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HomeMy WebLinkAboutSCIMITAR #1 BLK 2 LT 17imitar Block 2 Lot 17 #0§1-132-2§ Municipality of Anchorage ~ __L_M DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Re.pod P~mitNumbec ~V~(~C~)~L"~") I PlDNumber: OC~!''' ' Wastewater S,j~tem:. ~ 13 Up~r~c~ %n~o ABSORPTION FIELD ~ · SEPARATION DISTANCES ~ ~HoU~ ~ ~T~'. ~ BENCH MARl( -, NORTH ~' / BM--SW LOT CORNER ~ ~~,,. / / ~r~c~s (~) ~ ~ 1 18 65 151 ~ ~~-4 ~.o lo~.e ~7,~ 57.o -- ~ ~ ~ / ~-5 o.g 102~ 32.7 52,1 -- ~-7 ~-6 0.5 102.4 28.2 46.0 -- ~-7 0.5 82~ 65,4 61.0 -- 0 30 60 ft ~8 0.~ ~3,0 ~o.g 5~.4 -- ~-g 0.2 6&5 5g~ 52,8 -- I I I TCO-1 2.2 127.0 29.7 61.5 -- SCA~ ~0-2 1.a 118.9 28.4 57.4 -- ~ ~ ~ ~ %5 65.0 58.4 ~.7 -- "~ ~, ~ ~-~ ~o~.o ~.o~.o -- SITE P~N -- AS-BUILT ~,x-- LEGAL: SCIMITAR ~1, BLK 2, LT 17 ~':' A ':P~JI, OWNER: don Ross ~/~' ~ '"~' ~' 008 ~o.: oo-oo~ I o~[: ~2/~/oo :.~,./.u.~.~ EBEELE ENGINEERING SERVICES '~ -"~ 5875 MARIAH DRIVE q~... ..-~ ~GLE RIVER, AK 99577 ~Xw~,~'~ 907-696-0402 (phone and FAX) ,~- ,/oo'~<~ ' ~ 90.3 Ft Ft Thick (~r=vet I=yer--0.75 to 15 In., 2 I~ Cover Pipe ~ ~ ~ ~t Thick ~=nd rltte~ Fro~ Ou=tl~y SECTION Botto~ o¢ Gr~vel Etewt[on -- 89.7 ¢t 0 20 40 ft I I I ~0 ~ ~ SCA~ SECTIDN AND PRDFILE LE~AL~ ~C[H[T~ ~[, ~LK ~, LT ~7 OWNER: Jori Ross ~. _ CONTRACTOR/BUILDER: Poul Bergeron ~:49~ , ...... ~ .... ~..6 JOB NO.: 00-009 I DATE: 18/1/00 ~..~.. EBERLE ENGINEERING SERVICES ~,~. .~.,~ 3875 MARIAH DRIVE h~. CE92~ .~ '1~'. .... .'~ EAGLE RIVER, AK 99577 ,,~ .... N~NV~-- 907-696-0408 (phone and FAX) PAGE 02/e2 - f~et f,*d E~;/..-/.../...E-/..OG ~u~.ooH "qnqoJel4 a,T~,/oe£ e/..,g:/-.O TO l~ qe..I MUNICIPALITY OF ANCHORAGE Department of Health and Human Sen/ices On-Site Sen/ices Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT Renewal Date Issued: Aug 16, 2000 Expiration Date: Aug 16, 2001 Permtt Number: SW000301 Legal Description: SCIMITAR//1 BLK 2 LT 17 Design Engineer: 0024 Eagle River Engineering Services Owner Name: Leanndra Bergeron Owner Address: 18107 A. MacLaren Eagle River, AK 99577- Pamel ID: 051-132-25 Site Address: Lot Size: 44016 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18MC72 ) and Drinking Water Regulations ( 18MC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. must be either: Received By: ~/ Issued By: 4~ Date: MUNICIPALn'~ OF ANCHORAGE Department of Health end Human Services On-Site Services Program 625 L Street, Room 502 P.O. Box 196650, Anchorage. AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT Initial Date Issued: Aug 10, 1999 Expiration Date: Aug 09, 2000 Permit Number: SW990267 Legal Description: SCIMITAR #1 BLK 2 LT 17 Design Engineer:. 0024 Eagle River Engineering Services Owner Name: Micheal Eisenhauer OwnerAddmss: 415 Lynnwood Drive Huntington, IN 46750-- Parcel ID: 051o132-25 Site Address: Lot Size: 44016 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit Is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either:. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: ,ssuedBy: ~'~~ ~ /~ Date: Date: Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River. AK 99577-3294 (907) 694-3297 fax July 22, 1999 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Lot 17, Block 2, Scimitar Subdivision Narrative & Permit Application Dear lVir. Cross: The proposed well and septic system will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large parcels, allowing sufficient mom for septic sites if wells are placed in the North portion of the lots. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to absorption capacity of the gravel soil in this area. 4. Drainage will not be affected and is not a major consideration in our design. This septic system permit requires a variance to municipal code requirements of 50' to a change in slope of+25% to 35' distance. In support of our request is the fact that the slope is undisturbed and fully vegetated and the soil is a free draining gravel type, will utilize a sand filter and be spread out over a 645 SF area with no water table reducing the need for a large separation distance to prevent effluent surfacing. The slope above the change is level. Due to the caving of the loose soil it was decided to dig only one test hole, the soil is consistent gravel throughout this subdivision area. If you have any questions please call our office at 694-5195. Sincerely, \1997~99-020-1~A~ - -.--- ,~ ~ / /~ ~ - ~ HOLE · - MONITO~ o - S~ER C~ OUT ~ - NO SURFAC[ WAT[R --- P~POSED ~H NO KNOWN CURTAIN D~NS ~- ~I~NG ~H WELL/SEPTIC SITE PLaN LEGAL: LOT 17. BLOCK 2. SCIMITAR ~1 OWNER: L~NDRA AND LESLIE HAMPTON ~. ~ ..~. N~A P.O. Bo~ 778~4 EAGLE RIVER, AK. 99577 (907) 694-5195 FAX: (90D 694-329? Eagle River Engineering Services P.O. Box 773294 Eagle River, AK 99577-3294 Louis Butera, P.E. (907) 694.5195 tel {907) 694-3297 fax L£dAL: SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM Lot 17, Block 2, Scimitar Subdivision #I 7/19/99 A. GENERAL 1. The well and septic plan are for a single family residence only. 2. The drawing and or site plan shall be a part ofthls specification. 3. AIl materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. 4. All soll tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. 6. It is the resp~nsibi~ity ~f the ~wner t~ ~btain a~~ necessary permits ~r easements and t~ ~~cate any adjacent multi-family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. C. SEPTIC TANK 1. Septic tank construction shall be a minimmn of 1000 gallon steel two compartment tank approved by the Municipality of Anchorage. 2. Septic tank is to be installed level on compacted base material. 3. All connections are to be made with caulder couplings. Foundation cleunout to be installed. C. BED I. T~.e bed is to be located as shown on site plan. 2. The bottom ofthe bed excavation shall be level, plus or minas l.5~. 3. The total depth of the bed excavation is not to exceed 8' for the sand layer and 6' for the gravel layer, referencing the ground surface. 4. A 2 foot thick sand layer is to be installed under the bed gravel, sand is to be from and engineer approved sand source. 5. Thc leach gravel is to be 0.5' depth below pipe and 2" over pipe for width of bed. 6. The 4" leach line within the bed shall be lald level within 0.03'. 7. Thc bed gravel is to be covered with typar fabric material. 8. Soll or comblnation of soil and extruded board insulation to a depth of 3' or equlv~lent is to bc placed over the leachfield. 9. Thc area over the bed is to be finish graded to prevent ponding of st~rfacc water runoff. 10. The septic tank and Icachfield must not be closer than' 100' to any existing private well, 150' to any Class *C~ well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 6' GRAVEL DEPTH = 0.5' under pipe, 2" over pipe BED LENGTH = 43' BED WIDTH = 15' SOIL RATING = 0.7 GPD/ft2 (Filter) BEDROOM CAPACITY m 3 SEPTIC TANK = 1000 gallons install 2' Filter sand Layer under Leach gravel. Twenty-four (24) hours notice required for all inspections. \1999~99-020-sp~ Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 'L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERPORMEO FOR: 8 g. ~0- DATE PERFORMED: Township, Range. Section: SLOPE SITE PLAN WAS GROUND WATER /~/~,1 ENCOUNTERED? IF YES, AT WHAT ~ DEPTH? pO E Gross Net Deoth to Net Reading Date Time Time Water Drop / ~/~,/,, ~-,~wt'- ~;t~-." '~ ' ~" PERCOLATION RATE ~ / (mmutes~,nch} PERC HOLE DIAMETER TEST RUN BETWEEN 't. FTAND ~/ FT PERFORMED BY: ~F'~/~ ~[~, ~,~.~.~,~, I ~"~'-' CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85i [1 November 15, 2000 Municipality of Anchorage Health and Human Services Division Environmental Services Division On-Site Services Program 825 L S~'ect, Suite 502 Anchorage, AK 99501 RECEIVED Mun:c~pality ot Anchorage Dept. Health & Human Se~ices (Sent by fax to 343-4786) Dear Daniel Roth: Please accept this letter as an official notification of mc and my wife, Lcannch'a Bergemn, putting in our own septic system. I have enclosed with this letter a copy of our permit renewal, and the original permit that outlines the plans for the septic system. As seen on thc enclosed documentation, the septic system is going to be installed at SCIMITAR #1 BLK 2 LT 17, and will meet 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 (18AACS0). Our plan is to rent a back hoc and a dozer and to do thc work this coming week. We have already purchased most of thc materials and they arc already at thc Site. I am having my father-in-law help me, and he has put in his own several of his own septic systems over the years. Thc engineering for this septic system was done by Louis Butera, but Lou is out of State and he and I have arranged for Oreg Eberle work with us on the inspections. If you have any questions for me, you can contact me at 729-3272 or at 230-1457. Thank you. rb 8 9 1077 (IV Municipality of Anchor r, On -Site Water and Wastewater Progra JAN 2 3 LULU (907) 343-7904 A I CERTIFICATE OF ON-SITE SYSTEMS A VA 01 6 9 b 9 Parcel I.D. 051-132-25 Expiration Date: zo 1. GENERAL INFORMATION Complete legal description Scimtar #1 Block 2 Lot 17 Location (site address) 19919 Tulwar Dr. Current Property owner(s) Sean D. Lowther Day phone Mailing address Real Estate Agent 19919 Tulwar Dr. Chugiak, AK 99567 2. TYPE OF DWELLING: Z Single Family (w/wo ADIJ) F-1 Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual z Individual Well D Holding Tank E71 Individual Water Storage El Community El Community Class Q Well z Public Sewer El Public Water System n WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $_5 go - O'D Waiver Fee $ Date of Payment Date of Payment Receipt Number 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 ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future �� �►\ occupants or can ArcTerra guarantee that no unseenOF a L\ \ encroachments, deficiencies or discrepancies exist. �� s 1 vqTJl 6. DSD SIGNATURE ' System #1 Approved for � bedrooms. �t KENNETH >i.,,16 System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: b�kl1TY(OFr���� z ti -SITE Wq WASTEV gTEra ��o rwvl,•q� o,� By: Original tf f t g0 �2 20ZCD The Municipality of Anchorage Development Services Division (DSD) Issues Certificates of OnJ-ISite)ems 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 Septic System Advisory Well Flow Advisory COSA blue sheet 10-10-12.doc Nitrate Advisory Arsenic Adviso Other l COSA Checklist Schtar #1 Block 2 Lot 17 Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system 1 A. WELL DATA IN Well log is filed with Onsite (or attached) Date drilled 8/16/2000 Total depth 120 ft Cased to 101 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments Class C well B. TANK DATA Age of tank(s) 111 years Tank type/material Septic/Steel Measured operating fluid level in septic tank 49" Standpipes/foundation cleanout per record drawing Date of pumping 11/11/2019 D. ABSORPTION FIELD DATA Which system tested (date installed)11/21/2000 © ALL standpipes present per record drawing Total measured depth from grade 7 ft (max) Measured depth to pipe invert from grade '5 ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective 051-132-25 Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes No Coliform bacteria is Negative Nitrate 7.75 m /L g ❑Nitrate less than MRL (ND) Arsenic ug/L N Arsenic less than MRL (ND) Collected by ArcTerra Date of Sample 117/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Adequacy test date 1/16/20 Results Q Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 1 in Elapsed time 1 min Code -required soil cover over field Final fluid depth 0 in Absorption rate 450 + System presoaked p and (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) _ date of test) 2000 If yes, enter date Gallons introduced gallons Comments/Deficiencies:* Snow piles covered over parts of the fields and could not verify all standpipes 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' ® Yes if No ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft 0 Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25'21 Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' 0 Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' 0 Yes if No. Water Main > 10' ® Yes if No ft Community Wells > 200' 0 Yes if No _ Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' 0 Yes if No Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 1 NMY\NN.tlR Yf11tl\ Mf\N!� 's,KENNETH FUSc +,.{ y CE 71� COSA Checklist yellow sheet ft I 0 l ft l-litrate- Advisory Certificate of On -Site Systems Approval # OSC201019 Subdivision: Scimitar #1 BLK 2 lot 17 A water sample revealed a nitrate concentration of 7.75 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. zx Mailing Address P O Box 196650:* Anchorage, Alaska 99519 6'6S0 *www murn org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org Parcel I.D. 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 APPROVAL FOR A SINGLE FAMILY DWELLING ~:xpiration Date: GENERAL INFORMATION Complete legal description Mailing ad.dre, ss Lending agency Mailing address Real Estate Agent Day phone Mailing Address Unless othe~vise ~equested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class .~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site ~ Individual Holding tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HA,A) based only upon the representations Given in paragraph 5 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 se~/ed by a private or Class C well and may be reissued with new water sample results less than 30 days old. (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/er 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 Stale codes, ordinances, and regulations in effect at the time of installation. Name of Firm ]~ ~.V~J ~L. ~IA Address ~1~ O~ok~.~o~k lJ)j~,~L Engineer's Printed Name 5. DSD SIGNATURE ~ Approved for · '~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Progrem 4700 South Brag~ St. P.O. Box 196650 Anchorage, AK 99519-6650 · www.ct.anchorege.ak.us (~07) 343-79O4 Legal Description: A. WELL DATA Well type ~:~'~/~ If A, B, er C provide PWSID # Well Leg (Y,?4) Total depth 1ZO ft. Cased to I0 1 ft. Cas'~O height (above ground).'~'''''''''''''''~ FROM WELL LOG AT INSPECTION sta,cwata, tev~ ~ F ft. 0 ' ft. Well production ~ g.p.m, g.p.m. HEALTH AUTHORITY APPROVAL CHECKLIST WATER SAMPLE RESULTS: Date of sample: Collected by: L-~.~. [~.+~--v'~ B. SEPTIC/HOLDING TANK DATA T..kT..'. : Tank size I;z"c'~ gal. Number of Compartments ~ Cleanouts (Y/N) ~__.~_Z.) Foundation cleanout (Y/N) 'Y Depression ovar tank (Y/N) ~o High water alarm (Y/N) ~'~ Date of pumping ~J/ibt-- ~ Pumper ~ . .....~ .~ C. ABSORPTION FIELD OATA ~enm q.:3 ft. W=th I 5 ,. ~,ave, beiow pipe. To=~depth_~_ft. E~.=so,pUonarea ~,~r~,~ Uon~o~ingt~ ~S Oepre~siono~ar~e~d Elapsed~ min. Final ll~,.,~tfi in. Absorption rei~-- -- g.p.d. Any rejuvenation treatment (past 12.,,~ (Y/N & type) If yes, give date O. UFT STATION (~ ~.1~. , (,.: ,{;}L {-{-R."{' t; I~' Date installed )~//=e m gallons ____.~,2. Manhote~Access ~/JN~~ "Pump on' level at ,,~. "Pump off' level, id/ In. High water, illin level at / in. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: · ~lft station on lot Absorption field on lot Public sewer main Sewer/septic service line. On adjacent lots On adjacent lots > /o0 Publlo sewer manhole/cJeanout Holding tank ~ t O O SEP Tio. OlsTANcES FRO O OI.G TANK O. OTTO: aullding foundation ~-G Property line Z'~[ Absorption field Water main Nev','a- Water ,enace line~4 30 Surface water Wells on adJacent lots '~ ~.~)O G. ENGINEER'S CERTIFICATION ~ mat I h~ dete~ln~ ~h ~ ~pe~na and Engin~r ~ Pdn~ Name ~~ _. / I~ 4 ~, .. HAA Fee $ ~. ~:~ Date of Payment ~~:} [ Receipt Number ~ ~'~ ~ 7 (Rev. 12~0) Waiver Fee $ Date of Payment Receipt Number AB$ORPTION FIELD ON LOT TO: (.~rU.T.)---~' SEPARATION DISTANCE FROM Property line / (~) BulMing fotmdatlon Z ~ ~o > too Water Sen4ce line Surface water Curtain drain JL)~ ~V~V _'~ Wells on adjacent lots ~' ~v~tv~. F. COMMENTS efta(ed D~le/T~me 06/14/2001 13:51 Received Date~i~ ~l~l g:~5 T~nlcal Dt~r Ni~tc-N O.~CO IT~L EPA300 0 {<.101 C'611 ~01 SC'.. Ktctob to l.c(r]' Coliform O ~oVICOm[. SMIS 9'"'*ti (<11