HomeMy WebLinkAboutNORTH SLOPE BLK 2 LT 7Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201410 PID Number: 050-511-21
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
Terry Boone
ADSORPTION FIELD
U L�p Tch ❑ Wide Trench F-1Bed E] Mound
Site Address
30939 Prudhoe Bay Eagle River
771 Other
Phone
Number of Bedrooms
Soil RatingTotal
depth from original grade
3
D/S F
I Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original de
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
North Slope 2 7
Fill added above original grade
Ft.
Grp I length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distabetween lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between tre es
From
Tank
Field
Tank
Line
Ft2
F .
Well
> 100'
na
na
na
na
TANK [M Septic ElS.T.E.P. [I Holding E] Other
Manufacturer
greer
Capacity
1000 Gal.
Surface Water
> 100'
na
na
na
Material
plastic
Number of compartments
2
Lot Line
> 10'
na
na
na
NA
Foundation
> 10'
na
na
na
!
LIFTSTATION
Manufacture
Capacity
Remarks
Gal.
Alarm location
Elect ' stalled 6y
PIPE MATERIAL House to tank 3034Tank to 3034
drainfield
Installer
JRs Septic
Drainfield CO/MT 3034
Inspector Curtis Townsend
BENCH MARK (Assumed elevation) 100 ft
Inspection 15' 10/17/2020
Location and description
2
3d 4"a
Garage slab, point A
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
A',
• CurtisL'To n-�nrd
Date Z 2 W
e�� -'� ��- F'
/* No No. CE i 19 -t
rF�'
Septic System
%
Approved � � � Date u ,2uo
�
�� F�PROFESSt�t1n�,,� r
Note: this approval does not include well permit requirements.
tnev uDiuZriu)
r
O
J
NEW 1000 ('Al CC-oTnr TAKtV
(2) 35' x 12' x 6"
EFFECTIVE DEPTH BEDS, 2
INSULATION CONFIRMED
NEIGHBORING WELL IS >
100' FROM PROPERTY
LINE, FIELD VERIFIED
NEIGHBORING SEPTIC IS
> 10' FROM PROPERTY
LINE, FIELD VERIFIED
NEIGHBORING WELL IS >
100' FROM PROPERTY !1
rd
Septic Record Drawings Prepared for ...��
TERRY BOONE �F
30939 Prudhoe Bay Ave Eagle River, Alaska 99577AV
�,.�`•
NORTH SLOPE BLOCK 2 LOT 7 49r-" •
......................
OS P201410
EKLUTNA ENGINEERING LLC ••• TIS ��•••••••••••���D:
DATE: 11/7/2020 j� :•CURTIS TOWNSEND;� ��
19162 MOUNTAIN ROAD ���� ' N ` CE 104•• =�
DRAWN: CLT ; •''• � /,�/ �
CHUCIAK, ALASKA 99567 i
SCALE: 1"-40' ��•''•.........1�.��
(907) 406-1058 PID: 050-511-21 SHEET 2 OF 3
I
NEIGHBORING WELL IS > 00
100' FROM PROPERTY
LINE -�
\ O
J
NEIGHBORING SEPTIC
IS > 10' FROM
PROPERTY LINE
NEIGHBORING SEPTIC
IS > 10' FROM
PROPERTY LINE
NEIGHBORING WELL IS >
100' FROM PROPERTY
UDI -1
\
LINE \
SCOPE OF WORK
1. EXISTING SEPTIC TANK REMOVED.
2. NEW 1,000 GALLON SEPTIC TANK PLACED
AND TIED INTO EXISTING ABSORPTION
SYSTEM. THE TANK WAS PROVIDED WITH A
Y
MINIMUM 20" 0 MANWAY RISER SERVING
THE FIRST COMPARTMENT.
3. ALL CONSTRUCTION WAS IN ACCORDANCE
WITH ALL REQUIREMENTS SPECIFIED IN
\
ANCHORAGE MUNICIPAL CODE CHAPTERS
\
15.55 AND 15.65.
Septic Record Drawings Prepared for ...��
TERRY BOONE �F
30939 Prudhoe Bay Ave Eagle River, Alaska 99577AV
�,.�`•
NORTH SLOPE BLOCK 2 LOT 7 49r-" •
......................
OS P201410
EKLUTNA ENGINEERING LLC ••• TIS ��•••••••••••���D:
DATE: 11/7/2020 j� :•CURTIS TOWNSEND;� ��
19162 MOUNTAIN ROAD ���� ' N ` CE 104•• =�
DRAWN: CLT ; •''• � /,�/ �
CHUCIAK, ALASKA 99567 i
SCALE: 1"-40' ��•''•.........1�.��
(907) 406-1058 PID: 050-511-21 SHEET 2 OF 3
THIS TANK WAS INSTALLED DURING THE MONTH OF
OCTOBER. NO GROUNDWATER WAS PRESENT. THIS TANK
WAS NOT BALLASTED AGAINST BUOYANCY.
MARK
A
B
SVi
26'-4"
15'-11"
SV2
22'-5"
18'-7"
DCO
21'-0"
19'-5"
DCO
20'-3"
20'-3"
Septic Record Drawings Prepared for ,,
TERRY BOONE .�p�.•......... 14 41t4,0
30939 Prudhoe Bay Ave Eagle River, Alaska 99577AV
0
NORTH SLOPE BLOCK 2 LOT 7 ;'� 49TH
OSP201410 / ...: ""'0
. ..........................
l-�
EKLUTNA ENGINEERING LLC /
DATE: 12/21/2020 j . No. TOW NSENDc
0.G� '• No. C 1 1904 � � i
19162 MOUNTAIN ROAD DRAWN: CLT 112�2i 1904 �
CHUGIAK, ALASKA 99567 SCALE: 3" = 1' ................
(907) 406-10518 1�;
PID: 050-511-21 SHEET 3 OF 3
Detail
(Not to Scale)
2' 2
Eave J \
/ \ SET RBR
`\ CO \ �\\\`D RBR
w
S, Ay \ ora �. S
`\ or.-Ea6
ve �\ S•u�r38. E \
> X09 `\ / r cs't 3
NHouse / 20.5•x24.5• ,,D RBR
Frame
Gar
56'
nfle
Eave
FD RBR
1 Septic(
1 ro 3'x4.5' MM See
/ Steps Septic l — 1 DetaN
NSTE� \ Systam`C�1 �
Septic System has ® \ f 69'
9 pipes total. In
OF q�''' 1, 2' \ / C r addition, there are
�P� - - - • 9S�JJJJ Eave �¢� Manhole and 1 Septic \CS
ru
S' c Power Pole
:* 49TTH*% 1a
......... 1
�'• A thony P. Bonet a - , w®1
Lot 7
LS-10393 app_
JrIf',OA/�c�lsil �!� Power Pole 1' M
''1�t\\�\\\�����` Tel PeT--
I hereby certify that I have surveyed the following described SET RBR S , e
5 83, c sat. ) I
property: Lot 7, Block 2, North Slope Subdivision pRUe Field m$h
Plat No. 69-131, Anchorage Recording District, and that no DHpE inlet
Guy Anchor
encroachments exist except as indicated hereon. This As-built B
A y G z 300.0, CMP —�� Power Pole
will only show the easements that appear on the recorded _1dc�f.
subdivision Plat No. 69-131, Anchorage Recording District; \ SET RBR Tel Pad
under no circumstances should this data hereon be used for A 1
the construction or establishing of boundary or fence lines.
APB Land Surveying 9 to BD North Slope Subdivision ASBUILT SURVEY SHEET
12204 East Prince of Peace Drive SCALE IN FEET Lot 7, Block 2 Terry S Boone 1 /
Eagle River, Alaska 99577 1" = 80' As Depicted on: Plat No, 69-131 P.O. Box 6677 of
Anchorage Recording District Texarkana, Texas 75505 / 1
(907) 227-1361 GRID: SE0703
Surveyed; October 21, 2020 DRAFTED: RWR I CHECKED:
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
httpJ/www.muni,prg1onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201410
Work Type: SepticTank Upgrade
Tax Code Number: 05051121000
Site Legal Address: NORTH SLOPE BLK 2 LT 7 G:0703
Site Mailing Address: 30939 PRUDHOE BAY AVE, Eagle River
Owner: BOONE TERRY S
Design Engineer: EKLUTNA ENGINEERING, LLC*
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
rilcnr
r.
�.
f
1)cl>artoscnr
10/2/2020
Lot Size in Sq Ft:
Total Bedrooms:
10/212021
91824
❑ Private Well ❑ Water Storage
All construction shall 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 (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (2417).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: The test hole closest to the proposed tank observed groundwater at 4 ft (at the highest). if
excavation reveals groundwater cuuld be higher than 2 ft above the top of the tanK, addltional structural
assessments may be required for the tank.
Received B
Issued By:
Y 1 Date:
I:�U c�1UZ� Date: to ������+�
3
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201410, Rebecca Carroll, 10/02/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201410, Rebecca Carroll, 10/02/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201410, Rebecca Carroll, 10/02/20
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEIVi AND/OR WELL INSPECTION REPORT
~EW
E~UPGRADE
NAME
MAI LING ADD~E.(/.~ ~--~ ~ -.~ ~o7-~T'
LEGAL DESCRIPTION
LOCATION
Well
DISTANCE TO: /~O
Manufacturer
Liq,
IF HOMEMADE:
DISTANCE TO:
Manufacturer
*bsor,t,on%
I nside length
Dwelling
Material
Width
Dwelling
Material
Foundation Nearest lot line
length of lines Trench width
inches
NO. OFBEDROOMS
No. of compartments
Liquid depSh ,, ~
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.
Distance between lines
Total effective absorption area
DISTANCE TO:
No, of lines Length of each line
Top of tile to finish grade
Type of crib~
DISTANCE TO:
Class Depth
Crib depth
Driller
6
inches
Total effective absorp~)a
Nearest lot line
Distance to lot line
PERMIT NO.
line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
INSTALLER
REMARKS
by
DOC Co. dba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS / ~"-O
DEPT. oF WELL
STATIC LEVEL OF WATER FT.
I/,
LEGAL DESCRIPTION
DATE-St .eO
PERMIT NUMBER
zo 7' 7 ,-~ax'7/r',5z~o'~&
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
~O0
KIND OF FORMATION:
From ~) Ft. to -? Ft.
From ~ Ft. to .~ Ft.
From .~'~ Ft. to
From 3-(~ Ft. to
From__Ft. to
From__Ft. to .
From.__.Ft. to Ft.
From.__Ft. to Ft.
From__Ft to Ft,
From Ft. to Ft.
From Ft. to Ft
From Ft. to Ft
From Ft. to__Ft
From__Ft. to__Ft
From Ft. to.__.Ft
From Ft. to___Ft.
From · Ft. to Ft
From __
, Ft. ¢~ ~ ~ ~ From
From
From
From
From
From
From
From
From
From
From
From
Ft. to
.Ft. to__
.Ft. to
Ft. to
Ft. to
Ft. to
__Ft. to
Ft. to
__Ft. to
Ft. to.__
Ft. to
Ft. to___
Ft. to
Ft. to
Ff. to
Ft. to
Ft. to
Ft
Ft
Ft.
Ft.
Ft
Ft.
Ft.
Ft,
Ft,
Ft.
Ft.
,Ft.
Ft.
Ft.
Ft.
MISCL. INFORMATION:
DRILLER'S NAME
,~ Department,' ~-~i~-~d ~vi~6~~Protection
~ 825 ~ Street, Anchorage, AK. ~9501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~ ~ ~%-~( ~
WELL AND/OR ON-SITE SEWER PERMIT
Location: ~ ~?/~ ~J~ Phone Number: ~Z-
Legal Description: ~ Z /-~ ? ~-~'~. ~,~0~ ~. LOt Size: ~
Type of Soil ~sorption System Is:'~
Trench: Drainfield: Seepage Bed~ Holding Tank:
Maxim~ N~ber of Bedrooms: . ~ Soil Rating(sq.ft/br)
The Required Size of tee Soil ~sorption System Is: '
LENGTH ,~ GRAVEL DEPTH ~ ~' WIDTH
DEPTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the dista~oe between the surfaoe of the ground and
the bottom of the excavation(in feet). There is no set widt5 for trenches.
The gravel depth is the minim~ depth of gravel between the outfall pipe a~d
the bottom of the exoavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /2~ GALLONS * *
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.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspectio~ and approval by this departmen
will be subject to prosecution.
Min~um distance between a well and-any on-site sewage disposal system is 100 fee
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. ~inim~ distance from a private well to a private sewer line
is 25 feet and to a co--unity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * *
I certify that:
(!) I ~ f~iliar with the requirements for on-site sewers and wells as
set forth by the Municipality of ~chorage.
I will install the system in accordance with codes.
Z understand that the on-site sewer s~stem may require enlargement if
(2)
(3)
the residence is remodeled to inc'lude more tha~ 3 bedr~
Applicant
Date:
SWP/024 1/81)
ALASKA e:-r UIROrlm[ IqTAL CO[1TROL IFIC.
~n§in¢¢rini ~ ~nuiro'nm~nlc~J Stu~Ji~:s
SPECIFICATIONS FOR ELEVATED BED ALTERNATIVE WASTEWATER
TREATMENT SYSTEM- LOT 7, BLOCK 2, NORTH SLOPE SUBDIVISION
1.0 GENERAL
1.1 THE DRAWINGS~ SHEETS 1 THRU 2, SHALL BE A PART OF THIS
SPECIFIC ATION.
1.2 ALL MATERIALS AND WORKMANSHIP SHALL MEET THE
REQUIREMENTS OF ANCHORAGE DEPARTMENT OF HEALTH AND
ENVIRONMENTAL PROTECTION PERMIT.
1.3 ALL EXCAVATIONS AND DEPTHS ARE ADVISORY AND ARE TO BE
VERIFIED OR MODIFIED IN THE FIELD BY THE CONTRACTOR.
2.0 THE LIFT STATION (NOT USED)
3.0 SEEPAGE BED
3.1 THE GRAVEL FOR THE BED SHALL BE SCREENED TO THE SIZES
INDICATED; 0.5 TO 2.5 INCHES.
3.2 THE BOTTOM OF THE EXCAVATION SHALL BE RAKED WITH THE
BACKHOE BLADE TO INSURE THAT THE BOTTOM HAS NOT BEEN
COMPACTED DURING EXCAVATION. THE BOTTOM ELEVATION SHALL
BE PLUS OR MINUS 2".
3.3 AN OBSERVATION PIPE SHALL BE PLACED AS SHOWN IN THE
DRAWINGS. IT SHALL BE RIGID PVC, ASTM 3033 D-3034. THE
SECTION SHOWN WITH HOLES MAY BE EITHER DRILLED 0.5"
HOLES @ 6 INCH CENTERS ON OPPOSITE SIDES OF THE PIPE
OR A REGULAR SECTION OF REGULAR PERFORATED SEWER MAY BE
CLAMPED TO THE SOLID SECTION WITH A NO HUB COUPLING OR
SOLVENT JOINT. A RUBBER RAIN-CAP (JIMCAP OR EQUAL)
SHALL BE PLACED ON THE TOP OF THE PIPE.
3.4 IF INSULATION IS REQUIRED, THE INSULATION SHALL BE
DOW EXTRUDED BLUE STYROFOAM INSULATION BOARD OF THE
THICKNESS SHOWN ON THE DRAWINGS.
3.5 THE TOP AND SIDES OF THE BED SHALL BE PLANTED WITH A
WHITE CLOVER AND RED FESCUE MIX OR BLUE GRASS.
3.6 THE SEPTIC TANK OF BED MUST NOT BE CLOSER THAN 100 FT
TO ANY EXISTING WELL OR BODY OF WATER.
3.7 THE GRAVEL SHALL BE COVERED WITH A LAYER OF UNTREATED
BUILDING PAPER OR A NONWOVEN FABRIC SUCH AS MIRAFAR
FIBRETEX 200 GRADE, OR POLY-FILTER X OR EQUAL.
3.8 THE DISTRIBUTION PIPE SHALL BE 4 INCH RIGID PVC OR
POLYETHYLENE. THE PIPES SHALL BE LAID LEVEL.
3.9 THE SAND SHALL HAVE AN EFFECTIVE SIZE OF 0.4 TO 0.6 MM
AND A UNIFORMITY COEFFICIENT OR NOT MORE THAN 4.
3.10 THE BERM AROUND THE SEEPAGE BED SHALL BE CONSTRUCTED OF
IMPERMEABLE MATERIAL, AND ON A SLOPE OF 1 FOOT VERTICAL
PER 3.0 FOOT HORIZONAL.
1200 Lgest 33r~l J~oenue, Suite: [~ · J~nchoro§e, J~lasko 99503 · (907) 276-1361
ALASKA ENVIRONI~.-~-~TAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 276-1361
SHEET NO ~
CALOULATEDBY /' ~ / ~I~t
CHECKED BY
OF
DATE
DATE
SCALE
CONTROL SERVICE~ "NC. S,EET,O. OF
1200 West 33rd Avenue ~-'duite B ~- /~)~, ~/ ~ -/~ - ~ 3
ANCHORAGE, ALASKA 99503 CALCULATED BY ' DATE
Phone 276-1361
CHECKED BY. DATE
I
I
SOILS
LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~
PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720 '
SOILS LOG - PERCOLATION TEST
PE.FO.~E. FOR: C,'hock
LEGA' DESC.,.T,O.: /VoxY~ alt0/:'
OL
2
6
7
8
9
10
11
12
I'F. Br.
SLOPE
/
/
13
S'fTE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT q i
DEPTH?
b" diamefe~ holc
14
15
16
Gross Net Depth to Net
Reading Date Time Time Water Drop
,t--l.b.O~ ~/z~/~:~ u:s~ ....
- iz:0~ IO mi~. ,qD -~
20 Z8 (minutes/inch)
PERCOLATION RATE
COMMENTSZ~-----~fl ~]']b(~-~U~)~¥"}~ TESTRUN BETWEEN 2 FTAND ~ : FT
PERFORMEB.Y: D, 2~ CERTIFIED BY: DATE:
72-O08
W11 U NUPAUTY OF ANCHORAGE
Development Services Department
Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-511-21
1. GENERAL INFORMATION
Expiration Date:
Complete legal description NORTH SLOPE BLK 2 LT 7
Location (site address) 30939 Prudhoe Bay Ave Eagle River
Current property owner(s) TERRY BOONE
Mailing address
Real estate agent
PO Box 6677 Texarkana
Brent Mason
2. TYPE OF DWELLING:
Q Single Family (w/�vo ADU�i
F1 Duplex
�'
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone _
TX 75505
Day phone 907.360.3237
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment
Receipt Number,
COSA# OSC211095
Waiver Fee $
Date of Payment
Receipt Number
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Eklutna Engineering, LLC
Address 19162 Mountain Rd Chugiak AK 99567
Engineer's Printed Name Curtis Townsend, PE .
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
Phone 907.406.1058
Date Z� Z%
OF rk
rtls L 7 wn end f�
J No. C 11 014
bedrooms, with the followina stiDulations-
r
��Jii SFRVIC�-_s�; ��`�
Original Certificate Date: 2 —q --�> (9?—
The
9Z
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 oromissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: North Slope Block 2 Lot 7
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1983
Total depth 58.2 ft
Cased to 58.2 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12 in.
Date of flow test for COSA 9„6/2020
Static water level at beginning of test 2 ft.
Comments
B. TANK DATA
Age of tank(s) <1 years
Tank type/material septic 1plastic
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping tank installed Oct 2020
D. ABSORPTION FIELD DATA
Which system tested (date installed) 1983
❑ ALL standpipes present per record drawing
Total measured depth from grade 4 ft (max)
Measured depth to pipe invert from grade 3.5 ft (min)
❑ N/A —pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
Parcel ID: 050-511-21
Structure served by this system
Well production at time of test 2.5 gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 0.524 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Curtis Townsend
Date of Sample 22312021
C. LIFT STATION
❑ Required maintenance compl
Age of lift station y
Lift station material
Comment
Adequacy test date 9116,2020
Results []✓ Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 454 gal
New depth 5 in
Elapsed time 1440 min
❑ Code -required soil cover over field Final fluid depth 0 in
❑ System presoaked Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) no
date of test) If es, enter date
Gallons introduced gallons Y
Comments/Deficiencies: visual inspection was performed to confirm 2" rigid insulation was over field, Sept 2020
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
0
Yes
Community Sewer Manhole/Cleanout > 100'
r Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' F✓ Yes
if No ft
Absorption Field on Lot > 100' 0✓ Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes if No ft
Water Main > 10'
Animal Containment > 50' 0 Yes
if No ft
Q Yes
if No
ft
0 Yes if No ft
Water Service Line > 10'
F�
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' F-(1 Yes
if No
ft
M Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
0
Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Property Line > 5'
F/1
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
0
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
0
Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
F�
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
21
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓0
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' Q✓ Yes if No ft
Surface Water > 100'✓Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
both beds have a monitoring tube
one of the beds is under a driveway. confirmed there is 2" insul over bed
G. ENGINEER'S CERTIFICATION
l certify that l have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date. ENGINEER'S
OF.44,s
COSA Checklist yellow sheet
coo** °........
FIFO •,.FZ�%�J.:..:
�, pR�FF55f0;ip\ »<�
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
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
Agent ~
Address ll~l ~--~. ~-~, c~t~. ~/~.cl~'~,u~,"
Unless otherwise requested, HAA will be held for pickup.
[Jay pnone /~.-~,- ~ &O0
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system: ''
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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.
KND En.q,i; eering
Name of Firm 23441 p~mig-,~ Bird. Phone
Address Eagle Rive¢, AK 99577-8738
Engineer's signature
Date
DHHS SIGNATURE
.~'
Approved for 3
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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.
72-0'25 (Rev, 1/91) Back MOA ~21
Municipality of Anchorage SEP 2 3 1996[
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division R J~ 6 E I V E
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: /,,//o¢~--// ~,/~¢ "<//b/ /--7, /~ ParcelI.D.'.
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
,/
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~/8 _~
Cased to _4~' . Casing height (above ground)
/ Wires properlY protected (Y/N)
FROM WELL LOG AT INSPECTION
%-- g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform (Z)
Date of sample:
Nitrate ~, [~ Other bacteria
Collected by: %.o.
B. SEPTIC/HOLDING TANK DATA
Date installed ~/8:5
Foundation cleanout (Y/N)
Date of Pumping
Tank size laoo Number of Compartments ~ Cleanouts (Y/N)
~/ Depression (Y/N) ~ High water alarm (Y/N)
Pumper
C. ABSORPTION FIELD DATA
Date installed,, ~,/~, .%, ~i";.
Length 7~ ' Width.
Effective absorption area
Date. of adequacy test ~
Fluid depth in absorption field before test (in.);
Fluid depth O (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Re~/. 3/96)*
Soil rating (g~-or fF/bdrm)
z ~,
Gravel thickness below pipe
Monitoring Tube present (Y/N)
Results (Pass/Fail)
Absorption rate =
System type ~z~%.% ~'~
Total depth ~(o~
Depression over field (Y/N) ~
For ~ bedrooms
Immediately after4~O gal. water added (in.):
~-b-o+ g.p.d.
If yes, give date
D. LIFT STATION
~ ~ Size in gallons
(Y/N~Pump off" level at*
Manhole/Access
High water alarm level~""--at* *Datum ~
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot I
On adjacent lots
On adjacent lots
Public sewer main ~c)o ' ~- /~/~., Public sewer manhole/cleanout
Sewer/septic service line ~' ~ ~ Lift station .
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /-~ '4- Property line lo ' 4- Absorption field
Water main/service line '2-S'4- Surface water/drainage lo,o ~ +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line l.o ~ 4-
Surface water t o~ ~-~
Curtain drain ~:&"o' +
F. ENGINEER'S CERTIFICATION
Building foundation
LO ~
Wells on adjacent lots
Water main/service line ~% '-1-
Driveway, parking/vehicle storage area
~.u.¢~,¢.. wells~on adjacent lots
I certify that I have determined thru field inspections and review
in conformance with MOA HAA guidelines in effect on this date.
Signature ~. r/.~//~,,~
Engineer's Name /f'~¢,~ ,,~ ¢-7~//2. ~-/~%
Date.
t
HAA Fee $
Date of Payment
Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
~ND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
September 23, 1996
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: HAA - Lot 7, Block 2, North Slope S/D
Gentlemen:
Attached is our request for the HAA on the subject lot. During the course of our
investigation we received lab results indicating no coliform bacteria, but that there
were other bacteria found in the water sample. The clients are military and will be
moving out of state at the end of the month. In order to expedite the process we
are submitting the final paper work now pending new lab results. We will be
submitting these results for your review and approval by the end of this week.
If you have any questions regarding this application, please contact me at 696-
6111/FAX 696-8111.
Respectfully submitted,
I~I!~ Engineering
attachments:
HAA Checklist
Certificate for HAA
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 - FAX 456-3125
8005 SCHOON STREET ANCHORAGE, ALASKA 99518 (907) 349-1000 * FAX 349-1016
DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA
KND Engineering
20441 Ptarmigan Blvd.
Eagle River, AK 99577-3736
Phone No.
Purchase Order No.
Collected by: SO
Sample Type:
Routine Untreated
Method of Analysis:
Membrane Filtration
Public Water System I.D.#
Date Received:
Date Analyzed:
Date Reported:
Next Sample Due:
Comments:
S
U
POS
ND :
TNTC :
CG :
HSM :
09/12/96 Time Received: 11:00
09/12/96 Time Analyzed: 15:30
09/16/96 Time Reported: 10:02
SA :
Old :
Comments: R :
NT =
= Satisfactory
: Unsatisfactory
: Positive Test Result
None Detected
Too Numerous To Count (>200 Colonies)
Confluent Growth
Heavy Sediment Masking, Results May
Not Be Reliable
Sample Age >30 Hours But <48 Hours,
Results May Not Be Reliable
Sample Age >48 Hours, Too Old For
Analysis
Resample Required
No Test
* # Colonies/lO0 ml ** # Colonies/mi
Sample Sample Total* Fecal* Other* HPC**
Date Time Coliform Coliform Bacteria Result Lab# Location Comments
1 09/11/96 1t:24 0 ND 2 NT AC2067 Lt 7 B2 N. Slope S/D Satisfactory
En~l~onmental Analyst
NORTHERN TESTING LABORATODES, )NC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 o FAX 456-3125
8005 SCHOON STREET ANCHORAGE, ALASKA 99518 (907) 349-1000 ,, FAX 349-1016
KND Engineerin9
20441 Ptarmigan Blvd
Eagle River AK 99577
Attn: Ken
Report Date:
09/17/96
Date Arrived: 09/13/96
Date Sampled: 09/11/96
Time Sampled: 1124
Collected By: SO
MDL = Method Detection
Limit
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
F166448
Lt 7 B2 N Slope S/D
Water
* Flag Definitions
B = Below Regulatory Min.
H = kbove Regulatory Max.
Date Date
Lab# Method Parameter Units Results * MDL Prepared Analyzed
F166448 EPA 300.0 Nitrate-N mg/L 0.33 0.03 09/13/96
Senior Chemist
'~ ~_~
NORTHERN TESTING LABORATORIES INC r 3
3330 INOUSTRIAL AVENUE FAIRBANKS, ALASKJk 99701 (907) 456-3116 * F~( 456-31~,6
8005 SCHOON STREET ANCHORAGE, ALASKA 99518 (907) 349-1000 ' FAX 349-1016
DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA
Engineering
Ptarmigan Blvd.
River, AK ggB77-3756
'hone No.
,urchase Order No.
;ollected by: KND
;ample Type:
Check/Repeat Sample for
previous sample C
lethod of Analysts:
Membrane Filtration
~:i~ ;omments:
Public Water ~ystem I.D.# - "i
Date Receivedl~i~,09/26/9 Time
Date Analyzed)'~ii'~,09/26/96 Time Analyzed:09~30
Date Reported~'"L 09/27/96 Time Reported:-12:18
Next Sample Due:
Comments: ~
S ~ Satisfactory
U = Unsatisfactory
POS ~ Positive Test Result
ND - None Detected
TNTC ~ Too Numerous To Count (>~00 Colonies)
CG = Confluent G~owth
HSM ~ Heavy Sediment Masking,
Not BeReliable
SA = SempleiAge >30 Hours But,<48'[
Results May Not Be ~eliable
Old = Sample Age >48 Hours~ Too Old For
Analysis
R ~ Resample Required
NT = No Test
* # Colonies/lDO ml
** # Colonies/mi
Sample Sample Total* Fecal* Other* HPC**
Date Time Coliform Coliform Bacteria Result Lab# -Location ........ Comments .............
[ 09/25/96 21:00 0 ND -' "0 NT AC2188 Bathroom Faucet, Satisfactory
North Slope S/D B2 L7
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. # Lr~(~ - -~ ~\ - ~\
1, GENERAL INFORMATION
Complete legal description
~..- ~0rth S£°~ 'S~'bdiuision
Location (site address or directions) Mi£~ 10.2 Prudhoe. Bay
Property owner
Mailing address
Lending agency
Mailing address
Kathy Hamann Day phone 337-1536
HC 832430 Eag£~ River, AK 99577
Day phone
Agent Tamara K~££y/ HERITAGE REAL ESTATE Day phone
Address 3250 "C" Str6et S~it6 102 Anchoraq~ AK 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
3 ~
XXX
562-1222
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:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Re~,. I/gl) 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 t~.pe 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.
$& S ENGINEERING
i 7034 EagJe kiver L~t~oad
Name of Firm Eagle River, Alask~7
Address si nature ./~/" ~"
Engineer's g
DHHS SIGNATURE
~- Approved for '~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date ~ - 2 ,~ - ~.....2
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 th is 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 omi.~sions in the professional engineer's work.
Back MOA ,21 .................................
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~-~ ~ ~ k-~, ~..~?~.-~;::~ Parcel I.D.
A. WELL DATA
Well type '~t ~/~1"~
Log present (~N)
Total depth
Sanitary seal ~'~N)
Cased to
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~, ~ t~ ~ (~ 'z~ Driller
FROM WELL LOG
Date of test ~ ~ t.~ ~ <~ '~
Static water level ~---'~c, ~..~ ~ ,3 ~
Well flow ~
Pump level ~
~ ~:>~ 7~-¢ Casing height
Wires properly protected ~N)
AT INSPECTION
g.p.m. ~ -\
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
\ ~1~ ; On adjacent lots
~, \ ~' ~ ; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ~'~ ~ \ '1 -- ~,~
Cleanouts ~'N) ~[
High water alarm (Y~.)
Date of pumping
Nitrate ~), '~,
Collected by:
Other bacteria ~:~
S & S ENGINEERING
17034 Eagle River Loo~3 Road No. 204
Eagle River, Alaska 9~577
Tank size \ ~:>c:> c~ Compartments
Foundation cleanout ~N) ~ Depression /Y~.~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To propertyline \ ~
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in galtons
Vent (Y/N)
Manufacturer
Manhole/Access (Y/N) __
"Pump on" level at _ ~:rrfi~ff" level at
High water alarm level ./~~C~cles tested
Meets MOA electrical codes (Y/N.~._~
S~ANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ ~ t~.,~
Length '~ -a.~-' Width
Total absorption area ~o
Depression over field (Y/~
Results~il)
Peroxide treatment (past 12 months) (YN~
Soil rating '~-'~ ~' ~[/~¢_ System type ~;~-'%
Gravel thickness 'Total depth
Cleanouts present (~N) __ ~'
Date of adequacy test ~1 ~ ~71 ~ ~!, ~
for ~
i-~ o,~¢- ~/.~ ~ v~ ,,..L If yes, give date
bedrooms
Well on lot \ \~
To building foundation
On adjacent lots ~
Surface water
Curtain drain
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots ~ ~=~ Property line
"-~" ~ ¢'~ To elxisting or abandoned system on lot
Cutbank Water main/service line
\ ,-o o, ~' % Driveway, parking/vehicle storage area ¢o¢-~r',
E. ENGINEER'S CERTIFICATION
I certify that I have checked, ~e~d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature ///~~.~ ~lr:C~
/~1~-¢4 Eagle River Loop Road No. 204
Engineer's Name -~/9; 'e~iv. er, "~tka 9¢577
Date ~ ~//~'¢
HAA Fee $ ./¢(~ -~
Date of Payment ~--/'¢~ .,.?;~
Waiver Fee: $
Date of Payment
Receipt Number
CT&E ENUIRONMENT~L L~B SEROICES
~.NViRO~I~ENTAi.. LAEIORATOR¥ ~ERVI(;[='~ ' ...........
Chemlab ReE.~ ~93'2660~1
Client SamPLe ID ,~1 B2 NORTH
Matt ix
5033 t3 ~Ti~£ET
ANCHORAGE, AK 99bIB
TEL: (907) 562-2343
FAX: (907) 561-5301
WO~ Order :66991.
Report Ccmplete~ ~06/%~/9~'
:06/08/93 ~ 16~30
Celiac%ed :06/09/93 ~ ~4:45
Received ,
T~chr, ical D~rect°r ~T~/C'
ReleaSed BY,
Ordered By 3JKB
Project Name
Pro~ec%~
PW$ID :UA
hre,
hr~,
Sa~p£e ~ ' h!lowable ~xt. Anal
QC Limits Date Date
parameter Results Qua% Ur~its Method
Nitrate-N
===~._____======~_~ ....... ~=-- ........... NA = Not gnalYz
See Special lnstruction~ A~ove bT ~ Le~5 Than
e Remarks A~ve GT = Greater Tha~
See S~I ..... +md value ~ the practical ~an%ification %imit.
undetected, n~ ....
Secondary dilution.
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 7; Block 2; North Slope Subdivision
Location (site address or directions)
NHN Pr~doe, Bay Road
Property,oWner ~ Kathle,e,n Hamann
Mailing address HC83 Box 2430 Eagle. RZve. A,
Lending agency
Mailing address .'. ~::
Day phon~M
Alaska 99577
Day phone
Agent Day phone
337-1536
694-b08/
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well' ; ',v,X ..-~i:
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ink 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. 1/91) Front MOA~21
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
Address
Engineer's signature
17934 Eagle i{iver Loop R?ad No, 204
Ea~le River, Alaska ~V~/!
Phone
DHHS SIGNATURE
/~ Approved for ,,~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
~r;~,uJ/[,]~
· 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 MOA~Y21
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ "7 ~L--~,~. Z- ~¢~__~L Parcel I.D.
A. WELL DATA
Well type
Log present~(~N)
Total depth
Sanitary seal~TN)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~.~ - ~¢:~- 6'5 Driller
Cased to ~ ~-'~' '~'~
Casing height
Wires properly protected4CJ~TN) ~
FROM WELL LOG
Date of test ~,~
Static water level
Well flow
Pump level
SEPARATION DISTANCES .FROM WELL TO:
Septic/hc!d!.".g tank on lot I 4:~c:~
Absorption field on lot \ ~'~
Public sewer main ~ /'~
Sewer service line
; On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample:
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts~/N)
High water alarm (Y/N)
Date of pumping
Tank size ~ ~::~:::~:::~ Compartments
Foundation cleanout ~N) y · Depression (Y~
Alarm teste~l (Y/N)
~- ~[q----~ Pumper ~'~'~-'%
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
!
Well(s) on lot \ c~c> On adjacent lots
To property line \c;, ~ J¢ Absorption field
Surface water/drainage \ ~ ''~
~-F- Foundation ~ ~-~
Water main/service line \
72-026 (Rev. 7/91) 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)
"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 ,~ _ \--~ _
Length ~-~ '~" Width '~
Total absorption area ~'¢¢c:~-'~='
Depression over field (Y~P
Results (~fail)
Peroxide treatment (past 12 months) (Y~
Soil rating
Gravel thickness
Cleanouts presentE~N)
Date of adequacy test
for
~--,---.~v~-~ If yes, give date
System t y p e"-¢-----~'-~ ~
Total depth
¥
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
t
Well on lot \ ~ On adjacent lots \ ~ ¥'- Property line
To building foundation "-~P~ To~xisting or abandoned system on lot
On adjacent lots_ Cutbank /'~- Water main/service line
Surface water I E::;t-~''''~'
Curtain drain
E. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
$ & S ENGINF. EI~IN6
Engineer's Name
Date
SHAFER
No.
HAA Fees 'I'7~
Date of Payment
Receipt Number
72~026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE % 58827
Chemlab Ref.~ 92.5262 Sample ~ 3 Matrix: WATER
Client Sample ID
PWSID
Collected
Received
Preserved with
L7 B2 NORTH SLOPE S/D Client Name :S & $ ENGINEERING
UA Client Acct :SNSENGP
SEP 24 92 @ 13:35 hrs. BPO# :
SEP 25 92 @ 15:00 hrs. Req# :
: AS REQUIRED Ordered By :R. SPa%FER
POW :NONE RECEIVED
Analysis Completed : SEP 28 92
Send Reports to:
l)S & S ENGINEERING
2)
Parameter Results Units Method Allowable Li~ts
NITRATE-N 0.39 ~/1 EPA 353.2/300.0 10
Sample ROUTINE SABLE COLLECTED BY:
Remarks:
I Tests Performed ' See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA- Not Analyzed LT=Less Than, GT=Greater Than
r~-~ Member of the SGS Group (Socidt~ Gdndrale de Surveillance)
: APPLV" ,NT FILLS OUT UPPER ONLY
Phone
Buyer
Address Zip Code
Lending Institution Phone
Address Zip Code
Realty Co. & Agent Phone
Address Zi~ Corde~
Legal Description ~-\ ~. ~L ~.C~_[~-- ~'~. Q (~F~ ~' ~) ~)L
Street Location
type of Residence
XSingle Family
' LI Multiple Family No. of Bedroon~.
[] Other
W,~ 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
Se~ Disposal
,,,~lndivid ual
' LJ Public Utility
[] Holding Tank
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION I~EE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
MUNICIPALITY OF ANCHORAG!
DEPT. OF HE?,LTIt
ENVIRONM':N?AL PROTECTIOh
NOV
RECE! ED
( ~"~,.)APPROVED BEDBOOMS *GONDITIONS OF APPflOVAL
( , CONDITIONAL APPROVAL* ~ ~0~¢ ¢~"~ ~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
Well to Tank Septic T~k Size
72-023
/ ' "'.¥ / '. I
AOEQUACY TEST
WATER ANO SEWE~ INSPECTION
WELL INSPECTIONS AND
FLOWTEST
SITE PLANS
ROAD 0ESIGN
SOl L TEST'
ON SITE WASTE WATER
' DISPOSAL SYSTEM DESIGN
EXCAVATION WORK
Ifathy Hamann
2430 Eagle River Road
Eagle River, Alaska 99577
Dear Ms. Hamann,
ROBERT A. SHAFER
November 2, 1983
CIVIL ENGINEEE
694-2979
REFERENCE: Lot 7: Block 2: North Slope Subdivision
A well inspection was performed on the referenced property
as you requested. It was noted that the well casing is
e~dipped with an adequate sanitary seal and the wiring from
the pump is in conduit and the ground around the well casing-
is adequately sloped aw'ay from the well. At the time o:f
this inspection a water sample was taken from the kitchen sink
and submitted to Chemical and Geological Laboratories of Alaska
for coliform bacteria analysis. The results of this test
were satisfactory.
I£ we may be of further service, please do not he~itate to call.
since~.,
cc: Municipality of Anchorage
Department of Health and Environmental Protection
~RB 196X ~.AGLE RIVER, At. ASKA 99577