HomeMy WebLinkAboutHYLEN CREST #3 BLK 6 LT 13Hyl
Block 6
Lot 13
¢¢050-474 39
~ 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
'~AME-- PHONE
~AILI~ ADD,E88
LEGAL DESCRIPTION
_
ell ABsomdon area~ D~alling PER~IT
Liq, capacity in gallons Inside length Widtl3 Liquid depth
I~0 IF HOMEMADE:
.~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~ Manufacturer ~'~' Material Liquid capacity in gallons
~ WeI~/ Foundation. Nearest lot line PERMIT~
~ DISTANCE TO: ~. ~- ~ ~ ~ -
~ul ~ ~o. of lin~ ken,th o~ch line Total Io~ ~[ lines ~ ~idth Oistanco~twean lines
k' ~ ~ Top of tile t I~
~ ~h~rade Material beneath tile Total effective abs~ption a~e
Length Width Depth PERMIT NO.
~ ~ Type of crib Orib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~4 Class ~ ~ L~]~DepZt~ ~ Driller~ Distance to lot line PERMIT NO,
~ DISTANCE TO: Building~oundation Sewer*l~ne Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
72-013 (Rev. 3/78)
I:::'I~;RM I 't" hlO:
D A T E 1 ,.~.~UE.D.
AI:::'F1... I C;ANT:
A D D I::;: E S S ~
C:ON"I'ACFI' F:'I-IOI,,IE:
WAI...KER COIqTRAC;]' IIqG
F:'. 0. B[IX 7'?'J. 9~.."'.4
EAGL.E RIVER, hi< 99~¥7
694."'4858
L.EGAL.
I...OT S I ZE ,~
MAX BIiE.t)IROOMS~
SIJBD I V I S I ON'.' I-IYLEN C:R!S!3T
SECT I ON: 8 I"ONNSI4:[ P: :[4N
. ','SA (SQ ,, I:::"T'. C)R AC:RES)
3
I...EI'T' '.' :[ 3
RANG[ii:: ;I,W
BLOC:I< ~ 6
L, :i, !!st~d J::)~:].c)w i:~.l"(~<~ 'LH¢:.:? C)l::)'k:i. cJris a'vai],al::,le 'l:.c:) yc:~L,t :i.r'i des:i, gn:i.l']g ¥OL,U" se.p'L :i, c:
syr, r>'l',,em, Chc)ose 'Lhe opt:i.c)rl tl"~at best F:i.t,~ your' site.
.IEL, g:::..
DEP]"H TC) F:'II:U:'i: BC)'I""I"C]M (F"['.) ~.0 .x..x-
GRAVI:SI... DEI:::'TH (F:'T..) 0 ,, 5
"I"OT'~L DEF:'TH (F'I".) ~'~',, 5
C~RAVEI... I/JIDTH (FT.) J.<~, ()
C)I'd.~VI'~:L.I.,..I~]qGTH (FT.) :]';6; ()
GRAVEl... VOI...UMli!: (CU. YDS, ) :..'?.5.4
'TANI<: S I ZE (GALS) 1,00(),, () .,-.~.
SOIL. RATIIqEi (SD.FT',, /BI:;~) 150
.x..x- DEF:'TH "l"[] PIPE }30T"f'OM < 3,,5 F"T'. REQLJIRE:'S :[NSLJI...ATIOIq
· ~+.x. DEF::'"I"I...I 'TO F:' ]: PE BDTTCIIH < 4, 0 I:::T. MAY I::;:E(:;ILJ I RE ~ L.. I I::"T' STAT I lIN
.x-x-"['~lxll.::: MLJST HAVE AT LEAST "['NC:) C:OMF'AF:CI'MENTS
I cer"Lif'y 'Lhat:
:1,,, I am I'am:i. liaP ~v:[-LI] the r'ecluiPements FoP on-site sewer's anti wells as set
fo'p'l:.h by the Mun:[cipa',l.:i.'Ly oF Anchcmage (MDA) and the State ~:~' Alaska.
,?.,, I w:i.:l. 1 ins'Lall 'l:.he system ~.r'l ac:ccmdar'lce w:i.'Lh all MOA codes and Pc.)gu:Lat:i. ons,
a n,d i r'~ <::: omi:) ]. i an c: e w i t h 'L h ecl e s :i. g I] C r' :i, t E? P :[ a 0 f' t In i S p e P m :i. t ,,
...... ]: will adher'e 'Lo all MOA and State c)f Alaska l'"(.D[JLliPE,)m[+)r'l'~!~; {'(;)1r' 'Lh(':r~ Se'L bacl.::
distances fPom al'ly e:,>(J.s'l:.ing well, ~?Le~a'l:.ep dJ. sl:~C:lsa], sys'l:.(.~)m of publ:Lc
4,, :1: under'stand tl]a'[.' this peP~lJt :is valJ. d ~'o1" a m~:~ximum c:~' 3 bedr'ooms and
IF:' A L. II::'T S'I'A'I"ION IS INSTAI...LE:.D II'q AN ARIi.::A COVERED BY MOA BUILDIIqG []ODES,
TFI[~:N (1) AN ELE[:TRICAL. F:'ERMIT AND INSF:'E[:'T'II]Iq MUS]' BE OBTAIIqED; (~) AS-BL.III_."I'S
W]:LL.. NO]" BIS AF'F'ROVED WITHOLJT AN ELISDTRICAL :I:NSF'EC]"ION REPOF(T; AND (:3) 'T'HI~[:
ELEC"I'I::~I[:AL~ WORI< MLJST BE DONE BY A L. ICENSED IELECTF?IC:[AN.
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
lO
11
12
13-
14-
15
16
17
18
lg
2O
1,3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND I=NVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99,501 264-4720
SOILS LOG - PERCOLATION TEST
COMMENTS
SOILS LOG
[] PERCOLATION
TEST
SLOPE SITE PLAN
--I-
WAS GROUND WATER
ENCOUNTERED? , ~' O
P
IF YES, AT WHAT
__ / E
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN FT AND FT
(minutes/inch)
DATE:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchora0e, Alaska 99501 264-4720 ~,O~r'~-_,,
SOILS LOG - PERCOLATION TEST
[] SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
I0
11
12
13
14
15-
16-
17
18
19-
20-
COMMENTS
PERFORMED BY:
72-008 (6/79)
SLOPE
SITE PLAN
WAS GROUND WATER , r~,-~ S
ENCOUNTERED? I¥~' L
O
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND FT
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A 'SINGLE FAMILY DWELLING
Parcel I.D. 050-474-59
1. GENERAL INFORMATION
COSA# O SO Illl
Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
HYLEN CREST #5; BLOCK 6, LOT 15
10351 STEWART DRIVE *EAGLE RIVER, AK 99577
THOMAS & CATHLEEN ROSS Day phone
10551 STEWART DRIVE *EAGLE RIVER~ AK 99577
622-7417
Day phone
CRAIG BENNET W// KELLER WILLIAMS DaY phone 865-6500
101 W. BENSON BLVD. SUITE 505 *ANCHORGAE~ AK 99505
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 5
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well [] Individual On-site []
Individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System [] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATE,~{ENT OF INSPECT!ON BY ENGINEER
As certified by my sea/affixed hereto and as of the validation date shown below, ! verify that my
investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this appiication,
shows that t,Se on-site water supply and/or was~,ewater disposal &~tem is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I fu~her verify that based on the
information obtained fi'om the Municipality of Anchorage files and from m,y invest/gat/on and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Munic(Dal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 557-6179
Address 5701 Eo TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MQA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever'.
5. DSD SIGNATURE
///'" Approved for '~
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 11/05)
Arsen.c Adv,so~ '"', .~'0,~ 5,~x
Maintenance Agreements
Supplemental Engineer's Repo~
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: HYLEN CREST #5; BLOCK 6, LOT 15 Parcel ID: 050-474-59
A. WELL DAT,~,Ia ~,' PUBLIC WATER
Well type ~ If A, B, or C provide PWSlD# ,34-3.7-89- Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected
Total depth ft. Cased to .ft. Casing he~ in.
FROM WELL LOG AT IN,~SPECTION
Date of test
Static water level .ft.~ ft.
Well production Jg.p.m. g.p.m.
WATER SAMPLE R~8~~~'~.
Coliform ,.---~olonies/100 mi. Nitrate rog.IL. Collected by:
~ ug./L. Date of sample:
B, SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tanksize 1000 gal. Number of Compartments 2
Found~-tion cleanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping 4/'21/'11 Pumper.
Date installed 9/'1,3/85
Cleanouts (Y/N) YES
High water alarm (Y/N) N/'A
JRS PUMPING
I'BELOW EXISTING GRADEI
Soil rating (g.p.d./ft2o~ 150
Width 19 ft.
ABSORPTION FIELD DATA
Date installed' ~ :' 9/,1,3/85
Length 38 ft.
Total depth *6.0 ft. Eft. absorption area 722 ft2 Monitoring tube YES
Date of adequacy test 4/'26/'1 1 Results (Pass/Fail) PASS
Fluid depth in absorption field before test DRY in. Water added 460 gal.
Elapsed Time: 0 min. Final fluid depth DRY in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) KNOWN
System type BED
Gravel below pipe 2.1 6 .ft.
Depression over field NO
For 3 bedrooms
New depth DRY in.
450+ g.p.d.
If yes, give date -
Absorption rate >=
NONE
D. LIFT STATION
Date installed
"Pump on" level at
Size in gallons Manhole/Access~ ~
in. "Pump off" level__at--------fn?~-. 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
COMMUNITY WATER
On adjacent lots
On adjacent lots
~nout
~'""-"-"~ Holding tank
Absorption field on lot
Public sewer main
Sewer/septic service line
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water service line. 10'+
Wells on adjacent lots 100'+
Absorption field 5'+
Surface water. 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line * 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
Water main N/A
Driveway, parking/vehicle storage 10'+
F. COMMENTS
*ASSUMED. SEE AFl'ACHED DRAWING.
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 COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date ~"/~///
'(1~% '11 "CEr 7955 .."
"....~-' ,.. .." .,¢,4?
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
,!
~llL dy: IlL/'lvi~;~ ()~ LALfit.: h~VL~ iNC.;
HOUSE
17.4
Z
Municipality of Anchorage ..
Development Services Department
Building Safety Division <-~.
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPRO~/AL
FOR A SINGLE FAMILY DWELLING
ParcelI.D. ~.~'O - qT~ -.~
1, GENERAL INFORMATION '.
Complete legal,'description
Expiration Date:
Lre_~.-/' --,-~..7, , L,4+ 13 . Block, 6,
Location (site address or directions) I
Curr;~t Prop~y own'eris)-
Mailing address I0-~.~1
Lending ag~n~ '.'.. Day phone
Mailing address
Real Estate Agent
Mailing Address
166 (e,der~e. ltl
~, / l~ e m~t x'Day phone'
Or.; aT[:. ;ZOt. ~q.?l~
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDR~3OMS: 3
TYPE OF WATER SUPPLY:
I~dividual Well
Individual Water Storage
Community Class ,.Z~ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~.
Individual Holding tank ~
Community On-site
Public Sewer 'D
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system, DSD also issues HAAs upon request to homeowners, Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system, The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4, 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 Health Authority 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 fype 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 ail applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Eagle River Engineering Services
Name of Firm ..... ,,,-,,, ,.,_,
Address Eagle River, AK 99577
Engineer's Printed Name
5. DSD SIGNATURE
~f Approved for .~ bedrooms.
Disapproved·
Conditional approval for
Date ~//$/~ p"'
bedrooms, with the following stipulations:
Additional Comments
· Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
(Rev 01,~2)
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: (~ '''''~'- ~- 0 ,~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST '
Legal Description:
A. WELL DATA
Well type
Date completed
Total depth, ft.
Date of test
Static water level
IfA, B, or C provide PWSID # __
Sanitary seal (Y/N) Wires properly~N)
Cased to ft. ge~ip~'(above ground)
FROM WELL LOG PECTION
Well production . . . : g.p.m.
WATER SAM~
Co~"" coloniesll00 mi. Nitrate mg./L Other bacteria __
,,,,Arsenic: mg./L Dale of sample: Collected by:
~ ParcellD: OS'D-
Well Log (Y/N) ~ '
in.
coloniesll00 mi.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ,J~'~,~ J/",,'/" /,,~:' /
Tank size (~D~'gal. Number of Compartments
Foundation cleanout ~IN) .~ Depression over tank (Y~
Date installed ,~/I
Cleanouts ~N) y~-- .~'
High water alarm (Y~ ~'/...~
C. ABSORPTION FIELD DATA
Date installed ~//_~/,~3"'" Soil rating (g.p.d.lft= or ft=/bdrm) 15"D System type
Length ~ ~' ft. Width ~' ~ ft. Gravel below pipe ~- ~ ~ ft.
Total depth ~, ft. Elf. absorption area 7.~:2 ft= Monitoring tube ~/z"~ Depression over field
I '
Date of adequacy test For bedrooms
Fluid depth in absorption field before test {~ in. Water added__.,~L~2gal. New depth O in.
Elapsed Time: ~) min. Final fluid depth O in. Absorption rate >= ~"<~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y~)& type) ~OY~. ~ 14 ~1.~2F1 If yes, give date ~.,~/,,~
~te ar tarm level at ~' in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift station on lot
Absorption field on lot
Public sewer main
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation -t 5 - Property line '~' 5 - Absorption field
Water main 'f' [ O - Water service line 'P J ~;) - Surface water
Wells on adjacent lots 'P I ~)/P '
*5'-
7-
Property line +'
Water Service line
Curtain drain +'5"~
COMMENTS
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 'P/Q - Water main '/' I ~ -
Surface water ~ / ~)~) - Driveway. parking/vehicle storage
Wells on adjacent Iols 4- I ~)~-) ~
G. ENGINEER'S CERTIFICATION
rev~w of Municipal ~cords that the a~ve systems are in
Engineer'sPrint. Name C~ r, 5+~/~
HAA Fee $.
Dale of Payment
Receipt Number
(Rev. 12J01)
Waiver Fee $
Date of Payment
Receipi Number
ASBUILT-NO CORNERS SET THIS DATE.
I HEREBY CERTIFY .THAT I HAVE SURVEYI~D THE I SCN. E, .
FOLLOWING DESCRIBED PROPERTY: ~ "'"~'.
AND THAT NO ENCROACHMENTS EXIS¥ EXCEPT AS ~//~//~".~-
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA ~E:RCON BE USED FOR CONSTRUCTION
D~ FENCE LINES, OR I=T:)T% ~-~"TAE~L%ST%~NB I~OUND-
ARY LINES.
FB:
..~/-/,~'
DRAWN~
Municipality of And orage
Development Services Department
Budding Safety DMslon
On-Site Water and Wastew~ter program
4700 South Bragaw 6L
P.O. Eox lCJ6650 Anchorage. A~ .~9519-6650
www.cl.anchorage.e~.us
(gO7) 343-7S04
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel
1. GENERAL INFORMA. 'rioN
.'..Con~ptetelegaldes~ption !,ut 13, Block 6~ Hvlen Crest Addition #3
............ · · 10351. Stewart Drive
· .:Local;on (site address or d~recticns) _
· . - Current Propert,j~vner(s)_ Fannie tiao Repo Day phone
"::. Matiing addres~
Lending agency
Mailing address
. 'ReaIEstateAge~t
Expiration Date:_ ~ - t c). O .~.
Day phone
. Dayphone_ 261-760~
A~cborel~e, AK 99503
Dynamic/Bob Brock
"~a,,'lin~ddress" _3Itl 'C' Street, 'Ste 100,
2. NUMBER ~F BEDROOMS: 3 ;
TYPE OF WASTEWATER DISPOSAL:
IndMdual On-line
Individual Holding tank
Community On-site
Public Sewer
3.' TYPE OF.WATER SUPPLY:
Individual Welt
fndivtd~al Wate~ Storage
· Community Class_ , Well
.... Public Water System
Health Authority
-.The Mumctpality of Anchorage Development Se~ccs Department 035D) Issues Co,fica!es et'
e resenta~lons given in paragraph 5 by an independent pro~esslona!
royal HAA) based only upon.~.e r~ p ..... r~ royal are required for the
App. ( . . Ce~llr.~tu=, ef Health Au~o t,/App
eng~eer'reg~stered In the State Ut
-ti'Jo (except between spouses) for properties served by a single fan"uly on-site wastewater disposal and/or water
supply system. DSD also Issues HAAs upon request to homeowners. Ce~f;cates ef Hca!th Authority Approval are
valid for 90 days from the date of Issue for properties sewed by a private? Class C well.end may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a penocl of up Io one year with
valid wa!er'samples.) CaStrates ore valid for eno year fo~ properties sewed by Class A or B wells er a public
water system. The Municipality of Anchorage is ~ot ~espensIble for enors er omlssloas In ~e professional
englneer's wor~.
4, STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto End es of the valldation date shown below, I verify that my' Investigation,
based on procedures outlined In the Health Authorib/Approval Ouidefines for this application, shows lhat the
on-site water supply and/or wastevrater disposal system Is(are) ssi'e, 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
Munlclpallb/of Anchorage Iile$ and from my Investigation end Inspection, the on-silo water supply' and/or
wastewater disposal system Is(are) In compliance v..t~ all epp~cable IvlunElpal and State codes, ordinances,
and regulations In effect at the lime of Insta,qalion.
Name of F'~Tn
Address
Engineer's Printed Name Robert C. Coven. P.
Phone,
....%%
.., 81TE ·
W, *
5. DSD SIGNATURE 1~ .,~'.:... ~ROGrb, A~;( .:, ff ~f~.~/.~',4 CE-Sr, o1
-,llll.)l.t ·
Conditional approval for bedrooms, wlth the [ollowlng stipulations:
Additional Oornments
Attachments: .,
· HAA CherJdlst
· Septic SyStem Advisory '
· Well Fl~w Advlsory
MaTntenance Agreeme'nLs
Supplemental Engineer's Report '
Other
na cat ate:~ -
Municipality of Anchorage
Development Services Department
(m?) 343-7e04
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WEU. DATA
If A, B. or C pa:~de F%'V~ # Weft Log (Y/N)
D~ com~eted
Total eemh
Date ~ te~t
StaUc wmm leve~
.ft. 'FROMW~LL LOG ,. ~,~:~-C;TION
D. UlrT ~TAT~ON
D~e I~sta~ed .~~,//~e In'~,~s
Datum~ Cyde~ te~ad_
Mar, h~e~Acc~s (Ynq)
in. I~ w~c.- a~arrn I~vel at In.
E. SEPARATION D~ANCES
SEPARATION DISTANCES FRO~ WELL OH LOT TO: 'J,/~/'~.J C.
Public sewer rn~n
SEPARATION DISTANCES FROM SEPTtC~OLDINO TANK ON LOT TO:
Bu~ing founda~o~ ~' ~' properlyline ~"'. ~'' A~tkm flekJ
w.,~-m~ **','/*~/~/, w.,,~,,,,,,~ /,~ ~- ,~,-,~
SEPARATION i~STANCE FROM ABSORPTION FIELD ON LOTTO:
F. COMMENT6
HAA Fee S
Dele of Payment
Receipt Number
(Rev. 12/00)
oo1.I/0
W~ver Fee $
Imm of P~xme~t
Rece~ Number
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
050-4?4-39 HAA # 'L\~:_,~ ~r'~,C~ ~ '' '
· L ,C',~\::-)
1. GENERAL INFORMATION
Complete legal description
Lot 13; Block 6; Hylgn Crest ~3
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
10351 Stewart Drive
Eagle Ricer, AK
Gil Wolfe/Laurie Cappellino Day phone
8326 Black Castle San Antonio, TX 78250
Pacific Alaska Mortgage Day phone
Attn: Kevin Breeland
258-7534
Agent Bonnie Hochstein/ PrudePtia]. VJ, Sta
Address
Day phone 273-7256
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ,
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
XXX
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.
XXX
72-025 (Rev. 1/91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER
As certified by r-ny 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 $ & S ENGINEERING
17034 Eagle River Loop Road No. 204
Address Eaqle R ye.r, Alask~_~99577~
Engineer's signature ?'~/~/////. // /~'~---'~
Phone
Date -~//o/~'? ¢'
DHHS SIGNATURE
\// Approved for ~¢-~¢
Disapm "3ved.
Cone qal approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
~WhqONMENTAL SERVICEs DIVI$1L..
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES ¢-)
Environmental ServiceS Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
A. WELL DATA -~
Well type Po If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed
Total depth ~sed to
Sanitary seal (Y/N) '"%
FROM WELL
Date of test '"'
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed fi"lS"~5_Tanksize
Foundation cleanout ~;N)
Date of Pumping -7-'
C. ABSORPTION FIELD DATA
Date installed Oj. [.~5
Length :.~ I_~¢~'~ (~"3'~~ Width
Number of Compartments
Depression (Y(~ ¢O High water alarm (Y~ h) l/~
Pumper ~,~2- ,/~,~,rtl/~!//(.;/
g.p.m.
bedrooms
~, Cleanouts (~N) ~..~%_
Soil rating (g.p.d./ff~ or~ I JdO System type_
~q' Gravel thickness below pipe ~" _Total depth
Effective absorption area ~-~?..,~L ¢r'L' Monitoring Tube present~N) Lff?¢ Depression Over field (Y~)
Date of adequacy test ~1"'1 h~ Results ~..jCail) /~ .5~f For
Fluid depth in absorption field before test (in,); '~"/I Immediately after :~'1~ gal, water added (in.):
Fluid depth nj//} (ins) Minutes later: '"/t/4 Absorption rate = /'-/¢'-0 '+ g.p.d.
Peroxide treatment (past 12 rnonths) (Y/N) 1~51'.,l~-~ I(l~/J~ If yes, give date
72-026 (Rev, 3/96)*
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump off" level at*
Cycles tested ~.~.~.
E. S E'-PA'R~E S
SEPARATION DISTAN~ES'-FR~M WELL ON LOT TO:
Septic/holding tank on lot '"'"~_.._ On adjacent lots
Absorption field on lot ~ent lots
Public sewer main Public sewer"~'man~out
Sewer/septic service line Lift station '"--~.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
I~r
Foundation ~ Property line ¢
Absorption field
Water main/service line ~0 Surface water/drainage
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water 0(2 Driveway, parking/vehicle storage area O
Curtain drain
Wells on adjacent lots
ENGINEER'S CERTIFICATION~~ '
I cedify that l have determined thru field inspections and review of Municipa~~l't~,~,systems are
in conformance with MOA ~AA guideline~ in effect on this date. ~ ~ ./ ~,,~
S, nature Y~ ~ ~ ............... · -
.... _
Waiver Fee $
Date of Payment
Receipt Number
HAA Fee $ ,~ ~)
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
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. #
1.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
050-474-39
GENERAL INFORMATION
Complete legal description
Hylen Crest #3 Lot 13, Block 6
Location (site address or directions)
10351 Stewart Drive, Eagle River
Property owner
Mailing address
John B. Grohol
Day phone
10351 Stewart Drive, Eagle River, AK 99577
694-9267
Lending agency N/A Day phone
Mailing address
Agent Virginia Kohlfield/Re/Ma~. of Eagle R~)%eyrphone
Address 16600 Centerfield Drive, Eagle River' ~AK 99577
694-4200
Unless Otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
72-026 (Rev, 1/91) Front MOA #21
NOTE: If community well system, provide written confirmation from State ADEC ~ttest-
lng to the legality and status of system. ~',, ,~ ,,
· - ,'¢ '"'~:': ') Igl'l "'
T PE oF WASTEWATER D,S.OSAL:
Individual on-site x ~ ? ':? ~ .-.],,: ,~ ..~
. ' community on-site . ,.,, ,,~
'NOTE: If Community Wastewater system; provide Writtenconfirmation' from'"'"'State~'~'~ADEG
attesting to the legaflty and Status of S~tem. " ......
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 inves!i_gation 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.
694-5195
99577
Phone
Name of Firm Eagle River Engineering Services
Address P.O. Box 773294, Ea.gle River, AK
EngineeCs signature
DHHS SIGNATURE
/k~ Approved for ~ bedrooms'.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
J ~ ,', % .- ~'
',, , .~ ', ¢;> ~
~ '~$~e M~n~i~a[i~ of ~6~hQm~e Depa~ment of ~eal~h a~d ~u~an Se~[ces (DH~S) issues ~ea[th
'. ~pp~oval C~mf,cmes based only upo~ the representat,ons ~tven tn paragraph S a~ove ~ an ,ndependen
pFof?sSional engioeer (egistered in the State of Alaska. The DHHS does thru as a cou Aesy to purchasem of homes
and the~¢lend~ng institut~ons ~n order to sat~s~ ceAa~n federal and state requirements, Employees of DHHS do not
con~t'inspeCti~ns or analyze data before a cedificate is issued, The Municipali~ of Anchorage ~s not
responsible for errom or omissions in the professional engineeCs work, . :
72~(R~.1~1) ~ck MOA~I
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-/ Y/.. E'/V (~o~.ST' ~¢.~ Parcel I.D.
LoT I~ , /Z,' c~: 6¢
A. Well Data
Well type ,,PP, fSL/~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller ,//
Total depth Cased to Oasing~ght
Sanitary seal (Y/N) Wires properly protected~N)
FROM WELL LOG AT IN~SPECTION
Date of test
Static water level
Well flow g .g.p.m.
Pump levell
SEPARATION DISTANCES FROM WELL :
Septic/holding tank on Ici ; On adjacent lots
Absorption field on lot ,,/'
Public sewer main
Sewer service line
WATER SAreE RESULTS:
D~e of sample:
; On adjacent tots
Public sewer manhole/cleanout
Petroleum tank
Nitrate Other bacteria
B. SEPTIC/H~EDING TANK DATA
Date installed
Cleanouts (Y/N)
Collected by:
High water alarm (Y/N)
Date of pumping
Tank size /OOD Compartments
Foundation cleanout (Y/N) y~:~ Depression (Y/N)
,Z//,~ Alarm tested (Y/N) /V//~
//./~ ~/~'-/ Pumper ,,.~)2./S
SEPARATION DISTANCES FROM SEPTIC/~ TANK TO:
Well(s) on lot ,A//,/'q On adjacent lots
To property line ~ ~// Absorption field
Surface water/drainage
Foundation
/r¢~,,,4)Water mare/service line
72-026 (3/93)* Front CONTIN U E D ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Manufacturer
Manhole/Access (y/~)/
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N) ~
SEPARATION DIST~STATION TO:
We I on Jet/ On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length ,-~._~ /
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
"Pump on" level at ..--~"'%"Pump off" Level at
.-.~es tested
Surface water
/CD
Bedrooms
Width
p/zy'
Soil rating (GPD/FF) /~D¢¢./~..'~,'~ System type
/ c) / Gravel thickness ~-~-¢~ '/ Total depth ~,¢'"
Cleanout present (Y/N) _ YE ~, Depression over field (Y/N)
Results (pass/fail) /D/¢~% for
After test /~
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /',//~ On adjacent lots
To building foundation /~ /
On adjacent lots ¢3,~;
Surface water /V'//¢
Curtain drain /~//~
/' 7.-E)L2 / Property line
To existing or abandoned system on lot
Cutbank ,¢,/,4 Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in_effeqt'°n'(h.e.,,,, ...: ,...d,.,ate., of this inspection.
Signature ....--~_~:-~--~z.~Z~)
Engineer's Name J~cU/5 _~u'/-E/~/¢ ~. ~ ~ ,
Date //-- ¢ ~ '- ~ V
HAA Fee $ ,.._~0/_..), 0 0
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93) Back
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)
i (b) Applicants
~ Applicants Address
(c) ApplicatOr ~s (checl~gne) Lending Institution
uyer ]; Othe= i]<e×plain);
! ~ (d) Lending Institution
i (e) Real Estate Coo & Agent
~ Addres~
Telephone ~ Nome
Business
~ ; Owner/bnilder~ ;
Teleh~.~=~ne .....
(f)
Telephone
Mail the HAA to the follo~ring address:
T~L?~ of Residence
Single-Family~
Number of Bedrooms
Multi-Family.'
Other (describe)
Note: If community well system~ must have written confirmation from the State
Department of Environmental Conservation attesting to {:he legality and status.
4. Sew~
Onsite ~ Public ._~_~] Community ~-~ Holding Tank ~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status°
[Page 1 of 2]
E~i__neerin~ Firm Prov:[din~Ins~ctions~ Tests~._.File Sear_c_h3 Data and Information
As certified by my seal affixed hereto and as of the validation date showa below~
verify that my investigation of this Heslth Authority Approval shows ~h'a~ the
water supply amd/or wastewater disposal syst. em is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein.. I further verify ~hat,
based on the information obtained from the Municipality of Anchorage files and from my
imvestigatiom and inspec~iom, the em-site water supply end/or wastewa~er disposal
system is in compliance with all Municipal and State codes, ordinamces, and regula~
~io~s in effect on the da~e of this inspection°
Approved
~ Disapproved ~ Conditional
Terms of Conditional Approval
CAUTION
T~IE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY U~ON THE PdKPRESENT=
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES T~IS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE--
MENTSo 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.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2] 7-19-84
WELL [I~TA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification ~h[~O
Well Log P=esent (Y/N)
Total Depth Cased to
Static Water Level
Casing He ight Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances f~om Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
C leanout/Manhole
Water Sample Collected By
Water Sample Test R~sults
Coca, tents t~3~j~- ~ b/~ '~%~2~,~
MUNICIPALITY OF ANCI~ORAC'!
DFp/, OF HEALTII A
ENVIRONMENTAL PRCT[CTiO? I
Legal Description:
If A~DB, or C, D.E.C. Approved(Y/N)
Date Completed Yield
Depth of Grouting.
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Ne,%rest Se~r Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK 5~TA
No. of C~partn~nts F-
FOundation Cleanout (Y/N)
Date Installed ~-IB'~ Size Icao
Standpipes (Y/N) ~ Air-tight Caps (Y/N)
Depression over Tank (Y/N)~j Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~ ; for
Holding Tank High-Wate~ Alamn (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well '~3z ~ To Building Foundation ~ /
To Property Line ~ ~ To Disposal Field ~ot~
To Water Main/Service Line Io / ~ To Stream, Pond, Lake, or Major Drainage
Course
Receipt ~
Date Paid:
Amount:
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
l~z~D~'/~J~ of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
7~+ Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Wall 7~i°o~-
To Building Foundation
Lot ~ %
To Water Main/Service Line
To Property Line ~ ~-
To Existing or Abandoned System on
; On Adjoining Lots )OL/
Io ~ + To Cutbank(if present) ~+
To Stream/Pond/take/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Co~,~nts ~ ~ )~o~-u~7]~3 ~ IT-~!~.;
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Ele ctr ical Codes (Y/N)
Co~'~nts
Mar~hole/Access (Y/N)
k "Pump off" Level at
k Vent (Y/N)
Pumping Cycles during Adequacy Test.
\
\k
Check Permitted Bedrocm Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA
on the date of this inspection.
Signed ~-~~ Date
Company
Meets MOA
KB1/d5/s
[Page 2 of 2]
2-15-84
,/
/
TRACT "L"
9
DTIOOO741
HYLEN CREST ~UBDIVISION, UNIT
NO,
ROBERT C JOHNSON, t~L.S,
N
TRACT ~
E,4GLE RIVER ROAD
~CCEPTANC~ OF DEDICATFO&
DTI000743
4','// ?:
HYLEN CREST SUBDIVISION, um?/~o,!
ROBERT C. JOHNSON, RIL.S.
1983-946