Approved (Y/N) f� /� Well Log Present 6%1\1) Date Completed e"�� Yield i Total Depth �� `' I Cased to t Depth of Grouting p Static Water Level !I Pump Set At Casing Height Above Ground �' Sanitary Seal on Casingd)G Electrical Wiring in Conduit,(_WN) � Depression Around Wellhead (Y(N:)> ),) Separation Distances from Well: t e To Septic/Hokfi1g Tank on Lot d= ° t On Adjoining Lots To Nearest Edge of Absorption Fielc) on Lot On Adjoining Lots To Nearest Public Sewer Line/1 To Nearest Public Sewer 4_ Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ` i st"t (f' '`)/ k Date Water Sample Test Results Comments d `1 .;L B. SEPTIC' TANK DATA Date Installed ��'' "� Size r'� "� No. of Compartments Stand pipes((YGN) Air -tight Capsc(S` 'N) Foundation Cleanout(YiN) Depression over Tank (YM),',` 1s Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic 4491dr g.Tank: To Water -Supply Well - ' _ To Building Foundation " To Property Line C i To Disposal Field To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Comments 1 ;' ; d, t, i �e'e %F Page 1 of 2 72-026(Rev 8/861 Front G. ABSORPTION FIELD DATA Soils Rating in Absorption Strata _ J/ ` fY ____- Type of System Design Date Installed -_ -_ f'7 / L -_- Length of Field � Width of Field --_ __ •`-`'___ __ r __ Depth of Field Gravel Bed Thickness - Square Feet of Absorption Area _- --- - -Stand i es Present p p Depression over Field (Y/,N)-_ ____._ __j) ____ - _ __-_ Date of Last Adequacy Test UL /-' Results of Last Adequacy Test��- -- - - Separation Distance from Absorption Field: I Io Water -Supply Well - r�-i - To Property Line To Building Foundation i ~� "` To ExistingorAbandoned System on Lot —_-_ -------__- - - -_-- . _.__ ; On Adjoining Lots To Water Main/Service Line __ - -- - _ _+__-__ _- To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area _ o Comments -- _ - D. LIFT STATION Installed Size in 'Pump On" Level at High Water Alarm Level at . - - Tested for _-----__--- ___ Electrical Codes (Y/N) C'.nm mnntc _ Dimensions _ Manhole/Access (Y/N) "Pump Off' Level at Vent (Y/N) during Adequacy Test. Meets MOA "` Check Permitted Bedroom Rating Against HAA Request °° I certify that I have checked, verified, or conformed to all M A and HAA guidelines in effect on the date of this inspection. Signed S&SE4GINEI5RING------. Date Compan 17034 Eagle River Loop Road NoA4 03— / E � Receipt No. �S'S�.2 ( Cy ; ca�.f1 y/h- •.,. Date of Payment•�'•a- aP, Amount: $ — %() l �' %' / I= e01 eal Page 2 of 2 72-026 (Rev deal Rock �t174'- Al CHEMICAL & GEOLOGICAL LABORATORIES OF ALASK4, INC 5633 B STREET ANCHORAGE, ALASKA 95518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 :.Vk'LyS!3 P,'L'PORT RY i oi 1-lork Oicler It 7061 ';::Llted: P27 U 3E "? 03:37 3 AURI, p W ID ull Client Acct 31")Bcp Coilrcted UN 6 88 3 10 lfi 1, 0 N011h' RECD Received iUN 6 Vi :06 his, Req it Pres'3z "Ol'' :-, oalupe' BY lAnalysisI rad Repot o: Lli)ol:ul Ory zupo.rvis F.0' Lased. By - - - - - - - - - - - - - - - - opecic'. chollllab Re" 'B T�1) 1 ,A � 12�l!1TD: Dautmetez Tested Result/Units Method Lints E EF ik 3 . 2 10 Rojj,cjEl,S : SAI%IDLE COLLECTED B P, I Tusts Perfonapol See 'Special Instructions Above ?ID- 7 :done Detected. ")cp 3alrodo lkbole I'll"I :-, I I 0t A nGd y -z cl LT -Less 'Phan, C,4j eaaui Than 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 June 25, 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3; Bock 5; McK.intey Hei.ght6 Addition #1 Location (address or directions) Amon4on Road (b) Applicant Name Roy Schn.eckh-i.se Telephone: Home 688-2818 Business Applicant Address P.O. Bax 2062, Eagte Riven, AEaska 99577 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 1 ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Anea Commonweatth/ATTENTION: SandN Bant2ett Address Eaq.2e Riven, Alaska 694-9555 Telephone (f) 4�he HAA to the following address: S 9 S Eng.ineen,ing SRB 196X Eagte Riven., Alaska 99577 2. TYPE OF RESIDENCE Single -Family 1� Multi -Family ❑ Other Number of Bedrooms 4 3. WATER SUPPLY Individual Well In 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 0 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/94) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA w AND INFORMATION } As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional 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 5 ENUINEERING Telephone SR j5 i 96 AddressEA" 957 JUN 3 0 1986 Date i 6. DHEP APPROVAL _t�Approved for ti bedrooms by Date Approved Disapproved Conditional Terms of Conditional Approval cJhep 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) MAR 1 i'J Nbb CHECKLIST - FEBRUARY 1984 C `YV A. WELL DATALegal Description:,G�����' z Well Classification ' l �'%C'_ If A, B, or C. D.E.C. Approved(Y/N) Well Log Present( Date Completed _ii _� Yield .� Total Depth Z� V (( Cased to _ % Depth of Grouting Static Water Level / �'z / Pump Set At &i 4_�( Casing Height Above Ground 3 c) Sanitary Seal on Casing(Y� ) Electrical Wiring in Conduit QIN) Depression Around Wellhead (YA)) Separation Distances from Well: To Septic/ kAdl-ng-Tank on Lot /0 z On Adjoining Lots /00 To Nearest Edge of Absorption Field on Lot ! On Adjoining Lots /00 tf To Nearest Public Sewer Line To Cleancut/Manhole To Nearest Sewe Water Sample Collected By Water Sample Test Results Comments %L1 U )>J e B. SEPTIC/HOLDING TANK DATA Date Installed __S '_ -A `� Size Standpipes (YM) Air -tight Depression ver Tank kY ) Date Pumping/Maintenana, Con act on File Holding Tank High -Water Alarm Nearest Public Sewer Service Line Date 5-- 2L_ 46 ,a Lot No. of Compartment . Caps (Y ) Foundation Cleanou (Y ) Las�tt" P (Y/P�T for t� /p- 'Temporary Holding Tank Permit (Yz yl Separation Distances from Septic Tank: To Water -Supply TAJe11 102, To Building Foundation ,5 f To Property Lire /C`i ��. To Disposal Field �� t . /- To Water Main/Service i Line / To Stream, Pond, Lake, or Major Drainage Course r _j Comments fly A2 G Receipt #-- Date Paid: 1-/ Amount: - /')_ -y , [Page 1 of 2 2-15-84 C. ABSORPTION FIELD DATA / Soils Rating in Absorption Strata �` �� Type of System Design ��N/9z `/ Date Installed -5-16 6 '1 Length of Field Width of Field 50 Depth of Field fc� Gravel Bed Thickness i Square Feet of Absorption. Area ��� _ Standpipes Present Depression over Field (Y to of Last Adequacy Test Results of Last Adequacy st A, /4 Separation Distance from Absorption Field: To Water -Supply Noll To Property Lire r/ To Building Foundation"% To Existing or Abandoned System cn Lot /,) do �-i F On Adjoining Lots �) ( f t To Water Main/Service Line jU - To Cutbank(if present) iU o \-j/ To Stream/Pond/Lake/cr Major Drainage Course '0 /,J To Driveway, Parking Area, or Vehicle Storage Area !/ Continents D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (YM) "Pump On" Level at Off" Level at High Water Alarm Level at Vent (YM) Tested for Pumping Ci6,169 during Adequacy Test. Meets MOA Electrical Codes(YM) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. �rt► Si(gr ed S & ;' G �OIiyIE? '; Date Company 4,iM AIVBR, AI.AScC ; yT MOA No. S 7�0 '--3 �� .. Ise ,i _..:IV 4 KBl/d5/s (Page 2 of 21 2-15-84 I MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section township, range) Location (address or directions) (b) Applicants Name. -Tele honeBusiness "10 _2� Applicants Address—A �,4 (c) Applicant Js (check one) Lending Institution 9 Oirner/builder Buyer' -a Other [�::J (explain); (d) Lending Institution jelephonef-2�� L.S) /'I Address v 4_' (e) Real Estate Co. & Agent Address Telephone (f) ate'' the HAA to the following address: 2> j.jype oLRaJonce Single–FamilyM Multi–Family Other (describe) 7r Number of Bedrooms tqa tf r �Su ' Individual Well I 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 Public Community E:I 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] rn ineering F�.rm Providing Inspections, L°ests� Fila Search, Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional 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 crater supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula ttions in effect on the date of this inspection. Name of Firm — Telephone Address Date (E 5. DEEP Approval Approved for ° bedrooms Approved ` Disapproved Teams of Conditional Approval Ix _ M0 3 ; 9 f �t Datej ° LL �onslitional THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEN',ir-- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY 0 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE I01A BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR. ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/DLII [Page 2 of 2] 7.19-84 T dI"I -IPAUTY OF ANCHORAGE DEPT. OF HE/ LTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Descr tion: G 3 E,5- � --W-- / r , : 1986 A. WELL DATA' Ri°" W II CIt' ED 5,' I If A B O D E Approved (Y/N) e asst i i Well Log Presentr Date Completed ` `� � Yield t S Total Depth/7-0 ` Cased to 33;K Depth of Grouting Static Water Level 17 Pump Set At �C n Casing Height Above Ground -�� Sanitary Seal on Casin Electrical Wiring in Conduitcm)- Separation Distances from Well: Depression Around Wellhead t)1@ To Septic/Holding Tank on Lot /O—! On Adjoining Lots — To Nearest Edge of Absorption Field on Lo / On AdjoiningLots To Nearest Public Sewer Line �✓B To Nearest Public Sewer Cleanout/Manhole �— To Nearest Sewer Service Line on Lot 166" /06 1. Water Sample Collected by 5� � �—®� ; Date -7- Water Sample Test Results S t G c Comments B. SEPTIC/HOLDING TANK DATA Date Installed 5- e3 Stand pipe/W- Depression over Tank,ef-a Size �Z, No. of Compartments a Air -tight Caps/try Foundation Cleanou&/K)- f®_2%,6f- Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water-Ma4 /Service Line Course Comments Page 1 of 2 72-026(11/84) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Z' /. eF To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata S Type of System Design Date Installed S 3 Length of Field/ Width of Field 3a Depth of Field _ �Q �i q Gravel Bed Thickness Square Feet of Absorption Area 13/ r Standpipes Presen(V4 j _ Depression over Field) Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption r'Fiield: Tn WntPr-Ciinnly Wall / /,) / To Property Line --- 1,9 O - To Building Foundation To Existing or Abandoned System on Lot ✓� _ ; On Adjoining Lots 3a f - .1- i dc,/ To Water$Aam/Service Line `d To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) Pump Off' Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. signed & S ENGINEERING Date JUN 3 0 IgoraF� Com SR B 196X _ MOA No. ?46 E RIVER, AK 99577 >� Receipt No. '> `� `� _ �- A� � Date of Payment Amount: $ f" r �1 - 41 Page 2 of 2 72-026 (11/84) 8.h&,+ A. V1109; Ar too. tasr-G s P�QFESS�'��'r M