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HomeMy WebLinkAboutMOUNTAIN SHADOWS BLK 1 LT 8Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: _'S~/q uf[pOqO PID Nurnber: Wastewater System: [] New ~Upgrade Address: I 2Q ¢ { ~ ~ cH~ ~o &~ ABSORPTION FIELD No. el Bedrooms: Pbone: .¢7~ ~¢ ~ O ~.. ~ Deep Trenchzhall°w Trench ~ Bed ~ Mound ~ Other Total Depth from original grade; LEGAL DESCRIPTION Soil ~1i"9: Lot: ~ BIock:~ ~ O~ ~ ~Subdivisi°n: ~1 ~ ~¢~ Depth to pipe bottom Irom~original~ grade:~ Ft. Gravd depth beneath pipe ~ ~ I FL Township: Range: Section: Fill added above original grade: Gravel lengt~ .... Gravel width: WELL: ~ New ~ Upgrade Number of lines: D~stance between lines: ~s~ication (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date in tailed: Yield: Pump Set at: Casing Height Above Ground: o.~ ~,. ~,. TANK SEPARATION DISTANCES m Septic n Holding ~S.T.E.P, From Tank Field Station Tank S ..... L .... ~NC~j Material: Number of Co~arlments: SuF[ace Water M o eX E LIFT STATION Lot Size in gallons: Manulacture~ "Pump on" level at: "Pump off" level at: High water alarm at: ~urfain Pump Make & Modal Electrical Insp~ pe{fo~med by: Remarks: BENCH MARK ENG ~R~ ~EAL Inspections performed by: h~ Dates: 1st Department of Hca hu Reviewed and approved by: .Date: 72-013 (Rev. 9/9~) MOA 25 15~ SWING ?/ES: AC 27 FT EC 2& 5 AD 48.5 ED 89 AE 78.5 BE [16 £F 116.5 A? 85 \ AC 41 REVISED: JUNE 28, 1994 REVISED: JUNE 9, 1994 BENCH MARK: BOTTOM SIDINC ASSUMED ELEV. lO0. O0 TOBBEN SPURKLAND P.£. 205 W 15?N. AVENUE AK. 99501 J JLOT 8 BLOCIf 1 i~IOUNTAIN SHADO~fZ GEORGE KAPOLCNOK 112901 MICHAEL ROAD J J SEPtiC SYSTEE ASBUILT DATE: JULY 5, 1994 SHEE~' 2/5 GRID: 28d! ~'-A i/8" Holes ~ 1.7" J~-A 45 1/8" Holes ~ 14" 500 GAL STEP /, s" Jo/ipip~ ~ 1-1/4 PVC Holes Pointing Up 2 5-WIDE TRENCHES 5 FT WIDE 45 F? LONG .5 FT OF ROCK 3 FT TOTAL DEPTH 3 FT OF COVER SECTION A-A NO SCALE 2" Insulah'on - - 24" / Topsoil 8" Sewer ~ock --/ ~/ // ~l ~// / / //I ~irof/ 140 ~ I ~ // ~1 95 Ho7 ]0, 199~ BENCH ~A~K: /~ ~ .......... BEVISED JUNE29 ~994 BOTTO~ SIDING 5' "Voile?' Sand ~ ~ U~ ~prVt Z~, Z~4REViSED JUNE 9 1994 ASSUMED ELEK 100.00 F[ TOBBEN SPURKLAND P.E. 205 WISth Ave Anchoro~Te Ak 99501 279-5916 J J £OT S B£OCIC I Mou^rTAIN SHADO YS S/l J 12901 Ivl/CHAEL ROAD GEORGE M. KAPOLCHOK SEPTIC SYSTEId ASBUILT DATE: JULY 5, 1994 SHEET: 5/5 GRID: 2841 0 0 0 © 0 © © 0 0 0 0 ,ri 0 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940090 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:KAPOLCHOK GEORGE M OWNER t~DRESS:12901 MICHAEL RD ANCHORAGE,AK DATE ISSUED: 4/25/94 EXPIRATION DATE: 4/25/95 PARCEL ID:01740110 LEGAL DESCRIPTION: MOUNTAIN SHADOWS BLK 8 1 LT LOT SIZE: 35059 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: IT MUST BE CONFIRMED BY THE ENGINEER DURING CONSTRUCTION THAT THE ML STRATUM @ 7.0 FT. WILL PERC AT 120 MIN/IN OR LESS, AND THE GROUNDWATER TABLE IS AT 11 0 ET OR DEEPER. RECEIVED BY: ~i~ '~/~ l~.~~ ~- DATE: I;/'XI't.: ..' //__j -. / __ DATE: T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Subject: Septic System Design Lot 8 Block 1 Mountain Shadow Permit # SW940090 June 29, 1994 (v~u~ic;ptt~it¥ o~ Anchorage OepL Health & ~{uman Servioes Gentlemen; After clearing of the organics at this site it became clear that a bed would not fit. The total elevation difference between high and low point was found to be in excess of 4 feet. We excavated three testholes on the site and performed as "fast" percolation test on the underlaying material. In all three location sand or sandy gravel was encountered at less than three feet. After completely filling and draining 6-inch testholes the following percolation rates were observed. TESTHOLE WATER DEPTH TIME TO DRAIN #1 5" 3:40 Min #2 4" 6:25 #3 4.5" 3:30 These observations show that a percolation rate of less than one minute per inch can be assumed for the receiving soil. Due to seasonal high groundwater (during breakup) three feet of filter sand will be placed on top of the receiving soil, placing the septic rock at ground level. Due to the topography of the site two 5-feet wide trenches will be installed. The elevation difference between the trenches is three feet. The spacing of the holes in the distribution pipes has been adjusted accordingly to obtain even distribution in the two trenches. The system is being installed at this time, and we invite you to come and observe the installation. Yours T° T.SPURKLAND P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 LOT SEPTIC SYSTEM DESIGN 8 BLOCK 1 MOUNTAIN SHADOWS S/D GEORGE M. KAPOLCHOK Revised June 28, 1994 Ground Water at 3 FT Use 5-Wide Soil Rating. From test June 27, 1994 <1 min/inch Use Filter Sand q = 1 gal/ sq.ft. /p~,~! ~ ~mequmred Area per Bedroom: 150/ 1 = 150 sq.ft.. Number of Bedrooms Absorption Area Length of 5- Wide 3 3 x 150 = 450 sq. ft. 450/5 = 90 ft. SYSTEM CONFIGURATION TOTAL LENGTH 2 x 45 FT. ELEVATION DIFFERENCE BETWEEN TRENCHES 3 FT. TOTAL WIDTH TOTAL DEPTH ROCK DEPTH LAKE OTIS SAND COVER 500 GAL STEP SEPTIC TANK 5 FT. 3 FT. .5 FT. 2.5 FT. 3 FT. EXISTING The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 8 Block 1 Mountain Shadows S/D pg.1 PRESSURE CALCULATIONS Total head loss: 30 ft. Pump delivery at 30 ft. From pump curve: 33 gpm Discharge per 1/8" hole at 5 feet of head: 0.42gpm Discharge per 1/8" hole at 8 feet of head 0.53gpm Split total flow between trenches. Q/2 = 16.6gpm Number of holes at 5 feet head : 16.5/0.42 = 40 Spacing of holes: 45x12/40 = 14 [inches] Number of holes at 8 feet of head: 16.5/.52 = 32 Spacing of holes: 45x12/32 = 17 [inches] Septic System Design Lot 8 Block 1 Mountain Shadows S/D pg.2 N // £5 0 £5 7,5 100 ./-' ,. (" 50 FL L k/elL / / / / REVISED: dUNE 28, 1994 REVISED: dUNE 9, 1994 TOBBEN SPU£1(LAND P.E, 205 ~/ ISTH. AVENUE Al(. 99501 8 BLOdT( 1 3IOUNTA[N SHADOIfS GEORGE KAPOLCHOK I12901 MICHAEL ROAD :~C SYSTEM DESIGN DATE: APR~ 15, 1994 8HEEL' 2/5 GRID: 2841 A ,,. ~- 500 GAL STEP ~ 6" Halfpipe  / 1-I/4 PVC Holes Pointing Up 2 5-WIDE T~ENCHES 5 FT WIDE c~ .5 FT OF ROCK SECTION A-A ~ FT TOTAL DEPTH '~ 5 H OF COVER NO SCALE ._~ ~ ..... 6" ];"~'Vo/le~"C°norele SandSand _~/ REV/SEa JUNE29 1994 ~ BEVI~ED JUNE 9 1994 SPUBKLAND P.E. LOT 8 BLOCS( I MOUNTAIN StIADOtY5' SIt sEPtiC SYSrEW DESIGN 205 WlS/h Ave Anchorage Ak 99501 12901 MICHAEL ROAD DATE: APRIL 18, 1994 279-39X6 GEORGE M. KAPOLCHOK SHEEE' 5~5 OR/D: 284~ T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Subject: Upgrade for lot 8 Block 1 Mountain Shadows June 10, 1994 Gentlemen; On May 11 I observed groundwater at three feet on this property. I have therefore revised the design for the septic system. Please review and approve.. Yours Tobben Sp~rkland P.E. T.SPURKLAND P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 LOT SEPTIC SYSTEM DESIGN 8 BLOCK 1 MOUNTAIN SHADOWS S/D GEORGE M. KAPOLCHOK Ground Water at 3 FT Use Pressurized Bed Soil Rating. From test March 31, 1994 0.5 gal/min Required Area per Bedroom: 150/.5 = 300 sq.ft.. Number of Bedrooms 3 Bed Area 3 x 300 = 900 sq. ft. SYSTEM CONFIGURATION TOTAL LENGTH TOTAL WIDTH TOTAL DEPTH ROCK DEPTH CONCRETE SAND VALLEY SAND COVER 500 GAL STEP SEPTIC TANK 60 FT. 15 FT. 3 FT. .5 FT. .6 FT 2.5 FT. 3 FT. EXISTING The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 8 Block 1 Mountain Shadows S/D pg.1 ~ £5 100, 0 ~7, 0 N EX] 75 100 I50 ("::O::. ~ ~4,6 fRENCH REVISEO: JUNE 9, 1994 TOBBEN SPURKLAND P.E, 203 W 15TH. AVENUE AK. 99501 8 BLOCI( i MOUNTAIN SHADOWS SEORGE KAPOLCHOK I12901 MICHAEL ROAD SEPTIC SYSTEM DES/ON DATE: APRIL 15, 1994 SHEET: 2/5 GRID: 284! ~ ir-- 500 GAL STEP ) ~ NEW BED.. NO SCALE 15 FT W/DE 60 F? LONG .5 F? OF ROCK 4-6 £? TO~L DEPTH SECT/ON A-A 1-i/4 PFC Holes Pointing Up 4" Topsoil 8" Sewer Rock l -- I/4" Dis/ibution M/raft 140 6" Conorete Sand 3' "¥a/le?' Sand 1-1/4" Discharge 95 #lay 1~, 1994 REVISED JUNE 9 1994 ~OBBEN SPURKLAND P.E. 205 W1Sth Ave Anchoro, Ak 99501 LOCIFZ MOUNTAIN SI-IADOfl'S ~ '-~P-~SYsr£u DES/ON 12901 MICHAEL ROAD ~/-~ DALE: APRIL 18, 1994 GEORGE /vi. KAPOLCHOK k~~ GRID: 2841 Municipality gl Anchorage DEPARTMENT OF HEALTH 8, HUMAN SERVICES 82,5 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 3 4 5 6 7 8 10 12 13 14 15 16 ~7 18 19- DATE PERFORMED: Township, Range, Section: ,~ ~.~ ¢~.~ SLOPE SITE PLAN 2O WAS GROUND WATER ENCOUNTERED7 ND S IF YES, AT WHAT ~ DEPTH? p E Depth to Water Alter ~] Monitoring? [ { Dale:/I 5']q ~ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~1~ (minutes/tach) PERC HOLE DIAMETER , ~ /"h TEST RUN BETWEEN __ FT AND FT PERFORMED BY: . I CERTIFY THAT ~HIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE' DATE: ~[ ~ ~ [~ t~ -- 72-008 (Rev. 4/85) TOBBEN ~PURKLAND P.E. ~03 ~/ ]STFI, AVENUF ANCH, AK, 995~1 N 100. D I I I \ x, \ 'x \ \ 5-'~ ; de 101.0 /-- ~8, 0 EX]ff. T~ENCH GEORGE KAPDL CHDK 11£90! MICHAEL QDAD 94, 7 SEPTIC SYSTEM DESIGN DATE, APTe/L /S, I994 SHElL, T: 2/2 GR[D~ 2841 iii NEW 5 ET !VIDE 80 FT LDNd %k. £ F T DF ~DCK 4-~ F? TOTAL DEPTH Cleanou't~ -- H/mo Pi 140 . ~ £f: o£ Sep%'c JPock lO00 na~, Under Pipe J J ~ 85 Apr,? l~ 1994 ND SCALE BEN SPURKL. AND P,E, 203 ~IS'th Ave Anchorcge Ak 99501 8 .BLOCK I .MOUNTAIN I£901 MICHAEL GEOf~GE M, KAPDI_O~DK SEPTfC SYS1Ei'4 AS;BUILT DATE, APf~IL 18, 1994 gHEET: 3/3 GRID, 2841 T.SPURKLAND P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 LOT SEPTIC SYSTEM DESIGN 8 BLOCK 1 MOUNTAIN SHADOWS S/D GEORGE M. KAPOLCHOK Ground Water at 3 FT Use Pressurized Bed Soil Rating. From test March 31, 1994 0.5 gal/min Required Area per Bedroom: 150/.5 = 300 sq.ft.. Number of Bedrooms 3 Bed Area 3 x 300 = 900 sq. ft. SYSTEM CONFIGURATION TOTAL, LENGTH TOTAL WIDTH TOTAL DEPTH ROCK DEPTH CONCRETE SAND VALLEY SAND COVER 500 GAL STEP SEPTIC TANK 60 FT. 15 FT. 3 FT. .5 FT. .6 FT 2.5 FT. 3 FT. EXISTING The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 8 Block 1 Mountain Shadows S/D pg.1 PRESSURE CALCULATIONS Total head loss: 30 ft. Pump delivery at 30 ft. From pump curve: Discharge per 1/8" hole at 5 feet of head: Number of holes: 33/0.42 = 80 Spacing of holes: 55x12x3/80 = 24 [inches] 33 gpm 0.42gpm Septic System Design Lot 8 Block 1 Mountain Shadows S/D pg.2 203 W :5~. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 8 BLOCK 1 MOUNTAIN SHADOWS S/D GEORGE M. KAPOLCHOK Ground Water at 11 FT Use 5-Wide Trench Soil Rating. From test March 31, 1994 0.8 gal/miL Required Area per Bedroom: 150/.8 = 187.7 sq.ft.. Tank outlet invert: 93.6 Ground Surface at Absorption Field 98 Acceptable soil from 2 to 7 feet Rock Depth 2 ft, from 4 to 6 ft depth 100 Number of Bedrooms 3 Length of Trench SYSTEM CONFIGURATION .,'1 / _ 7q 'TOTAL LENGTH - -- TOTAL WIDTH ROCK DEPTH COVER SEPTIC TANK 3 x 187.7 / 5 x .7 = 78.8 ft 6-8 FT. EXISTING INSTALL BULL RUN DIVERSION VALVE The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 8 Block 1 Mountain ~hadows S/D pg.1 :',,, ./ MLINICIPALITY OF ANCHORAGE ~, ..~ '" i DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage. Alaska 99~01 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELl. INSPECTION REPORT NAME ~ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION PERMIT NO. ~ ~ Manufactu~ No. of ~ ~ Material compa~ents Liq~ ca.~acity in gallons_ IF HOMEMADE: Inside length Width Liquid depth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, O ~ ~ Manufacturer ~ -- ~ Material Liquid capacity in gagons ~ Well Foundation Neares~ ~= DISTANCE TO: / ~ f PERMIT NO. ~ N°'oflJnes/ Lengthof____c 'ine,~ ~,,~ ~ Total len th of lines Trenc~w~th Distance between lines ~ Top oftileto fini rade / Totaleffecti eabsorption a ea ~ CF-- r Material beneatb tile Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth I Total effective absorption area ~ ~ DISTANCE TO: Well Building foundation Nearest lot line ~ Class Depth Driller Distance to lot llne PERMIT NO. ~ DISTANCE TO: Building foundation Sewer ine Septic tank Absorption area(si OTHER PIPE MATERIALS p)2, '~ , SOl L TEST RATING REMARKS APPROVED DATE LEGAL PERMIT NO~ APPLICANT LOCATION LEGAL MICHELE, INC. MICHAEL ROAD LOT 8 BLOCK I MT. PO BOX ±0-t235 9~511 SHADOWS S?D LOT SIZE TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH 25000 SQURRE FEET MR~'~,IMUM NUMBER OF BEDROOMS SOIL RRTING (SQ FT?BR)= 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [)EPI-H= ?' THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRBINFtELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVAL BY THIS DEF'RRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR R PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DIS'¥RNCE FROM R PRIVATE WELL TO A PRIVATE SEHER LINE IS 25 FEET AND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 20 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. I CERTIFY THAT t: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 2 BEDROOMS. HPPLI _.HNT MIC:HELE, INC. [:,EF'FIRTHEr,,IT C!r HEALTH AN[:, ENYIF'_iNHEh~TFIL F'['OTECT 825 "' L~,~'S T F:E E T, 22 I-IEL_L Fi 1`4 IZ:, L--I _NI -- :~. I < > ~ 7/~ - 7/~0 SIZE ~.~d¢35 SC!LARE FEET LOT );'::IHUH HUHE:ER OF E:EDROOHS = .~ SClIL E:AFI.NG ,?-2.:.! FI'.-'E,R>= ?& ~--- tE REC&IIFTE[:, SIZE OF THE _,_Il. FE;SCF-TF'TION :,,:,Td'l IS: .E F'TH =: t/ L E I'-.1,3 T H == 3 / E:" [.:-~ F' -F H =: "7 THE LENGTI4 DIt'IEHSIOfi IS THE LENGTH (IH FEET> OF THE TREHCH UR DRF~IttF'IE! C:,. THE [)EPTH CrF FI TRENC:H OR PIT IS THE [:,[5:'RtiCE BETNEEH THE SURFRCE OF THE GFtOLIflD Rt4C, THE E:OTTOf'I OF THE E>::C:R'¢RTION (IN FEET>. THERE IS HO SET NIDTH FOR TRENCHES THE GRR'./EL DEPTH IS THE fdl~.4lf,lLIf.1 [:,EF'TH OF GRRVEL BETHEEH Tt~E OLITFRLL P~PE RNE) THE 8OTTOM OF THE E:XC:RYRT~ON (IH FEET). : E ,Z-! El I F;;.: [77 E':, ~ E F' -F I i: -r FI 1'-4 I-::: 5 I Z E == / ~ (-] ~3 F:i L_. l ._ (3 1'4 5:1 :1;:i'.1 1T RPPL I c:RN'r HAS THE ' - ' '- RE':,FOHz, IBILITY T(-J INFCffU,1 THIS [:,EF'F-~RTHE,',~T C,I..FF;'Ir4Fj ISTFflLLATIC~H INSF'ECTIOt",IS OF RNY NELLS RE:,..fFiCEr.iT T0 THIS F'F:0F'EPTY FIRE:, THE .~HBEF;: OF PESIDENCES THAT TIE HELL MILL SEF:YE THE -I- l-I F~_ ,:..--2· .':, I 1'-4 S F' f__: C: T I Cq 1'4 '-25 Fi F~: bE I';:2 E: 6:! LI ]: r4: [Z E: ....... E. KFILLIr-4G OF RNY _,?_-.~EH NITHOLIT FIHI-qL IN'-CF'EF:TIF~N RHC, APF'ROVFIL FrY THIS ¢F'RF:THEtH' N ILL E'.E SIJE',.!ECT TR PROSECUTION. 7HIMLli'I [:,ISTRNC:E BETI.IEEN R NELL RND RNY ON-SITE ~0 FEET FOR F! PRIVATE NELL OR Z$O TO 20Q FEET FROH Ft PUE:LIC HELL [>EPEH[,IHG :'OH THE T'T'PE CIE F'I_IE'.LIC I,IEI.L. tiIHLIH DISTANCE FP. EItt Ft PRIVFffE HELL TO A F'RI'v'~TE SEI,ER LINE I A COI'IHI_IflITY SD, lEe: LiNE IS 7D FEET ]LL LOG'SS F~FtE PEqI_,IRED RH[', HUST E'.E RETURNED TO THE [:,EF'FtRTHEHT ' THE HELL C:OHF'LETTOfL 'HEP F:EIpI.IIF'EHEHTS f'lFfl'T' RPF'LY. 5F'EIZ:IFICFffIOHS fiH[, C:LINZTRUCTIO/-I · 'RIL~Bt_E TO INSURE F'RI3PEP IHqTRLLRTI .:_, FEET HI [HIH F:' E F4:I'-1 I: -F E :;-': F' ]- f;: EE :5 E:, [71 C: E r-1 E: E F~: ~: ::!_ .- J_. S;' =~ '-J F EF:T I F'¥' THF!T I AH FHHiLIFIF: NITH THE PECCJIREr.IEHTS FOP. Of NSITE SD.ERS AHD 14ELLS RS ~PTH BY THE 1.1UN 1C I F'RL I TY OF RfCHOP~GE I [,EL_L_ IHSTHtZ THE ?¢STEN IH RE:C:O¢:DRHC:E 1,1] FH THE CODES [ IJtlC,EF:STRNO THRT THE ON-SITE $E[4ER S¢STEH f'lRN' RECdIRE ENL~RGEHEHT S I[:,Er.~E:E IS F'Et'IOC, ELED TO IHCLIIE:,E HORE THRH :~ ErEC, RI?3f'IS. F4F:'F'L [ C¢4t ;%UE [:, P'' E.¥ 'SE r I F THE PERFORMED FOR: LEGAL DESCRIPTION: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, AnC{loraf~e, Alaska 99502 276-2221~ SOILS LOG - PERCOLATION TEST ,,~ SOILS LOG [] PERCOLATION TEST I 2 3 4 6- 7 8- 12 13- 14- 15- 16- 17 18 19 2O PERFORMED BY: cp. SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN ~/ //~L (minutes/inch) FT AND FT , 72 008 (7/76) APPLI(~.~_NT FILLS OUT UPPER HAL_:ONLY P,rgpeltyOwner Rodney and Denise Widener Phone ~ 263-5609 (wk) MsgingAddre~ p, n Rnv ~n-!48!. anrhn-age~ av ZipCode Oe~11 ~45-0!9!~h) Buyer Address Zip Code Lending Institution Phone Address Zip Code Really Co. & Agent E11 i ot C. Lawson, Col dwel 1 Banker Jack White Company Phone Address 3201 "C" Street, Suite 100~ Anchora§e~ AK ZipCode 99503 277-1553 LegalDescription Lot 8, Block 1, Mountain Shadows Street Locatio~ NFIN i'q'icha~'l Rnafl Type of Residence [Z Single Family [] Multiple Family No. of Bedrooms 3 ., . * ·; [] Other Water Supply ~( individual 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). [] Public Utility Sewer Disposal Individual Year Individual Installed: 19~0 (ipspecte~1 1981 ) _ [~ Public Utility When Connected to Public Utility: [] Holding Tank 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 Field Notes: ~.~ ~z //~..~ ENVIR~f;~tr,~,;,.k..O.~cflON RECEJV[D ( ~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAP~OVED ( ) CONDITIONAL APPROVAL* DATE 2-- ~-- ~ ~ Soils Rating Date ~wer Installed Well TO Absorption Area ' / ~ Well Log Received ~, ~ ~ ~., J ~---~ WelltoTank ~ ~ ~ SeplicT~kSize / 72.023 ~ ~ i DATE RECEIVED INSPECTION APPOINTMENT,,Ii DATE DA~E DATE NSPECTOR INSPECTOR INSPECTOF~ .MUNICIPALITY MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~bI~IRONMENTAL P~OT~CTION 825 L Street - Anchorage, Alaska 99501 APR 6 ~98I ENVIRONMENTAL SANITATION DIVISION Telephone 2B4-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1 · Incomplete requests will not be processed, Please allow ten (10) days for processing. I. PROPERTY OWNER ~ PHONE MAILING ADDRESS / ' PROPERTY RESIDENT (If different fr~m above) PHONE 2, BUYER PHONE MAILING ADDRESS 3. LENDING INSTITL~TION PHONE MA~L~N~ ADDRESS 4. REALTOR/AGENT . -. PHONE STREET LOCATION f ,~?~ ~¢¢~ / /~/ 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [Z~SI [] One [] Four NGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~'~hree [] Six [] Other 7. WATER SUPP/LY ~INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LIT'( DIVIDUAUQN-SITE** [] PUBLIC UTI LITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) /'.,/¢ .~:~C) YEAR ON-SITE SYSTEM WAS INSTALLED. 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 NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [~ THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRtLLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER [~Septic Tank or []Holding Tank Size: I ~:~::3 If Tank is homemade SOILS RATING give dimensions: 'OTAL ABSORPTION AREA MATERIAL ~,~ ~; DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearost Lot Line 5, COMMENTS PPBOVE FOR 5 BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) DATE -.~ RY 72-010 (Rev. 6/79) Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~-/r~l--' II.) HAA# . t GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) F~ont MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverifythat 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. NameofFirm ' ~ [,t-)~,,-q '~-~I~u"~/~~¢(~ '~' ~' Phone Address /). (~ ~ q,~ /~5 l-;/ t=/ ~ ~ Engineer's signature ~--' ~l. ,.~.,-~-~ Date 7~/~ L/ DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments The Municipality of Anchorage Department of Hearth and Human Services (DHHS) issues Hearth Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-O25(Rev. 1/91) Back MOA~Y21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L,,-~- ¢, i~ ~_. ) ~ 0¢~.~.; >1 Parcel I.D. 6) I '7 - ~ Lo A. Well Data .~, ~ ~ Well type ~, If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed I °/2-~ / ~- E) Driller Total depth 1%- ~> Cased to ,¢L¢ f ~ ~ Casing height Sanitary seal (Y/N) 7 Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Static water level =l~i~ 2. ¢ ~L,.~ / L/. L Well flow ~-~ g.p.m, g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot __ / ~c~ ; On adjacent lots Absorption field on lot / '~- ; On adjacent tots Public sewer main ~'///-~ Public sewer manhole/cleanout Sewer service line ~ /¢-~ Petroleum tank ~'~ o WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample:_ -7/S-"/'? c/ / Z~/O~/'~,'v' B. SEPTIC/HOLDING TANK DATA Dateinstalled JO /icl I ~0 Tanksize Cleanouts (Y/N) "/ High water alarm (Y/N) Date of pumping '-~. 4~ Other bacteria ¢ Collected by: ~ ~ l ~ ~ r~ Compartments Foundation cleanout (Y/N) ~ o Depression (Y/N) I""[/iA,_ Alarm tested (Y/N) "~/1 / ~ Pumper A J¢ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots /~ /~,_D Foundation Absorption field z~ Water main/service line Well(s) on lot I 2-o ]'o property line -'~ Surface water/drainage 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) %// High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "-7/ "Pump off" Level at Cycles tested r'-./ Surface water Meets MOA electrical codes (Y/N) '7/ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot / "~C~ On adjacent lots "~ 1 D. ABSORPTION FIELD DATA Date installed G/.~ o Length ,~ Y LC -~ Width Total absorption area Date of adequacy test /'--¢/,".z~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot J 7.~ On adjacent lots Soil rating (G PD/FF) l System type ~ - ~¢- / ¢,/'6 Gravel thickness /~ '/ Total depth Cleanout present (Y/N) ~/,~, Depression over field (Y/N) Results (pass/fail) -~ for % Bedrooms h¢//_%_ After test /'"~//'/-%- If yes, give date Property line To building foundation LC / On adjacent lots .~ ,~-~ L~ Surface water ~) o ~4 ~ Curtain drain ~ ~ ,4 ~ To existing or abandoned system on lot Cutbank /""¢ ~ ~ ~- Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec!.on the da, te of this inspection. Signature N ! ' Engineer's ame. I ~ ~1 -~"~1~'~--.[~,~¢ T'~-L~- Date. ~ ~ l l~ ~t{ HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)~ Back Waiver Fee $ Date of Payment Receipt Number Parcel 1. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 8 ~ ~.Block !,,I~; .oMounta~ Sh~dWs Subdivision Location (site address or directions) Property owner Mailing address Lending agency Mailing address George Kapolchok 12901 Michael Road 12901 Michael Road Anehora~6t AK Day phone 278-8850 Anchoraq6~ AK 99516 Day phone , Kathy Chambers REMAX PROPERTIES Agent Address 2600 Cordova S~eet, Suite 100 Anchorag¢., Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 ~ TYPE OF WATER SUPPLY: .. Individual well XX× Community well Public water Day phone 257-0147 AK 99503 = 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 XXX NOTE: Holding tank Community on-site ' Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. :: ~; 72-025 (Rev. 1/91) Front MOA ~21 '5, STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the ihformation 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~s inspection. Name of Firm ~~~ Phone Address ~1. ~r~,~l~ Engineer's signature' ~ Dat....e~%.~ DHHS SIGNATURE ~, .Approved for J bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~25 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:. A. Well Data Log present~/N) Total depth Sa.itary seal ~d/,(,. I Noc;/cr'/~ll3 ~HA~:~oo.~.Parcel I.D. -~/~ If A, B, or C, attach ADEC letter. ADEC water system number /(/'/,A Oatecompleted /O/Z,~/(~ Driller ,3-~1'/" ~/fLU/4/HZ / Cased to 20/ 49'4_ Casing height / Wires properly protected ~)N) '-~'E-.~ Date of test Static water level Well flow Pump level1 FROM WELL LOG .g.p.m~ SEPARATION DISTANCES FROM WELL TO: Septi~ank on lot Absorption field on lot Public sewer main Sewer service line /0o "~ fOO'f AT INSPECTION ~ ~ C ; On adjacent lots /00 r% z ; On adjacent lots /00 Public sewer manhole/cleanout /~ Petroleum tank ~0~~ WATER SAMPLE RESULTS: Coliform. Date of sample: Nitrate ~),,d~, /~/.~ Otherbaoteria Collected by: .,-~' B. SEPTIC/~rTANK DATA Date installed /O/l~'/ clean0uted~N/ ~/~-~ High water alarm (Y/~ Date of pumping ,.~/ Foundation cleanout Tank size /~%0 ~C.~ Compartments ~ j~ /k,.)O _Depression (Y/~ ..X_~© Alarm tested (Y/N) ~/~ Pumper ~ Ho~ %~1~ SEPARATION DISTANCES FROM SEPTIC/N4;)LD,,~ TANK TO: Well(s) on lot /(~C~/--~-~- On adjacent lots. / O © ~ To property line /O/-/--- Absorption field U/'¢~ Sudaoewater/drainage /('20 /-/-- Foundation G/7z-- Water main/service line CONTINUED ON BACK PAGE 72-026 (3~93)* Front C. LIFT STATION Date installed Size in gallons Manufacturer Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "~off" Level at High water alarm level .~--C~cles tested Meets MOA electrical codes (Y/N) ~ SEPARAT~E-F~TATION TO: Well~b~Hol On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length '~r'/-Jr,--~ / TOtal absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) -~" ~Ehl I.Z A,'~5of~z~/,,c~ A'F- ~'/t£ ~/?/~tE / /,~/7' SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / ~.'/,~ Soil rating (GPD/FF) /~--~ /~'~ System type Width ~-., ~ ~ Gravel thickness .-~', ~' ~ Total depth /(-~ / 4~ z~ Cleanoutpresent~N) 7~_.~ Depression over field (Y,~ ,.,xJo Z-/~,~ / ~/~ Results~fail) /¢~ ~'~' ~ for ~ ~__~N,'"f~ Bedrooms ~;~r' J"zJ.-~7 After test .,..G'(~ If yes, give date Well on lot /(_.?C~ ~ To building foundation On adjacent lots ~ C) Surface water//'~('~ On adjacent lots /OEP f'-/-- Property line /0 C/ TO existing or abandoned system on lot Cutbank._/UO~ ,f~,'~jFj~J/~ Water main/service line //~ (-~ Driveway, parking/vehicle storage area /C) Curtain drain ./'(~O/C~-~ ,/~/'J~/"~.l , E. ENGINEER'S CERTIFICATION I cerbTy that l have checked, verified, or ~ MOA and HAA guidelines in effect on~s/nspection. Engineer's N,~034 Eagl:~~,ad Ne. 204 HAA Fee $ ~ PD /¢O Waiver Fee $ Date of Payment ¢~ ~ '~- ~¢ Date of Payment Receipt Numar Z~ ~¢~ ~,/¢/¢~ Receipt Number 72-026 (3/93)' Back Well and Septic Advisory Lot 8 Block 1 Mountain Shadows Subdivision WELL: The well on this lot currently meets the existing State and Municipal Codes, however, it is recommended that periodic sampling and testing be conducted to insure the continued suitability. The nitr~te concentration on March 31, 1990 was 8.7 mg/1 and on February 21, 1994 it was 8.4 mg/1 which compares with the EPA maximum concentration of 10.0 mg/1. SEPTIC SYSTEM: During an adequacy test perfomed on the leachfield on this lot, 5'¼" of water was observed standing in the 5'6" of septic rock. This high water level indicates that the absorption system is 97.35% saturated and the remaining life of the absorption system is questionable. RWR/ljm MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) ~ountain Shadows, ~ot 8, Block Location (address or directions 12901 Nichael Rd. (b) Property owner Mailing Address 1~901Hiahael Rd. Telephone: (home) ~ Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address 2600 Cordova, Telephone 276-2,761 Remax/Carol Douthit Anchora.~e (e) Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms_ 3 3. WATER SUPPLY Individual Well fq~. Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [i: Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-O25 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATIOI~ As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is Health Authority Approval StlOWS 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. Mountain Engineering 696-1700 Name of Firm Telephone 10251 Crestview East Eagle River, AK 995?? Address 6/4/90 Date 6. DHHS APPROVAL Approved for J_ Approved Uisapproved Terms of Conditional Approval Note: bedrooms by~~" .Date Seal Conditional The well for this prhperty meets existing State and Municipal Codes. There are nitrates present, however, it is suggested that periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 8.7 mg/1. EPA maximum concentration is 10.0 mg/1. --' __ '-- J,r. 117 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. TheMunicipalityofAnchorageisnot responsible for errors or omissions in the professional engineer's work. /'i"'_"_"_"_'~ MUNICIPALITY OF ANCHORAGE (MOA) (,.~_~] Health Authority Approval (HAA) ' "IOniA '~'~'"~"]~':~J .... CHECKLIST - FEBRUARY 1984 Mu,'~ ~.,~ ~'~nu;~/~OS 343-4744 ENVIRONMENTAL SERVICES DIVISION Legal Description: !.,9-90 Htn. Shadow,~ iJS, 12901 Hichael Rd., Anchoz'age B1 A. WELLDAT~CEJVED Well Classification Res~den%ial Well Log Present (Y/N) Y .... .Date Completed Total Depth j 20' ~based to _2,0' Static Water Level < 24 ' Casing Height Above Ground 2' , Electrical Wiring Jn Conduit (Y/N) Yes SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot >100' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line n/a To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~}?ez' ~e.l~.L Depth of Grouting Unknown If A, B, C, D.E.C. Approved (Y/N) Yield 4 gpm Pump Set At Unknown Sanitary Seal on Casing (Y/N) Yes Depression Around Wellhead (Y/N) ; On Adjoining Lots > 100 ' > 1.00 ,' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole n/a >75' Moun'ba.~.n En¢ineering ;Date Passed -- Coli:l~orm & NJ. trates 5/31/90 Log 10/24/80 B. SEPTIC/HOLDING TANK DATA Date Installed_lO/8(1* Size ;125(1. Standpipes (Y/N) Ye~; _Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) r~,/a SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well > 1 (10' To Property Line '~1 O' To Water Main/Service Line ~> I (1' To Stream, Pond, Lake or Major Drainage Course n/a Comments ;rl'..'~A,s--Bu~ ] t-. ')0,/1~/80 No. of Compartments 2,* Ye::~ Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) ~,/~ To Building Foundation '>1.0 ' To Disposal Field 5' 72-026 (Rev. 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed :] 0/:14/80* Width of Field 30"~x 12s sf/bed~ Square Feet of Absortion Area 489 Depression over Field (Y/N) Results of Last Adequacy Test Pa~ac] -- Type of System Design Length of Field 44. 5 ' Depth of Field I0, Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test 3 R~ H x'~,qii~. SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well >100' To Building Foundation '~20 ' Lot n/a To Water Main/Service Line '~ :[ 0 ' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments *Par As-9,:.~_!!: !0/:L4/80 Yes 5/31/90 To Property Line 14, ' >k To Existing or Abandoned System on ; On Adjoining Lots >100' To Cutback (if present) n/a D, LIFT STATION Date Installed ~/~ Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and :HAA gui~ inspection. Signed Company Hr, ur_,t.-~ ir: F-.n~ir_, e erina Date 6/4/90 MOA No. CE89'-00'? Receipt No. Date of Payment Amount: $ 72-028 (Rev. 7/88) Back i~d.~¢~'~ ,'";~e.ct on the date of this s ¢.,." A ',-,2' p "E gineers Sea Receipt No. ,. Waiver Fee: $ Date of Payment Page 2 of 2 R+ HOHE SERUICES, It, lC. HOME SERVICES, INC CUSTOMER 15900 Francesca [)rive Anchorage, Alaska 9951(4 34~-1890 or 345-2444 W~s & Li~a 12901 Michael INVOICE Anchorag'=, Alaska 9951(, Block Lot DATE DESCRIPTION AMOUNT 0.~'~'89 ~ump'" SeF, L lc $'/5 00 ...... "' y~'A'L ~ ~ REMARKS I{~0 Gallons ~ Saptlc ~ Cesspool ~ Hotdlng Tank . } ._ Standpipes /~,'4~O,#~Tlme [] PROBLEM AREA--CALL FOR MORE INFORMATION [] NEEDS TO BIZ DONE AGAIN IN Ii MONTHS [~ Good Shape [] Sludge buildup on bottom [] Floater on top ~ Jim cap missing or [] Cut standpipe to 1' above ground L~ Needs Septlctrine needs replacing --P[,ELaE P~.Y FROM THIS INVOICE-- CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. gllent Sample ID:MTN SHADOWS L8 Bi (RE-SAI4PLE) PWSID :UA Collected }MY 31 90 ~ 13:17 hrs. Received ~Y 31 90 ~ 16:00 hrs. Preserved with :AS REQUIRED 5633 BSTREET · ANCHORAGE, ALASKA 99518 ' TELEPHONE (907) 562-2343 FEDERAL TAX hD. #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 22153 Date Report Printed: JUN 4 90 0 15:18 Client Name : MOUNTAIN ENGINEERING Client kcct : MINENGN P.O.~ NONE RECEIVED Ordered By : Analysis Cmapleted :JUN 1 90 Send Reports to: Laboratory Supervis9r jSTEPHEN C. EDE 1)MOUNTAIN ENGINEERING Released By : ~ ~ ~ 2) Special NOLD FOR PICK UP. REFERENCE PREVIOUS WORKORDER ~90.1520. Inetruet: Chemlab Re£ ~: 901631 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 8.7 m§/1 EPA 353.2 iO Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY LOCRYER. 1 Tests Performed Soo Special Instructions Above UA~Unavailable ND~ None Detected "See Sample Remarks Above NAt Not Analyzed LT~Leee Than, GT-Greater Than