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Home My WebLink AboutHAMANN LT 18 Municipality of Anchorage Page 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 Report Neme: r~,/~./'T ~/t%y Wastewater System: ~New ~ Upgrade -- ~o of ~droo~s~ Phone: ~ ~¢ ~ ~ ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound C Other LEGAL DESCRIPTION so,, Rating: Total Depth from original grade: LoL / ~ Block:~ ~ ~ ~Subdiv"si°n: Depth ~o pipe bottom~ ~fr°m original grade FL Gravel depth ~,benea~h~ pipe Ft~ ~ Gravel width: Number of lines: Distance between lines: WELL: ~¢r Q New Q Upgrade ~ F~ / Classdicahon (Private, A.B.C) Tolal Oep[h: Cased To: Total absorption area; Pipe material: Driller: Dale Drdted: Slahc Water Level Installer: ~/~% Dale inslalled: Ymld:GPM Pump Se~ at: FI Casing He~gh~ Above Ground:Fl. TANK SEPARATION DISTANCES ¢~.~io ~ Holding ~ S.T.E.P. TO Sephc Absorption La~ Holding ~ubhc/PrwaleManulacturer: Capacity in gallons: Well ~ //~ M.t.rlah ¢ 7~.4~ / Numbe~Compartments: SurfaCewater ~/¢¢ ¢/¢¢' ,' .¢ ¢/¢¢ LIFT STATION Lot ,} ¢ ~2~umD &if" lever at: ..... ~h water alar~ al: Foundation %¢ 7% ~ ~" -- CurtainDrain -v ~¢ ~ ~/~ 4 /~ ~um~%del Electrical Inspeclions performed by: Remarks: BENCH MARK Location and Description: Assumed Elavation:/ ~ ~ ~ ~, Department of Healthand Human Services approval .,,~,.,.%,,, ....... Reviewed and approved by: ~ : Date:/D -2¢-:{~ 72-013 (Rev 9/91) MOA 25 Permit No, SW970149 P~De 2 Hunicip~Li~y oP Ancho~9e SEPARTHENT 8Y H(ALTH AND HUHAN SERVICES ENVIRDNHENTAL SERVICES DIVISION P.B, Sox 196650. Anchorage, Alaska 99519-6650 oTe[ephone: 343-4744 Dh-Site Was~ewa~er Disposal System and/or We[[ Inspection Report Legcd Description',LOT 18 HANANN SUB, PID No,: 05062105 SCALE 1" ~ =60' ,, ALL SEPT[CS [00' ~///42,~ ~ FR~N WELL ALL WELLS +100' SWINGTIES A-C = 52].8' B-C = 90.9' A-D = tOO.?' B-D = 91.7' ELEVATIBNS (NDT TO SCALE) DR IVEWAY B C ^ L .~'~' SEPTfC TANK [~TH2 [~rH1 TOP DF H~USE FDUNDAT[BN ASSURED ELEV = 107.97 GROUND I ALL WELLS +tO0' FROM SEPTIC ALL SEPTICS lO0' FRON WELL ~ - TEST HOLE PROPOSEO LF..&CHRELO 10/13/97 by t:~O. DO~ 670272, CHUGIAK, AI..A~KA 99~7 · 7~L~PHON~ DEPTH TAX INDENTIFICATION NUMBER 0~ ~- ! ~- Is well located ~t approve~ permit location? ~' ~ No Melhod of Drilling: ~J~ ~t~ ~ cable tool Casing Type J'7~'~__VVall Thickne~s._~ inches Liner l~pe' _ ~. Casing Sfickup Abeve Grouted: ~ feel Static Water Level (l'rom gN~uml level): ...... ~_~ _ feet Pumping level: ....... feet aiter bm. pumping ..... gpm Recover Rate: _ ~ O ~ __gpm Method of Tesling: W~II Intake O~eqing Type: ~pen End ~ Open Noie ~) Scceened: Slar[ ........... leto Stepped ........ feet [~ Perorations S~arl fe~t Stopped feet Grout TFp~: t~ ~, .-J. ~ Volume ~ 5 OL Oep~h: [rom ..... (:~ ...... feet, ~o ...... feet Pump Intake Depth'. ........................... Pump Size ................ hp ~and Name Well Disinfected Upon Commie{ion? ~ ~ No I. Driller'9 Name ATTENTION: It is the responsibility of tl~e proper~ gwner to submit a cop~ of lbo well log to the prope~ authorizy_ Of Anchorage: Depat[m~n[ of Health & Human 8e~ices and/or Depadment of ~nvironmental Cense~afion Depadment of ~nvironme~[al gonse~atiorl. --,,ECEIVED ........ --j-b N .................... Municipality of Anchorage P/ (? ('0/-'c-' ! PAGE MUNICIPALITY OF ~NCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970149 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NANE:SMITH PERNIE R OWNER ADDRESS:1515 MARTEN STREET ANCHORAGE, ALASICA 99504 DATE ISSUED: 6/24/97 EXPIRATION DATE: PARCEL ID:05062105 LEGAL DESCRIPTION: HAFL~NN LT 18 LOT SIZE: 182952 (SQ. FT.) NUMBER OF BEDROOMS: 6 THIS PERMIT: 6 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM 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 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. 1 OF 6/24/98 1 SPECIAL PROVISIONS: ISSUED BY: Eagle River Engineering Services Louis Butera, P.E, P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 f~ May 30, 1997 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Hamann Lot 18 Narrative & Permit Application Dear Mr. Cross: The proposed well and septic system will have very limited impact on adjacent properties for the following reasons: I. The surrounding lots are large, allowing sufficient room for septic sites. 2. hnmediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to absorption capacity. 4. Drainage will not be affected and is not a major consideration in our design. If you have any questions please call om' office at 694-5195. Sincerely, Louis Butera, P.E. MUNiCiPALITY OF ANCHORAGE ~NVIRONMENTAL SERVICES DiViSION RECEIVED \1997\97-028-NAR.DOC EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 Eagle River, Alaska 99577 (907) 694-5195 ERES Project No.: 97-028 Calculated By: LB Date: 6/11/97 Legal: Hamann Lot 18 Single Family 6 Bedroom Dwelling TEST HOLE Deep Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = 900 gallons Percolation rate = 1.22 minutes per inch Wastewater application rate = 1.2 gallons per day per square foot Required absorption area = 750 square feet Trench width (VV) = 3 feet Gravel depth (D) = 9 feet Required length = Required absorption area / 2 / D Required length = 750 / 2 Required length = 42 feet Total Excavation Depth = 12.0 feet / 9 · / ~ - TEST HOLE · - MONITOR TUBE o - S~ER CL~NOUT + - WELL NO SURFACE WATER ~SEMENT NO KNOWN CURTAIN DRAINS ~ PROPOSED L~CHFIELD ~- EXISTING L~CHFIELD W E L L/S E P TI C S IT E P LA N LEGAL: H~monn Lot 18 JOB~ 97-028 DATE: 5/50/97I SCALE 1" = 10C k EAGLE RIVER ENGINEERING SERWCES P.O. Box 77329~ (9o7) s94-s ¢ ss ~x.. 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 SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Hamann Lot 18 5/30/97 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 of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. 4. All soil 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 responsibility of the owner to obtain all necessary permits or easements and to locate 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. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. 9. Any remaining open test hole excavations shall be filled. B. SEPTIC TANK 1. Septic tank shall have a minimum capacity of 1,750 gallons and be a MOA approved design. C. TRENCH 1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom. 2. The bottom of the trench shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 12' at any point. 4. The effluent line within the trench shall be laid level within 0.03'. 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth oft or equivalent is to be placed over the leachfield. 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and [eachfield 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 = 12' GRAVEL DEPTH = 9' under pipe, 2" over pipe TRENCH LENGTH = 42' TRENCH WIDTH = 3' SOIL RATING = 1.2 GPD/ft2 BEDROOM CAPACITY = 6 SEPTIC TANK = 1,750 gal rain Twenty-four (24) hours notice reqnired for all inspections. \1997~97-028-spc.doc LEGAL DESCRIPTION: ? 12 14 18 19 20 · COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG ~ PERCOLATION TEST DATE PERFORMED:' Township, Range, Section: WAS GROUND WATER ENCOUNTERED? Loose IF YES, ATWHAT DEPTH? Depth Lo Waler After Moflil~rinll? SLOPE SITE PLAN Reading Date Gross Net Depth to Net Time T~me Water Drop Io Io PERCOLATION RATE ~.. ~-'~ (m~nules/inch) PERC HOLE DIAMETER .~" TEST RUN BETWEEN _ '~ FT AND 8 FT PERFORMED .qY; M'~' J~ I ~C P',~c 5 ~'~-~--~-ERTIFY THAT THIS TEST WAS PERFORMED iN ACCORDANCE WITH ALL STATE AND MUNICiPAL GUiDELiNES iN EFFECT dN THiS DATE. DATE, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~) / '/'~-- y CEGAL DESCRIPTION=, pS ~. ~ /./~ DATE PERFORMED:' O~ - '~%- ~'7 Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 '11 12 13 14. 15 16 17 18 19 20 COMMENTS T P,/kC..E SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED;:' IF YES, AT WHAT DEPTH? Oepm to Water Alter Monitoring? Reading Date Gross Net Deoth to Net Timo Time Water Drop 5 ~'.~ · ~!~ 'GM- PERCOLATION RATE ...~-,,'~ ~ (minutes/inch) PERC NOLE DJAMETER ~" ~ TEST RUN BETWEEN ~ FTAND ~ ~FT PERFORMED BY: /~/', ~ ~ ACCORDANCE WITH ALL STATE AND MUNICIPAL MUNICIPALITY OF ANCHORAGE Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC251004 Parcel ID 050-621-05 Expiration Date: O 2- D Legal description HAMANN LT 18 site address 24415 WILMA CIR Current property owner(s) MORTHORPE PARIS D X The On -site system(s) is/are approved for 6 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: The septic tank was not able to be pumped due to road conditions. Pumping has been prepaid and will be completed by JRs Septic spring 2025. Their number is 907.694.6454. New owner to confirm that this is done. JRs and the engineer are to report to MOA when this is complete. By: A Original Certificate Date: 1 /7/2025 This Certificate of On- ite Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist Absorption Field Advisory Tank Age Advisory Other X Well Flow Advisory Nitrate Advisory Arsenic Advisory Z�5_ Development Services Department On -Site Water 1A/oc+,=%Aio+,=r Section n +i 1� o " Phone: 907-343-7904 Fax. 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 05062105000 Complete legal description Hamann L 18 Location (site address) 24415 Wilma Cir., Eagle River, AK 99577-9680 ., Current property owner(.) Paris Morthorpe 2. ON -SITE SYSTEMS SIZED FOR 6 BEDROOMS Day phone 907-223-7522 3. TYPE OF WATER SUPPLY: MR Private Well R Private Well serving 2 dwelling units R Private Well serving 3+ dwelling units [:1 Community Well or Public F71 Water Storage 4. TYPE OF WASTEWATER DISPOSAL: FE-1 Private Septic E] Private Septic serving 2 dwelling units El Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: OR Steel R Plastic EJ Concrete R Fiberglass Age 27 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: F-1 AWWTS ❑ Bed X Deep Trench R Wide Trench R Seepage Pit Waiver request for: Expedited review requested: FE-1 Distance: By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ 6 EV LDate of Payment i COSA# SCE ILL( Waiver Fee $ Date of Payment Waiver # COSA Application —June 2022 IMUP11,411CIPALITY-OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT � '"'� 907-343-7904 1 On -Site Water i2 Wastewater Section f' 6-ax:343- 997 evilFnJltsf.C'nuti6.o§`g/ori.`si'Ee i Septic Tank Advisory Certificate of On -Site Systems Approval # OSC251004 Subdivision: HAMANN Block: , Lot: 18 The septic tank for this property is 27 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more, not including engineering, surveying, MOA permitting fees or site restoration. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. v _; Mailing Address:'P.`o. Box'1966506 *Anchorage; Alaska 99519'66504 www.miuni org , COSA Checklist Legal Description: Hamann L18 Parcel ID: 05062105000 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system 1 A. WELL DATA 110 Well log is filed with Onsite (or attached) Date drilled 5/22/98 Total depth 121 ft Cased to 121 ft FO-1 Sanitary seal is functioning correctly INE Wires are properly protected Casing height (above ground) 46 in. Date of flow test for COSA 1 /2/25 Static water level at beginning of test 19•8 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 49 Date of pumping See Comments ❑ Required maintenance completed, if AWWTS Comments: See below D. ABSORPTION FIELD DATA Which system tested (date installed) 9/12/97 ❑ ALL standpipes present per record drawing Total measured depth from grade 12.1 ft (max) Measured depth to pipe invert from grade 3.75 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 8.35 ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) no If yes, enter date Well production at time of test 6.7 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes X Nc F011 Coliform bacteria is Negative Nitrate 4.426 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑■ Arsenic less than MRL (ND) Collected by Brandon's On -Site Services, LLC. Date 10/29/24 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 1 /2/25 Results 0 Pass Fluid depth prior to test 0 Water added 904.8 gal New fluid depth 2 in Elapsed time 1440 min Final fluid depth 0 in in Absorption rate 900+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 108 in Effective depth used 7.8 in Effective depth remaining 100.2 in Comments/Deficiencies: The property is inaccesible at this time, the pre paid pumping will take place in the spring of 2025. The interior foundation cleanout is presnt and can be used inplace of the missing outside foundation cleanout. COSA Checklist June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Ceeanout > 100' Dn Yes if No ft M Yes if No Neighboring Tank > 100' FE] Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No Absorption Field on Lot > 100' '� Yes if No ft Holding Tank > 100' QYes if No Neighboring Absorption Fields > 100' Animal Containment > 50' ❑N Yes if No n Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑Q Yes if No ft Q Yes if No ❑ N/A - Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑m Yes if No ft Surface Water > 100' 0 Yes if No Tank to Property Line > 5' ro-1 Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' Foil Yes if No ft Private Wells > 100' 0 Yes if No _ Water Main > 10' ❑m Yes if No ft Community Wells > 200' ❑Q Yes if No _ Water Service Line > 10' 0 Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS The outside foundation cleanout was not accessible due to being cut off below grade due to its location. However the existience of the cleanout was proven by JR's Septic when they camera snaked the inlet line through the inside foundation cleanout and found no evidence of foreign debris inside of the inlet line. ft ft ft ft ft ft ft ft G. CERTIFICATION & 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, indicates that the on -site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Walden CONST. CONS. & ENG., LLC. Phone 907-354-6661 Engineer's Printed Name Robert Walden COSA Checklist June 2022 Date 1 /6/25 RESIDENCE SHED TWO STORY RESIDENCE 84.1' 40.2' 26.3'8.0' 12.0'1.6'9.7'1.6'11.9' 10.0' 24.2' 42.2' W/ WALKOUT BASEMENT 2.1' CANT. LEGEND FOUND 5/8" REBAR, NO CAP GRAVEL DRIVEWAY UTILITY PEDESTAL DECK CONCRETE POWER POLE EDGE OF ASPHALT RECORD DATA PER PLAT #73-173 SEPTIC PIPE WELL FOUND 5/8" REBAR, PLASTIC CAP SATELLITE DISH ELECTRIC METER TIMBERLINE SURVEYING AND MAPPING 17035 BARONOFF AVE EAGLE RIVER, AK 99577 907-242-5320 ryan@timberlinealaska.com FILE NO.: 24.196 SCALE: 1" = 60 FEET DATE: 1/2/2025 SHEET: 1 of 1 MOA GRID: SW0261 SCALE: 1" = 60 FEET(11"x17") 60'0' 120' AS-BUILT OF: ADDRESS: 24415 WILMA CIR, EAGLE RIVER, AK LOCATED IN: ANCHORAGE RECORDING DISTRICT LOT 18HAMANN SUBDIVISIONPLAT #73-173 NOTE: RECORD PLAT #73-173 CONTAINS NUMEROUS MATHEMATICAL ERRORS AND MISCLOSURES. THE FOUND MONUMENTS SHOWN HEREON WERE HELD FOR THE LOT BOUNDARY FOR THIS SURVEY. A BOUNDARY SURVEY WILL BE NECESSARY TO VERIFY OR DETERMINE THE TRUE BOUNDARY. HOUSE DETAILSCALE: 1"=30' Parcel I.D. # 1. MUNICIPALITY OF ANCHORAGE ' ,('~'~ %.. / / DEPARTMENT OF HEALTH & HUMAN SERVICES ~ "~-~' Division of Environmental Services ~ On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 425?Dd~_/~\, NAA# ~ ("~ ~:~ ('~ ~ '~ "~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent ~-' Address Day p h o~n e...9~,~ ,~¢ Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation front State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~025 (Re','. 1/91) Front MOA ~t21 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ?.O. ~o~ 22~, ~ ~,~ ~2~ Phone Address EngineeCs signature DHHS SIGNATURE J Approved for -~' Disapproved. Conditional approval for bedrooms. 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 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 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-O25(Rev. 1/91) Back MOAt-21 Municipality of Anchorage ,/~.~J~ DEPARTMENT OF HEALTH & HUMAN SERVICES JUL 0 6 1999 Environmental Services Division w~ur,lK=,ti,'ALIT¥ OF ANCHOJ, 825 L Street, Room 502 · Anchorage, Alaska 99501 · (9~~RVlC~S DWlSION Health Authority Approval Checklist Legal Description: A, WELL DATA Well type ,'~/z/V,,-4'z8 Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D.: If A, S, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Date completed Cased to / '-~-~ / Y Wires properly protected (Y/N)_ ~.~ Date of test Static water level Well production FROM WELL LOG AT INSPECTION g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed ~ -~ '7 '? Tank size Foundation cleanout (Y/N) Date of Pumping /,¢/,4 __ Nitrate ~,'545 Other bacteria Collected by: ~...2~,-.~ Number of Compartments ~ Cleanouts (Y/N) Depression (Y/N) r,J High water alarm (Y/N). /v/.,1 Pumper ~ C. ABSORPTION FIELD DATA Date installed ? ~ 5* Length ~ ~ Width Effective absorption area 757~ //5 Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Soil rating g~._~p..d,/fl~ff~r ft2/bdrm) / Gravel thickness below pipe Monitoring Tube present (Y/N) Results (Pass/Fail) System type. Total depth _ Depression over field (Y/N) __ For (~, Immediately after ~gal; water added (in.): Absorption rate = ---- .g.p.d. If yes, give date -~- bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access Size in gallons "Pump on" level at* *Datum "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on' lot /O'"d~ / Absorption field on lot /~ / Public sewer main /v / Sewer/septic service line '/~ o On adjacent lots f' /5~;~ " On adjacent lots z~/o~" Public sewer manhole/cleanout /¢' I ~ Lift station /v' 1 ,A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation _~-~ ~ Property line ,~3- ~ Absorption field ~/z.~ Water main/service line ¢-/o t Surface water/drainage -/-/0~¢ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ~:;O / Building foundation Surface water '/-z ¢ ~) ' Water main/service line /-/~ / Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots /-/~ / ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number