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HomeMy WebLinkAboutUS SURVEY 3044 LT 57 T10N R2E SEC 17/18LiM lotiq � G1SCQN Mark Begich Mayor Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907) 343-7904 Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue: Ate, efini„w(c..144ec; Legal Description S Stl/c' t7 "3o 9 L-57 Pump Installation Date: IN Property Owner Name & Addr ss: (&'l r6/I-lytsk4 lc -y. ‘cra 00A Pump Intake Depth Below Top of Well Casing: 5 5 feet Pump Manufacturer's Name: ed smote f Pump Model: 50(-31! S S 12 Pump Size V2 hp Pitless Adapter Burial Depth: /O feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? aYes ❑ No Method of Disinfection: £ L„/„p,ry,,,J, "11,6 S Comments: Pump Installer Name: W? Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services -- 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 November 15, 1994 Mr. Steven Shortreed Box 303 Girdwood, AK 99587 Subject: US Survey 3044 Lt. 57 Permit #SW930374, Parcel 11) #075-061-51 Dear Mr. Shortreed: The subject permit, issued September 17, 1993 by this office for a single family well and/or on- site wastewater system, has expired as of September 17, 1994. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If the on-site wastewater system has been completed and a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as -built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $320.00 for an on-site wastewater permit; $120.00 for a well permit and $440.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Sincerely, &3 Cern. James Cross, P.E. Program Manager On -Site Services JC/kb C4efk CR4 Z N 40.. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW930374 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:SHORTREED STEVEN W OWNER ADDRESS:BOX 303 GIRDWOOD AK 99587 PARCEL ID:07506151 LEGAL DESCRIPTION: US SURVEY 3044 LT 57 LOT SIZE: 35145 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 9/17/93 EXPIRATION DATE: 9/17/94 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS:/17 � RECEIVED BY: L '" �� ' DATE: Zv riff ISSUED BY: 2o+-F1J S 014. DATE: 11 (7793 M -W DRILLING, Inc. P.O. Box 110378. 10330 Old Seward Highway (907) 349-8535 • ANCHORAGE, ALASKA 99511 am-. blot- 5 SW ell 3'lii DRILLING LOG Steve Shortreed Domestic Well Owner Use of Well Location (address of: Township, Range, Section, if known; or distance main road USGS # 3044, Lot 57 - Girdwood „ i61 Size of casing 6 Depth of Hole 6 feet Cased to 24.6 feet Static water level ft (Ki (below) land surface. Finish of well (check one) open end ( X ) ; Screen ( ) ; Perforated ( ;; j., Describe screen or perforation 4 None Well pumping test at 15 gallons per : Xi L) (minute) for 1 hours with_ )-QO �, ft of drawdown from static level.. ; Date of completion September` 24 J 1993 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness o 2 TO 2 TO 5 GSGStiekttp Organics 5 T025 Gravel, ' silty w/med. boulders 25 TO 50 5Q , 61 frJa,ee Fjearng gravel; occasional silty lense TO ..ra. G;~avel, Fret silty/dirty t TO TO .3 TO TO TO TO TO TO TO TO RECEIVED JUN 1 1995 ._;y of Anchorage nept. Nraith & l luman Setyices NWWs �- Certificate it a. 1 —CUSTOMER NOV-03-98 14:40 FROM -CTE ENVIRONMENTAL 4 CT&E Refit Client Name Project Name/ii Client Sample m Matrix Ordered By PWSID Sample Remarks: CT&E Environmental Services Inc. rimmearearrirrosotworew.aorrsomrwa 986399001 AX Water & Wastewater Consultants Inc. L 57 455 3044 M1 1.7 Alyeska L 57 455 3044 Ml 1.7 Alyeska Drinking Water 0 Parameter Tatat Colt{orm Nitrate -pi 5615301 T-361 P.02/02 F-483 Client POW Printed hate/Tune 11/02/98 16:27 Collected hate/Tlrrte 10/29/98 08:25 Received Date/']tittle 10/29/98 12:30 Technical Director: Stephen C, Ede Results P_L unlra Nethoq AtJ.osabte Prep Amatysis Limits Date Date Init 36 OR COL/100 NL, 11Th COL! PRESENT 0.465 0.100 Man SM1S 92226 EPA 300.0 1D/29/98 RMV 10 max 10!29/98 70/29/98 GCP 74 EpbwS • Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 s.A. eT. Certificate of On -Site Systems Approval Parcel I.D. 075-061-51 Expiration Date:. / 1. GENERAL INFORMATION: Complete legal description _USS 3044: LOT 57 Location (site address) 1818 ALYESKA HWY *GIRDW00D, AK 99587 Current Property owner(s) DAVID & ALICIA HALL Day phone 615-785-3390 Mailing address 1818 ALYESKA HWY •GIRDWOOD AK 99587 Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS:3'-'YlC 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community Public Water System ❑ Public Sewer ❑ WaiverNariance request for. Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment `J��3��g Date of Payment Receipt Number Receipt Number COSA # Q S C hI `/(002 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness. Date: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. DSD SIGNATURE 3 "C— —4— System #1 Approved for bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the E79 S :1.1797 .17 d. nG' o' -O r=55+0 nClcG #AECC884 Y 0F< 4 Q 2 OPV -SITE WATER AND m st TNWATER o PROGRAM ��)JJ))999911��r� By: Original Certificate Date:�� 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_ Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet_tQ10-12.doc COSA Checklist Legal Description: USS 3044; LOT 57 Parcel ID: 075-061-51 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system A. WELL DATA El Well log is filed with Onsite (or attached) Well production at time of test 3.7+ gpm Date drilled 9124193 Water storage tank volume n/a gallons Total depth 61 ft Well disinfected for coliform test? ❑Yes 0 No Cased to 61 ft I Coliform bacteria is Negative t❑Sanitary seal is functioning correctly Nitrate 0.877 mg/L ❑ Nitrate less than MRL(ND) El Wires are properly protected Arsenic ug/L M Arsenic less than MRL (ND) Casing height(above ground) 12+ in. Collected by GEG, LTD. Date of flow test for COSA 5"0n9 Date of Sample 4/16/19 Static water level at beginning of test 26.3 ft. Comments PUBLIC SEWER B. TANK DATA C. LIFT STATION Age of tank(s) years ❑ Required maintenance completed Tank type/material Age of lift station years 0 Standpipes/foundation cleanout per record drawing Lift station material Date of pumping Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) sequacy test date ❑ALL standpipes present per record drawing Results ❑Pass For bedrooms Total measured depth from grade ft(max Fluid depth prior to test in Measured depth to pipe invert from grade ft(min) Water added gal 0 N/A—pressurized field New depth in ❑ Monitor tubes go to bottom of• -infield. If not, state Elapsed time min depth into effective ❑ Code-required soil er over field Final fluid depth in ❑ System press- ed Absorption rate gpd (Required if -cant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) date of rIf yes, enter date ons introduced gallons omments/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' N/A Community Sewer Manhole/Cleanout> 100' ['Yes if No ft ['Yes if No ft Neighboring Tank > 100' [lies if No ft Private Sewer/Septic Line>25' ❑✓ Yes if No ft Absorption Field on Lot> 100' ❑Yes if No ft N/A Holding Tank> 100' ['Yes if No ft Neighboring Absorption Fields > 100' Animal Containment>50' ['Yes if No ft ['Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main> 75' ['Yes if No ft ['Yes if No ft PUBLIC SEWER From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑Yes if No ft Surface Water> 100' [Nes if No t Property Line> 5' ❑Yes if No ft Driveway/Parking >0' ❑Yes ' ,o,comment Absorption Field >5' ❑Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑Yes if No ft Private Wells> 00' DYes if No ft Water Service Line> 10' ❑Yes if No ft Cop unity Wells> 200' ❑Yes if No ft From Absorption Field on Lot to: (Please enter distanc- " ess than required) Building Foundation > 10' ❑Yes if • ft Driveway/Parking>0' ❑Yes if No,comment Property Line> 10' II -s if No ft Wells on Adjacent Lots: Water Main> 10' ❑Yes if No ft Private Wells> 100' ❑Yes if No ft Water Servi - ine> 10' ❑Yes if No ft Community Wells>200' ['Yes if No ft -ce Water> 100' ❑Yes if No ft F. ENGINEER'S COMMENTS 046� o.N.,,,p4 G. ENGINEER'S CERTIFICATION .::::7,. .:,,.... ,9 4 I certify that I have determined through field inspections and review O11 4, •••� ' of Municipal records that the above systems are in conformance with Q 9 '\ MOA COSA guidelines in effect on this date. I VVA VA 0--•f- , ,I 01 .. f • •- s 1 Ot)c E-79 !3 ,•• , 4 s I ,IJ c4 , .•.5(i.3.1•ct COSA Checklist yellow sheet ��Op'4\-\' ,. . .p.0.---'ro£ess0� #AECC884 , rl wvu—I-I•r) > n: V'r, • l i N 66'08'29" E 198.03' Found Rebores i• i — _____ Not Reid LOT 57 li,S.S. 3044 lxvi 10 ,Ic, a n. tr., L.S.S. 304.1' 1 ! • D�' 80'; --,a.i1: 1.4' f 'V i "1"'...--, N :.7' • j' Srlf' o z r'' N + 01111 C--.1 i )24%'r£W.4Y CA :A. OW o �r C.IS * Ci /<,°.'i'o•-, ,VEIER •N ,NITER ,.. ,'h 1p- ,, h, 2 STORY . SNf.D), h 0 '41-,,,6.S,, fibf \to.,CONC: r, A _ •' PAO' / `1,5.-`V'' >' --•.. �Q; ,cV r DEC.•%%."c6. %�SI1+R ^ 97 ij i�' r:,`169. 35'00,. W 200 co.. -Rho —, Pro( ry ,7 p 5 56' Pell \ti . To` .._Gittpi00llllO Ftltslm r ' I © NOTES: 1) BEARINGS AND DISTANCES ARE RECORD PER REFERENCED PLAT UNLESS OTHERWISE NOTED. 2) SUFFICIENT BOUNDARY EVIDENCE WAS RECOVERED TO ESTABLISH THE SUBJECT PARCEL ON THE GROUND. NOT ALL CONTROLLING EVIDENCE IS SHOWN HEREON. PREPARED FOR: LEGEND s.....���\‘‘ `` , s'. r Tinder City Realty 0 Recovered Monument r OF a�\`t _ Imo. i74 Hightower Road ��c -i 1) Farf. po�nt Land Services, LLC Girdwood,At.995E7 ={ I SepticVent �+oP '� 01 'A " SURVEYING, MAPPING, LANG PLANNING, GIS ® water Wel! ��'• ��� '9 ) SURVEY CERTIFICATION:FARPOINT has Conducted *; 49TH /� * rl ry� I 13 I E. 7Gch Ave.. Suite I O I Anchorage,A4eka 995 18 a physical survey Of this property as shown on trns �/,y lr, FarpointAK.com (9071522-7770 eurveyefarpomtae.com aphydrawsicanurveyd that fthe iisprovertyassments i[wno ,A(...400 w'"^'{ uated ;hereon are within the property Imes I, ,MICHAE J.HORNE-o�j AS Bit OF: EXCLUSION NOTES:It is the owners responsibility to �+0/:•. LS�5 3'8 •4a`�i� Lot 57 of U.S.Survey 3044, determine the existence of any easements, Rk 4,- `10•,0,45 II-7F 1.%,� Girdwood,Alaska covenants,or restrictions which Co not appear on 1\‘ f $ A1 � „a ,, z the recorded subdivision plat.NOTE.Under no \\\\�-",.- nec.27.2015 I„=gtl' December 16.1015 circumstances should any data hereon be used for 15216 """"' °` "' `� the construction or for the establishing of prcperty 1 JLA ��-MEQ jSE4514 129)21 Iines. Parcel 1.D. 075-061-51 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description U.S. SURVEY 3044; LOT 57 Expiration Date: o Location (site address) 1818 ALYESKA HIGHWAY `GIRDWOOD, AK Current Property owner(s) DEB MCALLESTER Mailing address Day phone 529-5368 Real Estate Agent SAM DANIEL Day phone 227-4626 2. TYPE OF DWELLING: y Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community 0 Public Water System 0 Public Sewer WaiverNariance request for: N/A Distance: N/A Received by. Date: `Y/ 8/ I 6 COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $�o J— Waiver Fee $ Date of Payment 7/�%C' Date of Payment Receipt Number 061,12-O a Receipt Number COSA # O SC{ o 016 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 Garness Engineering Group, Ltd. (GEG) Address 3701 E. Tudor Road, Suite 101, Anchorage AK, 99507-1259 Engineer's Printed Name Jeffrey A. Garness In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fait. The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the person/party who paid for this report 6. DSD SIGNATURE System #1 Approved for ) bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for B Phone (907) 337-6179 Date ()z -o J/b :,..7.111Y014.. F t. - 4N -s/ . oma.. t7 . LR L. 0: bedrooms, with the followin tip rn on lvA� D m c t ROGRAh/ R o_- Original Certificate Date: 7 -e• -•-i(0 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 Septic System Advisory Well Flow Advisory COSA blue sheet 9-1-12.doc Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: U.S. SURVEY 3044; LOT S&? 51 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 9/24/1993 Sanitary seal (Y/N) YES Total depth 61 ft Cased to 61 ft FROM WELL LOG Date of test 9/24/1993 Parcel ID: 075-061-51 Well Log (Y/N) YES Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 12/22/2015 Static water level 24.6 ft. 26.0 ft Well production 15+ g p.m 4.3 g p m WATER SAMPLE RESULTS: Coliform -a- colonies/100 ml. Arsenic• wD ug./L. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. 0. giVo Nitrate 414 4mg /L.„Collected by: GEG. Ltd. !oVX0015 1/3 Date of sample / 2/2 PUBLIC Date installed Number of Compartments _ Cleanouts (Y/N) Foundation cleanout (YIN)_ Depression over tank MN).___ High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2or ft2/bdr System type Length ft. Width ft Gravel below pipe ft Total depth ft. Eff. absorptio - - - ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor• n field before test _ in. Water added _gal. New depth YES 12+ in a Elapsed T : _ min. Final fluid depth in Absorption rate >= g p d. rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date 4 D. LIFT STATION Date installed "Pump on" level at Datu Size in gallons Manhole/Access (Y/N in. "Pump off' level : High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main N/A N/A 75'+ Sewer /septic service line 25'+ Animal containment areas 50'+ On adjacent lots On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 75'+ Manure/animal excrete storage areas 100'+ 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Water service line Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION F PUBLIC Property line Absorption field Property line Water service lin n drain F. COMMENTS Surface water LOT TO: B'e oundation Water main Surface water Driveway, parking/vehicle storage Wells on adjacent lots G. ENGINEER'S CERTIFICATION 1 certify that t 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. Engineer's Printedj4ame JEFFREY A. GARNESS Date i 1212 !'l (Rev. 11(05) 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 ID # 075-061-51 HAA# L\���� 1. GENERAL INFORMATION Complete legal description Lot 57; U.S. Survey 3044 Location (site address or directions) Mile 1.5 Alyeska Hwy. Girdwood, AK Property owner Steve Shortreed Day phone Mailing address C/0 Jack White Real Estate 3201 "C" Street Lending agency Day phone Mailirig address Agent George McCoy/ Jack White R.E. Day phone 563-5500 Address Unless otherwise requested, HAA will be held for pickup. 3 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XX 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 Holding tank Community on-site Public sewer XX 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 F21 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 . this inspection. Alaska Water &'vtat ; . ter Name of Firmc� .,a�,_ �S Phone Engineer's signature ALASKA WATER & WASTEWATER CONSULTANTS, INC IS TO BE PAID #900— AT CLOSING FOR ENGINEERING SERVICES PERFORMED. . Gat.. : W�4 CE 953 . 6tl 6. DHHS SIGNATURE �044,a........ ., e Approved for %4i RL F bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments �. 7 Date 1 / — [_ - 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 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. 72-025 (Rev. 1/91) Back MOA *21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIC • MENTAL SEev Les o,v Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: Lot 57 I0•SOLfLf Parcel I.D.: 075 - 0G I - 5 1 1VOV U 195A A. WELL DATA x �y Well type 1)21J Nre If A, B, or C, attach ADEC letter. ADEC water system number NJ3/4 91 p u1 Log present (QI/N) `/Es Date completed `l /z`( /`t Y- 3 tl Total depth 6 I 1 Cased to 6, 1 1 Casing height (above ground) 21 .12). P-3 Sanitary seal ON) les Wires properly protected OS) N c ---J FROM WELL LOG AT INSPECTION Date of test a / vibs f o /z9 A S Static water level 2g. 6 Well production /S-1" g.p.m. -5+ g.p.m. 244.8 WATER SAMPLE RESULTS: Coliform 0 Nitrate o.'f€5 m91L Date of sample: fokihz 4- Collected by: A . 4. W • C_ I tJc. Other bacteria B. SEPTIC/HOLDING TANK DATA Date Foundation cleanout (Y/N) Date of 6e, MM QUIT? 4•J SR- Tank size Number of Co Cleanouts (Y/N) ession N C. ABSORPTION FIELD DATA Date "tailed Length Length Effective absorption area Date of adequacy test s (Pass/Fail) For Fluid depth in absorption fiel • : ore test (in.); Immediately after_ gal. wa -r ded (in.): Fluid depth (ins) Minutes later: Absorption rate = g.p.d. P - de treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* Pumper Con^MJN1rY Soil rating (g.p.d./ft2 or ft2/bdrm) High water alarm (Y/N) System type Gravel thickness below pipe Total depth ube pre /N)_ Depression over field (Y/N) bedrooms D. LIFT STATION ate installed Size in gallons Manhole/Access (Y/N) "Pump on" 1= - - "Pump off" level at* High water alarm level at* *Datum Cy d E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot C. o(AmuNITl7 On adjacent lots !oo Covimuri TY Sc�,-IKrz On adjacent lots I oo I-. Absorption field on lot 1 Public sewer main -LS i- Public sewer manhole/cleanout I oo r''" i Sewer /septic service line S Lift station N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: COMr+1uNITY SEwt& Absorption field water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Surface water Curtain . - Wells on adjacent lots F. ENGINEER'S CERTIFICATION Comm (NIT`v Water main/se SEW 612 I certify that l h in conforman Signature Engineer's Name Date n/6/98 eld inspections and review of Municipal most lines in effect on this date. - HAA Fee $ 3 (Jv , c (/ Date of Payment ///G Lb Receipt Number '`-3 Z$ CA Z6 7 72-026 (Rev. 3/96)* arnai;e : 19 �$PS �f ES51oN„+ 3aV+►.e�,J►gs. Waiver Fee $ Date of Payment Receipt Number