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HomeMy WebLinkAboutPARK HILLS #1 BLK 2 LT 3Onsite File .......... ............. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES E TO FROM SEPTIC TANK ABSORPTION FIELD WELL Address I Hjl WELL ccr-�- I l/ Phones Permit No. No. of Bedrooms c 00 Z170 1`5 LOT LINE ( 0 + LEGAL DESCRIPTION LotBlock 5 Subdivision u' l FOUNDATION Township, Range, Section AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, driveway, water bodies, etc.) TANKS XF KI SEPTIC ❑ HOLDING Manufacturer� Capacity in gallons iCI �1 %rlC opo Material No. of Compartments vd d v' oc of TYPE OF SYSTEM ❑ TRENCH XBED ❑ W. DRAIN ElOTHER e I Depth to pipe bottom from Total depth from original grade T I� X S original grade I; FT FT - Z. h Fill added above original grade Gravel depth beneath pipe 0 FT FT t l - Gravel length Gravel width - FT FT Total absorption area Distance between lines j p SO FT FT Number of lines Soil rating Pipe material :a SO FT Installer Date Installed .. 'tklIi '—' ..Z -- v WELLS PRIVATE ❑ OTHER (Identifv) Classification (A, B,C)Total Depth Cased to aPs� FT FT M r/x171 Installer Date Installed: /)� C9 ') 74 REMARKS: I AL 11111, Scale: tJ. j , 'rj• ENGINEER'S SEAL (. (� InspectionRPerformed �t ii;�ii000Ud66ddd by: ..,A� (, sri ,t Date: C� -vs S & S ENGINEERING E8910 Rif" f680119 RGBCI No.certify tha his inspection was performed according to all 17034 Municipal �I 1rf�In�ll�n�€B A9i5l� D 5 Y a 1 A ha'ct :Qi c;1"d Is. P., TE ea ao Health Department Approval • Dater 72-013 (3/85) u MUN1C1PAL1 /Y OF ANC�ORAGE Departmeni o� Health & Human Services 825 L Street, Anchorage, Alaska 99501 3�!3-4720 ON^SITE SEWER PERMIT �� ��� q� Permit. Number: 90O290 Upgrae d»�u^�l^�"�_� '~^ Date Issued: 09/13/90 Engineer Designed SEPTlC TANK: Minimum total septic tank capaciiy: 1,�00 gallons. Each septic iank must have ai least 2 compartments, Depth to top oF septic tank(s) < 4.0 feet requires 111sulat1on over tank(s)^ iVVFURM D.H.H.S. PRIOR TO INSPECTIONS BY ENGINEER, 1F AFTER OFFlCE HOURS, CALL 343^4681 AND LEAVE A MESSAGE, CONSTRUCT PER ENGINEER/S ATTACHED DESIGN, lMIS PERMIT EXPIRES 12/31/90 AND VALlD FOR A SINGLE FAMILY HOME. I CERTIFY THAT: 1, I am familiar with the requirements Aor on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State Alaska. of is. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of' this permit. 3" I will adhere to a1l MOA and State o[ Alaska requirements for the set back distances from any existing well, wastewater dispass a,l system or public sewerage system on this or any adjacent or nearby lot" 4. l understand that this permit is vaIid for a maximum o[ It bedrooms" I also understand that the capacity oA the total system is 3 bedrooms and any enlargement will require an additional permit. 'Zs SCALE vv� G / ` 3 Psiz- T ui �I l IJ�aS ar: x fl vtsD�CL p, vs W '� \�eL,L_ 2 � JPS N � 1 �r� 1 Y � 'l N ••O -dug i Te9 te' e Municipality of Anchorage r DEPARTMENT OF HEALTH & HUMAN SERVICES VVI 825 "L" Street, Anchorage, Alaska 99502-0650 b SOILS LOG — PERCOLATION TEST" PERFORMED FOR: KED L.A-IN (.r DATE PER LEGAL DESCRIPTION: �-1> t3.ot�Z (7p,.mK�tt„t„Ss ,ownship Range Section: —rj .® Ty ovkGA.4.4 %C'5 SLOPE 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS 8- 19- 20- COMMENTS GaM Uw 14.Il-4HT 'SIL T. ►so4Me- lh WAS GROUND WATER ENCOUNTERED? - t4o Ping e +� - sosi'*r� S G ?-bJr1PWOgL'-- IF YES, AT WHAT L �yJvCV/�1o�5 It' DEPTH? P E ms�st,, Depth to Water After GJ Monitoring? "[ Dale: ;(ENGINE;A'gSEAL) < �fi co��u� u4c .J .� 4:t •q . �t+3 w4�Jrt A. ilr,ie ,� ¢ ' •°° X94. {wit --i; SITE Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN _ _ FT AND r__ FT PERFORMED B'k7.034 Eagle River Loop Road No. 204 Eagle River, Alaska VYDlf ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDE 72-008 (Rev. 4/85) CERTIFY THAT THI`TEST AS PERFORMED IN ON THIS DATE. DATE: O/ - G7 ,- MUNICIPALITY OF ANCHORAGE A 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 /�'+•'-e vt, 1 6� �i �J 1 1 7-�,L PHONE EW { �(! •" ��U I ❑ UPGRADE MAI LING ADDRESS_ SRR 41 LEGAL DESCRIPTION I ZrK ii5 Subdivi5►a► lack 2=Lo-t -A0 LOCATI N es� 01rS Clo `i,.[ e NO. OF BEDROOMS vY Wei l�nil Absorption rea Dwell' DISTANCE TO: VVVV �0 �Q_gL �, V T PERMTNO. 1— Z aWi F Manufacturer �7�,-�� �.. M tojr�ial No. of co�artments Liq. cap c�y In gallons ov IF HOMEMADE: Inside length Width Liquid depth Y j�Z Well Dwelling DISTANCE TO: PERMIT NO. = Z F Manufacturer Material - Liquid capacity in gallons O= W Well n Founda ion, Neares to line -0ISTANCE TO: �f✓� • .i� PERMIT NO. FLL Z w No. of lines Length egph line Total length of lines TrencJ� yi dth Distance b ween lines cc F Top of the tc finish grade ,� •� / / inches Material beneath the Total effective sorption area W Length Width inches Depth PERMIT NO. 0 wa Type of crib Crib diameter Crib depth Total effective absorption area WWell on DISTANCE T0: Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. W W Z, DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE XMINIVEN milli MINES - oil MONEEMI&INIAME NEEME®EN�LI ricin>•uf:�f/Lf "luwtl.ir-MLI i 7 Ur ANLNUKAUt Department; Health and Environmenta 'rotection 825 '� Street, Anchorage, AK. �-��501 �) 264-4720 Permit # Lib 1 u2 (U # # # HANDWRITTEN PERMIT # # # WELL AND ON-SITE SEWER PERMIT Applicant: (�� ��� , Mailing Address:r,q�6 Location: Phone Number: c Legal Description: L 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 LENGTH L_ 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 _ {0::Z)4_ 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 feel 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 3 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 th the on-site sewer system may require enlargement if the resi. nce remodeled to include Signed: A,'/ Issued Ap ica SWP/024(1/81) Date: 4 -VI I i SOILS LOG MUNICIPALITY OF ANCHORAGE +.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR:ARC7-1C R0SNRCC-S ,QR1,L41N & , ZA /Ov. DATE PERFORMED:Z09ey -7,1983 LEGAL DESCRIPTION: (31"R ,2. ANRK "lLGS SUJ3p,7, a A- Sec. 3y, -')2N, iZ3W4 S.m. D 0r1G/9A0 C M%►T' SLOPE SITE PLAN 1 of- (59GAN1C Su -T, f�{own 2 Semsb()Q/ F'r4J7L 7`U P.,S J SM 914L7 -i Gf{AV861.Y SgN.0 3 Brown, cif y �4 5 P- SAND, O r-d-Wn.) c%Q.q J Sw Pryi meo1:v»-t 7 8 9 .19M 10 SM 11 12 13- 14 15 16 17 18 It -S'rw•,-, Ea -7y sA Af0 , ,Sr*vvn ,elotsi f Dyed: um f G1�undwat?(� a+ q•� '3%683 S11,7Y G1?jCtVELLY T/91YD ts-rzvt 7 / Sc3'�Vt'a�Bo/J WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? e-fe : G�vnd��Pr leve is, 6e ex 1ea� -to -f fv�io* yy �� •5"2aSn J-10. 1 CD OF ®� o .B Odea. e&n3e.b.ee.aoo.. �.. 19 e�) �� e Allan W. Murfitt e No. 4977-E � e 20 YGs 0 P / E e L. Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) BETWEENTEST RUN COMMENTS &CCMrne✓d 15.0 fY2 /,�jdrYY1D "D;m• BorP/1o/Ea'PAMX;/ytGi"{yer'tkie +3aa�6,�}a �oca-fian :c e�arox:.rnu'fla �.✓>rJ dtn� Cc.r�iay �.-d�P�_ PERFORMED BY: Je-Qfirer M• Ryles CERTIFIED BY: A110,vt W�v{� DATE:P/Aa. o MPA. cert-f:cate /v.. 9782-1901 72-008 (6/79) C. S AN ur"t ® `fin Y 8010 King St. o Anchorage, Alaska 99502 Telephone 349-7531/7533 March 14, 1983 Arctic Resources Drilling, Inc. 6361 Nielson Way, Suite 101 Anchorage, Alaska 99577 Attention: Mr. Ray Morris Re: Ground Water Levels Lots 3 and 5, Block 2, Park Hills Subdivision Anchorage, Alaska Our Job 783-053.01 Dear Mr. Morris, On March 14, 1983 we returned -to the subject site to measure the ground water levels.in Boreholes AWM-6 and AWM-3 on Lots 3 and 5, respectively. Groundwater could not be measured in Borehole AWM-3, Lot 5 because the hole had been :filled. On Lot 3 the groundwater was measured at 8.7 feet below existing ground surface. Should you have any questions, please do not hesitate to contact us. Yours truly, G'%L/'��l yw Jeffrey M. Ayres Senior Engineering Geologist 1 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 s,. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 017-142-16 Expiration Date: —` �5 1. GENERAL INFORMATION Complete, legal description Park Hills #1 Block 2 Lot 3 Location (site address) 14641 Park Hills Dr Current Property owner(s)•, Rixse Day phone 441-4114 Mailing address 'Same Real Estate•Agent Craig Lightle Day phone 441-4114 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: Date: 7 — Z COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment 7 —J-- f 6 Date of Receipt Number 100()()3 Receipt Number. COSA# Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm NorthRim Engineering Phone 694-7025 Address _PO Box 770724, Eagle River Engineer's Printed Name Steve Eng 6. DSD SIGNATURE System #1 Approved for System #2 Approved for 0 Disapproved. Conditional approval for bedrooms. bedrooms. Date 7/5/2016 ti t" a x mss. e la ooyoas,;ca-het • •-- zw, 70. bedrooms, with the following vvr%! c1\ �[N� Original Certificate Date: 7 The Municipality of Anchorage Devlopment 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 bWe sheet 9.1-12.doc If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of ®n-Site Systems Approval Checklist Legal Description: PARK X//LZS �f $Z G 3 Parcel ID:0/7-IAIZ-/6 A. WELL DATA Well type _, .If A, B, or C provide PWSID # Well Log (Y/N)\1 Date completed 3 Z2 83 .Sanitaryseal. (Y/N) Wres properly protected (Y/N) T— Total depth //. 9 ft. Cased to;IZ9 ft. / Casing height:(above ground) in. FROM. WELL LOG AT INSPECTION Date of test 3JZZZ�'3 S 741� Static water level ft. 7Z ft. Well production,,... g.p.m. �V g.p.m. WATER SAMPLERESULTS: Coliform __0_colonies/100 mL Nitrate a mg/L Arsenic Nb_ ug/L Date of sample: S�2 i,16 Collected by: /V A/ Ie �4 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SG� 7�1 C S I FEL Date installed 5 f s Tank size AM 0 gal. Number of Compartments 2 Cleanouts (Y/N)' Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y/N) /V r Date of pumping Pumper f C. ABSORPTION FIELD DATA Date installer 0 Soil rating (g.p.d./ft2 0 /bdrm .2 System type ee6 yam' Lengtf g "' tit,: Width ft. Gravel below pipe Q. S, ft. Tofpl d'eptii ft EfF: sorption area 5 0 ft2 Monitoring tube Depression over field Date of adequacy test Z�" Results (Pass/Fail) t For 3 bedrooms b i Fluid depth itNabsgC itihtp fieltlrfAre test_ in. Water added gal. New depth_.2— in. Elapsed Time`_ man , Final fluid depth in. Absorption rate >= g.p.d'. Any rejuvenation treatmenf (past 12 mo:) (Y/N &type) /t/0 If yes, give date D. LIFT STATION 4//4 Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off" level at in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARAT[ONDISTANCES' WELL ON LOT TO: Septic tankilift station on lot Z On adjacent lots Absorption field on lot/!') ©� f On adjacent lots f C7 Q rfi Public'sewer main Public'sewer manhole/cleanout ` !O'o r ?— Sewer /septic service line Z S '-f Holding tank COQ r f Animal containment areas f" Manurelanimal excrete storage areas /DO SEPTIC/HOLDING TANK ON LOTTO: Building foundation s Propertyline_.._/ZrLF Absorption field IO'"F Water main Al '(_ Water service line Surface water a'f Wells on adjacent lots d � ABSORPTION FIELD ON LOT TO: Property lineBuilding foundation Af Water main /_�, �F r Water SeNiice line Surface water /Da Driveway, parkin g1vehlc[a storage Curtain drain (//✓( Wells on adjacent lots /00 F. COMMENTS AA COSA yellow sheet_2-6-15.doc - - G. ENGINEER'S CERTIFICATION 44.;+o I certify that 1 have determined through field inspebtions and ��,.•• review of Municipal records that,: the above systems are in conformance with MOA COSA guidelines in effect on this date: Engineer's Printed Name c7 )%_:51JX Date two s COSA yellow sheet_2-6-15.doc - - nocae:U noon W4pOSfD ICI U KI CCAWk ZIYaia pI51l fNpli nuamoiG ff1BAIX } a0E WegeL YBACX ` � AFAY. NWDYiC ;£iBApK 1 1 A. ` CCI .'. •. 11 c.0.x x 2 1 f 1 1... 1 1 o 1 KnsrlNc a. . } i MpUS£ 1 a :6.p•oYz O' lid ii 1 � Ib x 1 oN .� NECLI 1 4 + 1 s _s 11 _ 1 v 1 s 1. SBTBAGK CFtfi@K h00' T'rt 1 EBM ZO !B6 ESIXT _ •� � � �, MALN �"h25 GREEK 00 aB�IJ 5TT° a h5B U2 UNDER NO CIRCUMSTANCES SHOULD AN AS—BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE ONES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABILITY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCALING, REPRODUCTION MAY CAUSE ERRORS IN SCALE, LeT 5;.w, SURVEY TYPE ❑ POUNOATION AS-BUILT SYMBOLS SET REBAR DRAINAGE ASPHALT ❑ FINAL STRUCTURE AS-BUILT O FOUND REBAR 0-0--e- WOOD FENCE - "' CONCRETE (� PLOT PIAN ... AS-BUILT ... LOT SURVEY , .. TOPOCRA Kr 00 ASSUMED ELEV. 9 14 )F METAL FENCE . WOOD DECK A -GUILT .. 0 MNMJ S&T Z AMItnCATIO AS-BUILT ... Mg COROERS SET _. PLOT PLANS & LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE SHOWN.. FENCES, WELLS, SEPTIC CLEANOUTS. SIDEWALKS, DRIVEWAYS, ETC-, ARE SHOWN IN THEIR APPROXIMATE LOCATION. ONLY. SNOW THEE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEAR ON THE.RECORDED SUBDIVISION PLAT. MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. Prepared by SURVEY CERTIFICATION aara\ C q���Q Robert E. Johns, Jr. & Assoc. PLOT PLAN Nut I. p.*B ye,Mpe .•� •• • • "'•`•• �j Professional Land Surveyors ,enWY.TM,Ify �m, >o.• ma aewe.A n , oa netw ml , m M r u.la °°'" mNq q+�P +• R*. 1700 Brink Drlve. ANCHORAGE. ALASKA 99504 a .�n e• em�ewtamy �nmi«, Scale: Rea. Lot S.F. Rec Plat Ale No- mw ma ar• '� no,. aam _ 49th) �f FOUNDATION AS-BUILT ^.RWM C .M•R J.. fle,AY only Ma I .�..Y«�. / oft. I' .r F 5v.... .y _ JL-.-•%a r Date 5urvayad: 06/29/16 Oruwn 4K REJ Checked 6JA A K wgeiwmwmAv-e•rt iw�vbUm m Nx wt and Nal a� N• - M,pm.':. /�.,„� • :• ♦f ;` * '. JR. ,Vi Date D.Lr ": 06/30/16 c a: 3037 W.O. 16-238 .m.,.naaw mu nrrcm•ua+ a lw.e ROBERT E. JOHNS : JO t: o /.'9�A •''+ 41 Z1 _S `•`aIt A Legal DeaCriptlpq; °� FlN0.L STRUCTURE AS-BUILT •., ' • ° ��,eP6d y RWst E .kM, r.. U�.�Y a'IRY N•t MM Urwm.4 a•. AY@,II a,MY of 1M w ,Na tat mt Nm m W. •.,......,.•e• ••' a �J ,'� p p� LOT 3 BLOCK 2 w•.otw• w asgi°'®ssl°"++++ lwaara. PARK HILLS #1 ew uNn'•Iw 0 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel LD. # (�l�l - � q n - Un n 1. GENERAL INFORMATION HAA# 1�f�1�i �K;117 Complete legal description Lot 3; Block 2; Pa)Lk H.i.M Subdiv.iz.ion ;t� I Location (site address or directions) 14641 Pa&k H.i.?.U3 Dive Anchorage, AK 99516 Property owner Ke?.ei. 9 Me2v.in R.Lxse - Day phone 345-2599 (h) 564-5945 (w) Mailing address 14641 PajLk H.i,P 6 Drive, Anchorage, AK 99516 Lending agency SEATTLE MORTGAGE (Dick Do.2man) Day 562-5626 phone Mailing address 560 E. 34th , Sure 100 Anchorage, AK 99503 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3`' V 3. TYPE OF WATER SUPPLY: Individual well ' XXX 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: Individual on-site XXX Holding tank Community on-site 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 021 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date that the the site waiter supply ty that my investigation of this Health Authority Approval app lication showsand/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 & s ENGINEERING Phone 17034 Eagle River Loop Address slca 99577 Date Engineer's signature A? C-2 o'mn 8s%�'$°® No. 8215 ��J1�QpRQFFSS�o�„�� 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. bedrooms, with the following stipulations: Conditional approval for Xu�5- Additional Comments Date 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. ___._ .,,.., .,,,e�, Municipality of Anchorage Department of Health & Human Services _ HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type if If A, B, or C, attach ADEC letter. ADEC water system number "5 - ZZ Driller— Log present (Y N) Date completed Totaldepth (1 t Cased to 1 t`t t Casing height— Sanitary seal ON) `� Wires properly protecte&Y 1) *FROM WELL LOG Date of test Static water level Well flow g.p.m. Pump level 1`4, <"" FP-. .4, t�►�4 ��- SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot AT INSPECTION t\ P J1L Z�1a- �7 "ilr-OA1-.ITY ^F ANr'H0RAGE ENVIk0Nh1ENT1,L SER\ K__ -S DIVISION ; On adjacent lots g:p- M.1 5 1993 --RECEIVED oak- — ; On adjacent lots — Absorption field on lot ,\ Public sewer manhole/cleanout Public sewer main Sewer service line Petroleum tank bock" r1, WATER SAMPLE RESULTS: o>S�L d L��� I t oo,,l Q• Nitrate D `� 'I Other bacteria Coliform S & S ENGINEERING Date of sample: Collected by: age wer oop oa o. Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date installed —,ate Tanksize ��no Compartments Foundation cleanout (�Y'ID (YN)— Depression (Y Cleanouts )-- I Alarm tested (Y/N) /.A - High High water alarm (Y& I SCJ 1 C -IL S Date of pumping C>f_ r. I 1 Cl 9 Z Pumper 144 t= cL\k� L L") ,N, <)\-X4cA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: s i I -f / � � � Wells) on lot /00 On adjacent lots o Foundation / To property line /b / Absorption field Il Water main/service line Surface water/drainage / by 14,- CONTINUED ON BACK PAGE 72-026 (Rev. 7/91) Front C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical s (Y/N) SEPION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Manufacturer Manhole/Access "Pump off" level at Cycles tested Surface water Date installed Z90/ j f Soil rating _ l g� System type �L>5 Length _5Zk i ZS Width Gravel thickness 0,5 -. Total depth g Total absorption area Cleanouts present8N) V Depression over field (Y& Date of adequacy test Results /fail) _ PA!. S for 'y,* g_ �"�S� _ bedrooms Peroxide treatment (past 12 months) u. ld If yes, give date "� 1A, SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 10 To building foundation On adjacent lots 3 t Surface water l6 0 / e - Curtain drain E. ENGINEER'S CERTIFICATION _On adjacent lots 6 o / Property line - 0 14 - To existing or abandoned system on lot Cutbank SIA- Water main/service line_ Driveway, parking/vehicle storage area l certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the " F: I'1GIN1,;guIN6 I%'t1i 4 t{6gl!3 ?"" L Signature — � t� 1,001) Road No. 204 w .,-e .)ver r Engineer's Name HAA Fee $ %6 ° v Date of Payment Receipt Number�S 0 72-026 (Rev. 3/91) Back MOA 21 / Waiver Fee: $ Date of Payment Receipt Number 0 1 4- to of this inspection. A. e4�i F RIVER, HEALTH AUTHORITY APPROVALS SEWER& WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION A FLOW TEST SITE PLANS PDA[) IJ{SIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN #,A 7 It A WELL FLOW TEST DATA ROBERT SHAFER, P E. ROGER SHAFER. P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694 1211 CLIENT: 1 t% �\l I,,& 21DATE OF TEST: 3 LOCATION OF WELL (Legal Description): 1-oT 3 5,,V- Z WELL DEPTH: \\°\ , CASING DEPTH: ��_ TESTED BY: DATE DRILLIKG COMPLETED: �7-ZZ �'> DRILLER: r d-- MISC. DATA: CASING HEIOHT: %z SANITARY WIRES IN CONDUIT?s V GRADING O.K.?t BACTERIA & NITRATE SAMPLES COLLECTED: ry RESULTS: WELL CURRENTLY PRODUCES 2.Z GPM WITH A 34. DRAWDOWN FLOW RATE NOT GUARANTEED --SUBSEQUENT VARIATIONS CAN OCCUR! 17034 EAGLE RIVER LOOP, SU17E 204, EAGLE RIVER, ALASKA 99577 �y CLOCK TIME DEPTH TO WATER DRAWDOWN PUMPING RATE(GPM) REMARKS 10: 4o -74' swl — �!_ I a ICiJ L L- PO J P S/2r- If Pi.v.q 11 : 32 / u 3 (e 12:17 Ilo' /:3 /10' 3r.' z.Z 110' r d-- MISC. DATA: CASING HEIOHT: %z SANITARY WIRES IN CONDUIT?s V GRADING O.K.?t BACTERIA & NITRATE SAMPLES COLLECTED: ry RESULTS: WELL CURRENTLY PRODUCES 2.Z GPM WITH A 34. DRAWDOWN FLOW RATE NOT GUARANTEED --SUBSEQUENT VARIATIONS CAN OCCUR! 17034 EAGLE RIVER LOOP, SU17E 204, EAGLE RIVER, ALASKA 99577 �y MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. #�� - \ L\ Q - \(n HAA # O'Q qqc' 1 LAC -)LA 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3 • Bloch 2 • Path H.i27b Subdivision Location (address or directions) 14641 Path H,iM Dt.ive (b) Property owner Ken Laing Telephone ; (home) 345-0979 Business 264-7347 Mailing Address (c) Lending Institution Mailing Address 14641 Path H.i22s Dt.ive, A2aaha Telephone (d) Real Estate Company and Agent PACIFIC RELOCATION SERVICE c/o lack White Company ATTN: Laity Mautciin Address 3201 C S.tnPPt SuitP 100 Arc nKago, A2a� 99503 Telephone (e) Mail the HAA to the following address: (or check herebl, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 En ite- Rlep Road No- 904 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family fix Number of bedrooms 3. WATER SUPPLY Individual Welles Community ❑ Public ❑ Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site IBX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 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 Telephone 14 9�/-2976 S 4 ;-NOINEERING Address 17n?4 raqle River.Loop Road No, 204 _aole diver, Alaska 99577 2 6 �?6 Date 6. DHHS APPROVAL Approved for bedrooms' "" ` Date Approved approved Conditional Terms of Conditional Approval CAUTION . The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88) Back Page 2 of 2 PNCNpRPGe M�NtGJvt`V1Pps R'405 . N MUNICIPALITY Health Authority Approval (HAA) (MOA) E��RpNMEl3( 'CHECKLIST - FEBRUARY 1984 a P 26199 343-4744 Legal Description: L of 3 : '&/oC_l_ !C 2 A. WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) ^� ✓+ Well Log Present (Y/N) Date Completed z o 3 Yield P M Total Depth 1 I y, Cased to 11 5 t Depth of Grouting Static Water Level Z Pump Set At U r Casing Height Above Ground Z Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot f 00 , f On Adjoining Lots 1 DU i t To Nearest Edge of Absorption Field on Lot (-00 /t ; On Adjoining Lots 1 00 �t To Nearest Public Sewer Line ^% To Nearest Public Sewer Cleanout/Manhole ti To Nearest Sewer Service Line on Lot .Z 5 rt Water Sample Collected by `f �S� C t%q 1 nJ e CJ' ' " ;Date Q- Z -tet o Water Sample Test Results fa c, to , - ,g F}c tP r� i V� �h A� t % ✓i�te5 Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size 00 No. of Compartments z Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) `1 Depression over Tank (Y/N) M Date Last Pumped -to ` `l 0 Pumping/Maintenance Contact on File (Y/N) A) /JA ; for 1AJ W Holding Tank High -Water Alarm (Y/N) 11JT—Temporary Holding Tank Permit (Y/N) /0to SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well / 00 7 f To Building Foundation To Property Line To Water Main/Service Line To Disposal Field To Stream, Pond, Lake or Major Drainage Course Ai [A Comments t(c- Pomoe_d to A t o Me- (r0; c- eS 72-026 (Rev. 7/88)Front Page 1.of 2-_ C. ABSORPTION FIELD DATA Soils Rating in Absorptiof Strata —Type of System Design�5 Date Installed Length of Field ----52 FI ' /S- 1125 Width of Field 1 fv Depth of Field 4 Gravel Bed Thickness 0,5' Square Feet of Absortion Area �/ �T Statndpipes Present ¢01\1) Depression over Field (YIM "f Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well / Do f To Property Line D t To Building Foundation ! O f To Existing or Abandoned System on Lot n ; On Adjoining Lots To Water Main/Service Line /0 t To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course �IA r To Driveway, Parking Area, or Vehicle Storage Area 5 Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) **Check Permitted Bedroom Rating Against HAA Request** "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 1baCr � ,� 1 lir Signed 51NUyNEERIN` f 17034 wale River f ®op Road No. 204 y, ' r%, Company ,` ,''•w> y r ag c River, �, c*' Date MOA No. r� ^ O(799r1 A. $il ef:il' VaA`�: Flt J> F;4 Receipt No. Receipt No. `A.. °� ' • `L`� �—b Date of Payment Waiver Fee: $ Amount: $ Date of Payment 72-026 (Fiev. 7/88) Back Page 2 of 2 2� MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date 2-27-84 (a) Legal Description (include lot, block, subdivision, section., township, range) Lot 3, Block 2 Park Hills Subdivision Sec. 34, T12N, R3W, SM Location (address or directions) Park Hills Drive - Rabbit Crk. Rd. to Golden View Dr. - Turn left - tak 1 1 f 2nd house on left (b) Applicants Nam Steve Pisa d/b/a Forest Ridge Homes Telephone 345-1901 Applicants Address SRA Box 475-5 Anchorage, Alaska 99507 (c) Applicant is (check one) Lending Institution avner/b.iilder ; Buyer Other � (explain); (d) Lending Institutionlct National Rank/Djabbic_ Gconn Telephone -)-7r,-c,-Ann Address 71 c mhel l An .hnra Alaska (e) Peal Estate Co. & Agent RE -MAX Realty - Terrie Pisa Address old Seward Highway and Dimond Blvd. Telephone 522-1030 2. Type of Residence Single -Family) ELI Multi -Family Number of Bedrooms 3 3. Water Supply Individual Wbll I—ET Community Other (describe Public Note: If commnity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Is the %ell adequate for the number of bedrooms specified in this HAA (YIN) Y 4. Sewage Disposal Onsite Public Community Holding Tank Is the wastewater disposal system adequate for the number of bedrocros (Y/N,) Y ( Page 1 of 21 2-15-84 5. Engineering Firm Providing Inspections, Tests, Data and Information I certify that I have checked, verified, or conic ..ted to all MOA KAA Guidelines in effect on the date of this inspection.. Signed ✓��.,�� .<� - Date Name of Firm Z—C-/ /c� v�v 1'2�eee-s �K Tele hone Sal — /j fps Address 3 Co .:c OF. ALA%9. Signed by X� ve o/ S Date (ENGINEER SEAL) 6.DHEP Approval Approved for 15 bedrocre Approved 2:1 Disapproved Terms of Conditional Approval Date j>e .. Conditional The Municipality of Anchorage Departrrent of Health and Environmental Protection does not guarantee the continued satisfactory performance of the water supply anal/or the wastewater disposal system. This approval indicates that, as of the validation date sham above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedrooms and type of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s (Page 2 of 21 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA MUNICIPALITY OF ANCHORAm DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOtq MAR 9 1PR4 RECEIVE' Well Classification Individual If A, B, or C, D.E.C. Approved(YM) N/A Well Lcg Present (Y/N) Y Date Colleted 3-22-83 Yield 5 gpm Total Depth 119' Cased to 119' Static Water Level 69' Pump Set At Depth of Grouting Unknown 114' Casing Height Above Ground 2' + Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) Y Depression Around Wellha'd'(Y Unknown7__ Separation Distances from Well: To Septic/Holding Tank on Lot 100 + ; On Adjoining Lots 100 + To Nearest Edge of Absorption Field on Lot 100+ ; On Adjoining Lots 100 + To Nearest Public Sewer Line N/A To Nearest Public Sewer Cleancut/Manhole N/A Water Sample Collected By M. McLean To Nearest Sewer Service Line on Lot N/A Date 2-29-84 Water Sample Test Results Satisfactory for Total Coliform Ccmrrents B. SEPTIC/HOLDING TANK DATA Date Installed 5-83 Size 1000 gal. No. of Ccnpartments 2 Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) y Depression over Tank (Y/N)Unk.,.* Date Last Pumped N/A Pumping/Maintenanm Contract on File (Y/N) N/A ; for Holding Tank High -Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) N/A Separation Distances from Septic/Holding Tank: To Water -Supply Well 100' + To Property Line 10' + To Water Main/Service Line Course N/A 10' + To Building Foundation 5' + To Disposal Field ill To Stream, Pond, Lake, or Major Drainage C COR rants * Snow cover restricts inspect;nn of d prPCSion over tank 'from= �- salt inspection Report the septic system and seepage bed are newly installed & unused. [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 150 Sa. Ft. Type -of System Design RPCI Date Installed 5-83 Length of Field 32 Width of Field 16 Depth of Field 2' - 4.5 Gravel Bed Thickness r11 Square Feet of Absorption Area 512 Standpipes Present (Y/N) Y Depression over Field (Y/N)Unknown * I Date of Last Adequacy Test N/A Results of Last Adequacy Test N/A Separation Distance from Absorption Field: To Water -Supply TRb11 100' + To Building Foundation 201 + Lot N/A 1 To Water Main/Service Line To Property Line 10' + To Existing or Abandoned System on On Adjoining Lots 301 + 100' + To Cutbank(if present) N/A To Stream/Pond/Lake/or Major Drainage Course N/A To Driveway, Parking Area, or Vehicle Storage Area 10' + • • • no . 11 . • • _ • e • - e . FIIZII takeno from MOA insipect on report. D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Dire ns ions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Tbst. Meets MOA ** Check Permitted Bedrom 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.OF a Signed � vi S at rr "`4a/zDate 3 , ''G 7 !'✓� : ` t� '`°� � e� Company✓Gi"%c Com. y�.,ee�_r4MOA No. ST�'�%�oa/`" _ e a R KB1/d5/s (Page 2 of 21 �t� � David v. rnas!tc:: 4 2-15-84