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HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 3 LT 21IViountain Park Estates #2 Lot 21 Block 3 #017-022-33 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency ~'~.~ ~ ~./cv-9 ~e,_s~ Day phone Day phone Mailin. g address Agent ' Jrt) ~' ~-~ Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 5. STATEMENT OF iNSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify tl~at 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. NameofFirm l o/~ ~-~u ~.~.~,_~,~'~' '~.[~--- Phone ,~- ~/~' Address ,~E"% L~ /~/] ~o-~... /~,~E~' ./~{ ~ I Engineer's signature ~(_ ~ c ~4 ~.~, {. Dete / DHHS SIGNATURE /-'"'" Approved for 2 Disapproved. Conditional approval for bedrooms. bedrooms, with th'e following stipulations: Note: The well for this property meets existing State and Municipal Cod~s. There are nitrates present. It is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate concentration is 5.09 mg/1. EPA maximum concentration is 10.0 mg/1. More informativ, u..iL~E=~ i~ ~w~ilabl~ f~um Lb= O~-~iL~ 8u~vicu~ P~u~Tam, DHHS. 343-4744. By: 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. Legal Description: k'- Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 JUL 2,7 , O00 MUNK. IPALII y Of ANCHOP, AGE "~"x~"~FNTAL -SF. RV CE~ D'/ HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D.: A. WELL DATA Well type ~ Date completed ~ o -~,q~'~t~ Total depth ,~/~'" ft Cased to FROM WELL LOG If A, B, or C provide PWSID # Sanitary seal ~ I~ ft Date of test lo ~,4-~i~ Static water level /¢ W ft Well production 2--,~ g.p.m WATER SAMPLE RESULTS: ¢ colonies/100 mi Coliform ! Date of sample: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed ~/~/g.-* Tank size Well Log ~ Wires properly protected ~ Casing height (above ground) ,~ in. AT INSPECTION Nitrate ,~'.¢ q mg/I Other bacteria Collected by: Cleanouts ~/ Foundation cleanout '-/ Date of pumping C. ABSORPTION FIELD DATA Date installed 1l/l~12r~'" Soil rating (g~p.d./ft2. or ft2/bdrm) Length ~_ft Width ~ ft Gravel below pipe Total depth I~,~""ft Effective absorption area ;/c°~,5~fF Monitoring tube . Date of adequacy test 7~'/7/o¢) Results (Pass/Fail) Fluid depth in absorption field before test ~ in Water added.~'¢-o Elapsed Time: ,~'~r,~ ~ Final fluid depth ~,._ in Any rejuvenation treatment (past 12 mo.) (Y/N & type) colonies/100 mi I~6~, gal Number of Compartments ~ Depression over tank t'-{ High water alarm . Pumper 1 A ococ~t-~ System type ft Depression over field N For d bedrooms __ gal. New depth ~¢[o~'~ in. Absorption rate ,¢=',~ g.p.d. If yes, give date __ 72-026 (Rev. 01/00)* LIFT STATION Date installed "Pump on" level at __ in Datum E. SEPARATION DISTANCES Size in gallons "Pump off" lev~ in Cycles Manhole/Access High water alarm level at in Meets alarm & circuit requirements F. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1'c, 2~ On adjacent lots Absorption field on lot l,¢ O On adjacent lots /CO+ Public sewer main 1"//A Public sewer manhole/cleanout Sewer/septic service line '~ .~ Holding tank h¢/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Building foundation Water main I"-/ Drainage Property line ¢ ¢ Water service line ,~?. ~' ~' Wells on adjacent lots I l c, Absorption field I 0 Surface water I'"~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I O t- . Building foundation ~o Water main Water Service line' r~ ~: Surface water r,-t I o Curtain drain COMMENTS Wells on adjacent lots I0 ~'2'... G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date, Engineer's Printed Name Date '7/7 / d,6J Driveway, parking/vehicle storage __ O HAA Fee $ Date of Payment Receipt N umber ~.~.~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* CT&E ReL# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 1003860001 Tobben Spurkland P.E. N/A Drinking Water 0 Client PO# Pre-Paid Coils/NO3 Printed Date/Time 07/20/2000 15:01 Collected Date/Time 07/17/2000 12:30 Received Date/Time 07/17/2000 13:i0 Technical Direct? _St~eshen- ~C~d~..~ Released By ~~a~,&c Sample Remarks: Allowable Prep Analysis Parameter Results PQL Units Method Limits Date Date Init Wators Department Nitrate-N 5.09 0.500 mg/L EPA 300.0 10 ma:~ 07/17/00 SCL Microbiology Laboratory Total Colifom~ 0 col/100mL SM18 9222B 07/17/00 KAP READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE CT&E Environmental Services Inc. Laboratory Division ~~,,~,jj~rj~j,~r~r~,,~,~r~,j~r~r.~'~, MUST BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM ID# PRIVATE WATER SYSTEM :~ Send Invoice Send Results ~Valer System Name/Company Name Con~ac[ Name State Zip Code Send Results Send Invoice Contac[ Name ~laiting Address 2ity S(ate Zip Code SAMPLE DATE: ~ -7 Month SAMPLE TYPE: FRoutine Repeat Sample (refer to lab no~. Special Purpose Day Year '- Treated Water ~) Untreated Water Time Collected Collected: by (initial): Location Collected from: MMO-MUG Result: Total Coliform Membrane Filter: Direct Count Verification: LTB BGB Fecal Coliform Confirmation: Final Membrane Filter Results: Reported By: Comments: 200 W. Potter Drive Anchorage, AK 995184605 Tel: (907) 562-2343 Fax: (907).561-5301 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ,~ Satisfactory ,/-~ Unsatisfactory ~ Sample over 30 hours old. Results may be unreliable. ~ Sample too long in transit. Sample should not be over 48 hrs old for analysis to indicate refiable results. Plcese send a new sample via special delivery mail Time Received: ( ~ *~ / O Analysis Began: J ('~ ~ Analytical Method: MMO-MUG Lab Ref No. 10038E 0 ,su,t. Analyst ~ [ · Number of colonie~ll0dml Sent to ADEC: ANC FBK JUN Date: Time: __ Fax Client notified of unsatisfactory results: Date: Time: E. Coil Colonies/100mi COLIFORM TNTC = TOO Numero[~$ to Coullt OB = Other Bacteria C~ Coliformll00ml Date:'~//c~ ~"~.- Time: <:~\ ~,~ Sr~S Member of the SGS Group (Soci~t~ G~n~rale de Surveillance} 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 IPHONE [~EW LEGAL DESCRIPTION Absorption area ~elling i PERMIT NO. ~ Z ~8nufecturer ~aterJ~ - r' capacity ip, gallons Inside length Width Liquid depth ~ / IF HOME.DE: ~ ~ DISTANCE TO: ~ell Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons ~ ~ , at in ~ ~ DISTANCE TO: gPO0:Q~ · ~vs~ N~res)l~ine PERMIT NO. ~' ~, ~ No. of lines / LengV~,ine Total lengths T~h~th inches Distanc~t~n lines ~; ~ ~ Top of tile to finish grade--~ Material beneath~ ~ tile inches Total effective/~()absor~tion~.area Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHEB SOILTEST RATING / INSTALLER ~ REMARKS P ~,~.' ~, .,. ~, APPROVED ~ DATE LEGAL , 72-013 (Rev. 3/78) DEF'~..n~'~ 1 ~'~!:=I,~ ~ OF= HEALTH AND EIqV.T. F',ONi iJ=l J I AL F:'ROTECT I ON F:'ERH i'T' NO: DA 1]E~ ISSLED: 11. :t..z.,; 8,: AF:'F:'L I C3AN'I' ~ ~.,,~ ~.).L) R Iz. 'd ¢::~: MOSE PIENDERGRASS P.O. BOX 11()804 ANCHORAGE, AK 99511 345-- 1888 I_IEGAL.,..q::rc'F'~:'II::'...,.x.,,n : SUEDIV]'SIOh. I: MDLIIxI'T'AIN F'K EST ~1:2 SECTIC]N: ~Z6 TOWNSHIF': :L2N L. OT S]:ZE: ?.()1:30 (SQ~F'T. OR ACRES) MAX BEDROOI"iS: 4 LOT: '~ RANGE: 3W BI...OCt<: 3 4.. ()*l.~ 4-., 0 4.. 0 8.0 ~ 0., 5 :.;..'; ,, 5 1.'2.. 0~-~ 4.. 5 7.5 2.5 ~-~ 27.0 5.0 64.0~ 52.0 iI:L.O ** 50, 4 5~ ,, 0 82 ,, 3 2.50,,0 ~* 1.,2.50~0 -~* 1~250,,0 *~ ~756 232 256 'K-'~f .'~KAVEL LEI"JGTH > 75 F:T', REQUIRES MUL. TIF'L.E RUNS (NC)T EX.,E,..:.I)INI.: 75 FT,, EACH) ~..x. TANK H,..tc~l t'~..~vl:. A'F I_EAST TNO CDMPAF?TMENTS certif'y t. ha'L: 1. I am familiar w:L'L!'~, ti-la, requirements for' on-sit, e !sewers and wells as set f/:)Pt.h by the Mur'lic::i. pality of' Ar'mhorage (MOA) and the Stat. e of A].asJ.::a. ~2,, I wi ]. ]. :i. nst. al I 'bhe !~iys'?..eiii ir'i ac:cor'dar'ic:e with al ]. MOA ar'ici in Ec)Mj]].ian(::e) ~t~:l.t.h 'khe:, des:Lgn cr:i.t, eria of thia~ permit.. 3,, ! will acJhepe t.o all M[]A and Stat. e of Alaska r'equiremen'Ls fop t. he set. back d:i. star'~c:es from any exzsting waiL, wastewat, e:,r disposal syst.~,m or' public sc?war'age system on t.J']].s or any 'actjac:errL of' r'~earby t, Ltl"id~)i'[Bi'.ai'ICJ 'Lha-L 'Lhis permit zs va].:ld for' a maxzmum of 4 bedr'c)oms and (ar'iI ~'al"l].~apgf)z, lJte~vl"Y[] wi]L], p~eCL.~].P(:~' ~TtB acldit, zor'hB.]. IF A L]:F:'T o P,I .,.Jl~ IIqSTAI....I_ED IN AN Ar;Iz.~-.~ C(.]vE:.F'~E..) ~' MOA BLJIt_DING CODES, ]HEN (:1.~ AN ELECTRIC;AL.. F EK~Ii AND INSF'ECTION MUST BE OBTAINED~ (2) AD-BUIL. TS W].f ........ NCYl" be. ~F F-I-d.-VE..~ NI]"HOLIT AN E_,:.C ~l..,-.L iI~SF'ECTION REPORT~ AND (3) THE t:::. L ,:z L, [ K 1 =u...~_ NOIM'-.. I~~IX.INE B Y l...t L. ~ CENoED =L..I::.L, t ,"~ I [., ~ AN Ar::','::'L ~ C,..~.l .,T ~ t"I~~RASS .~. ,:~ o L.~ c.,.~ ..:, ~ D A T E: DEF:'TH TO F::'IF'E BO"I'.T'C)M (F:'I-.) · GRAVEl.... i}EPTH (F'T.) T'OTAL DIEF'TH (F'T.) ' GRAVEL, WIDTH (FT',,) GRAVEL.. L. ENGT!'~ (F:rT. GI:?AVEL V[]L,UIME (CLJ. YDS. ) TANK SIZE (GAL. S) SOIL. RA]"ING (SQ.F'T. /BR) _~d I:)e:l. ow ar'E, t. he opt. ions avai lab].e 'Lo you in design lng your !sept ic sys'[,i~}iii. Choc:)~;(,:~, 'Lhe option that best fits yC)L.U" sit. e. 3 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6,650, Anchorage, Alaska 99602 276-2221' SOILS LOG - PERCOLATION TEST ~ORMED FOR:~ DESCRIPTION: FI SOILS LO~ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20 PERCOI.~AlloN: TEST DATE PERFORMED: 4/~' Y SLOPE SITE PLAN WAS GROUND WATER ENCOUN-rERED? Gross Net Depth to Net :)ate -rime Time Water Drop _.z~ c c 'z '1 ~-4 l: c .9/A" IF YES, AT WHAT DEPTH? Reading ~- ~' (minutes/inch) PERCOLATION RATE TEST RUN BETWEEN ~' C~ FT AND COMMENTS i.~.~ . ~. ~, -- uniciP ]tYof Anchorage P. O/'~'!")X 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES March 26, 1987 Mose Pendergrass PO Box 110804 Anchorage, Alaska 99511 Subject: Lot 21 Block 3 Mountain Park Estates Subdivision #2 On-site Well Permit #860077 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of March 25, 1987. Your permit expired on the date of issue basis by authority of Municipal Ordinance existing at that time. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. The new permit will come under the calendar expiration date as per the new Wastewater Ordinance (effective May 20, 1986). If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report (three part form) must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 343-4744. Sincerely, R.W. Robinson Program Manager On-site Services RWR/ljw #7 enc: copy of permit DEPARTMENT "-'"' HEAL'I"H AND ENVI RONME:NTAL~'~8'I"EK]'YION 825 L. STREET, ANCHORAGE, At< 99~C) 1 1.,.~/' 264-'4720 PtERM, t T NO: DATE .~. ~.~::~ ..,c i.: E. 6 ,:') ,:") '7 '7 APPLICANT: ADDRESS 2 CONT'AE T' F:'HONE: M[]SE:' PENDERGRASS I:::'~ 8,, BOX I:L0804 ANCHORAGE, Al< 99511 345-, 1888 L. IEGAL DE8CRIP: L 0 T E; l Z E: SLJBDIVtSISN: MT. F'ARI< ESTATES SEC ! l[].~.: !6 T'OWNSHIP: 1~,~.1 2':} 13,:]) (SQ,. F'T. QR ACRES) LOT: 21 BLOCI<~ .3 RANGE: .3W I certify thai'..: I am familiar' with the r'equipement, s for' on-site sewer, s arid wells as set ¢or't.h by the Municipality ef Anchor. age (MOA) and the Stat. e of Alaska. 2. I will install the system in acco~'dance with all MOA codes and r'egulations, and in cc)topi(ante with the design c:piter'ia of th:Ls permit. 3. ! will adher'e t.o all MBA and State of Alaska pequiPements fop t. he set. back d:Lstances fr'om any exist, ing well, was'Lewate~ disposal system or' public sewer'age system c~n this op any adjac:ent on neanby lot. SIGNED DATE: APPI...!CANT': MOSLE F'IEIxlDERGRASS I,.SSUIED BY /'~- ' : ? DATE~ ~ ..... PAGE 1 OF 1 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:SW930398 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:PENDERGRASS MOSE W OWNER ADDRESS:P. O. BOX 110804 ANCHORAGE, ALASKA 99511 PARCEL ID:01702233 LEGAL DESCRIPTION: MOUNTAIN PARK ESTATES #2 BLK 3 LT 21 LOT SIZE: 19800 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 9/28/93 EXPIRATION DATE: 9/28/94 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 DfSPOSAL 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 PROVISIO,N~:^ ~ DATE DATE CD-': ©: .~: ~:  © © © 0 © © 0 © © © 0