HomeMy WebLinkAboutMOUNTAIN PARK ESTATES BLK 8 LT 6
MUNICIPALITY OF ANCHORAGE
Di "MENT OF HEALTH AND HUMAN SEF
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Narne DISTANCES
/-e_~ ~))u(rY' / D~"r/nd {>r~re-F'/-Y ~:?~ u'_~ T~ SEPTIC ~BSORPTION
WELL
Add ....:ROM ~ TANK FIELD
Phone(s) [Pe, m,I No No o~ ~.d ...... WELL I J ~ ~ j 13
LEGAL DESCRIPTION
Townsh,p, ~ange, S~cuon AS-~'UILT DIAGRAM ~Show ~o~,on"o~ ~dL ~epuc sys~m, p~op~dy hn~s, ~ourdat~on~
~ SEPTIC ~ HOLDING ~~ ....... ~:~ ~
M~numcturer Capacmtymngauons - ~ (},L. L ~m ~ ~ '~
~TRENCH ~ BED ~ W. DRAIN ~ OTHER ~ ~
Depth Io pipe bottom from ~otal depg~ iron] original grade ~ 3~ .* /
Fmll added above o[Jgmrial grade ~ Gravel depth benealb pipe ~¢ L~ -/ ~
' Gra~e] lenglh Gravel wm~]b ~.~ ..I / ~ ~
~ P~IVATE ~ OTHE~ (Idenlifv)
FT~ FT
REMARKS:
Scale: NO~ 'Jo .~C,~/ ~
,nspechons Podormed by: ~2~.~/~ ~
on this dat~: '7/ E? i~(' ~(,'~'% CE-3589 ."
Municipal and Slate guidelines in ellecl 5 ~. *
Health I)epa~mnent Approval: ~ .... Date _ ~ ~
72 013 (3/85)
: Flattop Technfcal S( ,es
..... ' 14530 Echo Street
· Anchorage, Alaska 99518
'107t ~
0
S I -I-E PLA N
Lot g. 5~ocw 8
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
DATE PER FORMED:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
L I-/,
Or~xn~
SLOPE SITE PLAN
\
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time ((l'l'n) Water Drop ~yn.~)
Pre -So,,t~ G'/? or.'ooe~
lo:t7 ht~ ~'f
~2 ~' io.'~z ~ ~o e~' ye I zinc''
to.' b) h ~ e g ~
PERCOLATION RATE
TEST RUN BETWEEN
1'7 (minutes/inch)
FT AND {~'. O , FT
ff',o a,,o( [(,o ,f-/ ,
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 8, Geophysical Surveys
Anch. Ut. P~k 6 8 --o,--o,--or-- s~
~DISTAHCE ANO DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF W~LLtj~8
Addrlll: ~00 H~tzell
Till: grey ~d h~d, 160 165 dion. I.. fo ; fl.O,p,, Stlciup ft.
Alluviun: grey color, medi~ 165 1~ ~, FINISH OF W~LL:o~Q~
S~d: brown color, with water; 172 17~ s,o,/u..h size:
~ above or ~8,~0. land ..,tac* Dale
Equipment used: ~d
0 1 ~ ft. offer ~ h*l. pumping
Fo~s Drill g AA 7~8
~,.,,: 1336 Ingra Anch., ~J;. 9950~
•
GE
•1:c
Municipality of Anchorage „
On-Site Water and Wastewater Program a e,1- ji
(907) 343-7904 s A C T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 017-391-36 Expiration Date: f _ 27-17
1. GENERAL INFORMATION
Complete legal description MOUNTAIN PARK ESTATES BLOCK 8, LOT 6
Location (site address) 6000 BRISTOL DRIVE,ANCHORAGE,AK 99516
Current Property owner(s) FLORENCE M.SMOOT Day phone
Mailing address 6000 BRISTOL DRIVE, ANCHORAGE, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class _Well ❑ Public Sewer ❑
Public Water System ❑
Waiver/Variance request for: Distance:
Received by: Date: r/2.7//7
COSA to be relea •• • - •ineer, unless otherwise requested by the engineer.
COSA Fee $ 52,6 Waiver Fee $
Date of Payment 672.3/7 Date of Payment
Receipt Number D? 52 7 7) Receipt Number
COSA# O3C_ /7 /Z Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 6/21/2017
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineers Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen �� 4111h..\
encroachments,deficiencies or discrepancies exist. OF Az
� 1
- - L--
I *149 T111 / %
6. DSD SIGNATURE /---
System #1 Approved for bedrooms. `
T KENNETH . . U FF
System #2 Approved for bedrooms. , `ft 71 ."/
Ar
Disapproved. ` n`o sslo\�ti
Conditional approval for bedrooms, with the following stipulations:
VAN
ON-SITE G
WATER AND
WASTEWATFR
' PROGRAM
By: �^ Original Certificate Date: b — 2-7 l 7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet210-10-12.d«
If more than 1 septic system is on the lot:
COSA Checklist# of_
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: MOUNTAIN PARK ESTATES BLOCK 8, LOT 6 Parcel ID: 017.391.36
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 8118/1986 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 173 ft. Cased to 173 ft. Casing height (above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test 8118/86 6/9/2017
Static water level 160 ft. 166 ft.
Well production 6 g.p.m. 4.5+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 8.03 mg/L
Arsenic: ND ug/L Date of sample: 6/9/17 Collected by: ARCTERRA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 7/29/1986
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N
Date of pumping 6/9/17 Pumper One Stop
C. ABSORPTION FIELD DATA
Date installed 7129/1986 Soil rating (g.p.d./ft2r ft2/bdrm) 206 System type DEEP TRENCH
Length 43 ft. Width 2.5 ft. Gravel below pipe 7.5 ft.
Total depth 13.7 ft. (Measured 6/9/17) Eff. absorption area 645 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 6/9/2017 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 64 in. Water added 685 gal. New depth 81 in.
Elapsed Time: 1365 min. Final fluid depth 62 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm &circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO.
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+ _
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO.
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ _ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
Septic tank levels were inspected and found to be at appropriate levels. The absorption trench is operating in the top 2'of the 7.5'
effective sewer rock depth.
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. Air i OF A/
Engineer's Printed Name KENNETH M.DUFFUS `
Date 6121/2017 * 4• Ti1 �*
COSA canary sheet_2-6-15 doc �,
"""T" pl.
(�j 71 1 B (,
'ti7op''es s 1 o',;a" t
•
• Municipality of Anchorage
' ' i A"` Development Services Department
Building Safety 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 # osc 171253
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 6 of
Mountain Park Estates subdivision. This inspection revealed a nitrate
concentration of 8.03 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.
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble
in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass
rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is
in the form of ammonia or protein first, which through contact with oxygen and certain
bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from
wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also
result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or
three years, but is associated with a potentially fatal infant disease called
methemoglobinemia. In the digestive system of young children, nitrate converts to
nitrite, which can pass through the intestinal wall into the blood stream. There it
combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The
EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The
standard has been lowered from a previous level of 45 mg/L set by the US Public Health
Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and
other common home water treatment systems such as softening or iron filtration does not
readily remove nitrate. The best method for limiting nitrate in well water is source
control. This can include avoiding overdosing of fertilizer near the well and maintaining
good separation distances between septic tank leach fields and the well. A special anion
exchange filter that contains a media with a strong affinity for negatively charged ions in
water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical"
methods using a spectrophotometer to read the final color endpoint. Specific ion
electrodes also can be used to detect the activity of nitrate in water. This laboratory uses
several different wet chemical methods approved under the public water supply
laboratory certification program. They also have test kits available, which the laboratory
uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test
kit results against a certified analysis from the lab occasionally to verify the accuracy of
the kit. We recommend using a specially prepared bottle that has been rinsed in
hydrochloric acid for collecting samples.
PLAT NO. P-501
MOUNTAIN PARK ESTATES SUBDIVISION
LOT 6, BLOCK 8
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NOTE: LIMITS OF GRAVEL DE AND REAR DECK ARE APPROXIMATE ,�l?- �
RN
DUE TO SNOW COVER AT THF TIME OF THIS SURVEY. w�7
AS -B U I L T i HEREBY CERTIFY THAT I HAVE SURVEYED THE
GASTALDI LAND PROPERLY DEPK:I EU ABOVE AND THAT NO
ENCROACHMENTS EXIST EXCEPT AS INDICATED. ���s\\�
SURVEYING, LLC *7e.
JEFF A GASTALDI, R.L.S. RIS THE RESPONSILIIUTY OF THE OWNER TO 4�.CF,.OF.. .. ,
DLI1NMINE THE EXISTENCE OF ANY EASEMENTS, _
2000 E. UOWUNG RD., SUITE 8 �: '• `�'�-•i
ANCHORAGE, AI.ASFCA 99507 COVENANTS OR RESTRICTIONS WHICH DO NOT • �t 49LU •••�'.V'
APPEAR ON THE RECORDED SUBDMS1ON PIAT. r. A' •
PHONE 248-5454 UNDER NO CIRCUMSTANCES SHOULD ANY DATA ■; ■
GRID DATE HEREON BE USED FOR CONSTRUCTION OR FOR . s •. Jeffery A,Gostak : a
sw2838 3/17/2017 ESTABLISHING BOUNDARY OR FENCE UNES. + (SSI : `iv
` ANCHORAGE RECORDING DISTRICT. ALASKA �.�•7,.�.�.......•Tin 0 6, 41,
FB. JOB NO. S* 'oressiorwt I'....
UPFbs NOTE: NO CORNERS SET THIS DATE OffisiVef.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete Legal description LoT (~ BL,~ ,& HO~NTAI~I ?R~'K ~$7RT£¢ ~F I
Location (site address or directions) (0ooo BI~s'ToZ.
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone 2 '~,-
Agent Jr:IN p~ N~'~TO~ t~/~A X
Address 2G~o CoRDouA
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: '~ N
TYPE OF WATER SUPPLY:
Individual well v/'
Community well
Public water
Day phone 25'7. ol 7':7
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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. 1191) Front MOA ¢f21
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LoT (~, ELk' $, H'T. P~,~K ~ST/~TE~ Parcel I.D.
A. WELL DATA
Well type Pff~v'A1-E If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~' Date completed 8 It. 8/88 Driller FOSS
Total depth 173 ' Cased to 1'7 3 ' Casing height '2 ff"
Sanitary seal (Y/N) )/ Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test g/l~/eS(~ 7/3o/ClZ
Static water level / GO /b:~
Well flow /~ g.p.m. (~, ~'
Pump level /(~cl '~ / (~%
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holdingtankonlot I1~ 7o C.o
Absorption field on lot 113 TO C.o
Public sewer main ,> zoo'
Sewer service line ~ 95' /
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank No~4E OSS~VE b
WATER SAMPLE RESULTS:
Coliform tO
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/2~/~
Cleanouts (Y/N) ~
High water alarm (Y/N) N. A.
Date of pumping 7/3o/~Z
Nitrate
Collected by:
Tank size /coo
Foundation cleanout (Y/N)
Other bacteria ~¢ ~c,/ /loc ,',.,(
s¢_s
Compartments 2
Depression (Y/N) N
Alarm tested (Y/N) N.A.
Pumper 1S,4,~C ~
Foundation 12
Watermain/serviceline ~gS'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot II~ F,~t~ C,O.. Onadjacentlots
To property line ~' 35¢ Absorption field
Surface water/drainage ~/oo '
72-026 {Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 7/2fl
Length z~ Width 2..5'
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
NONE
Soil rating
System type
Gravel thickness '7, $
Cleanouts present (Y/N)
Date of adequacy test
for
K~ o ~.'N
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
t
Well on lot 113 FRor~ C, o,
To building foundation
On adjacent lots )"¢~¢
Surface water ~ Ioo
Onadjacentlots ~/00 Propertyline 12 ¢,¢~
To existing or abandoned system on lot N.A '
Cutbank f,t,A, Water main/service line > ¥o
Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date
HAA Fee $ /.~"~
Date of Payment
Receipt Number
72-028 IRc. v. 3/91~ Back MOA
· _.,~r.,Z
, TItEODORE
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
H87-0097
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 6 Block 8 Mountain Park Estaets Subdivision #1
Location (address or directions)
Briston Drive
(b) Propedy Owner Les Burr/Prime Pro~o~e: Home Business 344-0501
Mailing Address 8400 Hartzell Road, Anchorage 99507
(c) Lending Institution Rainer Bank Ak Telephone 276-8050
Mailing Address 550 West 7th Avenue, Anchorage 99501
(d) Real Estate Company and Agent Realty Center
Address 8400 Hartzell Road, Anchorage 99507
Telephone 344-0501
(e) Mail the HAA to the followino address: or: Check here [], if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family ~
Number of Bedrooms '~nre'e
(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 the legality and status.
SEWAGE DISPOSAL
Onsite [~x Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status,
Page 1 of 2 72-025 IRev 8/861 Front
rTOP TECHNICAL SERVICES
CIV1L & ENVIRONMENTAl, ENGBNEERING · ENERGY CONSERVATION & ANALYSIS
TttEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 ANCHORAGE ALASKA 99516
MUNIC PAL TY OF ANCHORAGE
Augusic 17 ~ 1987 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
M.O.A. Dep't. of Ileal. th and Human Services
P.O. Box 6650
Anchorage, AK 995119
AU6 '1 '7 1987
RECEIVED
Dear Sirs:
On August 13, 1987 I inspected the monitor tube of the
absorption field on Lot 6, Block 8, Mountain Park Estates? and
verified that the repairs specified on the IIAA of last February
20 had been accomplished. Accordingly, please issue a letter to
the property owner indicating your removal of the condition from
the approval.
Thank you.
Sincerely,
Ted Moore, P.E.
cc: Jim Allison/ Les Burr
Prime Property
8400 Hartzell Rd.
Anchorage, AK 99507
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIFtONMENTAt. PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date /--~r./~ '2¢:' /.¢ E; 7
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
/.oF
Location (address or directions)
Applicant Name L~-¢
t~'tzg,-r.~ Telephone: Home
Applicant Address
Applicantis(checkone):Lendinglnstitution~;Owner/builder~;Buyer~;Other~ (explain); _
Business L7 '¢¢/-~',~~~/
(d) Lending Institution __i~ c~ n ¢ .~ ,-
Address _
(e) Real Estate Company and Agent .
Address
Telephone
(f) Mail the HAA ~o the following address:
/
Telephone
TYPE OF RESIDENCE
Single-Family~ Multi-Family[]
Number of Bedrooms .~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community we system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: Il community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page i of 2 7202501 84)
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 verity that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-si!e 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 '-~]~¢f F¢~Jm~,c~{ ~,-~.'~_~( Telephone '7
Engineer's Seal
°HEP APPROVAL
Approved for '¢'A,,,¢.¢. (~.)bedrooms by ~ ~ ' ~~ . Date ~ ~ ~:~ -'~ ~
Approved Disapproved ~ Conditional ~/
Terms of Conditional Approval ~~ -~ ~ ~,'~ ~.~ ~
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (°HEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The °HEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of °HEP 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.
Pare 2 ,of 2
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA)
F-NVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
FEB 2 0 1987 264-4720
RECEIVED
WELL DATA
Legal Description:
Well Classification
Well Log Present (Y/N)
Total Depth j"'7~ ~
Static Water Level tt ~"~ '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
'i~''~zlE¢- If A, B, C, D.E.C. Approved (Y/N)
Y' Date Completed ,~¢/t~lE,'-~* Yield
Cased to ( ''/~ ~ Depth of Grouting
Pump Set At
~ ~ ~ Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N, ~,
Cleanout/Manhole ~t, t~,
Water Sample Collected by _
Water Sample Test Results
¢~, c. o, ; On Adjoining Lots ~.~
I I~; .¢~,c.~,; On Adjoining Lots ';~ t,c.O '
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~' tj .
; Date I'~"//(~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed. 7 /8) jcl( Size
Standpipes (Y/N) ~'
Depression over Tank (Y/N) ~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~
Separation Distances from Septic/Holding Tank:
Air-tight Caps (Y/N)
To Water-Supply Well _
To Property Line
To Water Main/Service Line
Course 7~
No. of Compartments '~-
~ Foundation Cleanout (Y/N)
Date Last Pumped /~,,4.,
t~, ;for
¢\h/)-. Temporary Holding Tank Permit (Y/N)
To Building Foundation ~ ';~ /
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
79-~76~11/841
C. ABsoRpTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test /~,/~'.
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
/['~¢~'~'~ Type of System Design
Length of Field
Depth of Field ti
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments /~/~'r ¢'*Zp ~ o,'~
To Property Line '?.d;' '
To Existing or Abandoned System on
; On Adjoining Lots ~ .~
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed _'¢'~.--~/~-~'-¢~--,-~ '~,~, ""'~'-~--,-~ Date ~ / ~¢/ /~ ~2'
Company I ='/~/"~¢-~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
