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HomeMy WebLinkAboutPTARMIGAN ROOST BLK 2 LT 13 GREA, - .NCHORAGE AREA BOR .. Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME"~b~'~~' ~<~S~I MAILING ADDRESS 6(~3~3 ~-'~'(~)~-~- PHONE~33- LOCATION LEGAL DESCRIPTION SEPTIC TANK: DISTANCE ~ FROM WELL , INSIDE LENGTH MANU FACTU RER,.~~'~ INSIDE WIDTH MATERIAL ~~-~ NUMBER OF COMPARTMENTS LIQUID DEPTH LIQUID CAPACITY /(~O O GALLONS. · SEEPAGE ~:'Tf~-n~ NUMBER OF PITS LINING MATER~AL BUILDING FOUNDATION ADDITIONAL ABSORPTION DIAMETER CRIB SIZE: NEAREST LOT LINE OR WIDTH LENGTH DEPTH DIAMETER__DEPTH DISTANCE FROM: WELL ~1 TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~7~O ~ SQ. FT. WELL: TYPE ~-.Q~ BUILDING FOUNDATION CESSPOOL APPROVED CONSTRUCTION NEAREST LOT UNE 4:o OTHER SOURCES DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK ( ~ ~J-- SYSTEM I~.--~'[ DISTANCES: INSTALLED BY: LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM DATE /d~/~.)~'' APPROVED GREATER ANCFiORAgE Area Borough DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 PERMIT NO. SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT INSTALLATION OF: SEPTIC TANK . ~:'~ SEEPAGE PIT ~/~/~ DRAIN FIELD ~ OTHER SOIL TEST RESULTS .~-~'~-~ ~ ~'~/' ~ '~--//~//'--~--: //~- <'~ ~~ ~; NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL COMPLETZON DATE ANTICIPATED . ~/ .~ '~ /~~/~:~/;~ // ~ flN~h INSP~ETION: ~ HOUR NOTIC~ REQUIRED. B~CKFILL[NG OF ANY SYSTEM WITHOUT FINal INSPECTION BY THE DEP~RTMENT OF ENVIRONMENT~h QUALITY AUTHORITY WILL B~ SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK "~ ..../ SEPTIC TANK TO SEEPAGE Pit WALL SE~PTIC TANK r;ro NEAREST LOT LINE. WE)~L)~O SEPTIC TANK ; DRAIN FIELD , DRAIN FIELD SEEPAGE PIT.;/:'~'~-- ~ , DRAIN FIELD SEEPAGE AREA SIZE//' SEEPAGE Pit ~/~'"~/ ALSO CONSIDER AREA WELLS, "WATER MAIN TO SEPTIC TANK /~) /' ///'~i '~ · . SEEPAGE Pit --~ DRAIN FIELD "SEPTIC TANK, /~ SeEPAge Pit //~)//~/ '~ ~ ~ . DRAIN FIELD TO RIVER, LAKE, STREAM. CAST iRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION ~ FEET iNTO UNDISTURBED SOIL. 4 INCH DiAMeTER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH F~EgULATIONS REGARDING INSTALLATION. OR LICENSED DESIGNER TYPE DIAGRAM OF SYSTEM ] CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-6S AND THAT THE ABOVE DESCRIBED__/iSYSTEM IS !N ACCORDANCE WITH SAID CODE. .~ ~//4/~- ~/~/~/~.~>.~/./~-~2:/ ~~ ~~/.~? SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH DRILLED AT The rate OF $:~?~00 PIEr FOOT. ~LL LOG: 27~ feet. 0x--24' Gravel & m~.ll boulders, 2/~-,23B' S~dimen~ary rock~ '~,' 238-~2' Gr~ ~ck ~c~g ~/2 G~. 24~266' S~,nt~ 3/4 subm,rsible ~p' should be ~t~ to 270 feet, T~s well sho~d ~prove to over 3000 ga~ per COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PaYaBLE TO rampart DRiLLiNg WORKS FOR The SUM OF THANK YOU VErY MUCh. LAUS OF RAMPART DRILLING WORKS ]~OX ~,,~;9~ STAR ]~OUTE A ANC~ORAG]E~, ALASKA SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF ,¢1~7-00 PER FOOT. PROPERTY OWNER 275 F6e,t.o LOCATION OF WELL SITE. DRILLER WELL LOG: 0 ..... 28' 25---155~ Be,~'~ocJc.~. ~6d.,O~F mock ~Z,,tlz ~ ~ ~ 153 Zo 155 ~e~ 155--263' S~ ~ock. ~o =~ ~od=c~o= ~ ~ ~. COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING, WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. DATE 10o75 BERNIE C~AU~. OF' RAMPART DRILL,{NG WORKS . MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-042-07 Certificate of On -Site Systems Approval Expiration Date: 'V- 5- -ZO 2 O 1. GENERAL INFORMATION gecy Complete legal description T1 5N R1 W �4 S2NW4SW4NW4 Location (site address) 22225 KNICK VISTA ST Current property owner(s) CATHY KINGREA Day phone Mailing address Real estate agent 2. TYPE OF DWELLING: Fx_1 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic R 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 $ 412.50 COV I D-19 Waiver Fee $ Date of Payment 1 a7, Igo �'C) Date of Payment Receipt Number. Receipt Number COSA# OSC201692 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE ISystem #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Date Conditional approval for bedrooms, with the following stipulations: By: w-. ' Original Certificate Date The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory . Other COSA Checklist blue sheet COSA Checklist Legal Description: Ptarmigan Roost 132 L13 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 90/1975 Total depth 275 ft Cased to 275 ft ❑® Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 16 in. Date of flow test for COSA 1215)20 20 Static water level at beginning of test 33.5 ft Comments B. TANK DATA Age of tank(s) 16 years Tank type/material Measured operating fluid level in septic tank 48" ❑® Standpipes/fo ation eanou e record drawing Date of pump' g 2--3c " Z C a5 - D. ABSORPTION FIELD DATA Shallow Trench (2) Which system tested (date installed) 9.15"2004 Q ALL standpipes present per record drawing Total measured depth from grade 4.4/4.8 ft (max) Measured depth to pipe invert from grade 3.4/3.3 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 1.011.5 Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 020-042-81 Structure served by this system 1 Well production at time of test 2.77 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes EN No Coliform bacteria is Negative Nitrate /. a mg/L E!Nitrate less than MRL (ND) Arsenic ug/L VLArsenic less than MRL (ND) Collected by ?din n Otic 7.,1C,7f -1, Date of Sample la llzo C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 72''52°2° Results E Pass For 4 bedrooms Fluid depth prior to test 1 in Water added 600 gal New depth 3 in Elapsed time 30 min Final fluid depth 1 in Absorption rate '600 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date 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' F/ Yes if No ft Q Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' 0✓ Yes if No ft Holding Tank > 100' F/I Yes if No ft Neighboring Absorption Fields > 100' ✓� Yes if No ft Water Main > 10' Animal Containment > 50' ✓0 Yes if No ft 0 Yes if No ft 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' �✓ 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' Yes Yes if No ft Wells on Adjacent Lots: Q Absorption Field > 5' if No Yes if No ft Private Wells > 100' ✓� Yes if No ft Water Main > 10' ✓0 Yes if No ft Community Wells > 200'✓� 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' 0 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' Q Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' Q Yes if No ft Surface Water > 100' F,71 Yes if No ft F. ENGINEER'S COMMENTS 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. plp� COSA Checklist yellow sheet MUMCIPAUTY OF ANCHORAGE .. .. ... ... ... .. _: _..g.�g�,e.m, -.__ ., ,.:,_-�+,.•r �'7 .� g"+ - ,4i �s-,•^-tR--w*r-s^-rwr---�*.,^xs��^s,+�m�z+, ar,., Development Services Department -343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 020-042-81 1. GENERAL INFORMATION Expiration Date: q- 5--20 Z' Complete legal description Ptarmigan Roost 132 L13 Location (site address) 16350 Sandpiper Dr. Current property owner(s) David Trowbridge Mailing address Real estate agent Miyun Stogsdill 2. TYPE OF DWELLING: Fx-1 Single Family (w/wo ADU) ❑ Duplex ^ ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic FE Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ / /'Z 5 0 ( CDU I b - N Waiver Fee $ _ Date of Payment 02 �� S-��D� y Date of Payment Receipt Number. 075156- Receipt Number, COSA# 05 -Cao J („qy Waiver# Distance: 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 m Engineer's Printed Name Steven R. Pannone P.E. Date OZ9 �z2� ER PROG84A.4 0. \` 6. DSD SIGNATURE .. • • • .. • • System #1 Approved for L bedrooms Steven P. -'on ,ne A CE 8149 e System #2 Approved for bedrooms�s ` v Disapproved N��R�_�_ Conditional approval for bedrooms, with the following stipulations: lllll((l(it � . up �^ Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet � nW ER AiVD m ER PROG84A.4 z \` �^ Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: Ptarmigan Roost 132 L13 Parcel ID: 020-042-81 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 9'z0"�"s Total depth 275 ft Cased to 275 ft FER Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 16 in. Date of flow test for COSA 12"512020 Static water level at beginning of test 33.5 ft Comments B. TANK DATA Age of tank(s) 16 years Tank type/material "fiUvw Measured operating fluid level in septic tank 48" 0 Standpipes/fo ation eanou e record drawing Date of pump' g 2-3 Ci " ZO C1e, D. ABSORPTION FIELD DATA Shallow Trench (2) Which system tested (date installed) 9-15-2004 H ALL standpipes present per record drawing Total measured depth from grade 4.4/4•8ft (max) Measured depth to pipe invert from grade 3.4/3.3 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 1.011.5 ❑® Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 2.77 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes (2g No F Coliform bacteria is Negative Nitrate /. a mg/L 0 Nitrate less than MRL (ND) Arsenic ug/L [,Arsenic less than MRL (ND) Collected by T)i n ,1 n 111 Date of Sample is �a 0 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 12-15-2020 Results Q✓ Pass For 4 bedrooms Fluid depth prior to test 1 in Water added 600 gal New depth 3 in Elapsed time 30 min Final fluid depth 1 in Absorption rate >600 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date 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' ® Yes if No ft 7 Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Q✓ Yes if No ft 0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ✓Q Yes if No ft F,71 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' ® Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' Q Yes if No. Water Main > 10' F/-1 Yes if No ft Community Wells > 200' Q Yes if No Water Service Line > 10' ✓0 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' E✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' U Yes if No Water Service Line > 10' F/-1 Yes if No ft Community Wells > 200' ❑✓ Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS 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. COSA Checklist yellow sheet Sty eri R. Pannone CE 8149 c ft ft ft ft 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 1. GENERAL INFORMATION Complete legal description HAA# I~ ~ ~f% -)-~ ~'J¢' Lot 13; Block 2; Ptarmingan Roost Subdivision Location (site address or directions) 16350 Sandpiper Drive, Anchorage, Alaska Property owner Mailing address Judy Doles Day phone 345-4234 Box 111973, Anchorage, Alaska' 99511 Lending agency Mailing address Day phone Agent Gene Bates/2001 REALTY Address 2600 Denali, Suite 400, Anchorage, Alaska Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 ~ Day phone 99503 276-2001 TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: NOTE: If community well sYstem, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Community on-site ', Public sewer If community wastewater system, provide written confirmation ~rom 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 h.,ereto 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 DHHS SIGNATURE Approved for -~ Disapproved. Conditional approval for 17034 f~agle River Loop Road E~t~ River, Al:s!'.= 99577 Phone Date 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. 72~25 (Rev. 1/91) BAck MOA#21 ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~A~AAI(~J ~? S"/O~. ~ ~'- Parcel I.D. A. WELL DATA Well type "~'z~LJPc?~_~ Log present (~'N) Total depth ~'~-S ' Sanitary seal (~N) y~c~ FROM WELL LOG Cased to r-~-~(~' 3~ '~.O~-,.~c~(. Casing height Wires properly protected ~¢~/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed c~_,,~_-~ _~ ~ Driller~. AT INSPECTION Date of test Static water level Well flow J Pump level (-~ g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot j j Absorption field on lot J Public sewer main Sewer service line MUNICIPALITY OF ANCi-IO?.AGE Fi, JViRONMENTAL SERVICES DIVISIC,,~I RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank /00 '¢- / 6o ~'f WATER SAMPLE RESULTS: Coliform (~ x Nitrate Date of sample: t ('_') --,~ ~ - c( ?-? r~-A Other bacteria O Collected by: -q ~ ~-~ Er-aGiruEEf~vc B. SEPTIC/HOLDING TANK DATA Date installed I(~-- ~ ~ ~ Cleanouts ((~N) High water alarm (Y/~ Date of pumping Tank size Foundation cleanout ('¢/~) ' /~Oc~ Depression (Y/(~ Alarm tested (Y/~ 1©OO (~(~ Compartments SEPARATION DISTANCES FROM SEPTIC/~ TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 7/91)Front CONTINUED ON BACK PAGE C..~I. IFT STATION~ ~ Manufacturer . Manhole/Access (Y~ Vent(Y/N) ~ High water alarm level ~ Cycles tested ~ Meets MOA electrica~ S~A~ANCE FROM. LIFT STATION TO: On adjacent lets W.._elPo-~ lot S u rface wat er"~ D. ABSORPTION FIELD DATA Date installed lO _¢c_~_~ _~. S Soil rating .~---c~c4z¢'~' /~.~&F//~ystem type Length · L~Oc Width ~' '~ Gravelthickness ~ ~ Totaldepth Total absorption area L~/. (~)(_~ ',%~ -~-~p. I'~¢0~-~, Cleanouts present (Y/N) Depression over field (Y,~_)~ ~ O Results (pass/fail) ~.%:~ Peroxide treatment (past 12 months) (Y/~j) Date of adequacy test //- for --~ bedrooms ~/6~,~.-~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots /00 r-h Property line .I~0 ~ To existing or abandoned system on lot Cutbank ~-)//)r Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ¢~ & $ ENGINEERING ~7034 Eagle River Loop Roa~ No. 204 Signature Engineer's Name Date HAA Fee $ f Date of Payment Receipt Number 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 Parcel I,D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~)~-~)- i~L\ ~- ~\ NAA# ~1 ~)~ GENERAL INFORMATION Complete legal description Sub Lot 13; Block 2; Ptarmiqan Roost : Loc_ation (site address or directions) 16350 Sandpiper Drive t PrOperty.owner Mailing address Lending agency Mailing address. Maureen McCr~a/ ¢larenc~ Pautzke Day phone · I~350 Sandpi?.r Drive_; Anchorage.: Ak. 99516 Day phone 271-2809 Agent Kris Kurtz _lACK WHITE COMPANY Day phone Address 3201 C. S;.¢~r~.¢J: S~t¢. 100 Anehm~a?.: Ab. 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 3 ~ XX NOTE: 563-5500 If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE. OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XX 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 ~ & 2 ?,%'C,',~;.'-."RINC Phone Address 17034 Eagle RI~er Loop Road No.. 2~ Engineer's signature , Date "7~ / - ~' / DHHS SIGNATUR /--'~AApproved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date / .... The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~'21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L~.'~/.'~ ~ ~,/~c..K'~ ~/~,'~;~,~ ,'~o_~ Parcel I.D. A. WELL DATA Well type ~ If A, B, or C, attach ADEC letter. Log present (Y/N) L~ , Total depth ,~ '~' Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level We, flow /. Pump level LJ Absorption field on lot Public sewer main Public sewer service line SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ,/ I '~ ADEC water system number _ Datecompleted~__.~.o~j~{,ec;~.~o~. A ~-- Driller ~? .... ~asedto ~j~ I~ ~~ Casing height Wires properly protected (Y/N) AT INSPECTION ' ; On adjacent lots ( ~ ; On adjacent lots [ ~ Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: COliform -~3~:.'~h'~-lc'R~"~o¢~ Nitrate --~-/~{~-/C~c--'~-oC~ (~O- ~.~'~ Other bacteria ~¢0 Date of sample: ~- O~ -- ~/ Collected by: ~ ~ ~/~r~ B. SEPTIC/HOLDING TANK DATA Date installed / t~ - ~ - ~ Cleanouts (Y/N) L( High water alarm (Y/N) Date of pumping Tank size / C~C~ / Compartments Foundation cleanout (Y/N) k.J Depression (Y/N) Alarm tested (Y/N) ~ /~/~:~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ! Well(s) on lot / ( ~- On adjacentlots To property line ( 0 1- Absorption field Surface water/drainage 72-029 (Rev. 3/91 Front MOA21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed ~"x~ Size in gallons Vent (Y/N) --'~ump on" level at ;ighwateralarmlevel---~ x~,~t..,~ eets MOA electrical codes (Y/N) \ SEPARATION DISTANCE FROM LIF TO: Well on lot On acljac~lots D. ABSORPTION FIELD DATA Date installed / ¢') - ~ - ~- ~- Length ,/~ (~ / Width ~ ~ Total absorption area ,~ O0 ~ Soil rating..~,~ Gravel thickness Depression over, field (Y/N) /~ Results (pass/fail) D ~ .~ ~ Peroxide treatment (past 12 months) (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water Cleanouts prese.nt (Y/N) Date of adequacy test for System type Totaldepth -'- ~ bedrooms If yes, give date Property line SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~ -~- ' On adjacent lots ( c~o 'f- / To building foundation I LO -f-- To existing or abandoned system on lot On adjacent lots Cutbank ./.. Water main/service line Surface water ,/O0 "f- Curtain drain k_)/~. [~ LF Driveway, parking/vehicle storage area ~-~'--~., ~r-'//~ I~ ~'rl~ , E. ENGINEER'S CERTIFICATION I certify that I have checke~, verified, or conformed to all MOA and HAA guidelines in effect of this inspection. Signature 17034 Eagle Ri~ver Leop Road No._. Engineer's Nam~=~= Date HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number '" D.~"~E RECEIVED \ ~.~,%/\ INSPECTOR I NSPECTOI:~.. INSPECTOR Z~ ~ .......... MUNICIPALITY OF ANCHORAL~I: MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTJ4JS~JRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION SEP 1 5 lg80 Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER PHONE Mr. Robert Kos~i 248-3030 MAILING ADDRESS SRA Box 47~ K PROPERTY RESIDENT I~ different ~rom c~ove~ PHONE 345-1764 2. BUYER PHONE ClArENCE G PAUTZKE ~MAILINGADDRESS 3, LENDING INSTITUTION J PHONE A]aska USA Federal Credit UnionJ 276--5100 MAILING ADDRESS 500 Be'n~qnn A~ahora~:e. ~laska c/o Sue Hocker 4, REALTOR/AGENT I PHONE Mary Dee HendersonJ 2771553 MAI LING ADDRESS ~201 C Street Anchorage~ Alaska 99503 5. LEGAL DESCRIPTION Lot 13 Block 2 Ptarmigan Roost Subdivision STREET LOCATION Sandpiper Drive 6. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five J~] Three [] Six [] Other 7. WATER SUPPLY [] INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. A well )og is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY 1975 YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EA_CH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) /~ .~) . ~ ~, J ~ I ~,~ ~ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: ) ~-~¢'~("~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line MANUFACTURER /~_~...._.~, MATERIAL Septic/Holding Tank Absorption Area ISewer Line INearest Lot Line 5. COMMENTS DATE ~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must ac/e mo~p~p..a~y certificate} [~'~ DISAPPROVED /~/'; ///' 72-010 (Rev. 6/79~ THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2, WATER SUPPLY PERMIT NUMBER [] iNDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER F'~Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line B, COMMENTS d APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED /~~.~ DATE BY (Title) LEGAL DESCRIPTION 0 (Rev, 3/78)