HomeMy WebLinkAboutMOUNTAIN PARK ESTATES BLK 8 LT 5Moutain Park
Estates
Block 8
Lot 5
#017-391-37
Municipality of Anchorage •' ; .
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Department of Health and Human Services
Building Safety Division
On -Site Water and Wastewater Program, 4700 South Bmgaw Street
P.O. Box 196650 Anchorage, AK 99519-6650 Page 1 of 3
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SW W040118 PID Number: 17-391-37
Name:
Wastewater System: ❑ New ® Upgrade
Address:
ABSORPTION FIELD
Phone: Number of Bedrooms:
❑ Deep Trench ®Shallow Trench O Bed Q Mound Q Other.
LEGAL DESCRIPTION
saRatlng:
Total Depth from w1l#Wgrade;
Block: Lot Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe:
Township: Range: Section:
FI, added above original prods:
Gravel Length:
0-1 Ft.•
Ft.
Well: ❑ New C]U rade
P9
Gravel width:
Number oflnes:
Dhm"`abetweenInes:
5 Ft.
1
ClasWcation (Private. A. B. C):
Total Depth:
Cased lo:
Total absorption area:
Pipe Material:
Exist'g
Ft.
Ft.
364.5 Fe
3034PVCIF810
Driller.
Date Drilled:
Static water Level:
Installer,
Oats kutalled:
Ft.
A+ Home Services
5/16/2004
Yield: Pump sat ae: casing tlelght Above Ground:
TAN K
GPM FL FL_
SEPARATION DISTANCES
® Septic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
ubWPrh*te
Manuracwror.
Capacity:From
Tank
Field
Station
Tank
Sewer Line
Anchorage Tank
1250ow.
Wei
104.4
105.1
90
Mme.
Steel
NumberofComparbrmft:
2
Surfacewaler
100+
100+
LIFT STATION
Let Line
26.3
26.4
Size:
Manufacturer:
Gal
Foundation
17.3
16.1
"Pump on' levell at
T -V or `aV*` "�
tipth water alarm at
in.
live
In.
curtain Drain
100+
100+
Pump Make: Model
Electrical knpections patormod by-
Renu Id Td— ':x)vil —d
BENCH MARK
I�
ConcreteC tion S b in back under deck
Assunwd Elevation:
f
1
100.0 FL
Engineer's Stamp
�,a��,aaaaa
OF
•qS�♦♦
Inspections performed by. Pannone Eng. Svc Dates: 1`5/16/2004
;' 49TH l �•��
2nd05117/2004
„..a. ..............«s..«.�
Department of Health and Human Services approval
....• ... .................e,....�
ve
-.Steven P. Pannone; s
Reviewed and approved by: Dater 4- D♦'
•' No. CE 8149 �i~
••'•
(Rev.71W
!♦ CG/6 •.•••' �ti
.............••
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PERMIT NO: SW040118 RECORD D RAW 1 N G
WASTEWATER DISPOSAL SYSTEM
Lot 5, Block 8 Mt. Pork Estates
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EXI 'G \
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REPLACEMENT
SYSTEM.
5'Wx72.9LFx3'ED,
6' TD
J
NOTES:
1) All work was performed in
accordance with AMC15.65.
2) Materials used was in
accordance with those
specified in AMC15.65,
Wastewater Disposal.
3) Connect post tank line to
midpoint 6f drain fi6ld, typicol.
4) Maintain 10' separation to
all lot lines.
5) Lots served by Private Well.
No wells within 100' of
proposed system.
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P.I.D. NO: 017-391-37
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12501 SEPTIC
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SEPTIQ
AREA \
EXIST'G DRAINFIELD\IN
FAILURE. REUSED \
N,
\ \
N.
\ DESIGN: \
CO A B PERS RATE: 1-5 MPI
T1 27.2 33.8 \ PUCCXkON RATE -2 SF/BR
T2 33.1 38.8 \1 D/SN
> o C1 70.8 60.6 \ � BR SE
M1 71.6 60 RE9.'D AR • 50
0�5
C2 66.8 .1 RF—
3' EFF'T TH, 0 L 5' T.D.
M2 60.6 0.0 300 SF TOT
1250 GAL SE \ T K \
PREPARED FOR: PANNONE ENG. SVC, LLC
Michael & Theresa Ford P. O. BOX 102954
5934 Bristol Drive_ ANCHORAGE: ALASKA 99510
Anchorage, AK 99516
271-5410 227-3522 P, 272-8218 Fax
DATE:. - 5 -1s -o4 RECORD
.....�_ .a ....
PERMIT NO: sw040118 RECORD DETAILS
WASTEWATER ABSORPTION SYSTEM
Lot 5; Block 8 Mt: Park Estates
NOTES:
1) ALL WORK SHALL BE PERFORMED
IN ACCORDANCE WITH. AND ALL MATERIALS
SHALL CONFORM TO. AMC15.65.
2) ADD A MINIMUM OF 2" OF R.I. OVER
ENTIRE BED. 1f10 Nv3 o c
3) MAINTAIN 30' SEPARATION FROM ALL
SLOPES GREATER THAN 25%. ti rn
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P.I.D. NO: 017-391-37
PREPARED FOR:
Michael & Theresa Ford
5934 Bristol Drive
Anchorage. AK 99516
271-5410
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P. 0. BOX 102954
ANCHORAGE, ALASKA 99510
272-8218 PHONE & FAX
NTE: 5-18-04 1 RECORD
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PREPARED FOR:
Michael & Theresa Ford
5934 Bristol Drive
Anchorage. AK 99516
271-5410
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P. 0. BOX 102954
ANCHORAGE, ALASKA 99510
272-8218 PHONE & FAX
NTE: 5-18-04 1 RECORD
OT TO SCALE
MUNICIPALITY OFANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
� :3-D
Date Issued: May 13, 2004
Expiration Date: May 13, 2005
Permit Number: SW040118 Parcel ID: 017-391-37
Legal Description: MOUNTAIN:PARK ESTATES'BLK:8 LT __51
Design Engineer: 0062 Pannone Engineering Services Site Address: 005939 BRISTOL DR
Owner Name: Michael & Theresa Ford Lot Size: 20400 SQ. FT.
Owner Address: PO BOX 113266 Total Bedrooms: 4 Permit Bedrooms: 4
ANCHORAGE, AK 99511-3266
This permit is for the construction of:
❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
W;'
All construction must be in accordance with:
1. The attached approved design.
t
2. All requirements specked 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Date:
Issued By: / )���"� liC� . %��d-�� Date: 3— 0
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage; AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017.391.37 Permit Number SW 0 q D / 19
Property owners) Michael & Theresa Ford Day phone 271.5410
Mailing address (1) 5934 Bristol Drive
Mailing address (2) Anchorage. AK Zip Code 99516
Legal description (Lot, Block & SuVd.) _Lot 5. Block 8 Mt Park Estates
Legal description (Section, Township & Range)
Lot Size 0.46 Acres/Sq.Ft. Number of Bedrooms 4
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. 1 further certify that this .application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Date of Payment:
Date of Payment:
Receipt Number. , 5—Z 1U 7 Receipt Number.
(Rev. 12/00)
Pannone Engineering Services, LLC P.O. Box 102954
Consulting Engineers Anchorage, Alaska, 99510
(907) 272-8218 (907) 272-8218 Fax
May 8, 2004
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject: Lot 5, Block 8 Mt Park Estates SJd
Septic field Replacement Permit
PLEASE RUSH
Gentlemen:
My firm was contacted to perform an adequacy test on the above referenced lot. When I arrived
to conduct the test, I discovered the field to be completely inundated with liquid. The field is in
failure. I conducted a single test hole on May 5, 2004. I have attached the soils report and
percolation test for your review. I am writing to request an immediate issuance of a septic field
replacement permit for this lot. No bedrock was encountered in the test hole. Ground water
seepage was noted at ten feet, but there was no standing water after seven days of monitoring.
There was saturated soil at the bottom of the water monitoring tube. I will use a conservative
depth to ground water of ten feet for this design.
The lot is approximately 0.46 acres in size and is served by a private well located on the northern
portion of the lot. Lot 5 slopes to the north at approximately 1 to 3 percent in the area of the
septic system. The proposed installation will be located in the south-central portion of the lot
The existing 1250 -gallon septic tank will be exposed and inspected. If it is found to have
corroded and is leaking, a new 1250 -gallon septic tank will be installed to serve the new drain
field. The existing drain field will be abandoned in place. Both systems are located greater than
100 feet from the well serving this lot and surrounding lots. The proposed location is greater
than 25 feet from the water service lines. The other surrounding wells are located greater than
100 feet from the proposed installation. The proposed installation will not affect the future
development of the surrounding or existing lots. See the attached design. .
If you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
Steven R. Pannone P.E. •""• 44
' Al _' r. A 0 TH S.
Attachments:
ren R. Panne
No. CE 8149
PERMIT NO: DESIGN DRAWING
WASTEWATER DISPOSAL SYSTEM
Lot 5, Block 8 Mt. Park Estates
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LIM
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REA1 \\ 4 �
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PROPOSED "—
� � REPLACEMENT 40.1
SYSTE -57.,
` 5'Wx60LFx3' D, 10 -
'TD
NOTES:
1) All work shall be performed
in accordance with AMC15.65.
2) Materials used shall be in
accordance with those
specified in AMC15.65,
Wastewater Disposal.
3) Connect post tank line to
midpoint of drain field. typical
4) Maintain 10' separation to
all lot lines.
5) Lots served by Private Well.
No wells within 100' of
proposed system.
/en R. Pannone
No. CE 8149 _<
1
5
1ST /
O` I
1
103.�r
(i 102.7
P.I.D. NO: 017-391-37
EXISrG
4 BR
15.
HOUSE /
1
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EPTICANK -
6.4 VERIFY iVGEGRITY
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`� %,\ 32.7 SEPTI � �—SEPTIQ
\�
EXIST'G �� �\ AREA \\ 6
SETIC EXIST'G DRAINFIELD IN \
AREA FAILURE. ABANDON IN \
PLACE \\
�� � ESIGN•
20
PREPARED FOR:
Michael & Theresa Ford
5934 Bristol Drive
Anchorage, AK 99516
271-5410
F'SRC • 1-5 MPI
PP C N RATE: 125 SF/BR
IN, PIP
1. !x/SF
RE1 D EA! -\500 SF
RF= 6 \
3' EFF" . D H."60 LF X 6' T.B.
300 SF Ti9AL
1250 GAL PT TAC
PANNONE ENG. SVC, LLC
P. O. BOX 102954
ANCHORAGE, ALASKA 99510
227-3522 P. 272-8218 Fox
ATE• 5-6-04-_ . M DESIGN
�. � mow.
PERMIT NO:
DESIGN DETAILS
P.I.D. NO: 017-391-37
WASTEWATER ABSORPTION SYSTEM
Lot 5, Block 8 Mt. Park Estates
NOTES:
1) ALL WORK SHALL BE PERFORMED
IN ACCORDANCE WITH, AND ALL MATERIALS
SHALL CONFORM TO. AMC15.65.
2) ADD A MINIMUM OF 2" OF R.I. OVER
ENTIRE BED. 1n0 N`d310
3) MAINTAIN 30 SEPARATION FROM ALL'i~}'?:
SLOPES GREATER THAN 25%.
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• Steven R. Pannone =
PREPARED FOR: Pannone Eng. Svc., LLC
CE 8149 •
''C�gcb�,,.•�'�'.••
P. 0. BOX
Michael & Theresa Ford
ANCHORAGE,
102954
ALASKA 99510
5934 Bristol Drive
...........
Anchorage. Anchorage. AK 99516 272-8218
PHONE & FAX
271-5410 A 5-6-04
DESIGN
NOT TO SCALE
0
a
SOIL$ LOCI - PERCOLATION TEST
s
PANNONE ENGINEERING SERVICES
P.O. BOX 102954
ANCHORAGE, AK 99510
(907) 272-8218
PERFORMED FOR: Michael & Theresa Ford DATE PERFORMED: 5/4 /04
LEGAL DESCRIPTION: Lot 5, Block 8 Mt Park Estates
TEST HOLE 1 SLOPE
!OREd Organics
1
Brown silt w/
2 Sand
3
4
S
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
SwISand & Gravel
well graded
GM/SM Gravely, Sandy
SILTS with
cobbles & bolds
BOH
TEST
49TM •_
Steven R. Pannone
No. CE 8149
O
WAS GROUND WATER
ENCOUNTERED? Yes
TEST HOLE
DEPTH TO WATER AFTER
MONITORING? 12'- Damp
DATE: 5-11-2004
SLOPE
READING DATE GROSS
77ME
NET
TIME
DEPTH OF
WATER
NET
DROP
5-4-04 4:50
6.
----
5.00
10
11/4'
41/4'
5.00
----
6'
----
5:10
10
1 1/4-
41/4-
1 4-
5:10
5:10
----
6.
----
5.20
10
1 1/4-
4 1 4-
PEROLATION RATE 2.4 (min/inch) PERC HOLE E
TEST RUN BETWEEN 5 FT AND 6 FT
COMMENTS: Test hole excavated by A+ Home Services. Test Hole was presoaked before pert test.
PERFORMED BY: Steven R. Pannone, P.E. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACC
WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST.
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GAR.NESS .ENGrINE.ERTNG GROUP, Ltd.
r � c: vxmwmvov CONSULTANTS 3 GENERAL COWMCTORS '
FARCE, FOR P14O iE MUMBER:
ERLING WESTLIEN 273-4590
L---C-A:- Fs:SCRIPT:CN!
WILDWOOD GLENN S/D; LOT 5
SITE PLAN
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5/13/2004
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i- MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
® ENVIRONME=NTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME�,y/��n{�( _.{) PHONE - NEW
XIL.� _3 r-1 5-3,F^ ❑ 7 UPGRADE
MAI LING ADDRESS
�3e'p J /6 cr� ( /J /�
l/�L-!/l./L
//�� l
LEGAL DESCRIPTION
y/.,•�
LOCATION {J{'
�✓lit-K�J' I��..� ice`-" ✓�.C��-_l/
NO. OF B DROOM�`��
�� 1.
_
DISTANCE TO:
WellAbsorption
area
Dwel!mg
-
PERMIT NO.
'� �3 _7
w2
Manufacturer
Material`
No. of compartments
w
Liq. capacity ingallons
IF HOMEMADE:
Inside length ai
Width -
Liquid depth
4 y'
DISTANCE TO:
Well -
_Dwelling
PERMIT NO.
O z d
Man UrL'r - —�� _ _ __ _
- ate
Liquid capjcity -nn'gallons
w w
DISTANCE TO:
Well
�_ t /-r-
Foundation
d
Nearest lot line
�`
PERMIT NO.
�� U 3 / (D
u- Z
Q b
No. of lines Length of rach Ill r. /
Top of tile to finish grade
Total nyth of ,I1Ines
Trench width
Distance betty en lines
Material beneath tile
..-mems
Total effective a sorp,(jg re
w
Length
Width
Depth
-
PERMIT NO.
-- —
Cry
Q b
w
Type of crib
Crib di meter
epth
Total efec absorpti o n area --
w
DISTANCE TO:
Wel
Building foundati(Zn
--Nearest lot line
OTass,
w
Depth u
Driller
Distance to lot line ��
f d
PERMIT NO.
� c� 7 0
w
DISTANCE TO:
Building foundation .
_
Sewer line
Septic tank
A Sol ptio a -ea )
OTHER
LEGAL
-
PIPE MATERIALS
D3c)3
SOIL TEST RATING
INS LLER
REMARKS
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/,/�J/� ,,(J'
APPR ED;DATE
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DEPHRTMENT Pr HEHLTH HND ENVIRONMENTHL ",OTECTION
8�5 ' STREET/ ANCHORAGE, AK 9K 1
U. . B{E/LB_ P-4C�:!n
PERMlT NO. ( 810]70 )
�^��
264�4720 /n/����" �
�����-9 EE'40 K ITT
HPPLICAN T MERLE BEETER SRR 1546~1,_-': HNCH
LOCFIT I:ON BRISTOL ST
L E Ci A I L.T 5 BLK8 MT. PK. EST LOT SIZE
TYPE OF SOIL ABSORPTION TRENCH
]45�]87
25000 SI.DU
MHXIMUM NUMBER OF 4 SOIL RATING (SQ FT/BR): 182
THE REQUIRED SI OF THE SOIL HBSORPTIC) N SYSTEM IS�
�[Hr ���� u �P--B 7" 9� ~' ���? F -A "%n' E7:_ L ��11'" B-A�
THE DIMENSION IS THE (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTHNCE BETNEEH THE SURFACE OF THE
GROUND HND THE BOTTOM OF THE (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFHLL PIPE
HND THE BOTTOM OF THE EXCHVHTION (IN FEET).
_1 EK, ll'=� '11 - I C- "T FA UNIP K S', 1: 2:7 -=--- 15 IC -3 �������
PERMIT APP[ ICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTHLLHTION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT' THE WP:LL WILL SERVE.
�........ ...... 1-0-11 CA ���7. �1 Cjp-jf-:�; F:"o R! ����I IF---:�
BHCKFILLTNG OF HNY SYSTEM WITHOUT FINAL. INSPECTION HND RPPROVHL BY THIS
DEPHRTM�NT WILL BE ::H:;UBJECT TO PROSECUTION
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON~SITE SF -WAGE DISPOSAL SYSTEM Izl�;
100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND
TO H COMMUNITY SENER LINE IS 75 FEET.
WELL LOGS ARL"..' HND MUST BE RETURNED TO THE DEPARTMENT WITHIN
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MHY F[ PPL. SPECIFICATIONS HND CONSTRUCTION DIHGRHMS AF E
HVHILHBLE TO INSURE PROPER INSTALLATION.
�����P'll I V- E. -K 4 F: - C T'" E H: CA E-7 BE: 01 ER EE, FT __L _1.���
I CERTIFY THHT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS HS SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE.
2: I WILL INSTHLL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]� I UNDERSTHND THA"I" THE ON—SITE SEWER SYST�M MR REQUIRE ENLHRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THHN 4 BEDROOMS.
~.... ....
�~~~~~�
APPLICANT MERLE BEETER
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
• +f.e` DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
625 L. Street, Anchorage, Alaska 99501 264.4720
--� SOILS LOG — PERCOLATION TEST
PERFORMED FOR: v� 12e�V �D `�.S �y DATE PERFORMED: 1
LEGAL DESCRIPTION: f\
SLOPE SITE PLAN
G_6
3 G 2' — �> W onto U e +
4 6 0 0
6
16
-
say
17
Depth to
Water
Net
Drop
18
19
20
: 22
COMMENTS
1
��� It
j
PERFORMED BY:(�
3G1t,
` /4"
72-008 (6/79)
cm
ae 43/'
C,arih O. Talbot
. No. 4069-E
WAS GROUND WATER �� S
ENCOUNTERED? L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
2
: 22
1
1
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j
x;37
3G1t,
` /4"
5
4j�
ff
f
v
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�
L
-
WAS GROUND WATER �� S
ENCOUNTERED? L
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
2
: 22
1
1
��� It
j
x;37
3G1t,
` /4"
5
4j�
ff
PERCOLATION RATE O (minutes/inch)
TEST RUN BETWEEN FT AND T FT
CERTIFIED BY:
DATE: / a;nry,A_- Zv/
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pq
Municipality of Anchorage
Department of E ecalth and Human Services
Toni Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
January 9, 1989
Francis Eickbush
PO Box 110496
Anchorage, Alaska 99511
Subject: Lot 5 Block 8 Mountain Park Estates Subdivision #2
Permit #880100, P.I.D. #017-391-37
A permit issued by this Department for an individual well
and/or on --site sewer system has expired as of December 31,
1988.
Permits are issued on a calendar year basis by authority of
Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system
not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the orginal as -built inspection report
(three-part form) must be sent to this office for review and
approval, and for documentation.
When applying for a new permit, the fees are: $90.00 for
an on-site sewer permit; $50.00 for a well permit; $140.00
for a combined sewer and well permit.
If there are any further questions, please call this office
at 343-4744.
Sincerely,
A��Uv / ®P
Daniel J. Roth
Acting Program Manager
On-site Services Section
DJR/ljw
enc: Copy of Permit
MUNICIPALITY OF ANCHORAGE
, Department of Health & Human Services
825 L Street, Anchorage, Alaska 99501 343~4720
ON~SITE WELL PERMIT
Permit Number: 880100 Upgrade
Date Issued: 06/30/88
Owner Name: FRANCIS EICKBUSH
Owner Address: P,O BOX 110496
ANCHORAGE, AK 99511
Day Phone:
Parcel Id: 017`391'37
Lot Legal: Subdivision: MOUWTAIN PARK EST #1 Lot: � Blo�k: 8
Section: 16 Township: 12N Range: 39W
Lot Gize .5A (s4.f,t. or acres>
Max Bedrooms: This Permit: 4 Total Capacity: 4
WELL: Log must be submitted to Municipality of Anchorage Department of Health
and Human Services within 30 days of' well completion.
PERMIT EXPIRES ON DECEMBER 31, 1988"
OLD WELL MUST QE PROPERLY �B�NDONED"
I CERTIFY THAT:
1" I am 1 amiliar with t. he requirements I'or on-site sewers and wells as set
I'orth by the 11L.1nicipality c.) f All chDPage (MOA) and the State of Alaska"
2. I will insta1l the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria oF this permit.
3" I will adhere to all MOA and State o1, Alaska requirements f,or the set back
distancrom any existing by c-') wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot"
4. I understand that this permit is valid f' Or a maximum of 4 bedrooms. I
also understand that the capacity c) I' the total system is 4 bedrooms and
anY enl l t
Signed: TE
(Owner} FRANCI�~�I`CKBUSH
- �
DATE: �/��
MUNICIPALITY OF ANCHORAGE
`. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
i Qom"n���Z
PH((
3 J 5"1�:�7
- NEW
❑UPGRADE
_i,✓
MAILING AODRESS�. G
C
LEGAL DESCRIPTION
LOCATION
NO. OF B°DROOM
Uv
DISTANCE TO:
Well
/
Absorption area _
Dwelling
PERMIT NO.
9/b3 _70
wQ
Manufacturer
Material C
No. of compartments
Llq. capa�ty inUl Ions
//
IF HOMEMADE:
Inside length �.
Width_
Liquid depth
Z
DISTANCE TO: _
Well f
D fling
PERMIT NO.
❑ 2 Q
S—<
Manufa re:` �f
aterial
Liquid capat-gallons
❑
w x
DISTANCE T0:
Well
Foundation
tet— L
Nearest lot line
PERMIT NO. v
O l Q 3 U
J LL 2
Lu 2
~
No. of lines
� �i
Length of each Ijye`, i
J '
Total length of I nes
J `f-
Trench width
ches
Distance between lines
'
h
n
Top of tile to finish grade I
Material beneath tile
,_r
—weHes
Total effective absor re
w
Length
Width
Depth
PERMIT NO.
Q I—
as
Ile
Type ofcrib
Crib di eter
epth
Total effecti bsorption area
LJ
N
DISTANCE TO:
Wel
Building fou found tC n
Barest lot line
J
ass C/I -, ,�
Depth
Driller
Distance to lot line
PERMIT NO. 7 0
W
DISTANCE TO:
Building foundation.
Sewer line
Septic tank `f
Absorptioft / area (s)
// �
OTHER
PIPE MATERIALS
(D303�{
SOIL TEST RATING
INS-29(LLLEER, _
VI
REMARKS V V
,
JL L
r
I
,
R
J
I
APPR ED DATE LEGAL
72-013 (Rep. 3/78)
L�
MUNICIPALITY OF ANCHORAGE
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
3AB! 2 51989
RECENED
LOCATION OF WELL
(Please complete either In, Ib or Ic.)
Subdle,siop Lot Block
Bar ",a
1-.
ib. I/4 qtrs..
Top
Bottom
DISTANCE AND DIRECTIUN FROM ROAD ii4TERSt
CTIONS
r
� I
f r ...
St r of Address and
Area of Well Locotlon
WATER WELL RECORD
STATk: OF ALASKA
DEPARTMENTOF NATURAL RESOURES
Division of Geological a Geophysical Surveys
Drilling Permit No.
A.D. L. No.
Section No. Township N❑ Range ED Meridian
—
3. OWNER OF WELL: /
Addroas: ✓
2. WELL LOG Feet Below
S f
4. WELL DEPTH: ( final ) 5. DATE -OF COMPLETION—�
. !r
B. ❑ Cable tool Rotary ❑ Driven ❑ Dug
❑ Auger C]Jefted ❑ Bored ❑ Other:
7. USE: Domestic ❑ Public Supply ❑ Industry
Irrigation ❑ Recliargo ❑ Commorlcal
❑ Test Well ❑ Other: -----
S. CASING: ❑ Threaded Q Welded A
diem-'M_In. to _Lift Depth Weight JL Z Ibs./11.
diarn, in. to ft. Depth Stickup__—, ft.
9. FINISH OF WELL:
Type:! `—
Slol/Meeh BISa: Length: ____
Set between ff and ft
Bockfilling -- Gravel puck -- _
10. STATIC WATER LEVLL
❑ Abovo or ]j-Bolow land surface
Date
Equipment used 6-'C.
I I , PUMPING LEVEL. below land surface and YIELD
.. J,y/4 it. after bra, pumping g.P.m.
—._ft. after �hra. pumping_—_g.Pan.
12.GROUTING Well Grouted: you LJ No
Material: ❑ Neat Cement ❑ Other: Tom.
---------------�-�-- --`- -_-- 13, PUMP: it available) HP
--'--------"- ---`�— ---- Length of Drop Pipe ft, capacity g. P.m.
"--"-"`—'----- --""—_� - - -�--- ❑ Suban. Jet ❑ Centr(fical ❑ Other
14. REMARKS:
- - ---- j'i,{
16. WATER WELL CONTRACTORS CERTIFICATION:
15. Water Temperature —° ❑ F ❑ C
This well was drilled up er my jurisdlctlor and this report Is true to thq bgst of my knowledge and bellef;
r i
?'yf� �`•.-� f`i r!57
Registeroo Business Nome' % j Contract License Number
r '--i Data
Signed
^Authorl zed Representative-�
Form 02-WWR (11/81) Copy Distribution: WHITE-S1ato DOGS, PINK -Driller, CANARY -Customer
_ u
ace
Top
Bottom
—
f r ...
j( f
4. WELL DEPTH: ( final ) 5. DATE -OF COMPLETION—�
. !r
B. ❑ Cable tool Rotary ❑ Driven ❑ Dug
❑ Auger C]Jefted ❑ Bored ❑ Other:
7. USE: Domestic ❑ Public Supply ❑ Industry
Irrigation ❑ Recliargo ❑ Commorlcal
❑ Test Well ❑ Other: -----
S. CASING: ❑ Threaded Q Welded A
diem-'M_In. to _Lift Depth Weight JL Z Ibs./11.
diarn, in. to ft. Depth Stickup__—, ft.
9. FINISH OF WELL:
Type:! `—
Slol/Meeh BISa: Length: ____
Set between ff and ft
Bockfilling -- Gravel puck -- _
10. STATIC WATER LEVLL
❑ Abovo or ]j-Bolow land surface
Date
Equipment used 6-'C.
I I , PUMPING LEVEL. below land surface and YIELD
.. J,y/4 it. after bra, pumping g.P.m.
—._ft. after �hra. pumping_—_g.Pan.
12.GROUTING Well Grouted: you LJ No
Material: ❑ Neat Cement ❑ Other: Tom.
---------------�-�-- --`- -_-- 13, PUMP: it available) HP
--'--------"- ---`�— ---- Length of Drop Pipe ft, capacity g. P.m.
"--"-"`—'----- --""—_� - - -�--- ❑ Suban. Jet ❑ Centr(fical ❑ Other
14. REMARKS:
- - ---- j'i,{
16. WATER WELL CONTRACTORS CERTIFICATION:
15. Water Temperature —° ❑ F ❑ C
This well was drilled up er my jurisdlctlor and this report Is true to thq bgst of my knowledge and bellef;
r i
?'yf� �`•.-� f`i r!57
Registeroo Business Nome' % j Contract License Number
r '--i Data
Signed
^Authorl zed Representative-�
Form 02-WWR (11/81) Copy Distribution: WHITE-S1ato DOGS, PINK -Driller, CANARY -Customer
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water and 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
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-391-37 COSA # Otyn 13 --
Expiration Date: — / — 0 ro
1. GENERAL INFORMATION
Complete legal description Lot 5 Block 8 Mountain Park Estates
Location (site address) _5934 Bristol Drive, Anchorage AK 99516
Current Property owner(s) Dave 8 Josie Hanneman Day phone 271-5225
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O. Box 112635, Anchorage AK 99511
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered In the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of Onsite 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 Pannone Engineering Services LLC Phone 272-8218
Address P.O. Box 102954 Anchorage AK 99510
Engineer's Printed Name Steven R. Pannone P.E. Date Z
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines &. Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features. •�„aa
lie operational life of all wells and septic systems depend on the local soil condition, ground water •••�� OF Al0#*
levels that may fluctuate during the year, and the water usage of the family being served by the system .• �p �"" `� �i
7liese conditions are outside the control of the evaluator of this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future i
performance nor give any estimate of how long the system will continue to meet the operational , j
requirements of the MOA DSD. lie content of this report is for the sole benefit of the owner listed P Steven R. Ponnonel�'i:
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �.� No. CE 8149
confer any legal right whatsoever. ��t •I I i
5. DSD SIGNATURE aa'aa�-••
Approved for _L�_ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attacnments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: (tet/ Original Certificate Date: J 0
67 4�1
(R�v 17105)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
A. WELL DATA
Well type E H A. B, or C provide PWSID B
Date completed 7n61'1988 Sanitary seal (YIN) Y
Total depth _W ft. Cased to 1&_fL
FROM WELL LOG
Data of test 7n8ng88
Static water level 151 ft.
Well production h " 00" Ofd, g.p.m.
WATER SAMPLE RES JLTS! I Lj�
Coliform oolonies/100 mL Nitrate mgr_
Arsenic: mgn Data of sample: 4M3=
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Anchoraas Tank Steel
Tank size 1250 gal. Number of Compartments j
Well Log (YM) Y
Wires properly protected (YIN) —
Casing height (above ground) 26 'in.
AT INSPECTION
4n9rM
153 ft.
5.2 g.p.m.
Other bacteria � coloniesl100 mL
Collected by: Laura Pannone
Cleanouts (YIN) Y
Foundation cleanout (YIN)Depression over tank (YIN) N High water alarm (YM) WA
Date of pumping 04I2005 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 5M7IM Soil rating (g.p.d.lftz or fe/bdrm) 1.2_ System type _Shallow Trench
Length T2.9 fL Width 5 ft. Gravel below pipe 3 ft.
Total depth ¢ ft. Eft. absorption area J4&ft2 Monitoring tube Y Depression over field N
Date of adequacy test 065W Results (PasslFall) Pass For } bedrooms
Fluid depth in absorption field before test = in. Water added= gal. New depth= in.
Elapsed Time: — min. Final fluid depth — in. Absorption rate >= bCO g.p.d.
Arty rejuvenation beat, ant (past 12 mo.) (YIN 8 type) JA,�Q If yes, give date
D. LIFT STATION
Data installed in gallorfs Manhole/Access (YM)
'Pump on' level at _ In. `Pump of / I a —in. High water alarm level at
Datum Cycles tes Meets alar 8 dreuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 104.4
Absorption field on lot 105.1
Public sewer main 100+
Sewer /septic service line 40+
Animal containment areas 100+
On adjacent kits 100►
On adjacent lots 100+
Public sewer manhole/deanout 100+
Holding tank 100+
Manure/animal excrete storage areas 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Ir Property line _E Absorption field r
Water main 50+ Water service line 40+ Surface water 100+
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 20.4' Building foundation 1S Water main 100+
Water Service line 40+ Surface water 100+ Driveway, parkeigArehide storage 35+
Curtain drain None Observed Wells on adjacent lots 100+
G. ENGINEER'S
I cer* that I have determined through field inspections and
review of Munictpal records that the above systems are in
conformance with MOA COSA guidelines in effect on this dale.
Engineer's Printed Name Steven R. Pannone, P.E. ��%+leve^CE A1noo"�
Date •++ice '...... �!'�'6�:
COSA Fee $ D�
Date of Payment 2
Receipt Number
(Rev. 1145)
Waiver Fee $
Date of Payment
Receipt Number
in.
SGS Ref. M:
1061809
Client Name:
Pannone Engineering
Project Name:
Mountain Park Est, L5, B8
Client Sample ID:
Mountain Park Est, L5, B8
Matrix:
Drinking Water
PWSID
Sample Remarks:
SGS Environmental Services Inc
200 W. Potter Drive
Anchorage, AK 99518
Tel: (907) 562-2343
Fax: (907) 561-5301
All dates/times are Alaska Standard Time
Printed Date/Time:
04/17/06 16:20
Collected Date/Time:
04/12/06 16:50
Received DateMme:
04/12/06 17:08
Technical Director.
/5tephe
Released
Allowable Prep Analysis
Parameter Results POL Units Method Limits Date Date [nit
Bacteria 0.00 9222B 04/12/06 04/12/06 tN
Nitrate
4.79 0.10 mg/kg EPA 300.0 10.00 04/13/06 04/05/06 alr
Arsenic ND 5.00 ugtL 200.8 10.00 04112/06 04/12/06 scl
.I
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sR • .2 ••yam\ . 1
-EASEMENTS -OF RECORD, OTH'R 7N44
THOSE S"Oyd"! ON TH.
R"COROCC
`j P141, ARE NOT SHOWN HULLON.
No Carron Set This Date
1 hereby certify Uat 1 have surveyed the following described property, Lot_Block
,440[l.yr4", �:d'K C5'J 77irC ] Anchorage recording Precinct, Alaska, and that
the Improvements situated thereon are within the property lines and do not overlap or
encroach on the property lying adjacent thereto, that no Improvements on property
lying adjacent thereto encroach on the premises in question and that there are no roadways,
transmission lines or other visible uwments on said property except as Indicated hereon.
Anchorage, Alaska 21 O c r. 1.994-
�� r
RfCET t/:T/CG �o ,M,) 40071 -'r. N•:/•(:, ,. _,
Book No. Page No.
/dints Hildonen
.� Me. 1304:
ee
1� �rsslo«kl
lj .SroRY
m •1 ry
�vt
o
FLAME
HOUSE
oe•B o -
mss•
� o
� ;qq fewer
` s
sy,/e,r7 0
fo o.
/,v,..,
0
1
sR • .2 ••yam\ . 1
-EASEMENTS -OF RECORD, OTH'R 7N44
THOSE S"Oyd"! ON TH.
R"COROCC
`j P141, ARE NOT SHOWN HULLON.
No Carron Set This Date
1 hereby certify Uat 1 have surveyed the following described property, Lot_Block
,440[l.yr4", �:d'K C5'J 77irC ] Anchorage recording Precinct, Alaska, and that
the Improvements situated thereon are within the property lines and do not overlap or
encroach on the property lying adjacent thereto, that no Improvements on property
lying adjacent thereto encroach on the premises in question and that there are no roadways,
transmission lines or other visible uwments on said property except as Indicated hereon.
Anchorage, Alaska 21 O c r. 1.994-
�� r
RfCET t/:T/CG �o ,M,) 40071 -'r. N•:/•(:, ,. _,
Book No. Page No.
/dints Hildonen
.� Me. 1304:
ee
1� �rsslo«kl
Municipality of Anchorage
• Development -Services Department *A9
Building Safety DivisionOn-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us ;�,.>
ZUZ (907) 343-7904'
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel 1. D. 017-391-37
1. GENERAL INFORMATION
HAA #�
Expiration Date: '- O 0 1+
Complete legal description Lot 5 Block 8 Mountain Park Estates
Location (site address or directions) 5934 Bristol Drive, Anchorage, AK 99516
Current Property owner(s) Michael & Theresa Ford Day phone 271-5410
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
_5934 Bristol Drive, Anchorage, AK 99516
Day phone
Katherine Donohue/Prud. Vista RE Day phone 244-6939
4241 B Street, Anchorage, AK 99503
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS: - 4
3. - TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
ED
Individual Holding tank
❑ _
Community On-site
❑
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 civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to home owners. Certificates of Health Authority Approval are
valid for 90'days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. 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.
(Rev. 11/99)
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation
based on procedures outlined in the Health Authority Approval Guidelines for 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Enq. Svc. Phone 272-8218
Address P.O. Box 102954, Anch, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 51101C L(
Engineers Comments: in conducting an adequacy test, I attempt to provide a thorough, conscientious ,�
engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The �� -`� OF 14444
.�
reported results describe the performance of the system under the conditions encountered at the time of ♦ X\P'•.•••' '••., �♦ ♦
the test, and separation distances measured to readily identifiable features. The operational life of all i �,� • /� •• ♦
o.
wells and septic systems depend on the local soil condition, ground water levels that may fluctuate L ' 49TH �/�[� •: •♦♦
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 this system. All systems eventually fail and satisfactory test results �
do not guarantee future performance of the system, nor do they guarantee that there arc no hidden defec ...... .... ... .................:, „t
or encroachments. PES can therefore not provide any warranty for future performance nor give any 8' -Steven R. Pon none: s
estimate of how long the system will continue to meet the operational requirements of the ADEC or ♦ 0%, M
♦ No. CE 8149 •.�•� �.
MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon i
♦♦J (p
�°
or use of this report by any other person or party is not authorized nor will it confer any legal right ♦♦
whatsoever.
6. DSD SIGNATURE ��� ����•
Approved for _ bedrooms.
Disapproved.
Conditional approval for. bedrooms, with the following stipulations:
wtt((llWr��i�,
Additional Comments jam:• ON-SITE ••;'�i
• m:
WASTEWATER :
PROGRAM =
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
By: 411
Expiration Date:
(Rev. I IM)
9))JJ11) Fwl
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: _� a- O _0q
Reissue Date:
.. ... F..
Municipality of Anchorage
Development Services'Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
.HEALTH AUTHORITY APPROVAL CHECKLIST
61 B ��
= n'
s• cTr
Legal Description: Lot 5 Block 8 Mountain Park Estates Parcel I.D.:- 017-391-37
A. WELL DATA
Well type P If A, B, or C provide PWSID # Well Log .Y
Date completed 7/16/1988 „Sanitary seal Y Wires properly protected Y
Total depth 247 ft Cased to 158 ft Casing height (above ground) 26 in.
:FROM WELL LOG AT INSPECTION
Date of test 7/16/1988 4/19/2004
Static water level 151 ft . 153 ft
Well production ,Ij,14 0*8 On 9 -P -m 5.2 g.p.m
�e�t t o9
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml Nitrate 3.76 mg/1 Other bacteria 0 colonies/100 ml
Date of sample: 4/19/2004 Collected by: Steven R. Pannone
B. SEPTIC/HOLDING TANK DATA
i
Tank Type/Material Anchorage Tank Steel
Date installed 5/17/2004 Tank size 1250 gal Number of Compartments 2
Cleanouts 2 Foundation cleanout Y Depression over tank N High water alarm NIA
Date of pumping Pumper New
C. ABSORPTION FIELD DATA
Date installed 5117/2004 Soil rating (g.p.d./f? or fe/bdrm)11_2 System type Shallow Trench
Length 72.9 ft Width 5 ft Gravel below pipe 3 :.ft
Total depth 6 ft Effective absorption area 364.5 ft2 Monitoring tube Y Depression over field N
Date of adequacy test .-Nfg&) Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test New in Water added --- gal. New depth in.
Elapsed Time: 0 min Final fluid depth — in Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
(Rev. 11/99)
D. LIFT STATION
Date installed Size i IonsManhole/Access '
"Pump on" level at in"P oft' level at ! in High water alarm level at in
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 104._ 4 On adjacent lots 100+
Absorption field on lot 105.1 On adjacent lots 100+
Public sewer main 100+ Public sewer manhole/cleanout 100+
Sewer/se tic service line '40+
P Holding tank 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 17 Property line 47 Absorption field 7
Water main 50+ Water service line '40+
Surface water 100+
Drainage 100+ Wells on adjacent lots 10_0+
SEPARATION DISTANCE FROM ABSORPTION FIELD ;ON LOT TO.-
Property
O:Property line 26.4 Building foundation 15 Watermain' 100+
Water Service line40± _ Surface water 100+ . Driveway, parking/vehicle storage 35+
Curtain drain None Observed Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION �P"""' �•.;Q�j,
/certify that I have determined through field inspections and Cj 9TH C
review of Municipal records that the above systems are in i""' �•••• •••'• • • •• ••
conformance with MOA HAA guidelines in effect on this date.
♦` Y'k even R. Po�ncne**
Engineer's Printed Name Steven R. Pannone. P.E. �� �, No. CE 8149 °�'
Date �1�D�<<d••°:
HAA Fee $ 75120511 7e. P,
Date of Payment 5 -aO eOL4
Receipt Number
(Rev. 11/99)
Waiver Fee $
Date of Payment
Receipt Number
4-2z-04; 4:04PM;
;907 S613301 0 3.- 3
w
SGS/CTBE ENVIRONMENTAL SERVICES
Drinking Water Analysis Report for Total Coliform" Bacteria
READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE
MUST BE COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM IDd
*RIVATE WATER SYSTEM
❑ Send Res ills
❑ Send Immice
u/r 6.1,sn •-w%8Ay
W
M•y
PF.9ANwnM•
9.Nunw9r
N.rriftr
7
8W.
LPCu
280 W. POTTER DRIVE
ANCHORAGE. ALASKA 99518
Tei: 907.562-2343
Fax 907-561-5301
1041844-*
Sand Results "nd Ir.W06
er )"'n..OT.aly H wocalm"
BacteriologlCai Water Analysis Record:
6.
rima .
N.rriftr
rex
.
(y�
V
..
.0 CDZS6
a NCu-
q,? r-1 b
SAMPLE COL�LEClT-IONJ: n.edw. r SAMPLE TYPE:
rxvw�ns vftn o�r.awa
at•_��
outine �. .
Treated Water
sro.m Coy Yew
Time: qgkda e,.1 ❑ Repeat Sarriple Untreated.Water
LecoMon: &OA• -c 00-.0t Z'��fmagSt.- infer to I -b no. 1
Collector: ❑ Special Purpose
muo Kwu Swain
Van ported
to Lab By: ame as collector Other
j'•'
PmoiodFayh
'O BE COMPLETED BY LABORATORY
Samole Receivina:
Date: 7�� �1 " Sample over 3C hours old; ❑ . RUSH SAMPLE
Time: Results may be unreliable
Temp: a -1A-6 ❑ 4e Hour Waiver Phone 0;
Delivery Method: F ole Lmations Fax 0:
Received By:
Co-nments:
.01.94.......19..................9..0.94u..u.nnu.0.u.u.u94.n.49........ .4..9...uu................4n...9u0n0.4...0
BacteriologlCai Water Analysis Record:
Sent to ADEC:
MMO-TALC (PIA) RESULTS:
ANC FEK JUN
lCaterrkne:
Analysts Saw: 1
Total Comm
Analyst: ts(i
E. Coll:
Sent to Client
Analytical Methed:
MEMBRANE FILTER RESULTS:
Phoned Q Faxed Q
Dlractrount
Cmades1100ml.
Detamme•
Membrane Filter
verification!
Spoke with:
MMO-MUG (P/A)
rwe.w..� LTB.
BGa:
Satisfactory
FC-
❑
Unsatisfactory
Reported By: `p . �j r
DatelTtme: y
mte - Tp Nu.n.ro.. ee co..:
eyreture
_
Form at FW- 0053 12117!03
t1petratpublic%DOCUMENTIFORMSthlicrolCoA Form 121703.1ds
4-22-04; t:OapM; ;907 ZSIBSO1
:G5 Reftl
1041844001
:Ilent Name
Pannone Eng. Srv.
?rojeetNameW
Front Hose Bib -1.5/B8 Mt Park
:tient Sample ID
Front Hose Bib-L5/B8 Mt Park
4&trtx
Drinking water
IWS1D
0
All Dates/Times are Alaska Standard Time
Printed DataMme
0422/2004 15:03
Collected Date/Time
04/19/2004 16:45
Received Date/Tlme
04/192004 17:03
Technical Director
StgpAn C. Ede
ample Remattts:
arametcr Results is
PQL UaIU Method Container ID LAllim t�e DDaetee ~p eater lnit
raters Department
NitrateN 3.76 0.100 mg/L EPA 300.0 B (<=10) 04/19/04 J1B
Liorobiology Laboratory
Total Coliform 0
coLfl00mL SM18 9222B A (<=1) 04/19/04 DKC
0
J...
rCAKT.
i
,.;_.... _ . +�ro I1 :5 roe Y
}LOUSE
JIV 8.49.
Z! 5du.+er r '
I j Sfdnd p1pei io' a
\ e ..:.. ...... _.....I .
v JNED Sy s IC177 0� .5C4 [ E l ••r.�0'
O
c �
Rp , \ . _-- EASMENTS.OF RF:CORO, OTHrk THAN
F' \ 1HOSE SI1,01/t/1: ON TH'c' R`COR0E..0
j PIAT, ARE NOT SHOWN HEREON.
I. \ \`
As Built No Corners Set This Date Book No. Page No.
I hereby certify that I have surveyed the following described property, Lot -S Block 8 ••t+� OF A1.4%1
Moc�Nry/N ,E•/< L=3 r -l# CE' S Anchorage recording Precinct, Alaska, and that i Q.` 00*00ei••ea•�s
the improvements situated thereon are within the property lines and do not overlap or ~e� i
encroach on the property lying adjacent thereto, that no Improvements on property
lying adjacent thereto encroach on the premises In question and that there are no roadways, /e •• eN••eeN•N•NNNeN•e •
transmission lines or other visible easements on said property except as indicated hereon. i ZL�
IF sa Mildooen ;
2/ O C r. l 9 e 4- 1I'siti. No. 1 �oi-s l
Anchorage, Alaska z G , r—*'_ c(�o, ...•... � �kC e••Nooeoo � r
,eEc E� r �F/ Er o M.� 7 �oo�{ fl 4 % offssIONM6 �J�
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES M}1
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
Parcel I.D. #/%-:� fil _� HAA #
1. GENERAL INFORMATION
Complete legal description
Lot 5; Block 8; Mountain Park Estates Subdivision
Location (site address or directions)
5934 Bristol, Anchorage, Alaska
Property owner REICCATTON RESOURCES G ' Day phone
Mailing address
Lending agency
Mailing add
Day phone
Agent Shel Hensley/AREA COLDWELL BANKER Day phone
Address 4105 Tudor Center Drive, Anchorage, Alaska 99508
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
561-2488
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 XXX
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 1121
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 5 3 5 ENGINEERING Phone
17034 age River Loop Road No. 204
Address Eagle River, Alaska 99577
Engineer's signature
6. DHHS SIGNATURE
Approved for _�p& (7./ bedrooms.
Disapproved.
Conditional approval for
Additional Comments
WTIC
Date 2 -24-g(3
ROG& J.$HAFER
82 5eo
8
�4k �1?®FESW .
bedrooms, with the following stipulations:
Date 71b��.3
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 ordertosatisfy 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 N21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: I.oT 5 SL 6 MoUNrAw E&ZK FS W�S
A. WELL DATA
Parcel I.D. l)
Z% .3Z/! 2
Well type 691V1125� If A, B, or C, attach ADEC letter. ADEC water system number
Log present `7/N) �€S Date completed
Driller 602LE /-W14',!/JGaEA11r
Total depth 042 —Cased to /S� r Casing height
2� rr
Sanitary seal O/N) Wires properly protected 6N) YE
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
%//SIRS
/SI
NUl DN G.oG g.p.m.
z 4v r
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
Z
u, o
� N
ur
U. u
'
It
c�
LU
g.p.r�. :g
i'UM i° �O% /2�l4 G /7 4RL3
r:.1
LL.1
�'. o
Septic/holding tank on lot oo r ; On adjacent lots /00 t
Absorption field on lot
/pd f ; On adjacent lots /Gb t
Public sewer main
NONE /OLEE. E,uT Public sewer manhole/cleanout 4Jn1/6- F/2ESE T
Sewer service line Z 5 r� Petroleum tank Kr1/ocJ1--'
WATER SAMPLE RESULTS: f%
Coliform lUO m'— Nitrate — Z. 3� MPJ & Other bacteria
DJ
Date of sample:
21alg3 Collected by: –�E--Ilq- S �iVG//JE dL/K�
B. SEPTIC/HOLDING TANK DATA
Date installed 21/S / F/ Tank size /ZSU Compartments
Cleanouts (�VN)
Foundation cleanout &)
Depression (Y(�) NU
High water alarm (YO
Alarm tested (YA J1
Date of pumping
Z/1Pumper A -t SEyU/GG�S
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /�� On adjacent lots
Topropertyline .—Absorption
Surface water/drainage ltl n"6 LA/oG✓rV
�t
16)0 Foundation /O r
i
Water main/service line
CONTINUED ON BACK PAGE
72-026 (Rev. 7/91) Front
C. LIFT STATION ,Uv NE P/ZEJ6_/,J7_
installed
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
— Manufacturer
Manhole/Access (Y/N)
"Pump off" level at _
Meets MOA electrical codes (Y/N)
SEPARATION DIST-ANCE FROM LIFT STATION TO:
We lot On adjacent lots
D. ABSORPTION FIELD DATA
Cycles tested
Surface water
Date installed '7//SlQ/ Soil rating IR2- System type /le&/CN
r �
Length IS Width 3 Gravel thickness / Total depth /d_//
Total absorption area 7Zo Cleanouts presentON) YES
Depression over field (Y, V(� tiU Date of adequacy test 2
Results as /fail) J° SS for
bedrooms
Peroxide treatment (past 12 months) (Y/N) tic'�/� i�f�A/ If yes, give date e�
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 600 '7Lg r
On adjacent lots �6 ° 7– Property line
To building foundation K– - To existing or abandoned system on lot .Vo,cJtr
Onadjacentlots20r� Cutbank tioNE �S��Watermain/service line 2S
Surface water N°iJLLP- SEI. E_ Driveway, parking/vehicle storage area 3a 114 -
Curtain drain
E. ENGINEER'S CERTIFICATION
l certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect oyynn((ll{ Lh date of this inspection.
.nom �tlM..
5 8, S I NGINEl RING2 � �� ese90066,o Cj��
17034 Eagle River Loop Road No, 204®� aaa Ana =6 ,t
Signature ;' �41aska 99579 e0 k
tb
lsta-es�aa aaeeeeecoeeo Bee scdao
Engineer's Name
�i oAceeaoeeee�oeo +.
/L�,y mGeo as oae
Date `�`T (' R0GL Ft J. ° iAFU1 t
('�a6e No. 8a 115 e°ate e
{ � eC aoe ��bcyEil
HAA Fee $ _ Waiver Fee: $
Date of Payments Date of Payment
Receipt Number Receipt Number
-2-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
Chemlab Ref.# :93.0665-3 REPORT of ANALYSIS
Client Sample ID :L5 B8 MOUNTAIN PARK ESTATES S/D
Matrix : WATER
Client Name :S & S ENGINEERING Collected :02/16/93 0 16:40 his.
Ordered By Received :02/19/93 6 09:45 his.
Project Name WORK Order :63347
Project# Report Completed :02/22/93
PWSID :UA Technical Director :STEP EN/ C. EDE
Released By
Sample ROUTINE SAMPLE COLLECTED BY: S.S. 7
Remarks:
Parameter
-------------------
NITRATE-N
QC Allowable
Results Qual. Units Method Limits
---------------------------------------------------------------------------
2.37 mg/l EPA 353.2/300.0 10
Extract Analysis
Date Date Init
-------------------------------
02/22/93 02/22/93 LLH
............................,........,...........................,.......................................,.,................................
' See Special Instructions Above UA - Unavailable
See Sample Remarks Above NA - Not Analyzed
U - Undetected, Reported value is the practical quantification limit. LT - Less Than
D . Secondary dilution. GT - Greater Than
QN S13S Member of the SGS Group (Socidtd Gdndrale de Surveillance)
� °e
`F �,
�r
U 80RATORY
COMMERCIAL TESTING & ENGINEERING CO. AK DIV
CHEAICAL & GEOLOGICAL LABORATORY
TELEPHONE (907) 562-2343
5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
C� PUBLIC WATER SYSTEM I.D. #
PRIVATE WATER SYSTEM
Nano S & S ENGINEERIN Phone No.
17034 Eagle River Loop Road No. 204
neer'!
Mailing Address Eagle r --' '
State ZP Code
SAMPLE DATE: TT b 1 3
Mo. Day Year
SAMPLE TYPE:
A Routine
❑ Check Sample (for routine sample
with lab ref. no. ) ❑ Treated Water
❑ Special Purpose ❑ Untreated Water
SAMPLE Time Collected
No. LOCATION rRPZK Collected By
z
3
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
I�Satisfactory
/❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 30 hours old at examination
to indic;ite reliable results. Please send
new sample via special delivery mail.
Date Rece wed Z�1
Time Race ved d o! �f 5
Analytical thod: Membrane Fitter
' No. of colonies/100 ml.
1
I
Lab Rai. No. Result' Analyttt
7
O�BACTERIOLOGICAL WATER
Membrane Filter: Direct Count
Verification: LSB
Fecal Coliform Confirmation
BGj
YSIS RECORD
Collforni ml
Final Membrane Filter Results 4
gCollform/100 ml
Reported By 1-/ Date
TNTC = Too Numerous To Count tl � 'r,0CY
a.m.
OB = Other Bacteria PART ONE OF TWO
ONSiGS Member of the SGS Group (Societe REMAINDER TO FOLLOW
u
Ili�i1t\
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER A WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
R FLOW TEST
S" F PLANS
POA'D DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
M
WELL FLOW TEST DATA
ROBERT SHAFER, P E
ROGER SHAFER, P.E
CIVIL ENGINEERS
(9071694-2979
FAX 694 121'
CLIENT: I DATE OF TESTI:
LOCATION OF WELL (Legal Description): Lor 5 m e Mowimmi Pgr2K ESTATES S/A
WELL DEPTH: Zq-% CASINnG DEPTH: Ste' BY: SS
DATE DRILLING COMPLETED: /l/S/�y DRILLERt
TEST DATA:
CLOCK
TINE
DEPTH TO
WATER
DRAWDOWN
PUMPING
RATE(GPM)
REMARKS
1:40 A
1522'swl
D
(o,z
FLo p vLL, Gvwa6GfEp
/0:10
S7 '
S '
6, 2.
81 Pgas'SoLot-1
to:zM
lS7
�• (
Tlz Y (r `°
0
/ S 7 `
�. 2
AIJA ';11461A1 A)6 .
l2 0
ISS'
S
�.Z-
2: 4,o
,
AJO 7- fe6ArHCO.
MISC. DATAt CASINO HEIGHT: ZC" SANITARY SEAL?: Y _
WIRES.IN CONDUIT?:�_ GRADING O.K.?t Y
BACTERIA 61 NITRATE SAMPLES COLLECTED: z
RESULTS: WELL CURRENTLY PRODUCES6,/ GPM WITH A S DRAWDOWN
PLOW RATE NOT GUARANTEED --SUBSEQUENT VARIATIONS CAN OCCUR!
MUNICIPALITY OF ANCHORAGE
DIVISION Of` EWIRONMENTAT, HEALTH
DEPAREMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION SUR HEALTH AT'.CHORITY APPROVAL CERTI 'ICATP
1, General Information
Application Dates
(fa) legal. Description ( include lot, block, subdivision, section, township, range)
Pi" 0 Q N)- 6 A,
Location (address or directions)
(b) Applicants Name Tele hone
Applicants Address
(c) Applicant is (check oto) Lending Institution Wrer/builder
Buyer. M--- ; Other (:I (explain);_. -
(d) ]ending Institution tele
Address
(e) Real Estate Co. & Agent
Address
Te le phone
2. Type of ib s ide nce
Single -Family Nh_i:Lti family Other (describe)
Number of Bedrocxr
c
i
3. ClkateL' Su�Y_
Individual. vAbl.l. 4--0 Community I Public
Note: If conuCe-lnity �nl.l. system, must have written confirmation fjrxi the State
Departsfent of Environmental Conservation attesting to the legality and status.
Is the 4 11 adequate for the number of bedrocxns specified in this [IAA (Y/N.) � a
4. Sewa 'e Disposal
Onsite rzj Ribl.ic Community Holding 'T'ark 4
Is the wastewater disposal system adequate for the rumter of bDdroaiis (Y/N)
(Page 1 of 21
2-15-84
S. 5nqineerinq Firm Provi.d:ina inspections, Tests, Data and Information
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in
effect on the date of this inspec_cion.
Signed
Date 14 /1.6- e
Name of Firm
Address SM O:S U� L
Signed by - -� _e_7c, zdv�t a'R✓!
Date_
(ENGINEER SEAL)
6. DHEP Approval
Approved for,__. /be drools
Y r
Approved /� Disapproved r
Terms of Conditional Approval
Conditional r::j
r 49L y
at oc cc o.acceuae au Do
2 22 5 E
)Illy 25, 1971 e
Date
I'he Municipality of Anchorage; Department of. Health and Environvental Protection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval indicates that, as of the validation date
shown above, used cn the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional for the number of bedroaTis and type of structure indicated.
(DHEP SEAL)
7, Mail the HAA to the follc_hairg address:
KB2/d5/s
(Page 2 of 21,
2-15-54
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) 'AUG 1 1. 1984
CHECKLIST -FEBRUARY 1984 J� LC E I V ED
A. WELL DATA Legal Description:
--- 1 H0L). _T&1W k`ArZK ES ATM SSC 2(,
,'
Well Classification If A, B, or C, D.E.C. Approved(Y/N)
Well Log Present (Y/N) �% Date Completed 7/9/8 Yield13p2n�
Total Depth q0.V1 Cased to I E;8 Depth of Grouting -- --
Static Water Level /70 Pump Set At %59-7
Casing Height Above Ground CV1 Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N1
Separation Distances from Well:
To Septic/Holding Tank on Lot I O On Adjoining Lots VACANT
To Nearest Edge of Absorption Field on Lot 102.S ; On Adjoining Lots VAC4N r
To Nearest Public Sewer Line W/A To Nearest Public Sewer
Cleancut/Manhole N//4 To Nearest Sewer Service Line on Lot N1A
Water Sample Collected By `r_s ; Date -7/9 A q
Water Sample Test Results S0" Lim
Comments A }ori" 3vo
B. SEPTIC/HOLDING TANK DATA
Date Installed to/a, Size IA6 D No. of Compartments ✓ cYi o
Standpipes (Y/N) i Air -tight Caps (Y/N) Foundation Cleanout (Y/N) a/
Depression over Tank (Y/N) fJ Date Last Pumped ���✓/ $ �-% ________ ��_
Pumping/Maintenance Contract on File (Y/N) Nq for
Holding Tank High -Water Alarm (Y/N) !1A Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well 110 To Building Foundation _1!:L__
To Property Lire -ice,, _,To Disposal Field 9_
To Water Main/Service pLine UN "6%4M To Stream, Pond, Lake, or Major Drainage
Course Y�A
Comments
[Page 1 of 21
�VD oma'"
V -)o
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 16),z Type of System Design _1AAc4c
Date Installed 1 n l �0 a Length of Field 3 4�
Width of Field 30 -1kC4 e s Depth of Field
Gravel Bed Thickness $
Square Feet of Absorption Area Standpipes Present (YIN)
Depression over Field (YIN) n1 Date of Last Adequacy Test 7/,b
Results of Last Adequacy Zest S a Li, ka.c. as -r
Separation Distance from Absorption Field:
To Water -Supply TAb11 gs To Property Line g
To Building Foundation 026 To Existing or Abandoned System cn
Lot NomE On Adjoining Lots VAee4tl r
To Water Main/Service Line [y,0 rA L To Cutbank(if present) X10 A LL
To Stream/Pond/Lake/or Major Drainage Course WANIF-
To Driveway, Parking Area, or Vehicle Storage Area 50 t
Comments
D. LIFT STATION N 0 til C
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(YM)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (YM)
Pumping Cycles during Adequacy Zest. Meets MOA
** Check Permitted Bedrocm 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.
Signed _ Date 71 /-
Company OA No. D!
KBl /d5/s
(Page 2 of 21
... SOFA
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-
2-15-84
CHEMMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
%:. TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER �\;a_111'IIYYII=II
5633 B Street
ueowwroeiee
Drinking Water Analysis Report for Total Coliform Bacteria
I� ETED BY LABORATORY
TO BE COMPLETED BY WATER SUPPLIER
�� l = (') See h on back
WATER SYSTEM: I.D. NO.
Lo '& V �- o00ArIN V
Phone No
Water System Name
; 59 3 4
Mailing Address
A .t, rt &. Vi Qe?-ND
State . . zip Code
City (� rn
SAMPLE DATE: �, r O 3 l� I� I
Mo. Day Year
SAMPLE TYPE:
v Routine
❑ Check Sample (for routine sample1 ❑ Treated Water
with lab ref. no. ❑ Untreated Water
❑ Special Purpose
Time Collected
SAMPLE� Col ectad By
N0, LOCATION
1 I 00-Irstp 4 —ii
2 I
3
4
5
READ INSTRUCTIONS
BEFORE
TO BE COMPL
An lysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No. Result' Analyst
EEI
iEEI
u m
J m
.No of colonies/ 100 ml or No of Positive portions
061220(b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1993
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Re ults
Reported By
COLLECTING SAMPLE TNTC = Too Numerous To Count
BG
Collform1100ml
orm1100ml
Date_ 1 —�—
Time: Z�a.m.
p.m.
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
CONSULTING ENGINEER TELEPHONE: (907) 2793916
TRANS AMERICA RELOCATION SERVICE INC. JULY 5, 1984
P.O.BOX 8019
WALNUT CREEK
CALIFORNIA 94596
Attn. Ron Whitmill
Case No. 66-432
Subject: Adequacy Test Of Well And Septic System Lot 5, Block 8
Mountain Park Estate. 5934 Bristol Drive Anchorage
Alaska
Gentlemen;
At the request of Stephen Crissman, owner of subject
property, I conducted an adequacy test of the well and septic
system located at this residence on July 3, 1984. The paperwork
regarding this test has been transmitted to Larry Houle of
Col -dwell -Banker/ Jack White here in Anchorage.
My test shows that the septic system meets the Municipal
Requirements. There are no specific requirements with regards to
the well. However, I pumped the well for 75 minutes at a rate of
5 gal per minute. During this time the well was being recharged
at a rate of one gal. per min. The wellcasing will store in
e>:cess of 300 gal. of water during periods of no water use.
My assessment of the well is that the well yield rate
combined with the storage ability of the well is sufficient to
meet the daily requirement of the residents of this house.
However, lawnwatering in excess of one and one half hour may
overtax the capabilities of the well. This is not a great problem
but something a prospective buyer should be made aware of.
The chemical analysis of the well water showed no
contamination.
Yours
G�.,.4a
Tobben Spur) and P.E.
Time
APP NT FILLS
OUT UPPER HAI ONLY
Property Owner
��,., -
, ,, ,.. '„ _ il._t..;
Phone
Time
Date
Mailing Address C `- O
', /._ G'.._i:i-' �:._` i�l ;\� (�,_ -`...
Zip Code
Buyer
Date
Address
'.� •. t -.: (\ p'_
Zip Code "-�l �•
Lending Institution
_ _
Inspector
Phone
Inspector
Inspector
Address
Zip Code
Realty Co. &Agent ..- � %_
r; ..- k_
-. , . -
Phone
Address
Zip Code
Legal Description _
_ (`, �:;• i._+,.-. ;- �., i..� '(�hR, ,C. r.-�.`:,;-t_!, -i,_
Street Location
Type of Residence
Cir 'T C"'
'jT., :
B Single Family
rr
❑ Multiple Family
c
No. of Bedrooms
❑ Other
Wate u ypply
Indi
2 vidual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
El Pub' 'Utility
Sew isposal
ee
( ) CONDITIONAL APPROVAL'
Individual
Year Individual Installed:
❑ Public Utility
-3
When Connected to Public Utility:
❑ Holding Tank
DATE
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
'1
MUNICIPALITY OF ANLNUKAOr
Field Notes:
Cir 'T C"'
'jT., :
ENVIf< :,. :P. •.. .0 TION
( APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
�J "^
-3
DATE
BY:
Soils Rating
InstalledWell
To Absorption Area / / °/ /
Well Log Received,.
Septic Tank Size
OateSew
Well to Tank 7 ,
72023 (3182)
CHEMICAL & GL LOGICAL LABORATORIES ALASKA, INC.
TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER
A�KGRAMRIE.
274-3364 5633 B Street
, Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER II TO BE COMPLETED BY LABORATORY
WATER SYSTEM:
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample ❑Treated Water
with lab ref. - ) ElUntreated Water
❑ Special Purposee
SAMPLE Time Collected
NO. LOCATION Collected By
1
I
2 I1
3 IL
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Analysis shows this Water SAMPLE to be:
❑ Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No. Result' Analyst
I I F7
I I m
I I m
J E
I m
.Noof colonies/100 ml. or No. of Positive portions.
06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected Source
a. M.
Date Received Time Recalvetl p.m. Lab. No.
Presumetive I om, Iom, loml loml ioml _ 1.0m1 O.lml
Multiple Tube Report:
Membrane Filter: Direct Coun
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 24 hours: Broth 4e hours:
10ml Tubes Positive/Total 10ml Portions
Col (form/100m1
BG
Data
Time
Collform/100ml
p.m.
I.D. NO.
Water System Name
Phone No.
Mailing Address
City
State Zip Code
SAMPLE DATE:
Mo.
Day
Year
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample ❑Treated Water
with lab ref. - ) ElUntreated Water
❑ Special Purposee
SAMPLE Time Collected
NO. LOCATION Collected By
1
I
2 I1
3 IL
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Analysis shows this Water SAMPLE to be:
❑ Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No. Result' Analyst
I I F7
I I m
I I m
J E
I m
.Noof colonies/100 ml. or No. of Positive portions.
06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected Source
a. M.
Date Received Time Recalvetl p.m. Lab. No.
Presumetive I om, Iom, loml loml ioml _ 1.0m1 O.lml
Multiple Tube Report:
Membrane Filter: Direct Coun
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 24 hours: Broth 4e hours:
10ml Tubes Positive/Total 10ml Portions
Col (form/100m1
BG
Data
Time
Collform/100ml
p.m.
!,n
�"'---'
DA.FERECEIV D
INSPECTION APPOINTMENTS
6. TYPE OF RESIDENCE
TIME
TIME
❑ One G& Four ❑ Other
TIME
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
INDIVIDUAL*
_t) t Q ,
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
DATE
DATE
DATE
�-
)5�11. INDIVIDUAL/ON-SITE**YEAR
ON-SITE SYSTEM WAS INSTALLED.
-
INSPECTOR
INSPECTOR
INSPECTOR
MUNICIPALITY
MUNICIPALITY OF ANCHORAGE DEPT. OF I IFALTI I &
& ENVIRONMENTAL PROTECTIOBENVIRONMENTAL PROTFCTION
DEPARTMENT OF HEALTH
825 L Street - Anchorage, Alaska 99501
`` P
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720
RECEIVED ECEI\/ED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTI ONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
PHONE
MAI LING ADDRESS
SZ kA ] CA
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER -��--- C—)
II \ ,,, ,,__
.� \`
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTO GENT
5_ c1. �A c , (._� -- w (--\�
PHONE
`2-`7 6-- 2 i 6
MAILINGADDRESS
Gc" �„�\� :i �, C-1 SDS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
FAMILY
❑ One G& Four ❑ Other
SINGLE
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
INDIVIDUAL*
_t) t Q ,
* 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 if available.)
S. SEWAGE DISPOSAL SYSTEM
)5�11. INDIVIDUAL/ON-SITE**YEAR
ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
Er SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO FOUR ❑ SIX
2. WATER SUPPLY
(1 INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
ZAGE DISPOSAL SYSTEM
IVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
l ,
Eteptic Tank or ❑ Holding Tank
Size: I If Tank is homemade
give dimensions:-'
soILS RATING
TYPE OF TANK ��
MANUFACTURER
TOTAL ABSORPTION AREA%MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
R( APPROVED FOR V BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
g
L-11
72-010 (Rev. 6/79)
CHEMICAL & GI LOGICAL LABORATORIES .,,'ALASKA, INC.
TELEPHONE (907)•2794014 ANCHORAGE INDUSTRIAL CENTER
274.3364 5633 B Street
"HORAMR1ae Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
WATER SYSTEM:7-7 Analysis shows this Water SAMPLE to be:
I.D. NO.
Satisfactory
Water System Name
Mailing Address
Phone No.
City state �j Zip Code
SAMPLE DATE:
Mo. Day Year
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample
with lab ref. no. ) ❑ Treated Water
❑ Special Purpose ❑ Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
1 1
2 1 1
3 L
4
5
06.1220 (b)
Rev, 1976
Data Collected
READ INSTRUCTIONS
Date Recelvetl
BEFORE
24 Hours
24 Hours
Unsatisfactory
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No. Result" Analyst
I I m
I I m
I I m
m
� I �
-No. of colonies/100 ml. or No. of Positive portions.
BACTERIOLOGICAL WATER ANALYSIS RECORD
_Time Received
lentil I 10m1 10ml
a. M.
p.m. Lab. No.
EMB Broth 24 hours: Broth 48 hours:
COLLECTING SAMPLE Multiple Tube Report: 10ml Tubes Positive/Total 10m1 Portions
Membrane Filter: Direct Count Collform/10oml
Verification: LTB Bi
Final Membrane Filter Results Collform/looml
Reported By Date
Time: A. M.
p.m.