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Home My WebLink AboutMOUNTAIN PARK ESTATES BLK 8 LT 2Mountain Park Estates Block 8 Lot 2 #017-391-40 MUNICIPALITY OF ANCHORAGE ZVI, 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address TO SEPTIC ABSORPTION T :15115 Na No. of Bedrooms tl-C�`1/l3 I_82OZ6� LEGAL DESCRIPTION Sobdiwsion Lot Block IN Township. Range. Section YANKS X SEPTIC ❑ HOLDING Manotactmer capacity in gallons Matenal No. of Compartments TYPE Or SYSTEM []TRENCH RED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom TO., �_ Iotal depth Iron original grade onglnal rade 11 I �T%llcUD 5«f L" 6111) FII added above original grade _ Gracel depth beneath pipe 6-) lJ Lll TII Gravel lengtli Gravel width 4o' _ FT Total absorption area Distance between Imes 71-1)G' Sp FTI 61 Number of tinesSoil rating pip . material �7 /40 SO FT 1-S 1 �t i7 w-S�j ?Saeid J[ess'C' Id, Installer Q O Date Installed FT FT FT FT WELLS ❑ PRIVATE ❑ OTHER Ndenti(v) � N Classlhcation (A, B,CI Total Depth Cased to L Instaum - Date Instaeed. FT FT REMARKS: V/l -I FIE [) .S 0i -1-1U4" _— SDI[_S - / /!/r?LVGCYyI -J� k'x (Gly Scale: � // Inspections Performed by. _9 y Y �PS` 'Arze� 4' ecs� ��DALE -C_rr-In is -IQ lied /1�X ({ � Y!� A r 11 i r ' _') certify ghat this inspection was performed according to all Municipal and State guidelines in effect on is date: Health Department Approval:V!�C'L' L_ Date 72-013 (3185) �rr NAu.N ®E ENGINEER'S SEAL _ a et { 1 cl t FROM TANK FIELD WELL WELL LOT LINE �C9r e, Xisi. FOUNOATION r r y r i. X1S T. AS -BUILT DIAGRAM (Show location of well septic system, property lines, loundaaon, driveway. water bodies, etc-) A4 I o 1 Er C. _ '. FT FT FT FT WELLS ❑ PRIVATE ❑ OTHER Ndenti(v) � N Classlhcation (A, B,CI Total Depth Cased to L Instaum - Date Instaeed. FT FT REMARKS: V/l -I FIE [) .S 0i -1-1U4" _— SDI[_S - / /!/r?LVGCYyI -J� k'x (Gly Scale: � // Inspections Performed by. _9 y Y �PS` 'Arze� 4' ecs� ��DALE -C_rr-In is -IQ lied /1�X ({ � Y!� A r 11 i r ' _') certify ghat this inspection was performed according to all Municipal and State guidelines in effect on is date: Health Department Approval:V!�C'L' L_ Date 72-013 (3185) �rr NAu.N ®E ENGINEER'S SEAL _ a et { 1 cl t MUN/(�lPAL{Y DF HNCHORAGE Department o[ Health & Human Services 825 L Street, Anchorage� Alaska 99501 343 - DN -SITE SEWER PERMIT ��\�Q��h� PermiL N�mdzer: 890263 Upg'`ade +��«��u '��"`~=" Daie 1ssued: 11/17/89 Engineer Desicned Uwner Name: LUMAS MOTGAGE USA Uw:er Address: PO 8UY 226407 DALLAS, lX 73222-64()7 Parce1 1�: o17-!91�4� ioi | ega1: Subdzvision: S�ctzon: 26 Lo� Size �V400 (sq.�t Max ooms: ��hzs Permi�: Ml` iARk ��i. Lot: Ulock� 8 �ownship: 1�N Range: 3W or acres) 3 Total Capacit�: 3 Day Phone: 561�0820 S!�Pl|C TANK: � Iinimum total ptic tank capacity: 1,000 god ]ons. Each sepL1,c (ank must have at least 2 compartments. Depth to top o< septic tank(s) < 4.0 fP-0et requires insulation over tank(s). I CER7IFY THAT: 1 l am {amiliar wzth the requirements �or on�site sewers and we1ls as seL forth by the Municipality o/ Anchorage (MOA> and the State o4 A1aska. 2. I 1 ii}1 stall the system in accordance with all MOA codes and regu1ations� wk in compii all ce with the design criteria o is permit. J. T wj1] adhere Lo a11 MOA and State o{ Alaska requirements {or the set back ��stances f/ um any exipit. ing 04e1l, wastewater disposal system or public sewera§e system on this or any adjacent or nearby lo".. 4. ] understa:d that this permit is valid 1or a maximum of 3 bedrooms, l a}so undersiand thai the ca;aczty o( the total system is 3 bedrooms and any pnlargemenc will require an additional permit. �~///�/'`�' t x ^ a Municipality. of Anchorage K DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: I—A WN 1=. MAF' Al AS KA DATE PERFC LEGAL DESCRIPT(ON:J==pT Z, 9 L L 0 Township, Range, Section: `l-- I J LI C �: 1q 52 6, DEPTH MT PAC ES - TAT ES SLOPE SITE PLAN (FEET) OM 2 n J I P G -0jeGi sct,j / 1 3 d S m 1 1 J 5 fone5 7_ 4 5 6 s l+y Jc rave l 7 �s 10 WAS ENCOUNTERED? ER ._IV..0 ENCOUNTERED? IF YES, AT WHAT OL i "- 12 DEPTH? P E{LD E 13 Dep U Water M �MGabrin ? Dale: i Depth to Water 0 14 . 75 16 17 ■■��'' 18 Vii.■■ 79 10 WAS ENCOUNTERED? ER ._IV..0 ENCOUNTERED? IF YES, AT WHAT OL i "- 12 DEPTH? P E{LD E 13 Dep U Water M �MGabrin ? Dale: i Reading Date Gross Net Time Depth to Water 0 14 . 75 16 17 18 79 Reading Date Gross Net Time Depth to Water , jj ENetTime 20 PERCOLATION RATE ( 33, 33 E ` ` rtunutes7inch) PERC HOLE DIAMETER ' / TEST RUN BETWEEN l� FT AND '- F7 rO"UrNTc ��— l�ror),/ a l'i.��.�1' �c ,,A I/lCi;r � � / r-,-, -/7n -J- I z / cam, l a f"I— S PERFORMED BY: f I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE: I 72-008 (Rev. 4185) CERTIFY THAT T IS/TJ�q/G�'T� WAS PERFORMED IN THIS OAT E. DATE: _ //fir i 1 c (l o WELL f �� I IEC WELL a SEPsYS,— / J 10 E�^^NE °o s'* /o,�. ° SEPTIC, �r` J F SYS. J VJ p SEPTI r- O N(-. In SYS. W Lt OKIDEVELOPED WE Q LOT 2Z I WEL 2" INSULATION TO BE IH.STALLED OVEP 2 6EO FABP_IG IF COVER IS 2 -- LESS THEN 3' 660 FABRL-_ 0 or Ii, I'6"SEweP 4" PE2F PIPE ROC, K Proposed System: BED 3 Bdrm) (150 Soil) (1.5) = 675 sq.ft. Required Construct Bed 18' x 38' = 684 sq.ft. Verify Integrity of existing Tank. Install 500 gallon Lift Station_ M.O.A. Approved Insulate Bed with 2' of High Density Styrofoam. IF COVER IS LESS THEN 3 FEET. INSTALL LIFT STATION BETWEEN TANK & BED IN ACCORDANCE WITH M.O.A_ SPECS. ALL CONSTRUCTION TO CONFORM TO M.O.A SPECIFICATIONS. COKISTF,UCT BED NoWITOP PIPE\ All 4" PEPF PIPE E 18' FPOM LIFT .STAT IO N L NOT . All Dimensions And Locations Must Be Field Verified Prior To Construction SEWER SYSTEM LOCATION PLAN LOT BLOCK( I SUBDIVISION 2 8 Mountain Park Estates R ' `•jI SECTION/ TOWNSHIP/ RANGE i ms: S 26 T12N 3W SCALE, NOTE +k Approx. J"=100' The Accuracy Of Location Of Exisi ting And Proposed b t^•' uc�+o�an"�"._ �� Sys to-aIndlatcd iscNot Wells, Bzactm OiSepticnd ens ons DRAWN BY, r. . Jerry Kress' Indicated 11"e Been DetcMined By Use Of Cloth NORTH F h P s •�; * Tape and or Municipal Re -cords, And Not By ry Sueying Techehniquiques 44 CtirSZti3 11-10 t , 1 PREPARED FOR, (f ...Oman _a�4 �^ ^$Q(�,� 95�r a ' FANNIE MAE ALASKA �y �^ v �1'Y•L'1PAii.`IWT'\(VWI DATE-- SHEET 10 89 SHEET 1 OF 1 }3' 6' 6' 3' I 0 ro to M NOT . All Dimensions And Locations Must Be Field Verified Prior To Construction SEWER SYSTEM LOCATION PLAN LOT BLOCK( I SUBDIVISION 2 8 Mountain Park Estates R ' `•jI SECTION/ TOWNSHIP/ RANGE i ms: S 26 T12N 3W SCALE, NOTE +k Approx. J"=100' The Accuracy Of Location Of Exisi ting And Proposed b t^•' uc�+o�an"�"._ �� Sys to-aIndlatcd iscNot Wells, Bzactm OiSepticnd ens ons DRAWN BY, r. . Jerry Kress' Indicated 11"e Been DetcMined By Use Of Cloth NORTH F h P s •�; * Tape and or Municipal Re -cords, And Not By ry Sueying Techehniquiques 44 CtirSZti3 11-10 t , 1 PREPARED FOR, (f ...Oman _a�4 �^ ^$Q(�,� 95�r a ' FANNIE MAE ALASKA �y �^ v �1'Y•L'1PAii.`IWT'\(VWI DATE-- SHEET 10 89 SHEET 1 OF 1 Municipality of Anchorage l 4d1'11�5 Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 December 22, 1989 Corwin & Associates, Inc. 1000 East Dimond Boulevard #205 Anchorage, Alaska 99515 Re: Lift Station Approval For Lot 2 Block 8 Mt. Park Estates PIN 01739140 Dear Mr. Corwin: Your design submittal for the lift station installed on the referenced lot has been approved. This approval applies to this submittal only. Future construction of lift stations will require an application to this office with the attendant plans and specifications for approval prior to installing. Sincerely, J n Smi , P.E., Manager -Site Services Program cc: Daniel J. Roth, Civil Engineer, M.O.A. MUNWIPAUTY 0j- I�J\1(�!-;OHAGE` ,� Q " DEPARfMll or, HEALTH R -O-1 I (,Il0r\j X; FAIVIRONME.NIAl. FNl(',1NF1-l1I1\JG DIVIS101\1 825 L StoOnt - Atl(horaqc, Alaske, 919'EJ 'I Tplet)l-wne 264-11790 ON -811T. ICIFIZ DISFOSAL r"Y('.'i Al WFj �fJl_Yn_jN1 - F_ Trini Amador NEW 1272-3571 1 J UPGRADE MAILING ADDRESS 844,West 5th Avenue, Anchorage. Alas_ka_ 99501 LEGAL DESCRIPTION - Lot 2, Block 8. Mountain Park Estates LOCATION NO, OF BEDROOMS 3 7'e I T DISTANCE TO: 100' rea Dwelling LRMHT_r7i6_.__-- 7 7T 81 16' 810778 f- z MallUfaCtUrej M< Miterial I\JO. of compattments LL] Greer I 0) steel 2 Lic. capacity i - ____=In��id _teng_t_h_____-- — n gallons Li IF HOMEMADE Width ClUid deptil I ANCE 7vvp7nq (D;p PERMIT NO. anufacturet TO L�dc�_Pac_ityin g-a—Ilons— Matpri 0 DISTANCE 1-0 oundation _Mo 71rl-st- I I I ine PERMIT NO, Ec Velljj VV V W 001. _jF,;Uz No.ol -T-1pen cq :0 �of Mil leogth 0�1�s T,ench oicith each Fine 2 LU T Distance between lines _____2__ 381 + - 19 1 5 7 24 inche's I- rop of tile to Enish grade 4 grav 96 ncl)es )q7��--kAjidth 912 s_q_.ft. Deptl) I —IN CT___ r C� b depth Total effective lbsorption arna < I- Type of crib DISTANCE TO: Well Puilding toundqtjorl Neirest lot lire I Let Distance to lot ine Building founell W 4P DISTANCE TO: Alh�olptlon Septic tank OTHER _MPE _MATERIALS SOILTEST RATING ....... f7L— Jame Riiigsta 251 sf/bedroom 0 r-a-Q— INSTALLER Monty Aches —on N —REMARKS The drainfield trench was inspect as 1 � indicated on the perc test, T_ soil en- countered was predominantly a grey gravelly sandy sil Ltn. One exse tion to the soi --p Ui I J\ log on the perc was a 4" sand seam at about 5' in depth.__Altho�h h some water seepag 44. _4_4 was evident through this seam after exca- vation, no seepage was apparent after a gjLi� Q d - - - - - - - - ...... TAP'R"O' rV_ E D" DATE LEGAL Kevin Braun November 6, 1981 72-013 (Rm 3/78) F:, E :DF !i;I. - .1 D 1: = I'T C111.1 I- k! E 1'.1 C F9 SOIL FR1:1-1-11,J3 (ty; Flyf3po�i., 12!yj, u :f L. S 11-.: 11 1 If 11 , 11 121 -T- 1-1 oil Fit Fw 142 K L- In. FE M ..H....1-1 F'E 1:---! 01 "1 1:::- F::, t, 1 C�: I,.,I I "FID T NF:. (..I F! I., I -I PIP .1 G H -IE 1: L. L r. T A I 'I Cj -1, f 1 1 1. C::T 1 C) F J . f C: E: I' I Y F1 1441T ME kjE:j 1, JF F." -.11 if - C: k: F, T 1... 1. . 1. 1. H., . . . .......... 'I I . Kim - Fr FAMS, INSFIECTICIN MD FIFAMOM. BY ljjp::: F." EF:, FIF: 1 1-.1 11 1: 0 P-4. A. YEN 10,11— I WEE fit E) F1 T/2.;oo/ CONS -I ,JC-_I_10N I -EST LAB PERFORMED FOR: _EGAL DESCRIPTION: THIS FORM REPORTS TRINI AMADOR Lot 2 Block 8 O Visual Soils Examination DEPTH SOIL BEET DESCRIPTION I Peat & Organic - Pt --- 16' Grey Gravelly Sandy SILT - ML BOTTOM OF HOLE a$° WAS GROUND WATER ENCOUNTERED- NO IF YES, WHAT DEPTH I �KM QD — Perc zone &S - Sample taken ly — Frozen zone V — Water table NOTES 18C W 48TH AVE. STE. 'C' ANCHORAGE, ALASKA 99503 248-1333 DATE PERFORMED: Subdivision Mt. Park Estates OPercolation Test XX 81-1602 JULY 2.2, 1981 ° .° Y°°°O.° e .° e �. ;° Kinney R. Baxter Ki1(4� dJiF°• 3656-E �ta� 9� •a°, °° ��'•�v 8 <oa °e.°•.°.° �ii� nOrFc�.t(1NPa� READING DATE GROSS TIME NET TIMEDEPTH TO H2O NET DRAINAGE _Lni-t _a — _ 1 -- 9:00 15 nia26"6 - 2 min-" 8' 3 - 4— 9: 30 15 min.36" — 2.1 38'1 2.1 —- 30 min. 40" 9 _ 5 10:15 PERCOLATION RATE. _30 Min/inch _DRAINAGE REQUIREMENTS 250 sf/br PROPOSED INSTALLATION: O SEEPAGE PIT XXX DRAIN FIELD O OTHER, :OMMENTS : Primed hole 7/22/81 9Field percolation rate 15 min/inch.) Due to the classified materia t e rainage requirements s ouldTeincrease to a ow or c ange con itions --inearea. he firs es ee eas , aiTe�T an cau ion s ou cen o avoi t� are o t e first test. - _ r TEST PERFORMED BY: Sam McDaniel_ DATA CERTIFIED BY: Kinney R. Baxter, P.E. DATE: 7/27/81 LY) LLJ 0 z L4 I.4 F—: SLLJ LU f-4 lo P7 W ;e. > . I Q) Ll 0 In Ul 0 0 (d 0 e,;, Im 1L) kj J3! T:0) 0: Of LL4 C\1 0U: OD: cq: 0 C): LT� v): LTI N r i l cr) LA 4 13-1 1j, LE IT, DAILY DRILLING LOG SYREN BROS. DRILLING, INC MUNICIPALITY OF AN(YqOP. AGE ' ' , ', ' ENVIRONMENTAL PROTEC~K~N .' n~w~,,. 260' ' DEPTII ............................................................ 1%?' from round level STAI~¢ LEVEL OF WATER FT ................................. .~ ............................ DRAW no',~ FT..:~..: ......................... '.....~ ............................................. D'~ ~ StAi~TE D.:...LO.:!.O...-...8..~ ........................................................... DATE: ENDED ....... ~,.0...-..1...2...-...8...1_ ................................................. GALS. PER II~n.,~ ............................................................................... v. 6"/~ Grd. B steel K,ND oF c.~sm~ ........... ~.3Z ........................................... --. KINDOF. FOR.MATION: ' ' : · ~o 82 sandy clay loam ~nn,a 82 FT TO .97 .... FT gr.a.v, el ............. = pxaces FROM FT TO .......... FT .................... 1 7 .~ ~-. 2~0 r.~ bedrock, ~ cpm FROM ...................... FT. TOJ. ................... FT .............................. FROM ........................ FT. TO ...................... FT.::...: ............................ FRO~L..:. ............... FT. TO ..................... FT .............................. FROM ........................ FT. TO ...................... FT ................................ FROM ............... I~T. TO ............ ~ ........ FT .................................. FROM ....................... FT. TO ............ ~ ........ FT ...................... ~ ......... FRO~,I ..................FT. TO ....................... FT....~ ........................... ! RO~,! ........................ FT. TO ....................... FT ................................ FROM ...................... FT. TO .................. FT ................................... FRO~,! ........................ FT. TO .................. FT ............................... FROM .......... .......... FT. TO ..................... FT ................................. ~v TO FT FROM ...................... r~ ........................................................... FRO,M.....i ................. FT. TO ....................... FT .................................. FROM ...................... FT. TO ..................... FT. .................................. : FRO~,! '_ ........ FT. TO.d .................... FT..: ............................... Municipality ®f Anchorage MEMORANDUM DATE: November 5, 1981 TO: Laura Crow FROM: Senior Office Assistant Sewer and Water Program SUBJECT: Request for Refund - Account 112460 Please make arrangements for the following refund. A private engineer is going to inspect the installation of the on-site sewer system. J.T. Amador III 5510 East 38th Court 44 Anchorage, Alaska 99504 Receipt # 155093 Permit #810778 Sewer/Well Permit Amount. $30.00 Laura J. ward Sewer and Water Program LJW attachements 91-010 (5/78) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 GL -w -f> 1t1 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING I� Parcel I.D. 017-391-40 COSA# U Sol L, a L 1 S5 1. GENERAL INFORMATION Expiration Date: 8 — -I- Complete Z Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MOUNTAIN PARK ESTATES; BLOCK 8, LOT 2 5824 BRISTOL DRIVE * ANCHORAGE, AK * 99516 JERRY MARKUS Day phone 5824 BRISTOL DRIVE * ANCHORAGE, AK * 99516 Day phone Day phone 947-8906 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well N Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-site N 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 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 axed 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. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and 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 served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Phone 337-6179 Date J /✓` t2 o�opp 000 �� q�F..A... •5��0 Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other t7.71 ]ft prof es By: Original Certificate Date: — (Rea 11!05) F Municipality of Anchorage R • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: MOUNTAIN PARK ESTATES; BLOCK 8, LOT 2 Parcel ID: 017-391-40 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 10/12/1981 Sanitary seal (YIN) YES Total depth 260 ft. Cased to 260 ft. FROM WELL LOG Date of test 10/12/1981 Static water level 157 ft. Well production 1 g.p.m. WATER SAMPLE RESULTS Coliform O colonies/100 ml. Nitrate 7.40 mg./L. Date of sample: 5/3/2012 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments 2 Well Log (YIN) YES Wires properly protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 5/10/2012 152 ft, 1.3+ g,l Arsenic: ND ug./L. Date installed Cleanouts (YIN) fNVIDTAE'1:31 Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (Y/N) YES Date of pumping 10/10/2011 Pumper NORTHLAND PUMPING C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE 11/6/1981 251 Date installed 12/22/1989 Soil rating (g.p.d./ft2or F/bdrm 150 1981 TRENCH 1989 BED TRENCH System type BED 57 8 Length 40 ft. Width 18 ft. Gravel below pipe 0.5 ft. *10-11.9 912 YES NO Total depth *4.2+ ft. Eff. absorption area 720 ft' Monitoring tube YES Depression over field NO Date of adequacy test **5/11 /2012 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 3 in. Elapsed Time: — min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date **TESTED 1989 BED ONLY. 1981 TRENCH WAS SURCHARGED UPON INITIAL INSPECTION. 1989 BED WAS PRE–SOAKED WITH 1000 GALLONS OF WATER ON 5/10/2012 AND REMAINED DRY. D. LIFT STATION Date installed 12/22/1989 Size in gallons 500 "Pump on" level at 11 in. Datum BOTTOM OF TANK E. SEPARATION DISTANCES "Pump off' level at 11 in. Manhole/Access (YIN) YES High water alarm level at 57 Cycles tested 3 Meets alarm & circuit requirements? YES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+/100'+ Public sewer main Sewer /septic service line 25'+ Animal containment areas 50'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+/5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 11981 TRENCH/1989 BED Property line 10'+/10'+ Building foundation 10'+/10'+ Water main N/A Water service line 10'+/10'+ Surface water 100'+/100'+ Driveway, parking/vehicle storagel0'+ 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+/100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed N me JEFFREY A. GARNESS Date S-11517- COSA Fee $ ` qo Date of Payment 5ltcr�°l t ;1/ Receipt Number GJg-3?6 (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage s , Community Development Department x Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121155 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 8, Lot 2 of Mountain Park Estates subdivision. This inspection revealed a nitrate concentration of 7.4 milligrams per liter (mg/L) was reported for the property's well water sample. 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. Municipality of Anchorage • -- Development Services Department 4 Building Safety Division Ir 1:' On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 9951941650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017 -?A) -yo eosA# N4 aR 0334 1. GENERAL INFORMATION Expiration Date: / a - -;z 8 - Q 1 Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MOUNTAIN PARK ESTATES• BLOCK B. LOT 2 5824 BRISTOL DRIVE • ANCHORAGE. AK • 99516 MARK FLETCHER Day phone 223-5003 5824 BRISTOL DRIVE ' ANCHORAGE, AK • 99516 Day phone NEIL THOMAS W/ COLDWELL BANKER FORTUNE Day phone 3000 CENTRE ST #101 ' ANCHORAGE. AK • 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well l� 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 talso Issues COSAs upon request to homeowners. Certificatds of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B welts or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers 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 riles 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 Finn GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines d Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily Identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benerit of the owner listed above. Any reliance upon or use of this report by any 337-6179 Date sl other person or party is not authorized, nor will it confer any legal right whatsoever. Ur \`\4\Qp •.....,, tip. 5. DSD SIGNATURE •'' Approved for 3 bedrooms. �J=� ON-SITE •••• Gi- `� WATER AND : rn Disapproved. ;WASTEWATER - Conditional approval for bedrooms, with the fllowing stipulations: p •, PROGRAM ' Attachments: COSA Checklisty Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineers Report Nitrates Advissoory Other By: (/� //_ Z/ / ` �/ Original Certificate Date: 9 ' Q (R. 11105) � Municipality of Anchorage -�1 Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: MOUNTAIN PARK ESTATES; BLOCK 8, LOT 2 _ Parcel ID: 0 17 — _�3 Cf I— `717 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 10/12/1981 Sanitary seal (Y/N) YES Total depth 260 ft. Cased to 260 ft. FROM WELL LOG Date of test 10/12/1981 Static water level 157 ft. Well production 1 9.p.m. Well Log (Y/N) YES Wires properly protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 9/23/2008 151 ft, 2.4 g.p.m. WATER SAMPLE RESULTS: Coliform —I—) colonies/100 mi. Nitrate mg./L. Other bacteria colonies/100m]. Arsenic: NO ug./L. Date of sample: cl - 2- 0 Collected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 11/6/1981 Tank size 1250 gal. Number of Compartments 3 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (YIN) YES Date of pumping 9/24/2008 Pumper MCDONALDS PUMPING C. ABSORPTION FIELD DATA IORFLOW EXISTING GRADE 1961 TRENCH 1989 BED 11/6/1981 251 TRENCH Date installed 12/22/1969 Soil rating (g.p.d./ft'o /bd 150 System type BED 57 6 Length 40 ft. Width 16 ft. Gravel below pipe 0.5 ft. 010-11.9 912= YES NO Total depth 0.56-5 ft. Eff. absorption area 720 ft Monitoring tube YES Depression over field NO Date of adequacy test **6/l/2009- Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 505 gal. New depth 0 in. Elapsed Time: = min. Final fluid depth 0 In.. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date - "TESTED 1989 BED ONLY. 1981 TRENCH WAS TESTED AND DID NOT MEET MOA ABSORPTION REQUIREMENTS. 1989 TRENCH CONNECTED AS RESERVE SITE. t i D. LIFT STATION Date installed 12/22/1989 Size in gallons 500 Manhole/Access (Y/N) YES 'Pump on' level at 11 in. 'Pump off" level at 11 in. High water alarm level at 57 in. Datum BOTTOM OF TANK Cycles tested 3 Meets alarm & circuit requirements? YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot 100'+ On adjacent tots 100'+ Absorption field on lot 100'+/100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+/5'+ Water main N/A Water service tine 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 11981 TRENCH/1989 BED Property line 10'+/10'+ Building foundation 10'+/10'+ Water main N/A Water service line 10'+/10'+ Surface water 100'+/100'+ Driveway, parking/vehicle storagel0'+10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+/100'+ F. 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 COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date 9 1z I lo! COSA Fee S 1/ % D, c e Date of Payment%11111ny Receipt Number__6 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage ,.. Development Services Department Building Safety Division ' / a• vr• On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 090334 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 8, Lot 2 of Mountain Park Estates subdivision. This inspection revealed a nitrate concentration of 7.19 milligrams per liter (mg/L) was reported for the property's well water sample. 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. .'i N 14 .I• V fr — -• .. .. .._ •:1-:r 'LC... i... -.7�a :t 1.: :. p•'It1i JN i .. (y.• �\•(: YY i•: Yid .:.ti �. `:. •,C •: '•iC.)''ti. .4164:1 •` - �. 1 1 rC +•- �' ; ri � ' .t � 1 1 •••- tii 1 ' - = F_'i I i n 1. 14 .I• V fr — -• .. .. .._ •:1-:r 'LC... i... -.7�a :t 1.: :. p•'It1i JN i .. (y.• �\•(: YY i•: Yid .:.ti �. `:. •,C •: '•iC.)''ti. .4164:1 •` - �. /< L !SS vF__ Municipality of Anchorage Development Services Department e Building Safety Divislon On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage ek-us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. Of 7 =39/ -'/U - HAA# ffA aJbo r{G Expiration Date: 1. GENERAL INFORMATION Complete legal description Lo f 2 Aloe le B MounlarA larle ErJo k- Phi Location (site address or directions) , 119 2-Y r3ru"Of Delve Current Property owner(s),Ty c .jun"ne Ne.rbi," Dayphone •S7 -L -d0'2-!_ htailing address P e floc rr r 3 03 A� A-ze 94-r/i Lending agency Day phone Malting address Real Estate Agent Oavt Woo -14 Re"ax PMa•'A`✓ Day phone 7-7e' Z7e., MaiiingAddress 3600 �rdo•w S�� A++ctiaia�q� il+r 99sG3 Unless otherwise requested, Hat Nal/ be held by DSO for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site IR Individual Water Storage ❑ 'Individual Holding tank ❑ Community Class Well ❑ Community On-sito ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional CIA engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of tide (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. Certficates of Health Authority Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results 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. r 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below. I verity that my Investigation, based on procedures outlined In the Health Authority Approval Guiderines for this application, shows that the on-site water supply andfor 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 andfor 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 ofFims_Ff..f1ddTeeArp* "� Strv«c. Phone 3yS-J?rt Address S-�.y &(±orj i4k 99ti,r Engineer's Printed Name ?'i,io. aOer F a,o� .... • Date Huy Z/, Zoo i 5. DSO SIGNATURE Approved for. 3 bedrooms, Disapproved. :THFMCR: t. §A0021 J- r t;•. CE•9589 f' ,.. ,F f: .., Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineers Report Well Flow Advisory Other By. (v, Original Certificate Date: S� — •Z / r Municipality of Anchorage Development Services Department �\ v Budding safety Division On -Site Water and Wastewater Program 4700 South Sragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.cr.enchorage.ek.us (907) 343.7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. o 1'7 - 3 91- H 1. GENERAL INFORMATION FAr H A# 'NR010046 Expiration Date: 5-22 - o! Complete legal description !-ot 8 Mtn Petrk ratht !wr V r Location (site address or directions) S6 z y 13 er!/v f O'i "c Current Propertyowner(s) 25 iron• -c Nerlf6- Dayphone 97z-eeZG Mailing address P o trox it, 303 14_ cAo� At. 9,7s it ' Lending agency 6:-mAC Dayphone,$6?-2rbr Mailing address N6o u� Tud�� R��rLb�oq�_ i4a 99So3_ Real Estate Agent Rx rr wf r fti AerYnx P=, Day phone 2 �76- zee l Mailing Address ?�JGO larda..�s sf Su•f. /«/ ilnC Der zv. hk99s0_ Unless otherwise requested, HAA will Ge 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 ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Deve!cpment Services Department (DSD) issues Certificates of Health Authority Approval (HAA) based only upon the representa6cns 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 sinSle family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to hememmers. Certificates of Health Authority Approval are valid for SO 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 less than 30 days old. (Certificates may be reissued for 2 period of up to one year with valid water samples.) Certificates ere valid ter one year for properties served by Class A or B weds or a public water system. The Municipality of Anchorage is not responsible for errors or omisslons In the professlonal 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 verity that my Investigation, based on procedures outlined In the Health Authority Approval Guldetines 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 an applicable Municipal and State codes, ordinances. and regulations In effect at the time of Installation. Name of Firm FI u flue 7eeA+n; eo 1 Strz.l ev Phone 3 ys-- /:r ci- 1 Address rNs3a EcAo A_ r4�_o, Ak9esir Engineer's Printed Name. ') A ed. Iaee F. �-cuor-e_ Datere-bi% 2cor CIF Ar° -it _ w,,..••••-' ' •v7 00 9 H iK �ENGlNEEF ...••.�.u.z.......•g STA.bIP �ra:oxze I. u^ S. DSDSIGNATURE .%sit;•. CE'3=ti9 ,� Approved 3 bedrooms. '��'j'l�i::'•;. '•. •l.. •.. A� ... Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments ; WATER AND PROGRAM Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report. Well Flow Advisory Other By: Original Certificate Date: 2 2 2 — 40/ VU% 1=1 Municipality of Anchorage ••., Development Services Department eutiding Safety Division ..... on•Slte Water 3 Wastewater Program 4700 South Smgaw St. P.O. Baa 198650 Anchorege, AK 89519.8850 rrww.cl.andtarage•ak.us (907) 943•-7904 HEALTH AUTHORITY APPROVAL CHECKLIST LegaiDeaffiplion: LoftN� Park 6Sf. #I Parcel ID- 017-39/-YD A. WELL DATA Well type met tf A, B, or C provide PWSID 0 -^ Wall Lag (YIN) Date completed _I t&'& 60; Sanitary seal (YIN) _ Y Wlroe p operty protected (YIN) . Y Total depth 2 —Oft- Cased to 157 R. Casing height (above ground) ? Q In. FROM WELL LOO AT INSPECTION Date of test to 1I% ! 1401__ Static water levet I S-7 ' R / •/ 9 1t. Wait pmduetkxi f O.P.M. g.p m. WATER SAMPLE RESULTS: Collwm _12_colonies1100 ml. Nitrate q-07 mglL Other bacteria colwlesN00 mi. Date of sample: ?.Lpj-eL. Collected by: F'/c+ Hjpi Tsch n on I Senvr c�� e. SEPTlcIHOLDiNO TANK DATA Tank TM MatwW Se. b r- / S'6( Data installed I r ! 6 / B I Tank size 1 Z.fO gal. Number of Compartments 2 Cleanouts (YM) 1' Foi ndatlon cleanout (YIN) e_ Depression over tank (YIN) .1 High water alarm (YM) PV—'4 Date Of pumping e'eyDO PumperC. ABSORPTION FIELD DATA Date Installed ,ll !6!B / Soli rating (9.p.dM or k=Ibdrm) 3,>ti �G=� system hype 7 eAaS Length C' it Wkfth 2' It. Gravel below pipe 8tL Total depth _L;_ ft. ERabsorption arae .E_ 2 ft: Monitoring tube Y Depression over field h1 Date of adequacy test 7 ! o Results (Pess/Fall) PSL For .7_ bedrooms Fluid depth In absorption field before test 7 Z in. Water added-fAigal. New depthjgL_'A. Elapsed Time: 2 6 min. Final Iluid deptht" In. Absorption rate >= 166 g.p.d. Any rejuvenation treatment (put 12 mo.) (YIN E type) -860e- icn litr n Ifyes, give date N•A. l4aft; 1'n rrlfbmee ,enf• 6"4 tys �!«et of in mA&,7 , /ww� rntkt//o�C on l++v (of, &,h,cA rvPnQ,wl r.. recennecke4 lie {T[ or-!q ,nw/ 4•rvAcA SyJ/-#4 etnsf !lou reonA,w.b(fo �✓tr J,ne�, '�rwf� �+o CurrY.�< «olepwaey I-vf �i Cowduelrlow *e o�,n•./ D. LIFT STATION Sec no k •�7 o 6Ve VC. Date Instafled Size In gadorm Manhde/AOOess (YIN) 'Pump on' level at _ In. Tump otr level at _ in. Mel water alarm level at In. Datum Cycles tested Gleets alarm E dreult reQWMT arm? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic lankAM station on let 13D' Absorption Bald on let IW ' Public sewer main W. A. Sewer /septkservice line '> 2E, On ed*wt bb -> !oa Onadjacentlob '> J&O' Public sewer mwtideldesnout M. A, Holding tank V. A SEPARATION DISTANCES FROM SEPTICMOLDtNO TANK ON LOT TO: Build4p famdation -15' Property line Is" Absorption fWd So Water main --y ro' Water service line > +o • Surface water t?, I oa Wefts on adjaeerA lots > l crj ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line IS" &Ading foundatlon 20' Water main -> ca r Water Servioe line > ra • Surface water > f CIO' Driveway, parkir4WAdo slorage , ,70 ' Curtain drain _ N. w. sa" Web on adjacent lets > IcN� •• F. COMMENTS of O. ENOINEER'SCERTIFICATION I codify that I have dalermbmd through Auld iupeedw and % .. .....�:....:... review of mwacrpel records that ft above systems are In 0 COI formarme wlih MOA HAA guideMes In elfed on M date. •f� { IOGtt v �.• �r..� Engineers Printed Name 7-AfE04e F r-rua.� TAMP...• , �,,.,'� Date 1=t4ra*4 ty, 2001 HAA Fee S =t Date of Payment ov Receipt Number In (Rev. 12M) 0 �� P�p I Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services cum On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel 1. D. # D 1 7 - 3 21 - ` Q HAA # 1�AQ—E�24 1. GENERAL INFORMATION Complete legal description 1 vt ? B/oc4 61. Mir Par' Est # Location (site address or directions) 5-,62-,/ fYru-,, l Dri Propertyowner RoGer-t Nainicin, Day phone 26'9-51 Mailing address 7,Yq Ocean view Dr'. /}nchore � A� 'HS6- Lending agency Al,%(�a QUA Day phone 7�6-6—— Mailing address y000 Creel f �� An(�02E 4q Agent n7ar c a Lvh, hroM S Prude }ru7 vaAa Day phone Address CAora P 9`23- o3 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well ✓ Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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. See hv4e( ol) clPck 111/, Name of Firm l=Iufn T2c� n,cc SP�,,`co� Phone Address y S :6/ actio 1I17c 1)c„r5y o /+K Engineer's signature Date 9/2-/96 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for Additional Comments c7 bedrooms. bedrooms, with the following stipulations: WON 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 orderto 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 k21 Date of test Static water level Well production FROM WELL LOG to / l7- /8 ( WATER SAMPLE RESULTS: 1S7 AT INSPECTION 8/l2 / 96 15R 2.2 g. p. m Coliform O cc( /(00M -Q Nitrate36) Other bacteria (None r!porEe.-Y Date of sample: 8/"/ / 9g Collected by: F to t �e Tec 4,n; ca / -Cern, c q/- B. r B. SEPTIC/HOLDING TANK DATA Date installed N / 9/ Tank size / 2SGc Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) V. A. Date of Pumping 2 / z / 9'9 Pumper f( t C. ABSORPTION FIELD DATA 12- //2/69 IS`U laarm Oea Date installed i 1 / 6 /B / Soil rating (g.p.d./ft2 or ft2/bdrm) 25 / u` System type 1 ren c!, fiP.r Ho' 16' a.5 1-3 7 Length 5' Width 2' Gravel thickness below pipe '9 Total depth J 2' 7 2U Y N Effective absorption area 9/ 2 +?' Monitoring Tube present (Y/N) Y Depression over field (Y/N) Al Date of adequacy test 5/ lz/ 96 Results (Pass/Fail) Pass For 3 bedrooms 1\101-c:Or'J`enal 7,-eneh 7kt1-,, C 3 Fluid depth in absorption field before test (in.); SS " Immediately afterlY77gal. water added (in.): 9/ �� Fluid depth 90 (ins) Minutes later: 20 Absorption rate = > 'oro g.p.d. Peroxide treatment (past 12 months) (Y/N) Nang LCnocvn If yes, give date �. A (-S•7-ru[/7Gh 5 '0 / � Con vT LJ ect S J/ -PM GC Y Municipality of Anchorage eECEIVED 72-026 (Rev. 3/96)* �� ns}crll e ctno!e hc�urP re DEPARTMENT OF HEALTH & HUMAN SERVICE or�q�a/ fi�tnch Environmental Services Division P 3 1998 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 3��--4744 � r�lur.» very �f Municipality of Anchorage Dept. Health & 1-luman Services Health Authority Approval Checklist Legal Description: 2 /& M" r) Park E.S/ulel Pl Parcell.D.: 0/7 39/ YQ A10k. Thee '( cc See-c.)n-C aybnne(onea rreI/ eee(i� u�l7rc,6 ex/enr1J A. WELL DATA 3ruyorero e/oc( on �Pd tocuf-n"e 6-/ �d l eUe/ 64 +'A ,-,L sl -eel p/a/•e ry% not -4 u well /n se r//ce . 0/ ey '6 have aJ ;J.� der DO,-) Jed /moi , Well type Pv t If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed 10 /6 / Total depth 266 ' Cased to 6edflock-&57' Casing height (above ground) 20 " Sanitary seal (Y/N) 1' Wires properly protected (Y/N) Y Date of test Static water level Well production FROM WELL LOG to / l7- /8 ( WATER SAMPLE RESULTS: 1S7 AT INSPECTION 8/l2 / 96 15R 2.2 g. p. m Coliform O cc( /(00M -Q Nitrate36) Other bacteria (None r!porEe.-Y Date of sample: 8/"/ / 9g Collected by: F to t �e Tec 4,n; ca / -Cern, c q/- B. r B. SEPTIC/HOLDING TANK DATA Date installed N / 9/ Tank size / 2SGc Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) V. A. Date of Pumping 2 / z / 9'9 Pumper f( t C. ABSORPTION FIELD DATA 12- //2/69 IS`U laarm Oea Date installed i 1 / 6 /B / Soil rating (g.p.d./ft2 or ft2/bdrm) 25 / u` System type 1 ren c!, fiP.r Ho' 16' a.5 1-3 7 Length 5' Width 2' Gravel thickness below pipe '9 Total depth J 2' 7 2U Y N Effective absorption area 9/ 2 +?' Monitoring Tube present (Y/N) Y Depression over field (Y/N) Al Date of adequacy test 5/ lz/ 96 Results (Pass/Fail) Pass For 3 bedrooms 1\101-c:Or'J`enal 7,-eneh 7kt1-,, C 3 Fluid depth in absorption field before test (in.); SS " Immediately afterlY77gal. water added (in.): 9/ �� Fluid depth 90 (ins) Minutes later: 20 Absorption rate = > 'oro g.p.d. Peroxide treatment (past 12 months) (Y/N) Nang LCnocvn If yes, give date �. A (-S•7-ru[/7Gh 5 '0 / � Con vT LJ ect S J/ -PM GC Y Gf(tl Pr/P/' 72-026 (Rev. 3/96)* �� ns}crll e ctno!e hc�urP re mnn�efr�ioe or�q�a/ fi�tnch Tht 9!/2/98 Gide CMC I-ef/' Cu ctl 8 , Sir// ..��Y fo GPonP on e ori<r inc / frt�+c Th2 1, e oNercr /r�K t1�c/�rbn r�rnp � r�lur.» very �f D. LIFT STATION Date installed 1'1• /i2 /89 Size in gallons SUo %,(I Ab C Manhole/Access (Y/N) Y "Pump on" level at* 5�:-- 8 "Pump off' level at* '-y" High water alarm level at* 7 6 " Cycles tested 1 E. SEPARATION DISTANCES *Datum R, oo l ,oE man Aa l e SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 130' On adjacent lots > too Absorption field on lot (00, On adjacent lots > 10�, Public sewer main X) • A. Public sewer manhole/cleanout Al. R. Sewer /septic service line > ZS' Lift station /3S ' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 15 from CO. #11 Property line 15 ' Absorption field B ` Water main/service line > to' Surface water/drainage > r clo' Wells on adjacent lots > UG' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line f 5 Building foundation z3 ' � In. t. Water main/service line Surface water > ICAO' Driveway, parking/vehicle storage area 3O' Curtain drain Mane leav) Wells on adjacent lots '> rvo Note: 7Ae 8/12-/96 G,elequctcy 1-e✓/ asSeSrc� e pew �ncence F. ENGINEER'S CERTI FIC/ATIynN oJ� fAe 0rlgtnal Soi/OtbSr,�p�0� 74rench rtc uctren kee �q t jic)ure o-er �n anre /.t Irn/�,� P� end no 74&rf wad rm. orac%P-< 9 � aSSr�Sd ALO a r/P� "re o�f( e 1? t cv� er- Sot / cz'GSar� fzoh hems. I certify that I have determined tnru feelld inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Signature -Z- 9-7- c Engineer's Name / --e Date S�,gy /99� HAA Fee $ 3ao �� Waiver Fee $ Date of Payment G1 -" l `b Receipt Number Ikik�—)�Q 72-026 (Rev. 3/96)" Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES Mj 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # C) k--) " F-Sr� t - �-Icl� HAA # o. ��<�C)\ C:) 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lc). 2 F i K ) PaL�l A i h'I PA K ES I ATES Location (address or directions) 5'6� L>1S 161- (b) Property owner FA Li Ll I F_ NdAF Ate_ Telephone: (home) Business t 41-o s Mailing Address S21 -2i F FF -1: Kir El A K (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone Telephone � /A (e) Mail the HAA to the following address: (or check here)if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On -sited Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7188( Page 1 of 2 5. 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 CCnehf 1 KI i Assoc Telephone Address Uro l= Dl ♦✓11 0 KI -%- A 9 1 l l A- % Date 's9 r t ;z :,r Engineer's Seal 6. DHHS APPROVAL Approved for bedrooms by j �� Date 12 _2 / -46f Approved — X_ Disapproved Conditional Terms of Conditional Approval CAUTION. The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 h4UfJ,-CIPALITY OF ANCHORAGE (MOA) • 4 4 y ; ;,\nWesalth Authority Approval (HAA) CHECKLIST - FEBRUARY 1984] �4 343-4744 Legal Description: Lar A. WELL DATA Well Classification [?PI VATE If A, B. C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed ib /fi Yield 6-�»'�' Total Depth260 Cased to �; 4S Depth of Grouting Static Water Level / bU Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 1 Z Pump Set At ( h) C/t,'Oc.),t) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots Icb To Nearest Edge of Absorption Field on Lot f 3CJ t ; On Adjoining Lots -,,- / OU To Nearest Public Sewer Line W To Nearest Public Sewer Cleanout/Manhole j To Nearest Sewer Service Line on Lot l Cx) I Water Sample Collected by JEEAy � � ; Date I0 ��2!2//5Trr�`f Water Sample Test Results s� %� S� -ITC�� `� — lec/'.t�rS' Y-'/`rG-.cam Comments T -d B. SEPTIC/HOLDING TANK DATA Date Installed -%s Size /000 No. of Compartments Standpipes (Y/N)—_Air-tight Caps (Y/N) y_Foundation Cleanout (Y/N) Depression over Tank (Y/N) If Date Last Pumped IZ /it )ki Pumping/Maintenance Contact on File (Y/N) kt 1A ; for /-A Holding Tank High -Water Alarm (Y/N) _KI 1 /4 Temporary Holding Tank Permit (Y/N)_/�� SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well / lZSI To Building Foundation 1 To Property Line (. r To Disposal Field % t To Water Main/Service Line Z S 1 CJ SEt��iXc l l v�- To Stream, Pond, Lake or Major Drainage Course Al 'A - Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �QS "�� i Type of System Design i Date Installed /� / �� Length of Field 1 Width of Field Depth of Field i �� IGNO 11 �7 / Gravel Bed Thickness Square Feet of Absortion Area / z C) -S� t'f Statndpipes Present (Y/N) C. Depression over Field (Y/N) �11 Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well 6C7 ' To Property Line IC/ To Building Foundation To Existing or Abandoned System on Lot 270 On Adjoining Lots To Water Main/Service Line S ` "7-0 Sz/lace 4;,u To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course K i /A To Driveway, Parking Area, or Vehicle Storage Area k> Comments D. LIFT STATION Date Installed ctDimensions /J x (5 f--l�f- , j4,1) Size in Gallons fle,? ' Manhole/Access (Y/N) "Pump On" Level at 2 aft l"rff "Pump Off' Level at �' h< High Water Alarm Level at 2 iiG�o7`i Vent (Y/N) / Tested for iF, Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) r '*Check Permi ted Bedroom ating Against HAA Request" I certify that / check v ified, or conformed to all MOA and inspection. Signed C Comoanv " n(/G/ Date d _/0 MOA No. �� ffle-v( Receipt No. � Receipt No. Date of Payment /g ' / Waiver Fee: $ Amount: $ (--' e,'o Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 ct on the date of this Engineer's Seal CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 5622343 \ FEDERAL TAX ID N 92.0040440 ANALYSIS REPORT BY SAMPLE for Work Order N 17799 Date Report Printed: OCT 30 89 @ 13:42 Client Sample ID:L2 B8 M"1. PK. ESTATES Client Name CORWIN & ASSOC PWSID :UA Client Acct CORWINP Collected OCT 25 89 @ 15:15 hrs. P.0A NONE RECEIVED Received OCT 25 89 @ 16:00 his. Rey B Preserved with :AS REQUIRED Ordered By : J. KRESS Analysis Completed :OCT 27 B9 Send Reports to: Laboratory Superv'so STEPHEN C. EDE 1)CORWIN & ASSOC Released By � C �/ 2) Special Instruct: Chemlab Ref II: 8242 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits --------------------------------------------------------------------------------------------------------------- NITRATE-N 2.2 mg/l EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY J.K. 1 Tests Performed See Special Instructions Above UA -Unavailable ND= None Detected See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than Zr- CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. R TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 v W°^•^°^•• Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY L PUBLIC WATER SYSTEM I.D.# Anal s shows this Water SAMPLE to be: PRIVATE WATER SYSTEM Satisfactory Unsatisfactory Mame Phone No. J Sample too long in transit; sample should not be over 30 hours old at examination Mailing Address _ to indicate reliable results. Please send new sample via special delivery mail. City v I- State Zip Code l D 2 `ter q Date Received ✓ SAMPLE DATE: I I ! I Q Mo. Day Year Time Received SAMPLE TYPE:�P1� Z 1 ❑ Routine Check Sample (for routine sample 'with lab ref. no. ) ❑ Treated Water Special Purpose ❑ Untreated Water SAMPLE NO. LOCATION Zr. +- 2 2 3 4 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Time Collected Collected B 3 /- Analytical Method: Membrane Filter No. of colonies/100 ml. Lab Ref. No. Result* Analyst 8242 ® �- J m U m U m ED BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: L BGB z Coliform/100ml Final Membrane Filter Results �� Collforrn/100ml Reported Bye► -E— i w a L ^^ — Date /0- T i m e: O Time: /�G2p a. M. p.m. TNTC = Too Numberous To C PART ONE OF TWO OB = Other Bacteria REMAINDER TO FOLLOW s•• s s s. s s s POSY IN A CONSPICUOUS PLACE s s• a• s s s s s s De movR 1401tCe is AlwheD ►tlA lwsp@amh 6E11VICs Bpd ELECTRICAL APVOH AND PERMIT eu[LOINOaiNo &Asery o)vieIoN MUNICAPA(,ITY 4F ANG140IU48 VW No, E PHONE 788 INSPECTION 583 -UM + wwnteE LOT 6 aueFap l (KNO K( °°K1gACi /' A LICEMI[ IE4FOFMY S[ANC� fAIJILY NEW AooaE4t . DUP%(Y.N[W oEg(`PIC110H d WDltK FF..,, NEW y AOOITI(N10 REPAIRS ❑ wit,6 ❑ IF 07I+Ep6. F%t Llf Y TONA[�111 iriQi�- #uoa[Mc nEF�AIVKf ^ w 1Twv r..d^'VAe^.F Fpp�cFre^V-0F^e.1N [GnlFntl lMF. wl t^F YfM J Ir OF bd oOnM 11yr11li JpM 1�F FOGF trod YAI a Apti rli e6JYdF/�.Frh N fVl• IM h^CI{W I!x �M bAiryKM etA+rr t.FFHe 1N Rep phW tl WdAK N Fqt COAFiMNA� TOYµ Re ;i y nn C. -- _-( FEE �y 'I�Ed ) r, �; W oAtp IV 6Y PERMIT APPAOM) A ISSUED BY AVI�T/I.fOAI=Y fa O%11 `'IA( II -.US R, r. Lr) �4 < a Lr) N 0 a a •-+ Q U 0 0 rd M H Z ro '1(� b al U a) GQ, N 1 N •i ❑ 11J Qi o 0) m a b LO a)r-A�Q o xw x aa)i ro ❑ ri U r-i P4 O N W r-i Nr) Jr r Oto h e N a) a) h >1 r-1 v V1 rd U) ❑ Q 01 CIO av a4 rd ax��° rim +-s ovm t•, Q I-- U) ?+ 44 j O r-ii O \\ � i 04 U O r I 3 •ri .N O U tr ro w r i r•i H 9 O ro a) E3 p5 r1 b Z F— >1 4-4 l�Q(n tl�i.JW r riHC:U3U7h304 O b r•i ro rd rd q d H U 0 - ri N(hv Lnt rm r C7 'L '� PPF i A b rtl C \ m Ici 04 P4 -c> c d t H N.N q 3 r-1LL .� x i � �US U i u9 uZT uZT J Z Ln d M N O J �pN O`O �Z x Q � a) I co (d>1I uZT `r LO Q w y q� q C4 � IIQ H Q rd I ❑ CD vi Lo QE °w CO N 110-19 Q Q) U a N N 121 b MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND h`'VIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE I. Goucral Information Application Date a (sxy T.eg;)j. Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants me Telephone w Home Business Applicants Address (c) Applicant is (check one) Lending Institution !� ; Owner/builder ✓ ; Buyer = ; Other � (explain); -- — g ��'� �- ��r J�aZ_•1 ��1 (d) Lendin Snstitution-, Add�gss a (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: L -,�L?—eye 6' 2. Type of Residence Single -Family CEIMulti-Family F-7 Other (describe)_ Number of Bedrooms J S. Water Supply Individual Well M Community = Public M Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite I 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] 5. Engineering Firm Providing Inspections, p Tests, File Search, Data and Infor;t;-„,•�,,t� As certified by my seal affixed hereto and as of the validation date shown bele,,. verify that my investigation of this Health Authority Approval shows that the oi. sbee water supply and/or wastewater disposal system is safe, functional and adequate foi 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 u�y investigation and inspection, the onsite water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm Telephone P Address Date G. DHEP Approval Approved for:_ -7' bedrooms mow' •G].�11-1 �XDf (ENGINEER SEAL) ...... ...,�.A `....” �• G' ro. 9SG•F ;Lzad ByNA l i Dates w t.•'a Conditional. V Approved Disapproved Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 PROTECTION REPRESENT - REGISTERED HOMES AND REQUIRE - BEFORE A FOR ERRORS (Page 2 of 2] 7-19-84 A,.. MUNICIPALITY OF ANCHORAGE (MOA) c HEALTH AUTHORITY APPROVAL (HAA) Qsl CHECKLIST - FEBRUARY 1984 A. WELL DATA Legal Description: G. f Well Classification,If A, B, or C, D.E.C. Approved(Y/N) N/a Well Log Present (YIN) /!Gs Date Completed /��z_ �' Total Depth v Cased to I y__ ; Yield p. M Depth of Grouting �c� /c„ Static Water Level �U3 Pump Set At c,,,t1610 ^ Casing Height Above Ground 3 0? " Sanitary Seal on Casing Electrical Wiring in Conduit Ly/N) / S Depression Around rAbllhead (YIN) Separation Distances from well: To Septic/Holding Tank on Lot_ jo v On Adjoining Lots ,> To Nearest Edge of Absorption Field on Lot yip On Adjoining Lots To Nearest Public Sewer Line /%/,q To Nearest Public Sewer Cleanout/Manhole A//41 To Nearest Sewer Service Line on Lot SbN� �rti� Water Sample Collected By B,,,e Date Water Sample Test Results �v s 61 Comments__ B. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Ccmpartments 2_ Standpipes (YIN) /ls Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Lr� Depression over Tank -(Y/N) ! , Date Last Pumped Pumping/Maintenance Contract on File (Y/N) �l ; for AIX Holding Tank High -Water Alarm (YIN) Temporary Holding Tank Permit (Y/N) ✓'//4 Separation Distances from Septic/Holding Tank: To Water -Supply Well jav X To Building Foundation 116 To Property Lire To Disposal Field ,? To Water Mair./Service Line 6" ' %`To Stream, Pond, Lake, cr Major Drainage Courses ter/ (Page 1 of 21 E� F7le S Receipt Date Paid: Amount: 2-15-84 C. _ABSORPTION FIELD DATA Soils Rating in Absor tion Strata mss'/ /Y- Type of System Design Date Installed /� �/� f Length of Field S 7 Width of Field Y " Depth of Field / Gravel Bed Thickness r Square Feet of Absorption Area Standpipes Present (Y/N) %f Depression over Field (Y/N) A19 D Date of Last Adequacy Test 3/z Results of Last Adequacy Test Afs(��fi°' I Separation Distance from Absorption Field: X To Property Line To Water -Supply Wb 11 d' To Building Foundation > To Existing or Abandoned System on Lot /v /l ; on Adjoining Lots Y v ' To Cutbank (if present) /Y//g /-_ To Water Main/Service Line dr / p To Stream/Pond/Lake/or Major Drainage Course /� j To Driveway, Parking Area, or Vehicle Storage Area > v Comment C D rE e r' , /e D. LIFT STATION Alj-v-� Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "pump On" Level at "pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Code s(Y/N) Comments ** Check Permitted Bedrocan Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. d Date Signed I -� Company MOA No. SrFrs-��3� is s % s10 �, KBl/d5/s (Page 2 of 21 ENGINE] 'R BET1 2-15-84 J r-. md- _ E'v DA, � „ EIVED INSPECTION APPOINTMENTS TIME TIME TIME NUMBER OF BEDROOMS SINGLE FAMILY 9'� DATE DATE DATE INDIVIDUAL* c. IN 9 INSPECTOR INSPECTOR depth (attach log'.f available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE**�YEAR (�� MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI'MPT OF HEALTH A 825 L Street - Anchorage, Alaska 99501 ENVIRO • MENIAL PROTrCTION; ENVIRONMENTAL SANITATION DIVISIONi� C 1 I�Ui Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SER66E M f DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing. 1. PROPERTY OWN�E�R _ PHONE C __ MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER/ /� �/�� p PHONE MAILING ADDRESS 3. L DI G INSTITUTION PHONE MAILING ADORES 4. REALTOR/AGENT PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION LOT d �1� _ g MT STREET LP T 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ MULTIPLE FAMILY ❑ Two ❑ Five Three ❑ Six 7. WATER S PPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log'.f available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE**�YEAR (�� ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 2-010 (Rev. 6/79) U ` e_e� __ J T141S SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ SINGLEFAMILY ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY PERMIT NUMBER ❑ INDIVIDUAL DEPTH OF WELL ❑ COMMUNITY DATE DRILLED ❑ PUBLIC UTILITY RECEIVED Connection Verified_LOG 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ❑INDIVIDUAL/ON -SITE DATE INSTALLED ❑PUBLIC UTILITY Connection Verified INSTALLER ❑Septic�Tafnik�or ❑Holding Tank Sizer �If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS 11,(1/ja; /� LTJ" APPROVED FOR - BEDROOMS CONDITIONAL APPROVAL (letter must accompany certificate) r El DISAPPROVED DATE BY I/I )0 C f'.h All.)i',L 1: Hav(., I)C!( to is with Vi w,L], Is 17") bw a,, c.i. �.ort neod tj 0A--j:(,ot foy, out, ovor to LA t 0 1 , Y) v nw.(2) i i L , _, 1