HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 3V LT 2ARabbit Creek
View &Heights
Block 3V
Lot 2A
#020-531-34
n 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
PHONE
❑ NEW
�% p`
t` I a � l r h, A L)Uhl
s
.1 /
UPGRADE
MAILING ADDRESS
77N 011'e 6'6
,pc- -le-
LEGAL DESCRIPTION
d
LOCATION
NO. OF BEDROOMS
Well
Absorption area
Dwelling
PERMIT NO.
U y�
DISTANCE TO:
MQ
Manufacturer
Material
No. of compartments
W F.-
rn
Liq. capacity in gallons
IF HOMEMADE:Inside
length
Width
Liquid depth
�-'
DISTANCE TO:
Well
Dwelling/
!
PERMIT,�I ��
_Jaz
(�� 7
= z
Manufacturer f
Y
Material
�L.
Liquid ca acity in fall ns
C✓ u
5E
7 ����
Well
DISTANCE TO:
Foundation
Nearest lot line
PERMIT N0.
=
J LL Z
No. of lines Length of each line
Total length of lines
Trench width
Distance between lines
BZW
inches
�
H
Top of tile -to finish grade
Material beneath tile
Total effective absorption area
p
+ inches
Length
Width
Depth
PERMIT NO.
W
C7
nQ a
W
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
4'L. �{ EZ� G14
,® P� I-
0FAw
/ •�.
v
4, Gly i".
N 2225-E
1UPE 25, 1971
APPROVED -� //•/pAT LEGAL
77-n11 (Rev 1/7R)
�KtSTINta `GESS Pool
OF A
It
` '49TIq
..... . ..•
o. 2225-E
11 UNE 2511 1971
d�
�L GGA
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,IVELL
I-IUuSE
LOT 2 8 LDC. K 3
P413B I -r cR I~ t=- K v i r_ -w
l M,- LAUGHLIN
G co'l * •. ("M 2 d 1
f
e t _
<<r� a. 2226-E;
UNE 25, 1971
LldCo
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<<r� a. 2226-E;
UNE 25, 1971
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POUCH 6-650
ANCHORAGE_, Ai ASIC/,
(907)264-4111
,Permit #: 820434
January 31, 1983
TO: Permit Applicant
Subject: Lot 2 Block 3 Rabbit Creek View Subdivision
A permit issued by this department for an individual well
and/or on --site sewer system has expired as of December 31,
1982,
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sinc7p,&�-
Q
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
717J 7
Data—__.._-_._
Tim
V/HIU.'� YOU OUT
cc,
Y �v
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III, Cr8 i-2 PXPE-
K"RIMIED YOUR CALL
MUNICIPALITY OF ANCHORAGE ��/G •-�/f/f/J��._,
Department! Health and Environmenta2"_"?rotection'"`
825 Street, Anchorage, AK. _:501
264-4720
# # # HANDWRITTEN PERMIT # # #
Permit # S `te-3/ / ON-SITE SEWER PERMIT
Applicant : INE -/!//N �% eG 4u6Z/ A," Mailing Address: W/4 12y q3l 2
Location
Phone Number:
Legal Description: T Z //kAldl&T' 6,c"�e f%/LurJ' Lot Size:
'hype of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: Holding Tank:."y
Maximum Number of Bedrooms:
DEPTH
Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption. System Is:
LENGTH
GRAVEL DEPTH
WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED & HOLDING) TANK SIZE _ _ GALLONS # #
?ermit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
Df residences that the well will serve. '
* # * TWO(2) INSPECTIONS ARE REQUIRED # #
3ackfilling of any system without final inspection and approval by this department
gill be subject to prosecution.
4inimum distance between a well and any on-site sewage disposal system is 100 feet
Eor a private well or 150 to 200 feet from a public well depending upon the type
Df public well. Minimum distance from a private well to a private sewer line
Ls 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Jther requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
# * * PERMIT EXPIRES DECEMBER 31, 1 9 u 2
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3.bedrooms.
Signed: Issued by: R"' _LZ f
Applicant
Date: 6el—e2
Pee
SWP/024(1/81) /
,50tx,Co%tib �ivG
MUNICIPALITY OF ANCHORAGE.
Department/_'f Health and Environmenta` protection
825 J Street, Anchorage, AK.. _9.50.1
264-4720
# # HANDWRITTEN PERMIT # # #
Permit : a 1 ;n WELL ANDAR-=OiN �zT�"�R :PERMIT
L M
Applicant: ��V1{' (�I l !n t"t i1�� IL�Ic «�� i i� _Mailing Address: 2rCr
1 7 ' I �1 h 1
Locations Phone Number: -7 - C
Legal _Description: W{'CA_Lot Size .:
Type of -.Soil Absorption System 1s:
Trench:—Drainfield: Seepage Bed.; Holding Tank:
Maximum Number of .B.edr.00ms: L�_ Soil Rating(sq.ft/br)
The Required -Size of .the Soil Absorption System Is:
DEPT, LENGTH.. _ GRAVEL.DEPTH_. WIDTH
The length.dimension is the length(in feet) of the trench or drainfield. The
:depth of a trench or pit_is the:distancebetween the 'surface of the ground and
the bottom of"the"-excavation(in.feet). There is no set width for trenches.
The gravel depth is the minimumdepth of "gravel between the outfall pipe and
the bottom of the ..excavation(in .feet)
* REQUIRED SEPTIC(HOLDING). TANK SIZE GALLONS #
Permit applicant has the responsibility to inform this department during -the
installation inspections of any.wells adjacent to.this"propertyrand the: number
of -.residences that the well will serve.
# # TWO(2),INSPECTIONS`ARE REQUIRED'# # #
Backfilling of any system without _final inspection and approval by this department
will be :subj_ect"to prosecution. -
Minimum distance between a.well and any on-site sewage disposal system is 100 feet
fora -private well or 150 to_200<feet from a.public well .depending upon the type
of public well. Minimum distance from a private -well to a private sewer line
is_25.feet_and to a.community 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 g u 2 # # #
I certify that:
(1) I 'am familiar with the.requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) Twill install the system in accordance with codes.
(3) I."understand that the on-site sewer -system may require enlargement if
the residence is remodeled to include more that .bedrooms.
.Signed: Issued by:-•.�ti�Jc"�6LJ
Applicant Date: —d&
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
Department of Beai; th and Protection
a treetd � AK. 9950L
764-4720
AANi 14R I TTEN PERMIT
WELL
� ' i •� I Yat _ .= .tom � �x Mailing Address:
Phone Numbers � � 7) 1 - f �
7,Lfigal Description., 41- K
Type of 11 A rPta ren uystem Z
r ha r infi id: --. S Holding Tank. y
Maximum Mum -bar f B r e. iL Fi�tL€�s�(�q. f�%brj - -
isegair 3 Site -t the mil Absorpt ion Syet-
e Lan th dbuension is the len th (in
feat) of trench or d is Ei Lz . 5
depth trench or
pit 's the distance between the surface oC the grouwi�.
the bottom of the excaavad n (in feet. Thane i� no *et width for trenctse
e raval depth is the mintmum depth Of Travel between the outfall � � 44
the bottom of the excavation (LA
REQUIRED TANK SIZEeAi LONE
it applicant Inas the responsibi-lity tO ianiorm this department during i�he
L'
aTixmf�s-
residances that the veil € itl serve.
s T i PIaPECT I ti 9 ARE REQUIRED
ekf l is of any sy#j ,.rm wlti';oilt final Lnspection and apprOuai by
rjUl be aubje t to pros hien.
r. i ta:. et€ es►a € al'I and any on-site sewage. € izJPasal eYStem is 101
for
a private xJell Or 154 to 200 feet from a public well deE andi.ng upon the .t
_
pubic is wa 1. Minimum dletance from a Priv4t8 ','All to a private sewer
is 25 feet and to a c-evimmunity iaewer line tz 75 feet. wall 1010 are required
and must be returned to this dapartc� €t within 30 da.ye, or the 1. €T91CO-PIata'd,
Other icemen q may aPPIY, -SPecitications and
available to insure proper instatl.atlon4
I FERMI T EXPI RES DECEMBER 3 2
I certiry that
(l} E amf i.liar with the r iirements for on-site Gower and walls- as
set Eort.h by r_he MjMiCipajXty vE Anchorage,
{ t i.Ll. install the sy te�-a in accordance with owes,
{3l I understand that the on-site sewer ;system may require enlargement.,,
hie residence is remodeled to include more that`_'# rt beds mG.
/ /, trF }
l tasuad try. `f - _ .,x =
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MUNICIPALITY OF ANCHORAGE
Department of Beai; th and Protection
a treetd � AK. 9950L
764-4720
AANi 14R I TTEN PERMIT
WELL
� ' i •� I Yat _ .= .tom � �x Mailing Address:
Phone Numbers � � 7) 1 - f �
7,Lfigal Description., 41- K
Type of 11 A rPta ren uystem Z
r ha r infi id: --. S Holding Tank. y
Maximum Mum -bar f B r e. iL Fi�tL€�s�(�q. f�%brj - -
isegair 3 Site -t the mil Absorpt ion Syet-
e Lan th dbuension is the len th (in
feat) of trench or d is Ei Lz . 5
depth trench or
pit 's the distance between the surface oC the grouwi�.
the bottom of the excaavad n (in feet. Thane i� no *et width for trenctse
e raval depth is the mintmum depth Of Travel between the outfall � � 44
the bottom of the excavation (LA
REQUIRED TANK SIZEeAi LONE
it applicant Inas the responsibi-lity tO ianiorm this department during i�he
L'
aTixmf�s-
residances that the veil € itl serve.
s T i PIaPECT I ti 9 ARE REQUIRED
ekf l is of any sy#j ,.rm wlti';oilt final Lnspection and apprOuai by
rjUl be aubje t to pros hien.
r. i ta:. et€ es►a € al'I and any on-site sewage. € izJPasal eYStem is 101
for
a private xJell Or 154 to 200 feet from a public well deE andi.ng upon the .t
_
pubic is wa 1. Minimum dletance from a Priv4t8 ','All to a private sewer
is 25 feet and to a c-evimmunity iaewer line tz 75 feet. wall 1010 are required
and must be returned to this dapartc� €t within 30 da.ye, or the 1. €T91CO-PIata'd,
Other icemen q may aPPIY, -SPecitications and
available to insure proper instatl.atlon4
I FERMI T EXPI RES DECEMBER 3 2
I certiry that
(l} E amf i.liar with the r iirements for on-site Gower and walls- as
set Eort.h by r_he MjMiCipajXty vE Anchorage,
{ t i.Ll. install the sy te�-a in accordance with owes,
{3l I understand that the on-site sewer ;system may require enlargement.,,
hie residence is remodeled to include more that`_'# rt beds mG.
/ /, trF }
l tasuad try. `f - _ .,x =
Daher r
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICESs.,
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. # , �L - it 'i -::� -i� ;� HAA #
1. GENERAL INFORMATION
Complete legal description L o T Z L D ch4 3 RA 3 %3 /
G EcK '' `'5X0
Location (site address or directions) Z-5% SD /�AAJ CESC/1 OeiVe?E_
Property owner '145A Day phone
2.
3.
4.
Mailing address
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection. /
Name of Firm z nJV /eon)1\.4 E /i�1 L IndlV4GGM/=rJ Phone 27 2 — 53 3
Address Z0,6 E" r//elf Wef 0 L114A/E r,ANG f lo%2/I G 4 9 950
Engineer's signatu
6. DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
Additional Comments
M
bedrooms.
NUTIC
Date
Pjc. N0.cE- 6i3
bedrooms, with the following stipulations:
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 orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
ECEl VED FAA),
DEPARTMENT OF HEALTH & HUMAN SERVIC 22 1998
Environmental Services Division muNIc dilh5
825 L Street, Room 502 • Anchorage, Alaska 995(#1Nthlt(�.4}oG�
AL SERVICES DIVlSlpryl
Health Authority Approval Checklist (�L'
Legal Description: L o-rZ. B1-ocK 3, �A013/7 C2EF/j Parcel I.D.: 020
V/C- / Sl0
A. WELL DATA
Well type PR I VA'FC If A, B, or C, attach ADEC letter. ADEC water system number
Log present (?/N) ILS Date completed 6 NO V 193
Total depth
Sanitary seal �,iY N)
Date of test
0
r %®t
Cased to
Y
FROM WELL LOG
6 /✓o V /R 8 /
Static water level 14 r Te S i a
Well production /-5- 9 P -n'� ' g.p.m.
0
Casing height (above ground)
Wires properly protected 19N) s
AT INSPECTION
to ,✓ _9 r n�ic o) sem/
9 / _k
6 r �
g. p. m.
WATER SAMPLE RESULTS: 1
1
Coliform Nitrate 0- � Other bacteria oCo .v+ L
co ���"''
Date of sample: / r�o � J2 i � `/ %� Collected by: S/moi✓ .5CN2oEe'o
B. SEPTIC6abNdj5jNK DATA
Date installed / 98 Z- Ta/nksize /0,40(7 Number of Compartments 3 Cleanouts&'N)
Foundation cleanout 6?/N) 1 Depression (YN) _ High water alarm ON
Date of Pumping )MS %GPumper f t Nl t� 5'ERV16 e7 S
C. ABSORPTION FIELD DATA
DatelraLalled Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length
Effective absorption area
Date of adequacy test
Gravel thickness below pipe Total depth
Results
Tube present (Y/N) Depression over field (Y/N)
For bedrooms
Fluid depth in absorption field before test (in.); Immediately after\�,j
Fluid depth (ins) Minutes later: Absorption rate = _
Peroxide treatment (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)'
water added (in.):
D. LIFT
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
ump on" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic olding tank n lot /00 / +
Absorption field on lot N11q
Public sewer main 1\1114
On adjacent lots
On adjacent lots
"Pump off" level at*
-,-;,/OU/
/ Public sewer manhole/clean�ouut�,CJ A// A
Sewer /septic service line /"/� Lift station ' "!
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
i r
Foundation `� A , Property line z "� Absorption field
—
Water /y!
Water main/service line A Surface water/drainage �� / Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: IVIA
Property line _ ilslino foundation Water main/service line
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
Driveway,
Wells on adjacent lots
area
I certify that l have determined thru field inspections and review of Municipal rec whatyl
in conformance with MOA 4iAAuideline an ect on this date.
49TH
SignatyreGz�y����C��-`_!_......
Engineer'sName' /^✓ i !—� /yC (c_ n�iC LAR
Date
55
HAA Fee $ 3 00 , 0 Q Waiver Fee $
Date of Payment C/123 A/ ) Date of Payment
Receipt Number 0,3S--76 Receipt Number
72-026 (Rev. 3/96)*
are
RPR -20-1999 1�:43 i=T&E E31 Hhli HOROGE � n75r1s- of P. t=t=.: 171.
CT&E Ref.#
Client Name
Project [Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Parameter
CT&E Environmental Services Inc.
981720001
Environmental Mgmt Inc (EMI)
n/a
L2 133 Rabbit Creek
Drinking Water
Client PON
Printed Date/Time 04/20/98 16:59
Collected Date/Time 04/16/9817:35
Received Date/Time 04/17/98 17:30
Technical Director: Stephen C. Ede
Released By
Allowable Prep
Results PQL Units Method Limits Date
Analysis
Date snit
Total Coliform 0 col/100mL SM18 92228 04/17/98 THW
Nitrate -N 0,111 0,100 m0/L EPA 300.0 10 max 04/18/98 RMV
>r v too V w re !r v
WF�C++N(p5 CUST*M'pdn[Ingu ki TO, iim.......n.A 63.7 NFa; L.�_.b1eNT::ryn, HMOY;n
'9�gAlaxi 'A `gym
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A+ HOME SERVICES, INC;.
12216 Wilderness Road
Anchorage, Alaska 99516
345-1890
CUSTOMER
Asn Tttr - —
15950 Francesca _
Anchorage. AK 99516
Rork __ - Lot ..
010 Pot
kaI xc. '. 012+Vt0++
INVOICE #13180
DATE
DESCRIPTION
AMOUNT
Q2 2 .
P>unn Holding Tank —5-- - -
_.
$1�0,(►0
_
r..
_—.
-Twto be thawed >o visit tultil T cal} Y oti?-- --
- ----- — --
TOTAL
Pre -paid
�
REMARKShfe
+
5396-006-0432-6469
Caw
Gallons Septic Leach Area Hoiding Tank
—_ Standpipes Time
❑
PROBLEM AREA — CALL FOR MORE INFORMATION
❑
NEEDS TO BE DONE AGAIN IN 6 MONTHS
❑
Good Shape ❑ sludge buildup on bottom
❑ Floater on top
❑
Jim cap missing or ❑ Cut standpipe to 1' above ground
❑ Needs Soptictrine
needs replacing
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES fi>,
T Division of Environmental Services ~}j
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.# HAA# ��Ga cc) 14
1. GENERAL INFORMATION
Complete legal description Loi 2; Block 3; Rabbit Cuelz View Subdivision;
Location (site address or directions)
Property owner H.U.U.#117-020367 Day phone
Mailing address 605 we6.t 4th Avenue Anehon.age, A2a6ka 99503
Lending agency
Mailingaddress.
Day phone
Agent Sandy Hje. ,s,tad ASSOCIATED BROKERS Day phone 563-3333
Address 640 West 36th Avenue A hanago A2nblza 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 y
3. TYPE OF WATER SUPPLY:
XX
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:
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
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation dates hown 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 S & S ENGINEERING Phone
17034 Eagle River Loop Road No. 204
Address Eagle River., Alaska 99577
Engineer's signature
6. DHHS SIGNATURE %�
Approved for `? bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date
CIO
.'.�a
1� 91 i ROGER SMA EFl� Y.E. e %�
68215 1y A
V �cr� • .. l7 ._;1
�PROFES570NP �,�►
bedrooms, with the following stipulations:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Z F'L Parcel I.D.
A. WELL DATA
Well type %I If A, B, or C, attach ADEC letter. ADEC water system number �4
Log present (9N) Date completed 1 I- (,P- 131 Driller
r �2_�-
It
Total depth � C>Cased to � d Casing height
Sanitary seal MN)
Date of test
Static water level
Well flow
Pump level
i
Wires properly protectedo?N) `f
Z
W N
FROM WELL LOG
AT INSPECTION
00
N
��-el_go
LLJ
a
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LLJ
S
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g.p..z
LU
g.p.m.
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A-)
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
WATER SAMPLE RESULTS:
r
Lot-->
r
On adjacent lots
On adjacent lots �
Public sewer manhole/cleanout
/ A
Petroleumtank /VOA1 K"&W
Coliform +� Nitrate /" • Other bacteria
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed II 113Z Tank size � o i Ce�:)c7 Compartments
Cleanouts L#N)
High water alarm (V?N)
Foundation cleanoutON) y Depression (YITV
Date of pumping 11'- 3- 9 I
Alarm testedeONN)) /
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot �I On adjacent lots + -4- Foundation 4 S
To property line I ± Absorption field Water main/service line
Surface water/drainage I dC;>
72-026(Rev.39)Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in Ions —
Vent (YIN )
High water alarm I
Pump on" level at
Meets MOA electrical co (Y/N)
SEPARATION DISTANCE FROM'
Well on lot
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Width
Depression over field (Y/N)
Results (pass/fail)
Manufacturer
Manhole/Access (Y/N)
T STATION TO:
On --adjacent lots
Peroxide treatment (Past 12 months) (Y/N)
Soil rating
Gravelth
"Pump off" level at —
Cycles tested
Surface water
System type —
es Total depth
Cleanouts prentent (Y/N) .
Date of adequ� y test
for
If yes, give d
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
On adjacent lots
Cutbank
Property line
To existing or abandoned system on lot
Water main/service line
Driveway, parking/vehicle storage area
bedrooms
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect;orr the, Fate of this inspection.
S & S ENGINEERING
n(
Signature
•17034 Eagle River Loop Road No 204�
Engineer's Name
Eagle River, Alaska 99577
;
` I�.:;'
� `�.,°
Date
,Re
HAA Fee $
Date of Payment
Receipt Number��� 7�
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
Client Sample ID : L2 B3 RABBIT CR. VIEW S/D
PWSID : UA
Collected JAN 3 92 @ 16:15 hrs.
Received JAN 3 92 @ 16:45 hrs.
Preserved with AS REQUIRED
Analysis Completed : JAN 6 92
Laboratory SupervisorST POER C. ED_ E
Released By : V,4C'
Parameter
----------------------------------------
NITRATE-N
ANALYSIS RESULTS for INVOICE # 50029
Chemlab Ref.# 92.0036 Sample # i Matrix: WATER
Client Name :S & S ENGINEERING
Client Acct :SNSENGP
BPO#
Req#
Ordered By :RAY
Send Reports to:
1)3 & S ENGINEERING
2)
POI :NONE RECEIVED
.....................................
Results
Tests Performed
Units
.
Method
Allowable Limits
--------------------------------------------------------------------------------------------
ND(0.10)
See
mg/l
EPA 353.2
10
Sample ROUTINE SAMPLE COLLECTED BY: RAY.
Remarks:
....................................................................................................................................
1
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��S13S Member of the SGS Group (Soci6t6 GdnBrale de Surveillance)
Time
APPLIr, -"'NT FILLS OUUPPER HAI---'' ONLY
Property Owner _ /J - Phone
Mailing Address
-e7 I
Com-- o�,� - Zip Code%-/d3��/
Buyer
y
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/y�',ti•_y'_�� i`��`'%ter'-�N.-/'fiL<�
Address
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(/'7� n'-�-- Zip CodeG.�
Date - -
Date
Lending Institution
- < nn A
Phone
Address
`� ` ,k,.�A, -��yf(
Zip Code
Realty Co. & Agent
11-L,- 61 LL -
Inspector
phone
Address
Inspector
Zip Code
Inspector
Legal Description
Street Location
OF ANCHORAGE
Type o__f Residence,..,
I
❑ Multiple Family
No. of Bedrooms_
❑ Other
Water Supply
EL>ydrvaid'uai
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
❑ Public Utility
- For wells drilled prior to that date, give well depth (attach log if available).
_
Sewer: Disposal
❑ Individual
❑ Public Utility
-�% J
p ,% /
Year
Year Individual Installed:
When C nne ted to Public Utility:
9-bleidTngTank
U�trl Il �. j`U(C//ar„_Ptc�tiS!
/ oPS)C� �6�
( ) CONDITIONAL APPR VAL/
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
-
Time
d `,'�(� m
Date - -
Date
Date
Date
11-L,- 61 LL -
Inspector
Inspector
Inspector
Inspector
Field Notes: N; j4,,� �,a , :.; si .r�r �, �=
fs
OF ANCHORAGE
.
MUNICIPALITY
DFPT C = T
f,U, TION
ENVIROid�.
RECEIVED
G o
(G APPROVED BEDROOMS !-
`CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPR VAL/
DATE
c�i
BY: _ _ `"1 __ Epi , I V.
r,_QPkc'��>) i
i. ar
Soils Rating
Date Sewer Installed
Well To Absorption Area
-
Well Log Received
Well to Tank
' Tank Size
NFA'911h1YG1
C%��� c
'�livt�
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TO
ISAAC& PUMPING SERVT
Norm Tibbetts (Owner)
6218 Quinhagak
ANCHORAGE, ALASKA 99507
DATE
I
f
SUBJECT
❑ PLEASE I I - REPLY � -I-,,- F1 11 N 1 0 REPLY, , I NECESSARY- I - - SIGN
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