HomeMy WebLinkAboutBEAR PARK LT 11B¢or Pork
Lot 11
¢051-042-75
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507 Page ~ of ~./
www.ci.anchorage.ak.us (907) 343~7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: ~)_~t 0 j &O?> PID Number: (~
FEDERAL NATIONAL MORTGAGE ASSOCIATION Wastewater System: [] New [] Upgrade
Address:
400 COUNTRYWIDE WAY SV-35 SIMI VALLEY, CA ABSORPTION FIELD
Phone: Number of Bedrooms:
4 I~' Deep Trench [] Shallow Trench [] Bed [] Mound [] Other:
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION 1.0 ~pD~t~ 10 Ft.
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe:
11 BEAR PARK 2.8 Ft. 7.2 Ft.
Township: Range: Section: Fill added above odglnal grade: Gravel Length:
1.1 - 1.3 Ft. 45 Ft.
Gravei width: Number of lines: Distance between lines:
Well: [] New [] Upgrade 3 Ft. 1 N/A Ft.
Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material:
EXISTING PRIVATE Ft. Ft. 648 Ft~ ASTM 3034/ADS/F810
Driller: Date Drilled: StaticWater Level: Installer: Date Installed:
Ft. TWEED EXCAVATING 6/22/10
Yield: GPM Pump Set at: Casing Height Above Ground:
Ft. Ft. TANK
SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other:
· T~ To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity:
Tank Field Station Tank Sewer Line PREMIER PLASTICS 1300 Ga~.
Material: Number of Compartments:
We, 100'+ 100'+ .................... 25'+ HDPE 2
Su~aoeWatar 100'+ 100'+ .................... ~ / LIFT STATION
Size: Manufacturer:
Lot Line 5'+ 10'+ .................... N/A Gal.
"Pump on" level at: "Pump off" level at: in. High water alarm at:
Foundation 5'+ 10~+ .................... in. in.
Curtain Drain .......... NONE KNOWN .......... Pump Make & Model Electrical Inspections performed by:
Remarks:
BENCH MARK
Location and Description:
BOTTOM OF SIDING AT POINT A
Assumed Elevation:
100 Ft.
Engineering Engineer's Stamp
Inspections performed by: t.~_~l~_t_ $;Birehwood Lp. Rd. Dates: 1st 6/21/2010
-- . ~ ~Alosko W~7 2nd 6/22/2010
Conditional Approval Date:
Reviewed and approved by: /~./~'"~ ~Z/. te' 7-,/~ '?>~ ~/
PERMIT NO.OSP101003 PAGE 2 OF 4
Municipo, kitsy o¢' Ancho~'o, ge
DEVELOPMENT SERVICES DEPARTMENT - BUILDING SAFETY DIVISION
ON-SITE WATER AND WASTEWATER PROGRAM, &700 BRAGAW STREET
P,D, Box 196650 ®Anchoro, 9e, Ato, sko, 99519-6650 ·Telephone: (907) 343-7904 ·www,ci,oncho~-o. 9e,o,k,u:
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPOR'
LEGAL LOT 11; BEAR PARK S/D P.I.D. NO. 051--042--75
EXISTING TANK
PUMPED, CRUSHED,
AND ABANDONED
I
~ VIEW
STATES
LOT 35
~( VIEW
~TATES
LOT 1 1!
EXISTING DEEP
RETAINED
FOR FUTURE USE
NEW 1500
HDPE
SEPTIC TANK
''''". / NEW DEEP/
-.. //-TRENCH/
...~o~ ..
TO BE
MUST
NOTE:
NO 90° COUPLERS
USED. ALL TURNS
NOT EXCEED 45°.
I
TOP OF \
SLOPE~t
ENG :P
PERMIT NO.0SP101003 PAGE 3 OF 4
DEVELOPMENT SERVICES DEPARTMENT - BUILDING SAFETY DIVISION
ON-SITE WATER AND WASTEWATER PROGRAM, &700 BRAGAW STREET
P,B, ]}ox 196650 ®Anchorage, A~osko 99519-6650 ®Telephone, (907) 343-7904 ·www,ci,anchopage,ak,u:
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPOR'
LEGAL, LOT 11; BEAR PARK S/D P.I.D. NO. 051--042--75
PARK LOT 12
EXISTING DEEP
RETAINED
FOR FUTURE USE
EXISTING TANK
PUMPED, CRUSHED,-
AND ABANDONED
NEW 1500
HDPE
SEPTIC TANK
24
KNIK VIEW
ESTATES
LOT 25
TOP OF
SLOPE~,
· . .... . , CO3
KNIK VIEW [-"' '". / NEw DEEP/
'. / /-TRENCH
· . .c?
//
/
~OTE: ?~ / /
NO 90~ COUPLERS TO BE
USED. ALL TURNS MUST
NOT EXCEED 45
ENGINEE
50'
STAMP
PERMIT NO0SP101003 PAGE 4 oF 4
[vlunic[pcLi~cy of Anchorage
DEVELOPMENT SERVICES DEPARTMENT - BUILDING SAFETY DIVISION
ON-SITE WATER AND WASTEWATER PROGRAM, /+700 BRAGAW STREET
P,B, ]}ox 196650 I ancho~'oge, a(osko 99519-6650 I Te/ephone: (907) 343-7904 ·www,ci,ancho~-a9e,ak,us
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPOR'
LEGAL LOT 11; BEAR PARK S/D
P.I.D. NO. 051-042-75
FINAL
INLET - 94.
ST1 ST2 /-GRADE - 98.8'
LON I~
LENE I ~- OUTLET
FINAL GRADE -~
ORIGINAL
GRADE - 93.4'
NO
MT1 =83.4'
MT2=83.4'
TOP OF
TANK -- 95.7'
= 94.3'
A B
ST1 26.2' 28.6'
ST2 27.3' 31.6'
DBL1 28.1 ' 33.4'
DBL2 28.2' 54.5'
TMT 29.0' 32.8'
DV 28.2' 55.5'
C01 122.1' 158.7'
MT1 125.4' 159.7'
C02 141.9' 170.4'
MT2 141.4' 170.5'
C05 85.2' 125.9'
CO1 =94.5'
C0~~=94.7'
·
WATER FOUND
77.4' B.0.H.
On-Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP101003
Tax Code Number: 05104275000
Work Type: Septic Upgrade
Permit Effective Dates: ~'/~O/~O to
Design Engineer: S & S ENGINEERING
Subdivision: BEAR PARK
Site Legal Address: BEAR PARK LT 11 G:1558
Owner/Address: FEDERAL NATIONAL MORTGAGE
ASSOCIATION 400 COUNTRYWIDE WAY SV-35 SIMI VALLEY CA 930656298
Site Mailing Address: 22618 URSA MAJOR CIR, Chugiak Lot Size in Sq Ft:
Total Bedrooms:
46801
4
This permit is for the construction of:
Y Disposal Field Y SepticTank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
IssuedB,: ,~-,f~ ~_~/~.~,¢I~¢~'-
Date:
Date:~/~
Apr.26.2010 09:35 PM PAGE. 1/ 1
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O, Box 196650
Anchorage, Alaska 99507
www, muni.org/onsite
(907) 343-7904
ON-SITE SEWERNVELL PERMIT APPLICATION
/~ "~ FOR A SINGLE FAMILY DWELLING
Parcel I,D, 05t 042 75,
Property owner(s) FEDERAL NATIONAL MORTGAGE ASSOCIATION
Mailing address 4o0 COUNTRWIDE WAY SV-35 SIMI VALLEY, CA
Site address 22818 URSA MAJOR CIR
Legal description (Sub'd., Block & Lot) LOT 11; BEAR PARK $/O
Legal description (Township, Range & Section)
Lot Size.... ~ 6, ~{ Sq. Ft.
Day phone
Zip Code 93065 6298
.Zip Code
Number of Bedrooms 4
THiS APPLICATION IS FOR ([~ all that apply):
Absorption Field
Septic Tank
Holding Tank
Privy
Pdvate Well
Water Storage
THIS APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
I certify that the above information is
Single Family Dwellin is in
I further certify that this application is being made for a
with applicable Municipal Codes.
(Signature of
agent)
Permit/Rush Fees: ~-'7_)..~..
Date of Payment:
(Rev, ~tt05)
Waiver Fees;
Date of Payment:
Receipt Number:
ROBERT C. COWAN .
CIVIL ENGINEERING
April 26, 2010
PH: 907-694-2979
FAX: 907-694-1211
HEALTH AUI'HORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
~EWER & WATER
INSPECTION
ENGINEERING,STUDiES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE
ROAD DESIGN
SOIL TEST //
;
PERCOLATION
TEST'
STRUCTURAL&
MECHANICAL
II',~ PECTIONIS,
ONSITE
W/'STEWATER
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 11; Bear Park S/D
It is requested that you issue a permit to install a new deep trench and 1300 gallon
HDPE septic tank septic system to serve the existing four bedroom house on the
referenced property. A diverter valve will be installed to allow the existing system to
be used a t a later date.
A test hole was excavated and a percolation test performed. The approximate location of
the test hole is located on the attached site plan. At the time of excavation (4/8/2010) water
was not found. After seven days of monitoring, ground water was not found.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
If you requir.e, jadditional information, please contact us.
Sincerely' /
Enclosure
15861 S. Birchwood Loop Road - C~hugiak, Alaska 99567
SITE-PLAN
DESIGN
1"=80'
SCALE
moo
Oo
°~
~RJOR
SITE-PLAN
\ o
0
'-.t
15' UTILITY
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
1
16
17
18
19
20
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, EE..
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
DATE PERFORMED:
//j' <~¢~-~ ~//~ Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT ~~ O
DEPTH? p
Depth to Water Alter 0
Monitoring?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RTE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND ~Z~ FT
PE.,:OR,,.,ED,,¥: .- r
ACCORDANCE WITH ALL STATE AN~ MUNICIPAL GUIDELINESY/' //IN~FF~T ON THIS DATE.
DATE: ' , ' '
,~ MUNICIPALITY OF ANCHORAGE
DII~RTMENT OF HEALTH AND HUMAN SER~IES
"', " Environmental Health Division
.,, ' 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Namel DISTANCES
Ad~r~s; - ' ~0 SEPTIC ABSORPTION
~,¢ ~. ~ ~ ~~ ~,~. . TANK FIELD WELL
~hone~s}~ ~o. o~ ~ WELL
s
I~' ~ ~ LOT LINE
LEGAL DESCRIPTION
Township, Range, Section
~ [~ ~ ~ ~ ~ W AS-BUILT DIAGRAM (Show Iocat,on of wen, septic system, property hnes, foundat,on,
driveway, water bodies, etc.)
~ I
TANKS N
~ SEPTIC ~ HOLDING ~
'M~~ ~ C apac,ty ,n gallons
~ateriai No. Of Compadments ~ f j~[%
TYPE OF SYSTEM .]I,~
~TRENCH ~ BED ~ W. DRAIN B OTHER '~' ~i~'~_
.......
Depth to p~pe bottom from ¢otal depth from original grade
original grade ~
/
Fill added above original grade Gravel depth beneath p~pe
~-~;eZl%n%{h Gravel w,dth
.otalabsorptlonarea~.~..~ ~+~'Distanoe~etweenllnes '/~ FT ~ ~' ~
Dine Installed
~_~ PRIVATE ~ OTHER (Identify)
Classd.cation (A.B,C) ~otal Depth Cased to
¢ F, FT
Instaile~ Date installed: ·
REMARKS:
Sc.~e: ~ ,~ 5. ~.~,.~.'S S~
~ ~ ~ Inspections Pedormed by:
I 17034 Eagle Ri~er L~ Road H~. 2~, c~ily t~t this inspection was peflormed according to all
Eagle River, Alaska 99577
Municipal and Stale guidelines in effect 0n this date: ~~ ~
Health Department Approval: ~ Date: ~--/~ ..... "~ ...... ' ~ '
72-013 (3/85)
l!iheiSi....iE ie ill gElR ~ ~/:~t:.'.' e9577
i::' l'"i ill} i".t ii~l :t'!: ,5 ':? ':-'i. '"- :,:.iVeY? 9
SCALE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
LEGAL DESCRIPTION:
2
6 - ~.'}
tO-~-a ~
12 -'~
16
17
,
,)
VATER ~x..~., (%
DATE PERFORMED: ~--~ -
SITE PI_AN
Gross 1 Net
Time Time
_
, ',/.._? ,)
Depth t9
Water
Net
Drop
COMMENTS
PERFORMED BY:
72-008 (6/79)
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
8:25 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME 1PHONE I I~Ew
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO, OF BEDROOMS
~ Z Manufacturer Material No. of compartments
Liq. capacity in gallons Inside length Width Liquid depth
I ~ IF HOMEMADE: ~.~
~ ~ Well / Dwelling PERMIT NO.
~ ~ Z DISTANCE TO:
O ~ ~ Manufacturer /~ Material Liquid capacity in gallons
~ ~ DISTANCE TO: Well ~' F ounda~ I N ear est lot lineI P ERM~
* ,e~h~f ,ines Trench Distance begones
~ .~'; ~ No. of lines Length of ~t~e~h~in~ Total
: ~ Top o~ tile to finish ~rade ~ Material beneath tile Total effective absor~tio~ area/
~ L inches
Length Width Depth PERMIT NO.
~ ~ T~Oe of crib Crib ~iameter rib depth Total effectiuo absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS ~~ ~~- ~
SOIL TEST RATING
INSTALLER
APPROVED . SRB lg6X DATE LEGAL
72-013 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED: ~ --8-- <~
LEGAL DESCRIPTION:
1
2
3
6
7
8
9
SLOPE
SITE PLAN
10
11
12
13
14
15
16
17
18
19
2O
liebert A. Sh~r ~
Ne. 1457-E
COMMENTS
WAS GROUND WATER x I S
ENCOUNTERED? ~ (~L
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERFORMED BY:
72-008 (6/79)
CERTI
FlEDge'
Drill
Casin~
Durbin Drilling CO.
Mile 1.2, Lucas Road
P.O. Box 871348
Wasilla, Alaska 99687
(9O7) ~
376-WELL
Name: Floyd Gray's Constr~cti~n
Address'~28 Boniface 2857 '
City: Anchorage, AK /Ph°ne:376-7938
Job -- -
Location~.O'r. ll, Bear Park Subd.
Crew: R. Durbin/S. Zachari~sen/R.Legerski
Date: April 29, 1985
Notes: Well cased to 265 ft. including
2 ftt.. stick-up
Stati'c water level:
14 ft. from
surface
GPM: 30
-~rc~Tn~-~ed pump setting:
60 ft.
Restrict flow to l0 GPM
Well Lo~
Sand and gravel
Depth /
0-15~
150-~62
162-~40
Mostly sand with some gravel
240-~ 62
262-~ 65
Clay and gravel
Sand, silt, water
Sand and gravel
G
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
;;M7
Certificate of On -Site Systems Approval
Parcel I.D. 051-042-75 Expiration Date: C, —
1. GENERAL INFORMATION:
Complete legal description BEAR PARK S/Q,• LOT 11
Location (site address) 22618 URSA MAJOR CIRCLE, CHUGIAK, AK 99567
Current Property owner(s) CHARLES JETTON Day phone 719-330-5562
Mailing address 22618 URSA MAJOR CIRCLE, CHUGIAK, AK 99567
Real Estate Agent ANNELIESE HENLEY Day phone 854-0310
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
1771 Duplex
1771 Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
.3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
0
Individual Water Storage
E]
Holding Tank
1771
Community Class Well
1771
Community
1:1
Public Water System
1:1
Public Sewer
1771
WaiverNariance request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55-10
Date of Payment V, 13,11 q
'
I o
'q
Receipt Number o 19 �7
COSA # 135r-1916174
Date:
Waiver Fee $
Date of Payment
Receipt Number.
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: CZ Z
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o� OF q
in accordance with the guidelines and regulations established by the Municipality of Anchorage and �.. • • • ..• • 504
industry practices. The reported results describe the condition of the system/s on the date/s of the O P Q
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 f r A. Gorn ss:
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of QO CE
em
the well or septic system. GEG makes no representation whether an alternative well or septic systs c G
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 �0 dpro f e s s10�°\
perform the evaluation. Reliance upon the information provided in this report by any other person or O�O��D000Q
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for bedrooms TYtpF
System #2 Approved for bedrooms
Disapproved
`a INAT' ; �� m
Conditional approval for bedrooms, with the followirgwipAo D
P TSR
�'OC'
ot:HVt ,��
`, i
Original Certificate Date:—Co—(
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 _ C Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_10-10-12.doc
Legal Description:
BEAR PARK S/D; LOT 11
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 4/29/85
Total depth 265 ft
Cased to 265 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 11/15/19
Static water level at beginning of test 23 9 ft.
Comments
B. TANK DATA
Age of tank(s) 9 years
Tank type/material PLAsTIc
Measured operating fluid level in septic tank 4411
ON Standpipes/foundation cleanout per record drawing
!
Date of pumping 1 —2—G —11
D. ABSORPTION FIELD -DATA DEEP TRENCH
Which system tested (date installed) 6/22/10
❑ ALL standpipes present per record drawing
Total measured depth from grade 11.1 ft (max)
Measured depth to pipe invert from grade 3.5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
Parcel ID: 051-042-75
Structure served by this system 1
Well production at time of test 7.1 gpm
Water storage tank volume NONE gallons
Well disinfected for coliform test? ❑ Yes ❑ Nc
❑ Coliform bacteria is Negative
Nitrate ND mg/L ❑ Nitrate less than MRL (ND)
Arsenic 6.39 ug/L ❑ Arsenic less than MRL (ND)
Collected by GEG, LTD.
Date of Sample 11/15/19
C. LIFT STATION
red maintenance completed
Age of lift sta years
Lift station material
Comments:
Adequacy test date 11/15/19
Results Q✓ Pass For *3 bedrooms
Fluid depth prior to test 0 in
Water added 920 gal
New depth 0 in
Elapsed time 0 min
❑Code -required soil cover over field (INSULATED) Final fluid depth 0 in
Absorption rate '600+ and
❑ System presoaked NONE
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
GalFons introduced gallons If yes, enter date
Comments/Deficiencies: `SEPTIC SYSTEM SIZED FOR 4 BEDROOMS, BUT HOUSE IS ONLY 3 PER MOA RECORDS.
TESTED 2010 TRENCH DID NOT EVALUATE 1985 & 1987 TRENCHES. DIVERTER VALVE APPEARED TO BE DIVERTING FLOW TO
THE 2010 TRENCH.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES *CANNOT CONFIRM SEPARTION DISTANCE TO 1985/1987 TRENCHES
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
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
0 Yes
if No ft
Neighboring Tank > 100' ❑v Yes
if No
ft
Private Sewer/Septic Line > 25'E] Yes
if No ft
Absorption Field on Lot > 100' ❑� Yes
if No
ft
Holding Tank > 100' 0✓ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ❑✓ Yes
if No ft
E✓ Yes
if No
ft
ft
If septic tank is under driveway comment below
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 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'
❑ Yes
if No
**5+ ft
Surface Water > 100'
❑✓ Yes if No ft
Property Line > 5'
❑v Yes
if No
ft
Wells on Adjacent Lots:
Wells on Adjacent Lots:
Absorption Field > 5'
❑r Yes
if No
ft
Private Wells > 100'r❑
Yes if No ft
Water Main > 10'
0 Yes
if No
ft
Community Wells > 200'
r❑ Yes if No ft
Water Service Line > 10'
❑r 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'
P1
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' Q Yes if No ft
Water Service Line > 10'
El
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
✓❑
Yes
if No
ft
F. ENGINEER'S COMMENTS
- -- - - -- — -- - - --
**MET SEPARATION
DISTANCE AT TIME OF INSTALLATION.
***ASSUMED.
G. ENGINEER'S CERTIFICATION
1 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.
COSA Checklist yellow sheet
oo��•0F•
� `� -- ��� ••.ter 0�
�'..4 A .................
et. Garne s,
� Opp CE -79 3 �� s I
40ea r 0 f e s sio�oo�
#AECC884
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1. GENERAL INFORMATION
Complete legal description
Lot 11; Bear Park Subdivision
Expiration Date:
Location (site address) 22618 Ursa Major Cir.
Current Property owner(s) Fedreal National Mortgage Association
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Bob Brock
Day phone 261-7678
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
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 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 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 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 s & s Engineering
Address 15861 S. Birchwood Loop Rd. Chugiak, AK 99567
Engineer's Printed Name Rober~A. Shafer
DSD SIGNATURE
~'/ Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone 694-2979
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
/~~Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
LegalDescription: ~T //j~'~-J~-~ ~/~ Parcel!D:(~::~z:~/--~-'~
A. WELL DATA
.c,"""-'"~
We, .^, or C .rov e
Date completed ~/,~/~ ' Sanitarysea~N)
Total depth c~ /ft Cased to
ft.
FROM WELL LOG
Date of test
Static water level
Well production
.WATER SAMPLE RESULTS:
Well Log(~l).~
Wires properly pmtecte([~)~
casing height (above ground) /~/~1c in.
AT INSPECTION
g~z,o
~C),O g.p.m. ~
/
Coliform 0 coloniesll00 mL Nitrate N~ mg/L
Arsenic: I~,~ ~"~ Ug/L date of sample: _ '_~3/fi~9
Tank size . ~ gal. Num~rofCompa~ments
Foundation cleanout (WN) ~ Depression over tank ~/N) .
Date of pumping ~/~/ Pum~r.
~ C. ABSORPTION FIELD DATA
Date installed ~to Soil rating (g.p.d./ff
Length ~ ff. Width ~ fl..
Total depth ~ ~ ff. Eft. absorption area
Date of adequacy test ~ ~~ Results (Pass/Fail)
Fluid depth in absorption field before test ~ in.
Elapsed Time:~ min. Final fluid depth
Any rejuvenation treatment (past 12 mo.) (WN & ~pe)
g.p.m.
Other bacteria 0 'Coloniesll00 mL
Collected by:
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
1(.5
System type I~E.P-~
Gravel below pipe '"~"Z- ft.
Water added f gal.
in. Absorption rate >=
Depression over field b/
For z'l bedrooms
New depth -'" in.
~C3~ g.p.d.
If yes, give date --
D. LIFT STATION
/
Date installed /,.J//~ Size in gallons Manh '
/ ~
"Pump on" level at.. in. "Pump off"~p,.v~4---7'"~ High water alarm level at
Datum ~ Cycles tested Meets alarm & Circuit requirements?
in.
E. SEPARATION DISTANCES
Absorption field on lot.
· Public sewer main
Sewer/septic service line
' SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ,/~)
/00
'Animal containment areas
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
/
Holding tank
Manure/animal excrete storage areas /od
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~ L{. Property line 5'- lA Absorption field
Water main ~) ~ Water service line ~/(::) ~ Surface water
· Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ [~)~t-/L Building foundation
Water Service line /& % Surface water
Curtain drain ~1~ (~-~q ~,,~ Wells on adjacent lots
Driveway, parking/vehicle storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through fieM 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 Nam~~°~''''
!
Date, "'7"' { Z -/d
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
/
/
/
AS-BUIlT
I hereby certify that I have surveyed the following described
property:/- ~ 7" i {,
Anchorage Recording Precinct, Alaska, and that the improve-
ments situated thereon are within the property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on prog~erty lyin~ adjacent thereto encroach
on the premises in question and t~at there are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at E~agle River, Alaska
this ~'~ 'T'b" dayof "-'~ ~/¥
ROBERT C. JOHNSON
SCALE: Registered Land Surveyor No. 880-LS
1" = L~," Box 77-0456, Eagle River, Alaska 99577
Phone (907) 694-2543
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 051-042-75
1. GENERAL INFORMATION
HAA# 0q' 0~
Expiration Date:
Complete legal description' BEAR
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
PARK SUBDIVISION; LOT 11, :-''
22618 URSA MAJOR CIRCLE * CHUGIAK, AK * 99577
TODD & MARILYNN WEATHERFORD Day phone 688-7757
22618 URSA MAJOR CIRCLE * CHUGIAK, AK * 99577
Day phone
LES BALLY W/ PRUDENTIAL VISTA Day phone 689-6451
166555 CENTERFIELD DRIVE * EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ,3
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 ]--1
Public Water System [~] Public Sewer ]-'-1
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 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. 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 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.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone 337-6179
Date
Engineer's Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
con.~cientious engineering analysis of the system in accordance with ADEC and MOA
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 sen/ed 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.
DSD SIGNATURE
L,~ Approved for ~
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the fllowing stipulations:
,,~'~. , ~
~ ~. ON-SffE . ~ ~
: WASTEWATER
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
..'
Manitenance Agreements
Supplemental Engineer's Reort
Other
(Rev. 12/01)
Original Certificate Date:
7-
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: BEAR PARK SUBDIVISION; LOT 11
A. WELL DATA
Well type PRNATE If A, B, or C provide PWSID# N/A
Date completed 4/29/1985 Sanitary seal (Y/N) YES
Total depth 265 ft. .. Cased to. 265 ft.
Parcel ID:
051-042-75
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
YES
YES
21 .in.
Date of test
FROM WELL LOG
4/29/1985
AT INSPECTION
7/2/200¢
Static water level 14 ft.
25 .ft.
Well production 30 g.p.m.
4.36 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/lO0 mi. Nitrate 0.1 mg./L.
Arsenic: N/A mg./L. Date of sample: 6/18/2004
Other bacteria 0 colonies/lO0 mi.
Collected by: KND ENGINEERING
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1250 gal. Number of Compartments 2
Foundation cleanout (Y/N) YES Depression over tank (Y/N)
Date of pumping 7/2/2004 Pumper,
NO
Date installed 7/7/1987
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
JR's PUMPING
Length 75
Total depth '7.3-9.0
Date of adequacy test
Fluid depth in absorption field .before test
ft, Eff~ absorption area 900 ft2 Monitoring tube**YES
7/2/2004 Results (Pass/Fail) PASS
**40.25 in. Water added 730 gal.
C. ABSORPTION FIELD DATA pBELOW EXeS'riND CEADEI
Date installed 7/10/85 & 7/7/87 Soil rating (g.P.d./ff2or~ 225 System type DEEP TRENCH
.ft. Width 2.5 ft. Gravel below pipe 6.0 .ft.
Depression over field NO
For 3 bedrooms
New depth **53.5 in
Elapsed Time: 740 min. Final fluid depth **49 in. Absorption rate >= 456 g.p.d.
· Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date -
**MONITORING TUBE ONLY EXTENDS 49.5 INCHES INTO DRAINFIELD. LIQUID LEVEL WAS BROUGHT
TO THE TOP OF DISTRIBUTION LINE AT THE END OF ADDING WATER. LIQUID LEVEL AT LAST
RECOVERY READING WAS 0.5 INCHES BELOW INVERT OF DISTRIBUTION LINE.
LIFT STATION
Date installed Size in gallons
"Pump on" level at in. ~ High water alarm level at.
Da...~.~.u.~tum ~ Cycles tested Meets alarm & circuit requirements?.
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot100'+ On adjacent lots 100'-I-
Absorption 'field on lot '1~0'~~ On adjacent lots 100'+
Public sewer main N/'A Public sewer manhole/cleanout
Sewer/septic service line 25'+ Holding tank N/'A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ prOperty line 5'+ Absorption field 5'+
Water main N/'A Water service line 10'-I- Surface water.
Wells on adjacent lots 100'-l-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation. 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage
Curtain drain NONE KNOWN Wells on adjacent lots
COMMENTS
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.
N/A
100'+
100'+
10'+
¸in.
Engineer's Prin}ed/Name
Date
JEFFREY A. GARNESS
HAA Fee $ ~-//,'~ ~
Date of Payment
Receipt Number ('~5//~'~
(Rev. 12/01 )
Waiver Fee $
Date of Payment
Receipt Number
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
051-042-75
1. GENERAL INFORMATION
Complete legal description BEAR PARK SUBDI¥$1QN; LOT 11
Location (site address or directions) 22618 URSA MAJOR CIRCLE OHU$1AK, AK
Property owner
Mailing address
Lending agency
Mailing address
MARGARET JOHNSON
c./o CAROLINE STRF_.ANO
WITH
Day phone (540) 665-4112
COUNTRY
RF. AL.TY
Day phone ;h-'~O ~ ,'¢ E~'~.~:
Agent__c/o CAROLINE STREANO WITH COUNTRY REALT'rDay phone
Address P.O. BOx 671925 CHUGIAK, AK 99567
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 5
TYPE OF WATER SUPPLY:
Individual well xxx
Community well
Public water
NOTE:
(907) 688-8500
If community weft system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site xxx
Holding Tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
/ng fo the legality and status of system.
72-025 (Rev. I191) Front MCA ;~I Computer Version
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,400.00 at,
or prior to, closing for the engineering services provided.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 vedfy 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 Mur)i,¢i~al and State codes, ordinances, and regulations in effect
on the date of this inspection. ~ ,,~//1
Name of Firm ALASKA.WATER..'&W'ASTEWATER CONSULTANTS INC. Phone (907) 337-6179
Address 6901 DEBARF~ ROAD,/S~I 'F_,~~ANCHORAGE, ALASKA 99504 / /
Engineer's Signature ~',___,.,_.~ tj
system in accordance with ADEC and ~O,A D!
performance of the system under the condition
measured to readily identifiable features. The o
pta a thorough, conscientious engineering7 analysis of the
~ls Guidelines & Regulations. The reported results described the
encountered at the time of the test, and separation distances
oerationa/ life of ali wells and septic systems depend
on the local soils condition, ground water 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 ,~ ! ~. .
.......
j ..'
'... ...... ·
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.
AWWC, Inc. can therefore not provide any warranty for future estimate of how long the
system will continue to meet the operational requirements of the ADEC or MOA DHHS.
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.
6. DHHS SIGNATURE
~ Approved for ~' bedrooms
Disapproved
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of
homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of
DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21 Computer Version
Legal Description: BEAR
A. WELL DATA
Well Type PRIVATE
Log present (Y/N)
Total depth ;~65'
Sanitary seal (Y/N)
MUnicipality of Anchorage R E C E I V
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental services iDiVision
825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 343-4~{~T I 0 Z000
MUNICIPALITY OF ANCHORAGE
Health Authority,Approval Checkli~NVIRONMENTAL SERVICES DM$10N
PARK SUBDIVISION; LOT 11 Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
051-042-75
YES
Data completed
Cased to 265'
YES
N/A
4/29/1985
Casing height (above ground) 21"
Wires propedy protected (Y/N) YES
Date of test
Static water level 14'
Well production ' 30
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: 10/5/2000
B. SEPTIC/HOLDING TANK DATA
Date installed 7/7/1987 Tank size
Foundation cleanout (Y/N) YES
Date of Pumping 9/25/2000
C. ABSORPTION FIELD DATA
Date installed .7-10-85/7-7-87
Length 7.5' Width
Effective absorption area. 900
Date of adequacy test 9/25/2000
FROM WELL LOG
4-/29/1985
AT INSPECTION
9/22/2000
31'
g,p,m. 6.2 g.p,m,
Nitrate ~ ~mg/L Other bacteria
Collected by:. A,W.W.C., INC.
1250 Number of Compartments 2 Cleanouts (Y/N) YES
Depression (y/N) NO High water alarm (Y/N) N/A
Pumper JR'S PUMPING
Soil rating (g.p.d./ft2 o~
'57' LONG TRENCH/ADDTIONAL 18' ADDED.
**MEASURED IN FIELD.
225 System type TRENCH
;~.5' Gravel thickness below pipe 6' Total depth *.7.3'-9.0'
SQ,FT. Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
Results (Pass/Fail) PASSED For. 3 Bedrooms
gal. water added (in.~__~~~[,
450+
Fluid depth in absorption field before test (in.);
Fluid depth 47" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)* Computer Vemlon
35" Immediately after 885
673 Absorption rate =
N/A If yes, give date
D. LIFT STATION
Date installed
Manho[e/Access~(Y/N)
High water alarm level at*
Size in gallons ~
'Pump on" I~.1~~'~''''~ 'Pump off" level
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
100'+
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
100'+
100'+
N/^
N/A . Public sewer manhole/cleanout
25'+ . Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+
Water main/service line 10'+ Surface water/drainage 100'+
SEPARA:I;ION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
10'+
Building foundation
100'+
N/A
NONE KNOWN
Absorption field
Wells on adjacent lots
5'-I-
100'+
10'+ Water main/service line 10'+
Driveway, parking/vehicle storage area 5'+
Wells on adjacent lots 100'+
field inspections and review
systems are in conformance
on this date.
JEFFREY A. GARNESS
Date of Payment /~)
Receipt Number (3
72-026 (Rev. 3/96)* Computer
Waiver Fee. $
Date of Payment
Receipt Number
-,%
oY
8£EI889i06 : 'ON BNOHB A±]UB~ A~±NnOD : WOmB
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 11 Bear Park Subdivision (T15N R1W Section 4)
H~-1282
Location(addressordirections)
Ursa Major Street
(b)
(c)
United BAnk of Ala~one:
Property Owner
Home
Mailing Address
Business 376-4147
Lending Institution Same as above
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e)
MailtheHAAtothefollowinaaddress:or:Checkhere[],ifholdforpickup.
Listcontactpersonanddayphonenumberbelow.
S & S Engineerinq
17034 Eaqle River Loop Road ¢204
Eaqle River, Alaska 99577
TYPE OF RESIDENCE
Single-Family [~x
Number of Bedrooms four (4)
WATER SUPPLY
Individual Well::~3~: Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~x 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 72-025 fRev 8/86/ Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S & S Enqineerinq Telephone
Address 17034 Eaqle River Loop Road ~204, Eaqle River 99577
Date
Engineer'sSeal
This department has received written confirmation from the engineer
regarding the Conditional Approval of January 8, 1987. The corrections
have been accomplished and an inspection has been completed by the
engineer. The subject property meets with Municipal standards and is
now approved.
DHHS APPROVAL
Approved for four (4) bedrooms by ~ -'~' ""~'/',-~'-"~ Date
XXXXXXXXXXX
Approved Disapproved Conditional
July 14, 1987
Terms of Conditional Approval
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
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.
Page 2 of 2 72-025 fRev 8/86) Back
ROBERT A. SHAFER
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST ~
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
July 13,
1987
CIVIL ENGINEER
694-2959
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
Municipality of Anchorage
Department of Health and Human Services
825 L Street
Anchorage, Alaska 99501
RECEIVED
REFERENCE: Lot 11; Bear Park
A conditional Health Authority Approval was issued on the referenced
property in January, 1987. The conditions of this approval required
the on-site wastewater disposal system to be upgraded to four bedrooms.
This work was accomplished under permit #870150 and a copy of the on-site
~astewater disposal inspection report is attached.
Request yo~sue the final HAA at thiS time.
'.AS/ss
SRB 196X EAGLE RIVER, ALASKA 99577
MUNICIPALITY OF ANCHORAGE ~ :! ....
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date January 7, 1987
Legal Description (include lot, block, subdivision, section, township, range) "'::
Lot 11; Bear Park Subdivision
Location (address or directions)
Ursa Major. Street
(b) Applicant Name United Bank of AlaskaTelephone: Home Business 376-4147
Applicant Address Wasilla, Alaska
(c) Applicant is (check one): Lending Institution ~; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution same as above Telephone
Address
(e)
Real Estate Company and Agent
Address
Telephone
(f)
I~fl~[the HAAtothefollowing address:
S & S ENGINEERING
17034 Eagle River Loop Road, Suite 204
Eagle River, Alaska 99577
TYPE OF RESIDENCE
Single-Family [Xi Multi-Family []
Number of Bedrooms 4
Other
Page I of 2 ".' i"! 72-025 (11184)
attesting to the legality and status.
SEWAGE DISPOSAL ::!" ""
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to th~ legality and status.
Note: If community well system, must have written confirmation from the State Dep. artment of Env ronmenta Conservation
WATER SUPPLY '-
Individual Well [] Community [] Public [] "i~ ..
pROvIDI
5. ENGINEERING FIRM TIONS, TESTS, FILE SEARCH, D AND INFORMATION
As certified by my seal affixed hereto and as of the validation date sh own below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on. the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S & S ENGINEERING Telephone 694-2979
Address 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577
Date January 7, 1986
The existing on-site wastewater disposal system was installed in July,
1985 for a three bedroom residence and was approved for three bedrooms
on a Health Authority Approval application dated December 5, 1986. This
system will require upgrading for the existing four bedrooms. A Municipal
permit and new soil test will be required for the upgrade work to be performed
after breakup and Prior to July 1, 1987.
E n g i n eff..~.~-""~_
Approved for 4 bedrooms by te ·
' ' C~)nditiona ..~-
Approved Disapproved
Terms of Conditional Approval Funds are to be escrowed to cover cost of upgrading as stated above.
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP issues Health Authority
Approval certificates based solely upon the representations given in p~iragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. 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.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL \~ .(~-
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date //' Z
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~['~ ~~ Telephone: Home Business ~q
Applicant Address ~ ~ ~ ~o~ ~,~'~ ~sf[[~ ;~ ~
Applicant is (check one): Lending Institution~; Owner/builder ~; Buyer D; Other D (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
S & S ENGINEEI~!~G
SRB 196X
EAGLE RIVER, AK 99577
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [~' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
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 I of 2 72-025 (11,84)
ENGINEERING FIRM PROVIDIN~INSPECTIONS, TESTS, FILE SEARCH, D,A~A AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S & S ENGINEERING
SR B 196X
Address
Telephone
Date
EAGLE RIVER, AK 99577
DHEPAPPROVAL ,'
Approved for
Approved ~N, . Disapproved
Terms of Conditional ApProval
r ~ bedrooms by ~~(~, -~'~ Date
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. 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.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
DEPT. OF HEALTh
ENVIRONMENTAL PRO ~
I!
RECEIVED
WELL DATA
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /-/' ~ ~,_~5' Yield
!
~--~,, ~~ Depth of Grouting r .- -
Pump Set At t.,'/',/c.
~// Sanitary Seal on Casing (~N)
Depression Around Wellhead (Y/I~L~
· On Adjoining Lots
!
' On Adjoining Lots
Well Classification
Well Log Present~/N)
Total Depth ~--~ ~, . Cased to
Static Water Level / ~ /
Casing Height Above Ground
Electrical Wiring in Conduit
Separation Distances from Well:
!
To Septic/Holding Tank on Lot /
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhote
Water Sample Collected by
Water Sample Test Results
Comments ~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
¢_~ ~,,J~,~4,~4. · Date //-a-~
B. SEPTIC/HOLDING TANK DATA
Date Installed -7-/o- _~
Standpipes ~1)
Depression over Tank (Y~I~
Size /~c~ O No. of Compartments ~--
Air-tight Caps (~N) Foundation Cleanout (~N)
Date Last Pumped ~ ,.~ ~/ -~ Vv~.¢~- T'zc~,~¢t~'
Pumping/Maintenance Contract on File (Y/N) Ir'l~/ i~- ' for ~
Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
(ot4-
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation ~ D /
To Disposal Field J~
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -/¢~-
Width of Field c//,~2 It
,,..,.-.--.,
Type of System Design
Length of Field -~ ~
Depth of Field
Gravel Bed Thickness
[~ L~' ~:~ Standpipes Present ~.~/N)
12-~r-~, ~ Date of Last Adequacy Test
Square Feet of Abso~ea
Depression over Fi~/~ ~V
Results of Last Adequacy Test
Separation Distance from Absorption Field:
/o.'~/
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line /O I-lc'
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line /(3 /
To Existing or Abandoned System on
· On Adjoining Lots ~ ~ ;_fo
To Cutbank (if present) t,.//,~
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test· Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify tha,t,t Jaa~e..~he. ckecL~erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
a ~,~ ~'N(~INEERING,
Signed ,',~ - Date
CompanycA ~.,. ~, '~,,..--
,..-...L.= ,~, V"K, AK ~5~7 MOA No,
Receipt No. 2,~/ ~/,~'
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date r-~ _
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name~ ~~/ ~ ~ ' ~ r Telephone: Home
Applicant Address! ~--~'-"~ ~/"~ 2--f'~ ,=~-"~
Applicant is (check one): Lending Institution D ' Owner/builder [] ' Buyer [] ' Other [~ (explain);
Business ~'.,'¢~ ~'-¢-~ l'Z.._~'
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent _
Address __ ~-~./~- ~. L~:.. ~ ~/~,~,
Telephone ~ ~;i~-~
(f) e HAA to the fotlow~ng address:
, SRB 198X-'
TYPE OF RESIDENCE
Single-Familyj~ Multi-Family []
Number of Bedrooms ~'~
Other
WATER SUPPLY
Individual Well ~, Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
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 72-025 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by rny seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm .~ ~ ~ ~.;'~G~JF-.~ii~ Telephone
Address
Date
DHEP APPROVAL
Approved for ,~/-~-.~-~-~/bedrooms by
Approved ,/~ Disapproved
Terms of Conditional Approval
Conditional
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. 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.
Page 2 of 2
,~, '5~ c~ ~ '~ CHECKLIST-264_4720FEBRUARY 1984 i j U L ~ ~ ~iQ~,',~"~
WELL DATA
Well Classification
Well Log Present ~)N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit~)
Separation Distances from Well:
To Septic/H~dfl'T~ Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole ~
Water Sample Collected by
Water Sample Test Results
Comments
S ~¢. If A, B, C, D.E.C. Approved (Y/N)
Date Completed '~'"' ~-~ - ~ Yield
Depth of Grouting '--"-
Pump Set At t.,) ~ ~/'~,
Sanitary Seal on Casing ~,1)
Depression Around Wellhead (Y~.~
Cased to
· On Adjoining Lots
~ c:>'~ ' · On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
B. SEPTIC/H~L-BfN~ TANK DATA
Date Installed
Standpipes ~N) Air-tight Caps ~'N)
Depression over Tank (Y/.~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Sepbc/~ ...... = . ank.
To Water-Supply Well ~ IG:~"~
To Property Line \ ~ ~-~-
To Water Main/Service Line .~t~ ~ ~
Course
Size t, ~=,~:, No. of Compartments "2-
Foundation Cleanout~N)
Date Last Pumped
t.~ j,~ ' for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-~26(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~..Z.-~' ¢
Date Installed ~ - 1 ~-- ~'
Width of Field ~ ~
Square Feet of Absorption Area ~:~ ~' ''~
Depression over Field (Y('~
Results of Last Adequacy Test /~/~
Separation Distance from Absorption Field:
To Water-Supply Well ~ c:=,."~ ~
To Building Foundation "~'~ ~
Lot t,~
To Water Main/Service Line ~ ~"¥"
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
II:z~fL-~ Type of System Design '"~.~1.
!
Length of Field ~ ~
Depth of Field L
Gravel Bed Thickness
Standpipes Present
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~ ~
To Cutbank (if present) tl' I~'
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed
Compan'~,
PH.
Receipt No. '"
P ym nt q- 5
Amount: $
Page 2 of 2
72-026 (11/84)