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HomeMy WebLinkAboutNORTH SLOPE BLK 2 LT 1B1c) Municipality of Anchorage Page > of 9 _ DEPARTMENT -OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL, SERVICES DIVISION P.O Box 196650 • Anchorage, Alaska 99519-6650 e Telephone: -343-4744- - On -Site Wastewater Disposal System and/or Well Inspection -Report Permit Number: G 3y PIDNumber: oSvsl� �9` Name:. C'7ACcv Wastewater System: ❑ New XUpgrade Address: �/e w;Qer1EK9't� 83 - ayal N- ABSORPTIOFIELD - Phone: -- -- - - No. of Be,Qrooms: --__ - ,`Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other- -- _ : LEGAL�`DESCRIPTION Soil Rating: "- - --jZ Total Depth from original grade: GPD/S .Ft. -.. Lot -Q Block; '' 1`Stibdi4tsion ` Depth to pipe bottom from original grade: Gravel depthbeneattr pipe:-- iperFt. Fl. Towns_..h.a, Ran I sell _-- Z Fill added above original grade. Gravel length:':: ---_ _' - 70" -.-` Ft. Ft. WELL: ❑ NeW ❑ Upgrade Gravel width: f Z Number of lines: I Distance between lines: o Ft. Ft. Classification (Private, A,B.C): ....:_ Total Depth: Cased To: -- Total absorption area: - _LO Pipe / , material: 34::)34- Ft. - Ft. - SQ. Ft. I"v G _ Driller: -: `.' `-. - -- Date Drills& -- Static Water Level: Installer. Date installed' - -- - - Ft. 8 g .�- Yield: - -Pump Set at: - -- Casing Height Above Ground: __.. -.. TANK �-- - GPM --- '-- - Ft. ....-._. Ft. - SEPARATION DISTANCES XSeptic 0 Holding ❑ S.T.E.P. To Septic Absorption Lir' Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines A "A --7A W-- coo Well ,r Material: Number of Compartments: Surface loo+ low J- f ,)/ A LIFTSTATION Water Lot t Size in gallons: Manufacturer: Line �' Foundation- -�-`- r] p /. / "Pump on" level at: "Pump off' level at: High water alarm at: - Curtain- Pump Make &Model Electrical Inspections performed by: Drain ......... Remarks: BENCH MARK - - Location and Description: - `J (� cor2N'u v— DIM 4-e s s if- - Assumed Elevation: O ENGINEER'S SEAL: ,. 4�®OF A tt � so roo*i Ta •» •••a• •••:_ ^ Inspections performed by:. 8�393 Dates: 1s 2nd 41 David R. paytotc = �d Department of Health and uman Services approval '%to%z< • No. 2205E t��n�•,•• eel Reviewed and approved by: Date: F* po OF'*" �oo"`�ov.► l __- 72-013 (Rev. 9/91) MOA 25 I: -19© N 72-013 A (2/91) MOA 25: - �4F�Gt�S SEAL. OF David Pi Dayton - 140..220&E, ,• 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:SW930262 DESIGN ENGINEER:DAVID R. DAYTON, P.E. OWNER NAME:BROOKE GARY OWNER ADDRESS:HC 83 BOX 2401 EAGLE RIVER, AK 99577 PARCEL ID:05051139 LEGAL DESCRIPTION: NORTH SLOPE BLK 2 LT 1B LOT SIZE: 49686 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 7/27/93 EXPIRATION DATE: 7/27/94 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 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. SPECTATE PROVTSIONS: RECEIVED B ISSUED BY: DATE:L DATE: (/•�jyMJA'nJ CSmT � /A zr-Asr' 300.40 ' /8 t0 10� �0 r J savr - 1 A ®sot-n�n cel Sv sYe�. p ��` Tri'Z / / /Yi'LONInK 7-�EI" 0( j 1 / i E�957 34,9.40' G<ft./hAcr! SrATc� ��i9.CK 1, PO•nP ©mac+ tftn��, (2csv ova Tole, Zl j Nil .-L -%O' X %, TI�TdJ J4 W.TT1 3�l ilh.i �. =0vea•aa•e•e9 441 1b a Osseo as 00 6 40 0. d 4 R t• David R. Dayton ; k �'EPfiI G S�i5T.- yS �'C9 pL�] David R. Dayton P.E. 20210 Donslar St. Chugiak, Alaska 99567 7� Nz7ug� I B z 000 qcc 110,3 �1L6 mow`» 4sM z7Stz.J 3� 0 0 � 0 D ,f p V .ZyN iS.i N/i+OG 4"SoL,o - _ F.I ` 4" A* X10 �I.g Lo 33.¢ qfl /8.9 � 6o i/• Co zoo .4- 5.4- %1 AV 64, �• • 4 b•qe • • Mp• ' be i% 9� • David R. Dayton b fZ 2205•E00 �® PROFESS�ON��` .. SCUT TO•/� �'4-WIQ4S MAT'S 0 David R. Dayton PX. 20210 Donalar St. Chuglak, Alaska 99567 S4 r'EFr- Z 17-- /'l f 3-7.5 Z% / D. R. DAYTON, P.E., R.L.S. Chugiak, Alaska 99567 20210 Donalar Lot 1B, Block 2, North Slope Subdivision (907) MEM 696-2417 The proposed septic system to serve 3 bedrooms, is to replace a system which was found to be approximately 40 ft. from the well. The lot, as well as other lots in the area, is large with ample room for a future replacement system. There are no private wells within 100 ft., or community wells within 200 ft. of the system. There will be no measurable impact on water or wastewater systems on adjacent properties. There will be no impact on drainage or reserved space. Ar � so�� *9aaa .S 0 •D° 9 DD•D aD9C sD1008 206D680 David R. Dayton NO. 2205•E Q Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: `- 7"y -V6g V 6. DATE PERFC LEGAL DESCRIPTION: br 13 t //urtrtrsoupa 5foTownship, Range, Section: �c -� Z, -')4,p, J.)C DEPTH a46.^+ ,e d SLOPE SITE PLAN (FEET) :Ei 1 E 4- 5- 6 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Sud ti'i-!y `J""rY 57A --o (ntti• --• W/vcGAJ/U:JhL (.ter --u. EveAD&O s I '�'TtY7�k u?liosv WAS GROUND WATER . / ENCOUNTERED? C7 IF YES, AT WHAT DEPTH? Depth to Water After,/ Monitoring? r^',-' Date: Reading ate Gross y Time Net Time Depth to Water Net Drop 6- z3/.n8 i. � .s L isltr ze 20P © „ IL_ JI PERCOLATION RATE � (minutes/inch) PERC HOLE DIAMETER � TEST RUN BETWEEN 4 FT AND '5 FT COMMENTS '>t J9eGzy G?u<}4R�r's z SCPTrL sV rn cU/u PERFORMED BY: "? '��"'i tTXJ I - CERTIFY THAT THIS /TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) 'w/� • ae Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST -r-i-< "'` --Z-- PERFORMED FOR: <'"� R �9 r-- C LEGAL DESCRIPTION: Lr 18) ,✓U� ` t "�'t DEPTH -fitQTY Sr}Nn �; C%YL-t.s (FEET) '"- 2 3 4 5 6 7 8 9 10 11 12 — 13 14 15 16 17 18 19 S�t4tfrrr/ Seg -t--{ 3�A�+D W ALL G!r fin 3'� - DATE PERF( Township, Range, Section: 3L, SLOPE 6ur� 1. a WAS GROUND WATER ENCOUNTERED? _ 'TU s3� IF YES, AT WHAT DEPTH? _ Depth to Water Attejj/ Monitoring? V041 ' Date: /ltd S L O P E 7 g3 SITE PLAN .>2/ e Reading Date Gross Time Net Time Depth to Water Net Drop 20 I I PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER u yy TEST RUN BETWEEN FT AND FT COMMENTS Asl rX-IA-t_ I D LMJ% -eM.. -11-> ijs r PERFORMED BY: �- � T� `1 3 E7 I CERTIFY THAT T 1S TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 4 72-008 (Rev. 4/85) Mnaicipality of Anchorage Department of Health and Human. Services 825 "L" Street Rick Mystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650 Mayor 343-4744 August 23, 1995 Robert T. Creighton PO Box 232383 Anchorage, Alaska 99523 2383 Subject: Lot 1B Block 2 North Slope Subdivision Permit #SW940311, PID #050-511-39 The subject permit, issued August 23, 1994 by this office for a single family well and/or on-site wastewater system, has expired as of August 23, 1995. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as -built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $320.00 for an on-site wastewater permit; $120.00 for a well permit and $440.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Silycerely, J0am,,es Cross, P.E. ram Manager On-site Services enc: Copy of Permit MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940311 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:CREIGHTON ROBERT T OWNER ADDRESS:P.O. BOX 232383 ANCHORAGE, ALASKA 99523-2383 PARCEL ID:05051139 LEGAL DESCRIPTION: NORTH SLOPE BLK 2 LT 1B LOT SIZE: 49686 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 1f— 1 DATE ISSUED: 8/23/94 EXPIRATION DATE: 8/23/95 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) . 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVTnT^wT' - RECEIVED BY: ISSUED BY: DATE: -2 - �tj DATE: g`2?' /T 2 U I hereby certify that l have surveyed the following described io property: I N6e,-rtF :5LoPlg 450 Pb P.d�� jJ ••• NO. 3215 „'`:'•.9 r A ��0+�0'•.. w ••.•'''Oyv.v Anchorage ecording ec nct, A.133M'011 t o e Improve- '$V."OrEssisp,0-.0V menu situated thereon are within the property lines and do �y., n.�•. sig not overlap or encroach on the property tying adJaeent thereto, that no improvements on: property lying adjacent thereto encroach on the promise, in question and that there are no roadways, transmission lilies or other visible easements.. on :aid. property excspt. as. indicated hereon. r; _. .Doted.. at Chugiak, Alaska - this �_ day of 414ca , 19 93 RESIDENCE OF PREPARED 8Y: - �,9,c,� r3eoores D- R Dayton .R.L.S_ 43 ?;210 20210 DONALAR ST. .4L 99577 CHMAK, ALASKA 99567 Phone (9071 696-2417_ . DATE: W.O.ND. DRAWING N0. FIELD BOOK NO. DRAWN BY: _O -R -ti 8/7 f 4.3 93/ CHECKED BY, SCALE: PLAT FILING. NO. SECTION, TOWNSHIP, RANGE GRID N0. 75- 33 :52c32,7—/4N; /Z 5& 03 A N i i . I • a ' �p' UT/L x ��a .A ESmT 4 p 39.4Aj ' � �3. M1L F.« S � h t i"3�^•� • av � 3 0 � � .,c/�ST 300.92 /fie. 300.23 OM1 2vtiat I %Z"2e4+a I i 41 I hereby certify that l have surveyed the following described io property: I N6e,-rtF :5LoPlg 450 Pb P.d�� jJ ••• NO. 3215 „'`:'•.9 r A ��0+�0'•.. w ••.•'''Oyv.v Anchorage ecording ec nct, A.133M'011 t o e Improve- '$V."OrEssisp,0-.0V menu situated thereon are within the property lines and do �y., n.�•. sig not overlap or encroach on the property tying adJaeent thereto, that no improvements on: property lying adjacent thereto encroach on the promise, in question and that there are no roadways, transmission lilies or other visible easements.. on :aid. property excspt. as. indicated hereon. r; _. .Doted.. at Chugiak, Alaska - this �_ day of 414ca , 19 93 RESIDENCE OF PREPARED 8Y: - �,9,c,� r3eoores D- R Dayton .R.L.S_ 43 ?;210 20210 DONALAR ST. .4L 99577 CHMAK, ALASKA 99567 Phone (9071 696-2417_ . DATE: W.O.ND. DRAWING N0. FIELD BOOK NO. DRAWN BY: _O -R -ti 8/7 f 4.3 93/ CHECKED BY, SCALE: PLAT FILING. NO. SECTION, TOWNSHIP, RANGE GRID N0. 75- 33 :52c32,7—/4N; /Z 5& 03 r ITI "I oz ITI 0%1 In 171 01 "f1 It ITI 'n ITI O . H . H H H H . . . H H H H H H H H H H H H H O O O O O O O O O O O O I� Le 1% "J "it :,i y. I fl, Y Ln tv d "C6� c tdn x 'b3 fii .�y t'1 PY � H Er, J.1 NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 • FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 • FAX 274-9645 DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA Robert T. Creighton Public Water System I.D.# P.O. box 232383 Anchorage, AK 99523 Date Received: 10/12/94 Time Received: 10:00 Date Analyzed: 10/12/94 Time Analyzed: 13:00 Date Reported: 10/18/94 Time Reported: 09:13 Next Sample Due: Comments: S = Satisfactory U = Unsatisfactory POS = Positive Test Result ND = None Detected Collected by: RC TNTC = Too Numerous To Count (>200 Colonies) Sample Type: CG = Confluent Growth Routine HSM = Heavy Sediment Masking, Results May Not Be Reliable SA = Sample Age >30 Hours But <48 Hours, Method of Analysis: Results May Not Be Reliable MMO-MUG (Colilert) Old = Sample Age >48 Hours, Too Old For Analysis Comments: R = Resample Required NT = No Test Sample Sample Location Date Time Lab# ----------------------------------------------- 1 North Slope Subdiv. 10/12/94 08:30 AB5602 B2L1B �l i Julie 5 haefer Enviropmental Analyst * # Colonies/100 m1 ** # Colonies/ml Total* Fecal* Other* HPC** Coliform Coliform Bacteria Result Comments ---------------------------------------------- ND ND NT NT S NORTHERN TESTING LABORATORIES, INC. 0 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 • FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 • FAX 274-9645 Reported By: Antho J. Lange Chemistry Supervisor Report Date: 10/26/94 Robert Creighton Date Arrived: 10/12/94 PO Box 232383 Date Sampled: 10/12/94 Anchorage Time Sampled: 8:30 AK Collected By: Attn: * Definitions B = Below Regulatory Min. H = Above Regulatory Max. Our Lab #: A134819 E = Estimated Value Location/Project: M = Matrix Interference Your Sample ID: Well Head D = Lost to Dilution Sample Matrix: Water MDL = Method Detection Limit Comments: Lab Date Date Number Method Parameter Units Result * MDL Prepared Analyzed ------------------------------------------------------------------------------------------------ A134819 EPA 150.1 pH Unit 8.0 10/13/94 A134819 EPA 160.1 Total Dissolved Solids mg/l 370 1 10/13/94 A134819 EPA 170.1 Temperature Deg F 20.0 10/26/94 A134819 EPA 310.1 Alkalinity as CaCO3 mg/l 160 1 10/19/94 A134819 EPA 353.3 Nitrate -N mg/l 0.80 0.10 10/17/94 A134819 EPA 354.1 Nitrite -N mg/l <MDL 0.020 10/12/94 A134819 SM 203 Langelier Index Unit 0.34 10/26/94 Reported By: Antho J. Lange Chemistry Supervisor NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 • FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 • FAX 274-9645 Robert T. Creighton PO Box 232383 Anchorage AK 99723 Attn: - Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: F143435 Well Head (A134819) Water Method Parameter Units --------------------------------------------- EPA 200.7 Calcium mg/l Hardness as CaCO3 mg/1 Iron mg/1 Magnesium mg/l Manganese mg/1 EPA 206.2 Arsenic Reported By: Patricia AWoody Senior Chemist mg/l Report Date: 10/19/94 Date Arrived: 10/13/94 Date Sampled: 10/12/94 Time Sampled: 0830 Collected By: - MDL = Method Detection Limit * Flag Definitions B = Below Regulatory Min. H = Above Regulatory Max. Date Date Results * MDL Prepared Analyzed ------------------------------------ 40.4 0.017 10/18/94 152 0.1 10/18/94 0.321 H 0.010 10/17/94 12.3 0.017 10/18/94 0.012 0.005 10/17/94 <MDL 0.003 10/17/94 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 Parcel I.D.# Q5C`5_/1-3q 1. GENERAL INFORMATION Complete legal description H A A # �dtN L'LC �-nS PIN 6 C 2,"C j js y Location (site address or directions) Property owner Day phone Mailing address 3�b ��Gi2�i G—L� �i /� 2 . % v Lending agency Day phone Mailing address Agent/ZocK �TILTNC� (�O %��r/¢ Day phone Address CMZ Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well X Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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 MOAN21 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 & 5 ENGINEERING Phone 6,1 y - ;k,cl 7cj 17034 Eagle River Loop Road No. Address Eagle River, A�aska 99577 0 Engineer's signature 6. DHHS SIGNATURE Approved forT _AZ L / bedrooms. Disapproved. Conditional approval for Additional Comments 0 11ITlr Date %/ 3 -;L / q j ........ l r � {':�, /,��•. ,!mow ,. CE -esoi bedrooms, with the following stipulations: Date % -2,9- 1 1 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-02 (Rev.1/91) Back MOAp l cVtL Municipality of Anchorage JUL 22 1999 DEPARTMENT OF HEALTH & HUMAN SERVICICIPAurr OF ANCHO Environmental Services Division ,NVIRONMEWALSERVICES DI 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: LOQ / 'GOCK 2-' Parcel I.D.: O S/J-39 N6�T7-f5C_�0�� 5`D A. WELL DATA Well type 1?4 / ✓A re7-- If A, B, or C, attach ADEC letter. ADEC water system number Log present &N) Date completed Z7/%4 Total depth A�c Cased to Casing height (above ground) -7- Sanitary f Sanitary seal &N) Y E FROM WELL LOG Date of test g 2 -7 Static water level 4z' Well production ZS g.p.m. WATER SAMPLE RESULTS: Coliform to Wires properly protected(O/N) 765 AT INSPECTION 5 +pp g.p.m. i� �hfT4 cTiO RY P.,%', g— Xumgglti: Nitrate / • 31 Other bacteria 0 Date of sample::;2 -Z 0 1,?q Collected by: S & S ENGINEERING B. SEPTIC/HOLDING TANK DATA 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Date installed Tank size ( Number of Compartments -2— Cleanouts (YIN) GS Foundation cleanout (Y/N) `6-5 Depression (Y/N) NO High water alarm (Y/N) n/ Date of Pumping Pumper 7/2 S C. ABSORPTION FIELD DATA Date installed ?5 " Soil rating (.p.d./ftz rffdbdem) o Z System type _7_2r.,yc Y Length Width +' Z Gravel thickness below pipe Notal depth %4 Effective absorption area 4z0' Monitoring Tube present&N) &S Depression over field (YO N O Date of adequacy test !7 �% Results Pass Fail) 9SS For �& bedrooms Fluid depth in absorption field before test (in.); -&- Immediately after gal. water added (in.): 4. " Fluid depth -& (ins) Minutes later: /S Absorption rate = 45D f g.p.d. Peroxide treatment (past 12 months) (Y/N) IY/91 E krr¢wrd If yes, give date 72-026 (Rev. 3/96)" D. LIFT STATION Date installed Manhole/Access (YM) "Pump High water alarm level at* �/ *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /00 /-t Size in "Pump off" level at* On adjacent lots /00 /f Absorption field on lot /UO f On adjacent lots X00 7 Public sewer main FF Public sewer manhole/cleanout i Sewer /septic service line ZS f— Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation Property line Absorption /-I,- Water t Water main/service line 25 ' Surface water/drainage A-70 �L Wells on adjacent lots /� f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Building foundation /0 Water main/service line i Surface water /OD Driveway, parking/vehicle storage area /0//-- Curtain Of' Curtain drain AlONe- KN6tJN Wells on adjacent lots 1001,4- F. 00/,4 - F. ENGINEER'S CERTIFICATION I certify that 1 have determined thru field inspections and review of Municipal reco rdit(a'ystems are in conformance with MOA %�j g rd nes effect on this date. rye. .......... .4� Signature %✓�J , 4 _ PVf )� �T b Engineer's Name � c dt✓�� . Date 7 /a 3 ! ai Ii� aoaear c: cownN M1 �r�Q s O. 4 CE - 8801 .e- HAA e HAA Fee $ `-3 q Date of Payment 7 c� 3 -1- Receipt Number 0 / � 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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 Parcel l.D.# vS05)13°7 HAA# l�0LtZ� 1. GENERAL INFORMATION Complete legal description ��r 1 �- n�op�rl+Swpiz SUN, Location (site address or directions) oC az'c r - Property owner �� y a_001t:'5 Day phone Mailing address � 'Q'`� `�"" Zoo 1 f'� c, LG e,ul-ic- �'` R `i37-7 Lending agency Mailing address. Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well X Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev.1/91) Front MOAa21 5. [-1 0 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 furtherverify 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. David R. Dayton P.E. Name of Firm 20210 Donalar St. Phone Chugiak, Alaska 99867 Address Engineer's signature DHHS SIGNATURE _ Approved for 3 bedrooms. Disapproved. Conditional approval for Additional Comments Date 9 bedrooms, with the following stipulations: Date 8— // — �`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 order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rev.1/91) Back MOAN21 Municipality of Anchorage O Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: kb r-, -6 )BLYL I' AICA'A5�6e Parcel I.D. 0 S-0 57 11327 A. Well Data Well type NO UA -N If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) /,/ Date completed 1172 - Driller Total depth 1174- Cased to "+ Casing height Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump levell SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 10 Absorption field on lot Wires properly protected (Y/N) AT INSPECTION On adjacent lots Public sewer main 4)IA- Public sewer manhole/cleanout AJ Sewer service line WATER SAMPLE RESULTS: Coliform 0 Nitrate Petroleum tank 0 '7 3 Other bacteria 0 Date of sample: 3/9 3 Collected by: 7CV-b� B. SEPTIC/HOLDING TANK DATA Date installed �' C% 3 Tank size 10-00 Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) % Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) X11 Date of pumping N6%J Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 4 o / On adjacent lots ) coca .- Foundation Cy To property lined Absorption field Surface water/drainage j oc3 4- 72-026 (3/93)` Front Water main/service line �i CONTINUED ON BACK PAGE z C= m p.m.1 g.p.m. r ,' I cr) r m m i -r I w n o On adjacent lots /IS e M Z On adjacent lots Public sewer main 4)IA- Public sewer manhole/cleanout AJ Sewer service line WATER SAMPLE RESULTS: Coliform 0 Nitrate Petroleum tank 0 '7 3 Other bacteria 0 Date of sample: 3/9 3 Collected by: 7CV-b� B. SEPTIC/HOLDING TANK DATA Date installed �' C% 3 Tank size 10-00 Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) % Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) X11 Date of pumping N6%J Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 4 o / On adjacent lots ) coca .- Foundation Cy To property lined Absorption field Surface water/drainage j oc3 4- 72-026 (3/93)` Front Water main/service line �i CONTINUED ON BACK PAGE C. LIFT STATION Date installed AJ % Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water Date installed q3 Soil rating (GPD/Ft2) 1 , L System type . Length Width Gravel thickness 3 Total depth Total absorption area,, // 4 2-6' Cleanout present (Y/N) Al Date of adequacy test OW SY5 r&M Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot // 1� On adjacent lots To building foundation 71 On adjacent lots 100 + Cutbank Surface water j oy f- I Curtain drain lJC ki�tr }GA QW^J E. ENGINEER'S CERTIFICATION a,cwe-t}- 1� Depression over field (Y/N) for / After test " If yes, give date �v 1 Property line To existing or abandoned system on lot 1�0 w >a Water main/service line 115 , parking/vehicle storage area 12� A.1 Bedrooms 1 certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection Date of Payment /-3 Date of Payment Receipt Number oZ / �o �� Receipt Number. 72-026 (3/93)` Back David R. Dayton P.E. ` 20210 Donalar St. Signature y0° Engineer's Name DOvid R. Dayton uJ 1® °� Date �5 /`��3 s°°° NO. 22o�-e e C-. 00 °°po eo .sv ee ee° � pROFFSS�Oe�P d � HAA Fee $ G � D Waiver Fee $ Date of Payment /-3 Date of Payment Receipt Number oZ / �o �� Receipt Number. 72-026 (3/93)` Back D. R. DAYTON, P.E., R.L.S. MxxlVx I E Chugiak, Alaska 99567 (907) 20210 Donalar 696-2417 July 10, 1993 WELL FLOW TEST Legal Description: Lot 1B, Block 2, Northslope Subd. Date of Test: July 9, 1993 Well Depth: 117'+ Water level was measured to 117' during test. Casing Depth: Measured to 40'+ Static Water Level: 71' Requirements: 3 BR - 450 gallons per day Test: The well was tested with the existing pump through an outside hose bib. The well was pumped at varying rates, While measuring volume, time and drawdown, until the drawdown remained steady. Pumping was then cont- inued until the daily requirement was met. Results: The well produced 1.13 gallons per minute. The well is currently producing adequately for a 3 BR home. •°••aro°je`V "f�V iao •a 191 David R. Dayton j NO. 2205-E ar