No preview available
HomeMy WebLinkAboutPRATOR BLK 1 LTS 2 & T12N R3W SEC 35 SE4SW4NE4 PTN Dec_28.2022 11:04 AM Anchorage Well & Pump Service Inc 9072430742 #4947 P 1/ 1 MUNICIPALITY OF ,ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 017 _ 091 _ 93 Date of Issue: - Legal Description Block Lot Property Owner Name & ,Address. PRATOR ENGLISH BRENT S & HOL4DAY-ENGLISH BEVERLY J "LOT 2 & T12M R3W SEC 35 1 6901 RABBIT GREEK ROAD SE48W4ME4 PTN ANCHORAGE AK 99590-3738 Pump Installation Date: 12 - 23 - 2022 Pump Intake Depth Below Top of Well Casing: 180 feet Pump Manufacturer's Name: A.Y. MCDONALD MFG CO Pump Model: 3075V3LB Pump Size: ' 75 lip Pitless Adapter Burial Depth: 10 I Pitless Adapter Manufacturer's ,Name; I Pitless Adapter Installer; feet MARTINON IWell Disinfected Upon Completion?Yes ❑ No Method of Disinfection: PELLETS Comments: Dump installer Name: _ ANCHORAGE WELL & PUMP SERVICE Company: 7640 ICING STREET ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 City. State: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221487 PID Number: 017-091-93 Dwelling: 6Z Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name Brent & Beverly English A ORPTION FIELD Existing FE] De Trench ❑Wide Trench El ❑Mound Site Address 6901 Rabbit Creek Rd. Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 /SF Ft. LEGAL DESCRIPTION Depth to pipe invert from originalg e Gravel depth beneath pipe Subdivision Block Lot Prator 1 2 F _ Ft. Fill added above original grade Gr I length Township Range Section Ft_ Ft. Gravel width Ft. Beds: Number of Lines Dista a between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between tr ches From Tank Field Tank Line Ftz Well 1100'+ 25'+ TANK 2 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 1007+ I Greer 1250 Gal. Material Number of compartments Lot Line 59+ I NA Plastic 2 Foundation 110, I I TATION Manufacturer Capacity Remarks Gal. Alarm location Electra i alled by Installer PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Northern Excavation Drainfield CO/MT D3034 Inspector Arcterra Consulting BENCH MARK (Assumed elevation) 100 ft Inspection 151 Location and description dates: 1/20/23 21d 1/20/23 31d 1/25/23 41" Bottom of siding. ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp ••♦��~,pF Conditional Approval: Date ��j w 493h_* t f M f= KENNETH M. U5 Z 4.r i CE 71 6 ,`: Septic System % Approved �/ Date t • ����ES51�••• Note: t is approval does not include well permit requireme ts. �I\GV VJI V GI IV) d�-ck A -C=14.5' B -C=13.2' A -D=19.0' B -D=15.6' A -E=20.2' B -E=16.6' A -F=21.0' B -F=17.3' AS—BUILT SYSTEM DETAILS/SITE PLAN Permit 11SP221487 PRAT❑R BLOCK 1 LOT 2 PID# 017-091-93 WLLLI� I _ 1 � 1 1 DFck 1 \ 1 \� d o c 0 \ f dD \ < l Hp��jNG _ r CO NEW 1250 Z SEPTIC TANK CO w Vl 0 99.96 Of 7-n O J 0 Vi 1250 GAL SEPTIC SCALE, NTS _ft+_N r \ * 4 TH 41 - . ' KENNETH S : . CIP z PREPARED FOR: BRENT & BEVERLY ENGLISH 6901 RABBIT CREEK RD. ANCHORAGE, AK FIELD BOOKS B(XUNDARY: N f A STAIONQ N /A ASBUILL JLS DWG. FILE: ACAD FILE` FILE COMPUTED: DRAWN: KS€? CHECKED: K MD DATE: 4/10/2; GaD: Sw3039 " N- 22175 G1 M D � SCALEt V = 30' 1 SCALE: NTS LOT 1 N0°03'00"E 202.67' R&M PRATOR STREET ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: PRATOR SUBDIVISION LOT 2 & REMAINDER LOT 4 BLK I PLAT 74-136 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shout( any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DAM SCALE: E—MAIL MAR 31, 2023 1 "=40' schucierOok.net 23-016 DRAWN BY: CHECKED BY GRID NUMBER. BOOK/PAGE: JLS SW3039 230120 = FND AL M MUNU) MhNT` = .FIND 5/8" REBAR _OT 3A _OT 1 A ����► !NNNI SU AM" O F � V LA ,V 6 41 49TH '• �' � � � � ,�. FA � •-.JOHN L. SCHULLER.•0 LS -10408 to.... • ' ��{ � x.831 Talkeetna Street • ' .., -! b ,� Anchorage, Alaska 99508 i4r '\ Mr o fe c� Lo ,■., (907) 227--1455 office '�,l s Sl4`•��� (907) 274--4992 fax MUNICIPALITY OF ANCHORAGE �icnr On -Site Water & Wastewater Program�oI s, PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite Department On -Site Wastewater Disposal System Permit Permit Number: OSP221487 Effective Date: 12/14/2022 Work Type: SepticTank Upgrade Expiration Date: 12/14/2023 Tax Code Number: 01709193000 Site Legal Address: PRATOR BLK 1 LTS 2 & T12N R3W SEC 35 SE4SW4NE4 PTN G:3039 Site Mailing Address: 14651 Prator ST, Anchorage Owner: ENGLISH BRENT S & Lot Size in Sq Ft: 72939 Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 (24/7). 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 sew y: 55(,te d 14rf Issued By: c� Date: Date: MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section - Parcel I.D. 017-091-93 ANCHORAGE ON-SITE SEPTICIWELL PERMIT APPLICATION Property owner(s) Brent & Beverly English Day phone Mailing address 6901 Rabbit Creek Rd. Anchorage, AK Site address 6901 Rabbit Creek Rd. Anchoraue, AK Legal description (Sub'd., Block & Lot) Prator Block 1 Lot 2 Legal description (Township, Range & Section) Lot Size 72,939 Sq. Ft. Number of Bedrooms 4 Phone: 907-343-7904 Fax: 907-343-7997 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) NI (w/wo AD U) Septic Tank ❑X Upgrade Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Dea Duffus (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: lalg12-a Receipt Number: oPoa 4 Permit No. 6s11P?-Iq8 -� Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221487, Deb Wockenfuss, 12/14/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221487, Deb Wockenfuss, 12/14/22 LOT 1 X __X NO*03'00"E 202.67' R&M PRATOR STREET ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: PRATOR SUBDIVISION LOT 2 & REMAINDER LOT 4 BLK 1 PLAT 74-136 SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shoul4 any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determineW the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DATE- SC&E: E-MAIL NOV 26, 2022 1 "=40' schullerftk.net 22-113 DRAWN BY; ICHECKED BY, GRID NUMBER: BOOK/F° JLS SW3039 220370 r NIJ ALUMINUM MUN U MtN I FND 5/8" REBAR _OT 3A _OT 1 A Sul? AMW AM0 F 4 L "V V,6�, AMW ASW <1 *00 .te - r � �. 49TH ...... ........ .......x R'A A % � .... ......i........... i ........... ... . 106 NL. SCHULLER.-' o LS -10408 1831 Talkeetna Street AW Anchorage, Alaska 99508 Of AdW (907) 227-1455 office lk�-, essiond (907) 274-4992 fax  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME P~E []NEW MAIUNG ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well Absorption area Dwelling PERMIT NO. DISTANCE TO: I~0 '~ ~0 ~T, p ~ Manufacturer Material No. of compartments ~ ~ Liq. capacity~ gallons I Inside length Width Liquid depth j~I IF HOME'DE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ ManUfacturer Material Liquid capacity in gallons ~ Well ' Foundation Nearest Jot line PERMIT NO. ~ DISTANCE TO: /~0 ~. ~ ~ ~:O No. of lines ~ Length of.~each line~ Total length.~of lines~ Trench~width inches Distance between lines~/~,~ ~ ~ ~ Top of tile to finish grade ' Material beneath tile -- ~ ~. Total effective absorption area Length Width Depth PERMIT NO. ~ ~ : Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ ;lass Depth Driller Distance to lot line PERMIT NO. m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS ~ ~1~ ~O~ ~ ~o SOIL TEST RATING INSTALLER ~ REMARKS ~,'~;..,. No. ].783- E TE LEGAL MQEN IUG-GRE~ 5-22-78 72-013 (Rev. 3/78) ! .~ 1 1 I .,, I J I ~ I J I J I ..] I t'i!::i::.:;]:HLtFI NL.I!'"IBIEi;: O1::' E:!E[:,F;:OEd'"!S ::: i4) 'ji!;().1;L. I:;;:l::fT']:hl(:_; (S(;! F'T',.."E;!:;:)= GROUND FiND TI...IIE !E=OTTEff'I OF' THE EXE:I:::!'v'F::IT:L'(.%N ,::]:l'q FEET). FIND THE E',OT'T'OH (31::' THIE EXE:F:iVFITtOI',! ,::IN FziEET). H t' N ~Z HI...IH D :!: S'T'I:.:IN(;:E E:['L'T'I.,.IEEI'..~ F:! i4EL..L_ RF,ID '.!..OE~ FEET F:'OF.: FI F'F~'.Z',,,~F:f't~E[ !.,.IEI._L...~ :~.5!~:.1 TO ;[.'..:E!li2!l t::'IZET F'F;:OH F:! F:'UE:',I._ !' E: !.,.IEL.L. I)EF:'Ei'.,I[)]:NG iJF:'OI'.4 THE 'T'"r'PE OF F:*UE~!....IC NELl.... NELL !_OGS FIRE L")F THE': I.,.!EEM... COHF:'L. ET 'J: O1",!. OTHER F;:EE:!I...I .T. RIEHEI",!TS i"lF:t"r' F:!I:::'F'I...."r'. SPEC ]; F ;[ C;:!::~"[' ;[ Oi"~i::J~; F:I!",!D COI",!~;'!"F;::LiE:T :[ ON [:, ); !:::iGi:;;:I:::II"i'."}!; F:IF;:E F¢,/I:::I:[!_FII_:~;L.E TL") ~i~.,ISIJI:;]:E; I::'F~OF:'iZF]: :[ CEF?.'T'I F"r' 'T'Hi::iT ::i..: ]: F!H F'FIHZI...T. FIF..: !4:[TH 't"HE ,r';?.IE¢!U:i:F:EHENT:ili; FOR Oi'-,I---S:[TE '.'-_:;!EklERS FINE:, H!E!_.L.£~; i::i~; SET FEIF,?.TFI B? THE i',iUI'.,I:!: C ]: PFIL. I T'-r' OF::' i::fl'.,IC::I...IORI:::!CiiE. :2: ~ !.'-!:[ L..L. I 1"4'."~:;TFIL. L. 'T'H['E :!:"..;'.r'STIEr'I :[I'.,! F!CCOI:~fl;)Ffi'-,!(;;:E H :i: TH THE: CEiE:,ES. Z-':: :i: UI.,I[::,EF~:STF!I",![:, THF::IT THE: OI'-,I...-.S]:TIE .':SE!.,.IEF;: S'.r':i?T'r'~:H HF!"r' I;;:.r:D:;¢J:[F:E Eh!LI:::iF;~:GEHEi'.,I'T' IF::' THE RES :!: DEI'.,ICE :[ S I::::Er,IO[)!EL.E:J:::, 'T'O ~ I'.,IE:L. UDE .h'IEi!;;:E THF!N ,::!. [.:.,'ED,r';i:OOHS. f..;:i:GF,IE[::,.~~.,i~.~, , . ................................................ ~__'" ~:::' '::' ... ': .~:.:: .", ' ' ..: ~ -.~' /[~,. SOILS LOG MUNICIPALITY OF ·ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99~02 276-222'~ [] PERCOLATION TEST SOILS LOG - PERCOLATION TEST SLOPE ' SITE PLAN 1 2 3 4 5 6- 7 8 9 10- 11 12 13 14 15 16 17 18 19- 20- WAS GROUND WATER ENCOUNTERED? ' Gross Net Depth to Net Reading Date Time . Time Water Drop I PERCOLATION RATE ~' minuteS/inch) TEsT RUN BETWE~ -- FT AND " 't 5 - 12-008 ~15o. O0 ~ltJ NO O0 8UFtVEY CERTIFICATE I hereby oertlfy that I have iurve~ed the f~ll~l,~ ~eearlbe~l ,Pro~ert~ ¢ Illv~b~ art al Iho~ hereon. Date Stanley E. 8eom F~O~ FL~'T O~~ LO~5 I-4 ~l_.OC P~CO~DINtzq 140, 7q- I~b. PLOT PLAN SURVEY Date STAN SEARS & ASSOCIATES REGISTERED LAND SURVEYORS POST OFFICE BOX 285 EAeI..E RIVERt ALASKA 995~T'f 8oale ~'id , Dravm b~ , i W.O. Checked by F, B. MUNICIPALITY 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. 017-091-93-000 Expiration Date: 7/11/2023 Legal description PRATOR BLK 1 LTS 2 & T12N R3W SEC 35 SE4SW4NE4 PTN Site address 6901 RABBIT CREEK RD Anchoraqe AK 99516 Current property owner(s) ENGLISH BRENT S &HOLADAY-ENGLISH BEVERLY J X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: bedrooms, with the following stipulations: Original Certificate This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA ApprovaLJune 2022 MUNICIPALITY OF ANCHORAGE Development Services Department cl Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 017-091-.W Complete legal description Prator Block 1 Lot 2 Location (site address) 6901 Rabbit Creek Rd. Anchorage, AK Current property owner(s) Brent & Beverly English Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: © Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: © Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass Age 0 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed © Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ Waiver Fee $ Date of Payment Z-1 J �_'% Date of Payment COSA # 0 S(, 2 3 i o l Waiver # COSA Application—June 2022 Legal Description: Prator Block 1 Lot 2 Parcel ID: 017-091-93 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ✓❑ Well log is filed with Onsite (or attached) Date drilled 6/1/78 Total depth 200 ft Cased to _12_ft Q Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 21 in. Date of flow test for COSA 11/15/22 Static water level at beginning of test 58 ft. Comments B. TANK DATA Measured operating fluid level in septic tank New Date of pumping New tank 1/20/23 ❑ Required maintenance completed, ifAWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 5/22/78 Z ALL standpipes present per record drawing Total measured depth from grade 7.8 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 3.8 ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Defici COSA Checklist June 2022 Well production at time of test 1.1 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ✓❑ No 0 Coliform bacteria is Negative Nitrate 1.42 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L P1 Arsenic less than MRL (ND) Collected by Arcterra Consulting Date 3/20/23 C>UZT STATION ❑ Require ' b Age of lift station Lift station material Comments: nance completed Adequacy test date 11/17/22 Results ✓❑ Pass Fluid depth prior to test 6 in Water added 600 gal New fluid depth 24 in Elapsed time 200 min Final fluid depth 6 in Absorption rate 600+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 32 in Effective depth remaining 40 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Yes if No Community Sewer Manhole/Cleanout > 100' ./1 Yes if No ft 0 Yes if No ft Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25' FV if No ft Absorption Field on Lot > 100' [Z Yes if No ft Holding Tank > 100' ✓❑ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' 0 Yes if No ft ✓❑ Yes if No ft ft If tank or field is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft ❑✓ Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10'J❑ Yes if No ft Surface Water > 100' Q Yes if No ft Tank to Property Line > 5'✓❑ Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' © Yes if No ft Private Wells > 100'✓❑ Yes if No ft Water Main > 10'[]✓ Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Arcterra Consulting Phone (907)-696-6111 Engineer's Printed Name Kenneth Duffus Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. + The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the �+ surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic w i4 49 fills >1 �� systems are subject to these various and dynamic characteristics and are outside the control of the evaluatorA of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. KENNETH M. S W r CE I • COSA Checklist June 2022 ♦f11%,1y� aiMo �� 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 MUNICIPALITY OF ANCHORAGE NVIRON?~ENTAI SERVICES, DIVISION MAR 2,5 1998 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING d} I - S~ G ' HAA # 'F..~. c"\ ~('-.~; I,,~ ('~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone ) ¥ ¢'' - ) ¢~ '7 Day phone Mailing address Agent Address Day phone Un/ess otherwise requested, HAA will be held for pickup. 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. 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~)25 (Rev. 1191) 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/orwastewater 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. $ & $ ENGINEERING Name of Firm 77054 Eagie River Loop Road No. 204 Eagle River, Alaska ~9577 Address Engineer's signature Phone DHHS SIGNATURE ~ Approved for ~OU'i{~-. 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. 724325 (Rev. 1191) Back MOA #21 of Anchorage MAR 2 3 1998 Municipality DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Se~ices Division ~ECEIVF~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type /3~ ~ ,~,~ Log present (~fN) Total depth Sanitary seal ({~/N) Date of test Health Authority Approval CheCklist /3LooK I ¢3¢"~7°'~ ~'//'/~ ParcelI.D.: ~)/ 7-0¢/ f- 5-~ If A, B, or C, attach ADEC letter. ADEC water system number (~/~z~'4~,)Date completed G J I [ '7 ,~ Cased to '7 ~- Casing height (above ground) Wires properly protected (~/N) FROM WELL LOG Static water level Well production WATER SAMPLE RESULTS: Coliform O Date of sample: 3 ]/o / ~/ B, SEPTIC/HOLDING TANK DATA Date installed ~-//;~" / 7~¢ Tanksize Foundation cleanou:t ~/N) Date of pumping. 3//I~3/~ ~' C. ABSORPTION FIELD DATA Date i~stalled ~-/~/7 c~ Length . .~ '7 Width. AT INSPECTION 7 g.p.m. Nitrate g.p.m. Collected by: Deprassion (Y/¢ Pumper ,,g ¢ ,Vc,~ ,L Other bacteria O' S & S ENGINEERING ii0,~4 Eagle River Loop Rea({ No. 204 Eagle River, Alaska 99577 Number of Compartments. ,¢¢ d High water alarm (Y/~) ,/v O S~/~v, c,,~ 5 Soil rating (g.p.d./fF o~ J ~ '/x, Gravel thickness below pipe System type Total depth Effective absorption area. ~ c¢ ~ ~r ~-Monitoring Tube present ~N). ¥~- J- Depression over field (Y/,~ Date of adequacy test (~ } ~' / ~/7 Results (Pass/Fail) /3/~ ~ £ For ~ bedrooms Fluid depth in absorption field before test (in.);q~ ~-~,~lmmediately after(;~'0 gal. water added (in.): i e Y~" ~ '~'< '~ ~ Absorption rate Fluid depth I '7 (ins) Minutes ater: = .g.p.d. Peroxide treatment (past 12 months) (Y/N) /¢¢~'~¢ ¢.~¢~v~,./ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* SEPARATION DISTANCES Size in gallons "Pump on--Pump off" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM~..~HOLDING TANK ON LOT TO: Foundation ~' ~/- Property line 4~ ¢- Absorption field Water main/service line ! 0 -/- Surface water/drainage /o o ¢- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ! 0 4- Building foundation I 0 Surface water / o 0 -/~ Curtain drain ( Wells on adjacent lots / /80 ¢ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent Pots / 0 b /-~-- ENGINEER'S CERTIFICATION ~ I certify that l have determined thru field inspections and review of Municipal record:~'~,e~o..~.~/~¢ms are' in conformance with MO,~ HAA ~lu~delinesJn effect on this date. ~ ~'~' '~"'~ ' Engineer's Name ¢8,¢~* 7- ~= ~ o,~/¢ ~~J HAA Fee $. ~0~>,, 0 ~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)*