HomeMy WebLinkAboutHYLEN CREST #1 BLK 1 LT 2Hyl n Cee 1' Block Lot 2 #050-472-86 MUNIGIPALITY OF ANGHORAGE DE.ARTMENTOF HEA'TH AND HUMA. SE.WCES 070- Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address K~"A C ''~ ~ ~ ~ ~; ~ ~ SEPTIC ABSORPTION WELL Phone(s)~qq ' I~qq ] Permit No.~~ No. of Be~oms~ L0T LINEWELL + gOO~, ' Township, Range, Section AS-BUILT DIAGRAM IShow location of well, septic system, properly lines, foundation. ~iq N , RI V, ~. ¢ Oriveway. wa,erboOies, elc.) TANK8 ~ SEPTIC K~i~In~ ~ HOLDING Manufaclurer Capaciiy in gallons Material No. of Compa~menls TYPE OF SYSTEM ~ TRENCH ~ BED ~ W, BRAIN ~ OTHER odgina] grade ~ FT ~ FT Fia added above odginal gFade Gravel depth beneath pipe FT / FT Total absorption area Distance between lines ~ Number of lines Soil rating Pipe material I IZ5 SQFT ~S~m 3o~, F~o 5' WELLS ~ PRIVATE ~ OTHER {Identity) Classification (A,B,C) ~otal Depth ET Cased to Eagle River Engineering 8e~lces ~, :'. DateEagle River, AK 9957? /v :,/~ o~ ,r ' ~ "h, "~: ' I cedily that Ibis inspe~len was pedormed according to all Municipal an~ State guidellnas in ellecl e~is dato: ~ 72-013 (3/85) Lou Butm'a, P.O, ]?,ox 77320,1 Englo River, Alaskn 'l'olsphons {90'/] 3!, 1990 Mr. Dan Roth D.H.H.S. 825 "L" Street Anchorage, Ak. 99502 RE: Lot 2, Block 1, Hylen Crest Subdv. Dear Mr. Roth, We are requesting an upgrade permit to allow the existing 3 bedroom system on this lot to be upgraded 'to 4 bedrooms. The existing tank is a 1,250 gallon tank as shown on the original inspection report and as per our surface measurements and verification by pumping. The existing trench is rated based on a 225 soil rating. Our 'test hole revealed a sand layer at 5-7' level and we will place the new drainfield on 'top of this layer for maximum absorption capability. It is our opinion that this system as it exists is underrated and adequate for 4 bedrooms but we will add the additional leach area to be conservative. If you have any questions or any further concerns please call me at 694-5195. S~ncerely, Louis Butera, P.E. [ 109.78' 15' 'El'ect~ic- & Telephone N,w ,l~ting CO ZIO.O0' ~ - ~ HO~ · - MONITOR o - S~EE C~NO~ v,v,',mv,',- PROPOSED L~CHRE~ NO KNOWN CURTAIN D~INS S E P T I C S I T E P LA N ¢~",; ~' 4,'":% LEGAL= Hylen Crest Subdv, Lo( 2, Block 1 OWNER: CONTRACTOR: N/A ..... ',..-,%;::~ ........ ~ ..... '.;'~ JOB ¢ 90-048JDATE: 05/~0/90 SCALE 1"-= 30' 'j~ ~~ ~ ~A~LE 'RIVER ~N~INEERING SERVICE~ ~ P,O. Box 773294 '*:~',v:,:::, -., , ~ ¢A¢L~ RIVER, A~ 99527 '~:'"":'' '*" ..... (907) 694-5195 F~X: (907) 694-3~97 109.78' 15' Bec hone Ee,'eme ,t 3~, /- Existing 110.00' ~ - ~ HOLE · - MONITOR o - S~ER CL~NO~ mmm~- PROPOSEO NO KNOWN CURTAIN D~INS ~EME~ LEGAL: Hylen Crest Subdv. Lo~ 2, Block 1 OWNER: Chamberlin JOB ¢ 90-048J. DATE: 05/30/g0] SCALE 1" = 30' k EAGLE RIVER ENGINEERING SERVICES *' (907) 694-5195 FAX: ¢907) 694-329~ ..... ""' SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Lot 2, Block 1, Hylen Crest Subdv. 1. The ~ell and septic plan are 'fop a ,single family nesidence onlv. 2. The dr'awing and on site plan shal 1 be a paP~ o'¢ this specification. 3. A]q matepfa]s and workmanshi p shall meet: the Anchorage Department of Hea'lth and State Depamtment o¢ Envinonmental Consepvation pequipements. 4. Aql soil tests are advisor'y ~o the design and are to be vepi'F~ed or modified in the fie~d bv the engineer. 5. All excavations and depths ape advissor, v and ane to be veni'fied or rnodified in the field by the contnactop to meet Municipality o'F Anchorage, Department o'¢ Env~ ronmenta] Consenvat i or~ PeqU S r'ement s. 6. The excavation is to be exactly Xn the ar'ea s;hown on the site pqan, any devfiatior~ ~-equines engineep appr'ovaq. 7. It tis always recommended that a surveyor 'locate the nearest lot line position and the location o{: any easements. 1. The bed 'is to ~Follew the natupal 'land contour to maintain uniform totaq depth of the bed bott:om. 2. The bottom c>f the bed shall be ]8ve], plus on rnfinus 1.5". 3. The tot:a] depth of the bed excavation is not to exceed 5 ' at mnV point. 4. The sewer l~ne is to be connected into the existing 'leach 'line to aqlow ovon e'f~]uent distn4butior~ to t:ho upgrade 'leach'fie'ld. 5. The bed qnavel is to be cow, red wlth typan 'febnic maten4al. 6. So'i] on combination o-~ ~;oil and extruded boend ~nsuqation to ~ depth o¢ 4' on equiw~lent is to be placed even the 'leach¢ield. '~. The aPea oven the bed is to be 'fin4sh graded to pnevent ponding of surface wate~ punof'f. 8. The septic tank and ]eachffie]d must not be closen than 100' to any exfistfing ppJvate well, 150' to any Class "C" ~e]] . on 200 'feet to any communffty we'll. RECOMMENDE[) LEACHFIEL, D DIMENSIONS TOTAL DEPTH = 5' GRAVEl_ DEPTH -= 1' S~ED L, ENGTH :-~ 22' BED NIl)TH Soil Rating = 125 upgr'ade Bedroom Capacity ~- 4 total Septic Tanl< Size = 1,250 gallon existing SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS / SLOPE . DA E PE..OR ED: S/SO/40 SITE PLAN WAS GROUND WATER S ENCOUNTERED? /~/O L O P IF YES, AT WHAT /.~_~,/~,,.~,~ E DEPTH? 'f-? o/~-.~r Gross Net Depth to Net Reading Date Time Time Water Drop -~- " {O:Og lO ~ gill~ PERCOLATION RATE TEST RUN BETWEEN -~--, ~ (minutes/inch) /,,~. FT AND ~,.5~ FT PERFORMED BY: 72-008 (6/79) Fagie Hiver ~:ngineenng 5c v,cr:s P, 0. Box 773294 ~-agle Hirer, AK 69~'1,-5195 CERTIFIED BY: DATE: NAME MIUNICIPALITY OF ANCHORAGE DEF'ARTiVlENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 8'25 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE ~- ~ ~/~4~'/,.,(-(~ [] UPGRADE MAILING ADDRESS .~o~ ~-~ LEGAL DESCRIPTION LOCATIDN ~ DISTANCE TO: [We,l~ &'~/~O~q~z~)'l,~' ~ Absorptio~ areal~ IF HOMEMADE; Well DISTANCE TO: Well Length cf each line .Manufacturer DISTANCE TO: No. of lines Top of tile to finish grade Width Inside length __ Dwelling Foundation Total length of lines Material beneath tile Depth Length Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Driller DISTANCE TO: Sewer line Building foundation IDwelling Material Width Materiel Nearest lot line/- ' /~ Trench width '?w~~inches Z-// /' -4r, ehes NO. O1~ BEDROOMS PERMIT NO, No. of c%artments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption ar~ea¢,. /V~ PERMIT NO. I T otal effective absorption area Nearest lot line Distance to lot line PERMIT NO, Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TES'C]C(ATI NG INSTALLER REMARKS 22 E 25s ,~971 PALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION 'AUG 6 1984 APPROVED DATE LEGAL RECEIVED 72-013 (Rev. 3/781 IL.II [F"ql ~ IIi: ]E I~::r~" ~'~ IL_ Iii q[' '~lr" I[~]l F~:= ~:~I~ II'"ql 1[]: ~'"tl IL'.]I IF~: ¢-~-'~ IE!!]i IFil DEPARTMI!ENT DF= HEAL. TH AND IEINIVI'rRGINIHENT~L PROTECTION 8:25 L ,STIRIEET, ANCH(]RAGE, AK 99'.5C) 1 264-4720 PERM I T NC: DATE ISSLIED: 84.()6:~;7 07 / 30 / 84. IF=`' EE: F~ I1'~'~ .~ 'IF" AIZ'I:::'L I CAI I 1: A D D R E S S ~ CON'I"ACT' F"HONE: SHASTA CONSTRIJBTIDN GUITE 556 200 WEST 34TH ANCHGIRAGE, Al.::: 99503 274-0 :IS& I_EG~I.... DIESCF~IF:': !~UBDIVISIGN: HYLIEN CREST LOT: 2 BLGCK: 1 SECTION: 6 'I"OWNSHIP: 14N RANGE: :LW I....O't' SIZE: 2(}()C)0 (SQ,,FT. OR ACIRES) MAX BIEDROGMS: 3 Li:=rLed below are i:,he Ol:rl:.:i. ons available to) you in designing your septic sy~.~tem,, Choose i:he Ol.mLioln tha'L bc~.st fits yoL~r' site. ~F ~'"~. E. ~' .~ CZ. ~.,H~ ~ E: ][Z~ I~,~ ~.., F~,. ~"':~ Z INI DEPTH 'T'G F'IF'E BOT'T'OM (F'T.) 4,, 0 4,, () 4,, 0 GRAVEL DIEF:'TH (F'T,,) 4,. 0 (),, 5 3. 5 TE)TAL DEF'TH (I::rT,) G. 0, 4 ,, t?J 7. ',"?l GRAVEl.... W I DTH (F"T.) 2,, 5 22., 0 5,, 0 GRAVEL I_ENGTH (IZT,) 85. () *.~, 4.4,, 0 '73,, 0 GF~AVEI.... VOLLJME (CLJ. YDS. ) :];5,, 4 35.8 54. () TANK SIZE (GALS) :L,000,,0 *~ 1,O()C).O *'~ 1,00(),,0 ** GDIL RATING (SQ.FrT. /BR) 225 213 225 ~',~' GRAVEL I...I.ENGTI-I > 75 F'I". REQUIF~ES MUL.TIF"LE RUNG (NOT EXCEEDING 7,5 F']",, EACH) *'~' TAI~II< MUST HAVE AT I.J::A,~f TWO COMF'AI'"(T'MEIxtTS I (::er'tify that: 1,, I arrI familiar, with the r'equipements for' (mn-site ~-~eweps'and w(~lls ars siet far'th by the Hurlic:ipallty of Ar'ichor, age (Id{]A) ¢~r'ld"l:.he Sta'Le of A].asl.::~,, 2. I will. ins't:.all tine system in ac:cor, dance with a]:]. MOA codes ar'H:l r'egu].a'Lior'H~, and irt comp ]. iance with the des:i, gn cPit~picA of 't]his~ per'mi'L. :;$. I will adhere to a].l MOA and State (If Alasl<a r'equ:LremerrLs for the s~'t:, ba(zk distances fr'om any exist:Lng well, ~aste~atep disposal system op J:)Ld;lic: sewepage system on this or any adjac:~fl'~t or near'by 4. I ulqdepstal]d that 'Lh:i.s permi'L :i.s va].id for' a h]~AximLtm 0¢ 3 bedr'aoms arid .any en lapgement w:i. 11 I"eqLti ne an addi'Lional per'mit,, IF A L..IIZT STATIGN IS INSTALLED IN AN AREA COVERED BY IdOA BUILDING CGDES, THEN (1) AN ELECTRICAl.... F'IERIdIT AND INSF'ECTION MIJST' BE OBTAINED; (2) AS..-.BUILTS WILL. NGT BE APF'IRGVED WITHOLJT AN IELECTRICAI_ INSPECTION REPORT; AND (3) THE EL..ECTRICAL. WGRK IdUST BE DGNE BY A LICENSED EI...ECTRICIAIxl, ,~ 1GNED DATE:: AF'PLICANT: SI'"IAS~ CONSTRUCTIGN MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99B01 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION; 1 2 3 4 5 6 7 8 9 10 11 12 13 0~-- 6-Arqt c ~//27/~,,! d,¢,4¥, IF YES, AT WHAT ¢'~ ~'/~'~ ~"~. '"'-~ DEPTH ? SLOPE WAS GROUND WATER Vt_.~ S ENCOUNTERED? . / L 0 P SITE PLAN 14 15 16 17 18 SUN£ 25, t97! 20- Reading Date Gross Net Depth to Net Time Time Water Drop ? ~/~/~// ~ ..,~/ /~ ~,~ ~- ', ~,, V ~, ~/,, ¢~. ', ~" ~', PERCOLATION RATE TEST RUN BETWEEN COMMENTS ~ ~/~ ~" C PERFORMED BY: CERTIFIED BY: 72-008 (6/79) rCiunicipa ity of AnchoraGe Development Services Department Building Safety Division ~/ // On-Site Water & Wastewater Program " ' 4700 _lm~r~ Road P.O. Box 196650 ,/? ... ¢' Anchorage, AK 99519-6650www.muni.ora/onsite(907) 343-7904 ~f/'~"~'"7~i~ OF ON-SITE SYSTEI'4S APPROVAL SINGLE FAI'41LY DWELLING CERTIFICATE FOR A Parcel I.D. 050-472-86 1. GENERAL INFORMATION COSA# (~ ~ ~ ~ \ ! Expiration Date: Complete legal description HYLEN CREST S/D #1; BLOCK 1, LOT 2 Location (site address) 21026 UPPER LOWLAND AVENUE * EAGLE RIVER, AK * 99577 Current Property owner(s) THOMAS WEBB Day phone 865-.500-4476 Mailing address 21026 UPPER LOWLAND AVENUE * EAGLE RIVER, AK * 99577 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing .address Unless.otherwiS'b. requested, COSA will be held by DSD for pickup. 'NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site · Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System · Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. ~ Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY. ENGINEER As certified by my seal afffxed hereto and as of the vafidation date shown below, i verify that my invest~ation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, sho~'/s t,ffat the on-site water supply and/or wastewater disposal system is (are) safe, functiona! and adequate for the number of bedrooms and type of structure indicated herein. I further veri,~y that based on the information obtained f,"om t,ffe Municipality of Anchorage Nes 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. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone ,557-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.Eo Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. DSD SIGNATURE ~'"' Approved for J~ bedrooms. Disapproved. Conditional approval for ...... ":4 .~N ~ ~ ~ , WASTEWATER , bedrooms, with tho *ollowin~ stipulations: Attachments: COSA Checklist Septic System Advisow Well Flow Advisory Nit[ate Advisory (Rev. 11f05) Arsen.c Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date:_ b "-? O' / i Muni,cipality of Anchorage Development SerVices Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni,org/onsite (907) 343-7904 CERTIFICATE OF 0N-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: i WELL DATA Well type Date completed Total depth ft.: HYLEN CREST S/D #1; BLOCK 1, LOT 2 IPUBLIC WATERI If A, B, or C provide PWSID# ~ Parcel ID: 050-472-86 Well Log (Y/N) Date of test Static water level Well production WATER SAMPL~ Coliform ~ colonies/100 mi. Arsenic: __ug./L. Sanitary seal (Y/N) Wires properly protecte~J Cased to_ ~ ft. Casing he__round) in. FROM WELL LOG ~CT!ON . Nitrate mg./L. Date of sample: Collected by: SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal: Number of Compartments 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumpin~ Pumper. ABSORPTION FIELD DATA I'BELOW EXISTING GRADE~ 8/19/1984. 225/ Date installed. 6/~1/1990 Soil rating (g.p.d./ff2o~ 125 Length 87/22 ff. Width 2.5/5 ff. 675/ fi2 Total depth ~,.o ft. Eft, absorption area 126 Monitoring tube YES Date of adequacy test *'6/2/2011 Results (Pass/Fail) PASS Fluid depth in absorption field before test 31 in. Elapsed Time: 120 min. Final fluid depth 59 Any rejuvenation treatment (past 12 mo.) (YIN & type) **TEST_.D Date installed 8/19/1984 Cleanouts (Y/N) YES High water alarm (Y/N) N/A JR'S PUMPING 984 TRENCH/1990 TRENCH System type TRENCH/TRENCH Gravel below pipe 4/1 ft. Depression over field NO For 4 bedrooms Water added 610 gal. New depth 46 in. in. Absorption rate >= 600+ g.p.d. NONE KNOWN If yes, give date - 1984 TRENCH ONLY. 1990 TRENCH WAS DRY AT TIME OF INSPECTION. D. LIFT STATION Date installed "Pump on" level at Size in gallons Manhole/Access~ J in. "Pump off" leve~.------'i~T""---~igh water alarm level at .in. ~ ~ Cycles tested, E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Meets alarm & circuit requirements? On adjacent lots IPUBLIC SEWERI Absorption field on lot On adjacent lots / Public sewer main .......~:~i~e~anhole/cl~nout Sewer/septic s~~ -----~'- Holding tank ~ment areas. Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main 10'+ Water service line 10'+ Absorption field 5'+/'5'+ Surface water 100'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 11984 TRENCH/1990 TRENCH] Building foundation 10'+//10% Water main 10'+//10'+ Surface water 100'+/100'+ Driveway, parking/vehicle storage10'+//10'+ Wells on adjacent lots 200'+ Property line *'6'+/10'+ Water service line 10%//10'+ Curtain drain NONE KNOWN F. COMMENTS *PER 1990 INSPECTION REPORT. **PER EXISTING WAIVER G. ENGINEER'S CERTIFICATION I certify that I 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 Printed Name JEFFREY A. GARNESS Date #050060. COSA Fee $ Date of Payment Receipt Number. (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number J'Rs Pumping PO Box 77341~ Eagl: Kiver, AK 99577 (907) 69n-6454 FROM:JR'S SEPTIC PUMPING 90734498E1 IBIlling In:[o._rm a_~_t.!q~! ....... Thomas Webb 21026 Upper Lowland Ave Eagle River, AK 99577 (907) 694,8538 ~o__.b. Site I__nfo_~r._m_ation Thomas 21026 Upper Lowland Ave Eagle River, AK 99577 (907) 694-8538 Job Description: 1250g P.O. Number' Terms: Net 30 Salesrep: Dawn-Dawn Map Book: Cress St:roots: Job Comment=: Service Agreement Number: 033405 Order Date: 18-May-2011 Service Date: 23-May-2011 Teohnician: Dan Tax %: 0 Job Type: Repeat Map Grid: 102- - Stewart Drive L-est s-~'~- .... ,~07/2.9/~016; ....... ';i~50g tank levels Iow a lot of solids 13ack flushed 2 times clean out & leach field ok Additional Location Comments: 4-Bdrm -Tan w/blue trim~'s on garage Access System through left side Septic @ back of home Diagram: 8.\Db~lrorns\17437.bm~ Gallons Planned: 1250 Gal. Actual: ...... Hose Length: 3 Double Tank: ~ Pump System: ~ Baffles Inlet: [] Baffles Outlet: [] __,,__ Service Type Qty Price Each Tax? Septic Serv 1250K 1 $000 No Extension Actual $0.00 Tax Total Grand Total Estimateci charges: NonTaxable Total Taxable Total Actual Charges: _ Customer agrees to the terms end conditions shown. THIS IS A BINDING AGREEMENT. Signature andTitle of Customer Representative Date " " " D;~te Accepted Accepted by JR~ Pumping For your added convenience we accept; Dicover, Visa and Master Cars payments over the After 30 Oays account will be turned over to COLLECTIONS. $30.00 For NSF Checks Returned. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAFIILY DWELLING Parcel I.D. ~0 "q~'o?' ~, 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address HYt. EN CREST ~1; BLOCK 1, LOT 2 21026 UPPER LOWLAND AVENUE *EAGLE RIVER, AK 99577 SANDRA RUIZ Day phone 696-3474 21026 UPPER LOWLAND AVENUE *EAGLE RIVER~ AK 99577 Day phone KATHI OLMSTEAD W/REMAX Day phone 694-4200 16600 CENTERFIELD DRIVE *EAGLE RIVER, AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site ~] Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site Wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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. Name of Firm GARNESS ENGINEERING GROUP. Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone Date 337-6179 Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidofines & Regulations. The repoded results described tho performance of the system under the conditions encountered at the tlmo of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being sen/ed by tho system. These conditions are outside the control of the evaluator of the system. Satisfacto~ test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG. LTD. can therefore not provide any warranty or future estimate of how long tho system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal dght whatsoever. 5. DSD SI,~TURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the fllowing stipulations: ..... · . WATER AND : m: : WAST AT : Attachments: COSA Checklist Septic System Advisor,/ Well Flow Advisory Nitrate Advisory .y: Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: 8 '" ] ~-'i~)OO Municipality of Anchorage Development Services Department Building Safety Division On*Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.munl.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEHS ,b, PPROVAL.!CHECKLIST Legal Description: A. WELL DATA HYLEN CREST #1; BLOCK 1~ LOT 2 Well type Date completed Total depth ft. Date of test Static water level Well production ~ ug./L. PUBLIC WATER ff A, B, or C provide PWSID# Well Log (Y/N) Sanitary seal (YIN,~ Wir:s preperl..Y~ Cased to FROM WELL LOG ~,,,,,,,,~INSPECTION g.p.m, g.p.m. Nitrate mg./L. Date of sample: B. SEPTIC/HOLDING TANK DATA Tank TyPe/Material SEPTIC,/STEEL Tanksize 1250 gal. Number of Compartments 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping ~ Pumper ~ ~ ' ,C~ C. ABSORPTION FIELD DATA PeEl. OW EXISTING CRAD[I S/19/1984/ Date installed 6,/15/1990 Soil rating (g.p.d./ff~o~'~ 225/125 Length 84,/22 ft. Width 2.5,/5 ft. in. Other bacteria Collected by: __ colonies/100 mi. Date installed Cleanouts '(Y/N) YES High water alarm (Y/N) N/A DEEP TRENCH/ System type SHALLOW TRENCH Gravel below pipe 4/1 ff. · 9.33/ 696/ Totaldepth '5.91 ft. Eff. absorption area 126 ft~ Man toring tube. YES ! Depression over fie d. NO Date of adequacy test 7,/8/08 Results (Pass/Fail) **PASS . For 4 bedrooms Fluid depth in absorption field before test 30,/DRY In. Water added 402,/250 Ual. New depth 51,/6 in. Elapsed Time: 660 min. Final fluid depth47/DRYin. ' Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - D. LIFT STATION Date installed Size in gallons ~ 'Pump on' level at in. "Pump off" ~igh water alarm level at in. ~ ~Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: PUBLIC WATER Septic tankJlift station on lot On adjacent lots Absorption field on lot Public sewer main ~u lic sewer manhole/cleanout Sewer/septic sen/ice line / ~H~old~~  Manure/animal excrete storage a SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main 10'+ Water service line 10'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property llne '6' Water service line 10'+ Curtain drain NONE KNOWN Absorption field 5'+ Surface watec 100'+ Building foundation 10'+ Surface water 100'+ Wells on adjacentlots 200'+ Water main 10'+ Driveway, parking/vehicle storage 10'+ F. COMMENTS "WAIVER ~050060 G. ENGINEER°S CERTIFICATION I certify that I 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 Printed Name JEFFREY A. CARNESS Waiver Fee $ Date of Payment Receipt Number Municipality o.f Anchorage Development Services Department Building Safety Division · On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HF. ALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. o,5'o - y?~- z~¢' 1. GENERAL INFORMATION HAA# D-%OS'q Expiration Date: Complete legal description L,, f- 2/ Location (site address or directions) Current Property owner(s) Mailing address Lending agency Day phone ~'~ .- ?,s-¥,~' Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise raquested, HAA will be held by DSD for plckup. ? l c~'~ ¢ ,, tl Cl, r.u, o,.- ~o,~ ,, ,'~ 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [~ Individual On-site [] Individual Holding lank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of AJaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewatar 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(ara) in compliance with all applicable Municipal and State codes, ordinances. and regulations in effect at the time of installation. /-.~./ h,~ ~<.,o ~,..,,,... n NameofFirm I~l~-~p ~4d,¢,,=1 ~e",. ;~ Phone Address I'/,C~' ~c~, ~'t..., ~-,~c~,,:,,~vp.~, ,~ Engineer's Pdnted Name "7-,~ -~ ~'o,--¢ ,c. /'~'~,o r~ Date 5. DSD SIGNATURE Approved for Disapproved. Conditional approval for S~,t,'~'' . bedr~ms. ~ .... ~..~.~.;..~ bedr~ms, with ..... . tho followmo ,bpu~a~ons,.u .. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~ - ~ - 0..~~'- Municipality of Anchorage Development Services Department BuUdlog Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Ancbomge, AK 99519-6650 ww~v.cLanchorage.ak.us (9O7) 343-79O4 HEALTH AUTHORITY APPROVAL CHECKLIST LogalDascription: ~.(r,f ~ ~/~,¢~ /~ Hyl/n ~'~J" Wall type -- Date completed Total depth If A, B, or C provide PWSID # San~y seal {Y/N) Cased t= ft. FROM WELL LOG Parcel ID: Well Log {Y/N) Wires pmpe~y protected (Y/N) Casing height (above ground) AT INSPECTION Date of test Static water level Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: -- Coliform colonies/100 mi. Date of sample: Nitrate rng./L Other bacteria __ colonies/100 mi. SEPTIC/HOLDING TANK DATA TankType/Material X~?~;c / Tenksize IZ.Y~, gal Number of Compartments Foundation cteanout (Y/N) Y' Date of pumping '7 / I~' / ~'_~" ABSORPTION FIELD DATA Date instaited ~/'8 y Cleenouts (Y/N) ¥' Depresalon over tank {Y/N) /~' High water alarm {Y/N) Pumper ;~'R '~ Pum p;n~ ft. Fluid depth in absorption field before test ~/' 2. in. Water added"~ gal. Elapsed Time: 9'/ min. Final fluid depth ~',?* in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (YiN & type) No,~ ¢ k ,, ,~.,-,~ If yes, give date ~J..4, I,~: D,~/,,*~, ¢'~e ,==4,,~c,e,c,~. /~t~ 'l~ ~.-I~.~'. n~.¢," b.,IF ~p ~, ~ Dateinstalted ~l~y Sol, rating (g.p.d./It~or~/bdrm) ~-_~,.,..Systemtype Length ~ -/ ff. Width *~.~- ft. Gravel below pipe ,~;~--~ Total depth ,~.C ft. Eft. absorption area ~ Monitoring tube . Date of adequacy test 7 / Z# / o~- Results (PassJFait) P,~.c~. Depression over field For './ bedrooms New depthS'~.~f in. 0" ¢:~ g.p.d. D. UFT STATION ~. ,4-. Date installed 'Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons *Pump off' level at in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: /J*/f. Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line Manhole/Access (Y/N) High water alarm level at Meets alarm & ckcuit refluimments? iN. ~ ~/-c,' ~'~( ?~'-~h'c On adjacent lots On adjacent lots Public sewer manhole/deanout Hbldlng tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~;" Property line "~ 5' Water main . '-~ ~ ' Water service line Wells on adjacent lots ~ P_co ' Water Service line Curtain drain Me, SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '~ ~ Building foundation ! ~ Surface water ~ Ioo' Wells on adjacent lots '7~ z~,o, Absorption field ~' ' Surface water ·/~,~' Water main ~. lc,, DHveway, parking/~hide storage ~, ,f~ ' HAAFee $ '*'/,..¢'~ ~ WaiverFee$ 1'7..g' ~ Z~,,/- Date of Payment ,~ / I / ~p~-- Date of Payment ,~/ / /~,~-.- Receipt Number '"7 I '7 / ?-- ~ . ip, Number "~ ! ? /' ~ F. COMMENTS ~ I ~H~ that I ha~ de~ln~ th~h rev~w of Mun,~l ~ th~ ~ a~ sy~ am ~ ~n~an~ ~h M~ H~ gu~ell~s Date Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastcwatcr Program 4700 Bragaw Stroct P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Waiver Review Worksheet WP, g: ~)50060 PID#: 9~(I-472-86 Date Received: 8ol-05 Legal Description: Hvten Crest #1 Block 1 Lot 2 Engineer:. Tg~ Moore 14530 Echo St. Anchoraae Ak. 99516 Applicant: ~hris Victor HA#: 050374 Permil~:. Waiver Requested: 6 feet eeoartion distance absorotion field to oroeortv line. Cdtafla: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ~x' Waiver is not Granted: Waiver is Granted: Ltst Conditions or Reasons for above: Rec#: 8-1-05 Amount: $175 Date Paid: 814/2005 Municipality of Anchorage C 81412005 Ted Moore Flattop Tech Service 14530 Echo St., Anchorage AK. 99516 Subject: Waiver Request for HylenCrest Itl Block 1 Lot 2 Waiver Request ItWR050060 Parcel ID It050472-86 HA#050374 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation from the absorption field to property line has been approved. The approved separation distance is 6.0 feet. This waiver approval applies to the existing absorption field to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Jeffrey W. Poet Engineering Technician On-Site Water & Wastewater Program Community, Security, Prosperity ASBUII.T-NO CORNERS SET THIS DATE. . I HEREBY CERTIFY THAT I HAVE ~URIFEY£D THE FO~LOWINg D~SC~IBE~ PROP£RTY~ ~ylen Crest Su~.,~t No. 1,~t 2,~lk. I 1"=20' ~111) ~ 57 13-11 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 2; Block 1; Hylen Crest Subdivision #1 Location (site address or directions) 21026 Upper Lowland, Eagle River, Alaska Property owner Mailing address · '-.,. Day phone (Dup0nt RelOcation) Lending agency Mailing address · .Day phone Agent Barbara Crittenden/JACK WHITE COMPANY Address 10928 Eagle River Road, Eagle River, Alaska Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS:, -4 ~ Da.y phone 694-5500 99577 .... TYPE OF WATER SUPPLY: Individual well Community well Public water XXX 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. 72-025 (Rev, 1/91) Fronl 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 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 S & $ ENGiNF. E~,iNG 17034 Eagle River Loop Road No, 204 Eagle Rivet'.. Alaska 99577 Phone bedrooms. Disapproved. Conditional approval for 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) 8ack MOA t/21  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L-~-~- "~ ~..~ \ ~L.~ ~P-C-~'~"~arcel I.D. A. WELL DATA Well type ~ E::~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Cased to Total depth Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well flow Casing height Wires properly protected (Y/N) Pump level SEPARATION DISTANCES FROM WE~:O: Septic/holding tank on lot g'p'm'r-l~ r~ ~ ~ Absorption field on lot ~/ ; On adjacent lots Public sewer main ~' Sewer se~~ WATE~M PLE RESULTS: Zorf%a~p id.. ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed \~ '¢/~'~/~'"'//~ ' Tank size \?--~'~ Cleanouts (~N) ~ High water alarm (Y~.~ Date of pumping Compartments Foundation cleanout(~/N) k~ DePression (Y/~ Alarm tested (Y/N) o~..?...--'~'2-~ Pumper //~4-- ~c~¢,~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot '7..o¢ t .v- On adjacent lots ~¢~ To property line \~ ~ Absorption field ~' ~ Surface water/drainage \ c~ c~ Foundation '~ Water main/service line ~,~ \ b 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) ~ ~:;: (wY:~e)r alarm level "Pu m P °n" level atj-~'~Ooy~eVe~ ~t Meets MOA electriC__. ~ M L ' F~ ~;~ 'c~nNt 7o~; Surface water D. ABSORPTION FIELD DATA Date installed \o~ Length b-I'- Total absorption area Depression over field (Y~) Results ~([~ail) Peroxide treatment (past 12 months) (Y~) Width ~.~' /~'/¢~ ¢''2'''~ ~' ~¢"'~-~yst e m type Soil rating - I?--~'~ ""- Gravel thickness Total depth Cleanouts present ,~Y-1/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / Well on lot ~¢,~ I ~' On adjacent lots "~//'-' Property line "~ To building foundation t~ ~ 4' To existing or abandoned system on lot On adjacent lots '~° ~ ~ ~ (k/~ Cutbank Water main/service line Surface water \ ~ ~ tr.- Driveway, parking/vehicle storage area urta,n dra,n ~/A- ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect 17034 Eagle River Loop Road No. 2~ Signature Ea91c Rh'=;-, Alaska 9~577 Engineer's Name Date ¢~f this inspection. HAA Fee $ /TP Date of Payment /- ¢-./~ ~' ,~ ,ecei,t.umber 2-4 . / ¢ / 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number  MUNICIPALITY OF ANCHORAGE Deparlment of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Hylen Crest Lot 2, Block 1 T14N~ R1W, Sec. 8 Location (address or directions) 21026' Upper Lowland Ave. (b) Property owner Emily Chamberlin Telephone: (home) 694-1644 Business 552-5268 Mailing Address 21026 Upper' Lowland Ave., Eaqle River, Ak. 99577 (c) Lending Institution N/A Telephone Mailing Address (d) Real Estate Company and Agent Remax / Marry Stienried Address 16600 Centerfield Drive: Eagle River: Ak. 99577 Telephone (907) 69424200 ~. (e) Mail the HAA to the following address: (or check here~ if hold for pick up.) ' '.' List contact person and day phone number below: · ' 2. TYPE OF RESIDENCE Single-Family~ Number of bedrooms 3..WATER SUPPLY Individual Well [] Community [] Public [] -',. ,, Note: If., com~u.nity, well system., must h,ave written confirmation.from the State Department.off,Environmental 4: sEWAGE DISPOSAL " · .',.On-siteB]. Public[] .Community[] · Holding Tank [] , ,, - ' Notb':'lf'community. well syst6mj must h~,ve written confirmation from~!,he State DePartmer~t of Env!ronmental 72-025 (Rev. 7/88) Page 1 of 2 ')~JOM s,Jeeu!6ue leUO!SSejoJd eq~, u! SUO!SS!LUO JO sJoJJe JoJ el'q!suodseJ 1ou s! eSeJoqouv jo Xl!led!olu nJAI eqJ. 'penss! 9! e~eolJp, Jeo e eJojeq elep eZ,~leUe Jo suoRoedsu! ~onpuoo lou op SHHQ jo see/~olduJ3 's~,ueLueJ!nbeJ e~,els pue leJepej ujmJeo/,jsp, es o~, JepJo (q suop, n~Rsu! 8u!puel J!eq~, pue seuJoq jo sJeseqoJnd o1 ,~sm, Jnoo e se s!q~ seop SHH(] eq.L 'e~selV jo e),elS eq~ u! pe~e),s!SeJ Jeeu!Sue leUO!SSejoJd ~,uepuedepu! ue/~q eAoqe B qdeJSe~ed u! ue^!6 suop, m, ueseJdeJ eq~, uodn ~lUO peseq peleo!jpeo le^o~ddv ~1poq~nv q),leeH senss! (SHHQ) seo!AJes UeLUnH pue qHeeH jo ~,ueLu~jedeQ eSeJoqouv JO/q!led!oiun~ eqj. leUOR!puoo leAoJddv leUOR!puoo .jo SLuJe.L pe^oJddes~C]. ,,. Z,; [V--~/.~,/,~, peAoJddv /~q SLUOOJpeq ~ JOJ pe^oJddv lYAOldddV SHHQ '9 066T '~I XgN elea MUNICIPALITY OF DEPT. OF HEA~,~I~.,~,,/ ENVIRONMENTAL UUN Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~'~ Well Log Present (Y/N) Total Depth__ Cased to __ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments Date Completed Depth of Grouting If A, B, C. D.E.C. Approved (Y/N) Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed /~,¢¢¢ Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ,%,/~ /~?~¢;;?~ r No. of Compartments Air-tight Caps (Y/N) ./v- Foundation Cleanout (Y/N) ~ Date Last Pumped St4, /'"/~ ;for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line -'~/,-'" To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72-026 (Rev, 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /?~o Width of Field Square Feet of Absortion Area ?'~ Depression over Field (Y/N) Type of System Design Length of Field ~-¢- ' J¢ Depth of Field 5- ~,J~' / Gravel Bed Thickness .~, /,¢' J4- Statndpipes Present (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~"~"¢ F='~'/~J'~/'~ '~';'/'--~ ,/ To Property Line To Existing or Abandoned System on ; On Adjoining Lots '~ -~" ' To Cutback (if present) D. LIFT STATION ,¢¢j¢ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** ..:......,.-,,.,.. I certify that I have checked, verified, or conformed to all MOA and HAA guidelf~s i~':bff~c¢t, (~,~*;the date of this inspection. Signed Company Date MOA No. Receipt No. Date of Payment Amount: $ 72-026 (Rev, 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 .-~' ' ~ ' ' MUNICIPA[~ITYOFANCI~IORAGE ,, ,,, . ,*. (,~jl~_~/ Department of Health & Human Services :~'~' ~- ~/:-'~i'; ~;;-~;:~,,"~ '*; ~ '~" ;,~ DIVISION OF ENVIRONMENTAL SERVICES ~:~? ' ::' ':'~ '" " ' :~ ' ~ 44 ''~ .... ' ~, ::--' ~;-. i -,~,~:: CERTIFICATE OF NSPECTION FOR HEALTH AUTHORITY-APPROVAL OF. ON-SITE SSWER AND WATER FACILITY, FOR SINGLE FAMILY DWELLING · Parcel I.D. # ' .(~',)~/~r'~ 2. q"-),,_,~, '~,~;'3 HAA # ' ~f~qF"{~'"l(r~ · 1. GENERAL'INFORMATION (Must be completed prior to submittal) - ' (a) Legal Description (include 10t, block, subdivision, section, township, range) H¥1en Crest Lot-2, Block 1 T14'N, R1W, Sec. 8 Location (aodress or directions) 21026 Upper Lowland Ave. (b) Property owner Emily Chamberlin Telephone: (home) 694-1644 Business 552-5268 Mailing Address 21026 Upper Lowland Ave., Eaqle River, Ak. 99577 (c) Lending Institution N/A Telephone ' Mailing Address (d) Real Estate Company and Agent Rema× / tv[arty Stienr±ed Address 16600 Centerfie±d Dr±ye, Eagle River', Telephone f907) 694-4200 (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: 99577 Pickup by Engineer 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms 3 3. WATER SUPPLY Individual Well [] Community [] Public [] Note: If community w?l.system, ~ust-have written confirmation from the State Department of Environmental C0nse~vati0n~attesti'ng ~0 th]eg~iit~;an~'~t~bs.' .... , ' , ', '~ ''. '.' '"": " ' 4. sEWAGE DISPOSAL . , On-site [] Public [] Community[] ' Holding Tank[] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 · ' ' '){JOM S,J~IUI6U9 leUOlSSeJoJd eq1 u~ suolsmLuo Jo S JoUle Jo~ elq~suodseJ ~,ou Si e6eJOL~L~V.ZO Xll ed o UnlAI eqJ.'penss! s! eleo!J!lJeo ~ eJojeq e~p eZ,~l~Ue Jo Bu!puel,'J!eq~ pue SeLUOq JO sJes~qoJnd ol XselJnoo ~ s~ s!q~ seop SHHC] eqj..'e>is~lV jo ejel$ eq~ u! peJe~sd~eJ JeeulBue I~UO.SSejOJd ~,uepuedepu~ ue Xq eAoqe ~ qdeJDeJed u! UeA!~ suoq~ueseJdeJ eq~ uodn,{lUO peseq j~AoJddv Xi.Joq~n¥ qJleeH sensm (SHHQ) seo!AJeS umunH pue qll~eFI ~o 1ueuJ1J~dea e~eJoqouv jo X~!led!o!unl/N eqJ. 066I '~I Xram elea ££S66 '~['¢ '~aAT~ 916gZ '~6~£LL xo~ '0'~ sseJppv S6IS-~69 (L06 euoqdelel SaOTA.~aS 5UT~aaUTbUZ :~aAT~ aISeZ u~J!3 to e~ueN 'uo!loedsu! s!q~ ~o eiep eql uo loette u! suo!lelnSe] pue 'seou~u!pJo 'sepoo ele~$ pue led!o!un~ lie ql!A eoue!ld~Uoo u! s! uJelsXs I~sOds!p Jele~else~ Jo/pue XIddns Jele~ ei!s-uo eql 'uo!loedsu! pue uo!leB!lse^u! X~u cuoJt pue Sely eBe~oqou¥ to XMled!o!un~ eql LUO~t peu!e~qo uo!lebu~otu! eql uo peseq leql Xtpe^ ~eqpnt I 'u!e~eq pel~o!pu! eJnlon]ls ~o edX~ pue SLUOO]peq tO Jequunu eql J0t elenbape pue'leuo!lount 'e~es s! uJeisXs lesods!p ]e~eMelse~ Jo/pue XIddns ~eleM .el!s-uo eql leql SMOqS le^o~dd¥ Xlpoqln¥ qlleeH s.ql jo uo!le6!~se^u! Xu] 1~ql XtpeA I '~oleq UMOqS elep uo!lep!le^ eql to s~ pue ole~eq pex!'IIe lees XLU Xq Pe!J!lJeo s¥ NOIJ. VV~UO~NI ON¥ ¥$~/O 'HO~/~$ ~ll~ '$.L$]J. '$NOIJ. O]dSNI 9NIOI^OUd ~l~ 9NI~NI9N~ 'S MUNICIPALITY OF ANCHORAGE (MOA) ~ Heallh Authorily Approval (HAA) CHECKLIST - F,E.~BRUARY 1984 ENVIRONMENTAL SERVICES DIVISION Legal Description: ~-~ ~,~-- A. WELL DATA /¢////~ Well Classification ~ Well Log Present (Y/N) Total Depth Cased to __ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments RECEIVED Date Completed Depth of Grouting · <~'f,,'r ? If A, B, C, D.E.C. Approved (Y/N) .,,'J" Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed i¢~ ~'~ Size Standpipes (Y/N) '~ Air-tight Caps (Y/N) Depression over Tank (Y/N) 14, Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~1//& SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: Iooo%~4 No. of Compartments ~ Foundation Cleanout (Y/N) Date Last Pumped N//~ ;for Temporary Holding Tank Permit (Y/N) N,/'/~ To Building Foundation To Disposal Field To Water-Supply Well -~ ~OO ' To Property Line ~' I O ' To Water Main/Service Line + I O ' To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Type of System Design Length of Field ~ ~7 Depth of Field c¢ ' Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ik~ / ~ To Water Main/Service Line -P TOO' To Property Line IO ~ ~O' To Existing or Abandoned System on ; On Adjoining Lots ~' .~© + ~O' To Cutback (if present) O, l ~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION ,/~/,~ Date Installed Size in Gallons ~ "Pump On" Level at ~ High Water Alarm Level at ~ Tested for ~ Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this i n s p e ct io n, ' ¢ :;:' t ~i;. ": '~ ' i'.: ~;' Signed ,;~. ,.~ ~:. .. . ,. Company P. 0. Box 773294 Date ~,^ MOA No. ?¢~-,z5, 694-5195 Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88i Back / Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 EAGLE RIVER ENGINEERING SERVICES P.O. BOX 773294 EAGLE RIVER, ALASKA 99577 (907) 694-5195 LEGAL: LOT ~ OWNER: TYPE OF TEST: TEST RECORD BLOCK ! , /7/~,j~_~ ~-~-- /~ SUBDIVISION DATE: S- - /z ~IME METER LEVEL LEVEL LEVEL FLOW - LINE NOTES READING IN IN IN RATE PRESURE (WATER IN) MONITOR WELL TANK G.P.M. P.S.I. TUBE NOTE: AFTER INTERVALS OR RECOVERY. TURNING WATER OFF, OBTAIN 4 RECOVERY READINGS A~ lO,MINUTE UNTIL FULLY RECOVERED IN LEACHFIELD. USE SEPERATE FORM FOR WELL SEN[BY:Xerox Telecopier ?020 ; 5-14-90 ;ll:20AM DEO SCRO~ DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN D/STRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 STEVE COWPER, GOVERNOR 563-6775 May 12, 1990 FOR: EAGLE RIVER ENGINEERING Attn; Russel PWSID: #2132~.~ According to the records on file in this office, the ~ ~_~~water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, cRA ? _,(3. ~.nvironmental FiL~i,d Officer VEC:bas MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL 'EALTH ~-~ ,~.~ ~ /L-~~--¢~''2'~ CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date $6ptcrnbC~. 1986 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Block I; Hylen Crest Subdivision Location (address or directions) (b) Applicant Name Bill Vchnckamp Telephone: Home 694-7892 Business 263-9642 Applicant Address 102 Upper Lowland, Eagl~ Riv~, Alaska 99577 (c) Applicant is (check one): Lending Institution []; Owner/builder [~; Buyer []; Other [] (explain); (d) Lending Institution M~rritl Lynch Address Telephone (e) Real Estate Company and Agent H~ta,~¢ Homes/D~¢ Price. Address SRB 126 Eaql& River Road~ Ea,ql~ Rive% Alaska 99577 Telephone 694-4994 (f) 'fvfu~ the HAA to the following address: S ~ S Engineering SRB 196X Eagl~ Riv~r~ Alaska 99577 Ordered by Dale Price 2. TYPE OF RESIDENCE Single-Family I~ Multi-Family [] Other Number of Bedrooms ~-., ~ 3. WATER SUPPLY Individual Well [] Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 SEWAGE DISPOSAL Onsite.[~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) t ENGINEERING FIRM PROVIDII,.,.~ INSPECTIONS, TESTS, FILE SEARCH, D,~, A AND INFORMATION 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 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. 5 & $ ENGINEEEIN6 Name of Firm 5-~6X Address --E~fl[~[ t - Date Telephone / / '-/ 6. DHEp APPROVAL/ ~} Approved Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (1 ~/84)  MUNICIPALITY OF ANCHORAGE (MOA) O~. I~,,~ ,~..~.\O~ HEALTH AUTHORITY APPROVAL (HAA) ~t~'¢~ ~. 264-4720 ~*~ ~ ~ Legal Description' WELL DATA Well Classification Well Log Present (Y/N) Total Depth Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption, Field on Lot If A, B, C, D.E.C. Approved Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/~ TANK DATA Date Installed Standpipes ,~,N) Air~tight Caps (~N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ,2~..~ t To Property Line /(~ "f' To Water Main/Service Line /~'" Course /~, c/, Size /¢.-/,r/.~ ¢,.~f,.. No. of Compartments ~ Foundation Cleanout ~N) Date Last Pumped ~/~'~/C'~ ; for ~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /~'~ ~'/ Width of Field Square Feet of Absorption Area Depression over Field (Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ,~4'~/ Lot ~ To Water Main/Service Line C/E;' /'"'(''' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~' Depth of Field Gravel Bed Thickness Standpipes Present ~N) Date of Last Adequacy Test To Property Line //~ / To Existing or Abandoned System on ; On Adjoining Lots ,~ /¢' To Cutbank (if present) .)~'/,/~ Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that~ I~.~erP~'~[.,r~[N~r conformed to all MOA/and HAA guidelines in effect on the date of this inspection. Signed SR B '[96X Date Company EAGLE RIVER, AK ~)~)577MOA No. ReceiptNo. ' oo! 0o/6, Date of ~ayment Amount: $ Page 2 of 2 72-026 (11/84) ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 BILl. SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 DATE: Sept. 3, 1986 PWS I.r).~ 213289 To Whom it May Concern: According to records on file in this office the I~ZLI~CI~W.~T Water Systemis in compliance with the State Drinking Water Regulations Sincerely, , / aynes'C. Allen, RS ( ~gional Sanitari~ Supervisor , MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF I{EALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date Nov 9, 1984 (a) Lesal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name Shasta Construction Telephone - Home Business Applicants Address (c) Applicant is (check one) Lending Institution Buyer~ ; Other~ (explain); (d) Lending Institution Address ~-~ ; Owner/bullder~-~; Telephone (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: T~pe of Residence Single-Family.~ Number of Bedrooms Multi-Family~-~ Other (describe) 3. Water Supply I~ Community~ Public~--~ Note: If community well system, must have written confirmation from the State Department of Environmental C~nservation attesting to the legality and status. 4. Sewage Disposa~ Note: If community well system~ must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineerin8 Firm Providing Inspections~ Tests~ File Search~ Data and Information 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 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 regula- tions in effect on the date of this inspection. Name of Firm 7~ A Az-~ ~o~ ~ /~z( /~, Telephone Address ~P -3 ~ ? 3-- ~'~, ~z ,..~. ~ -~ /~/~ ~ ~ ~$~ ~'~ : ,',... n / 1., uzsapproved ~ Conditio~ "' ,~x,,:~.v - DHEP Approval Approved for Approved~___ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERI~ IN THE STATE OF ALASKA. TIlE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP 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. (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 A. WELL DATA Well Classification Well Log P~esent (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~sePa~ationDistan~s f~omWell: '~ To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewe~ Line Cle anou t/Manhole Wate~ Sample Collected By Water Sample Test P~sults C~,~ents MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: If A, B, or C, D.E.C. Approved(Y/N) .Z Date Completed Yield Depth of Grouting Pump Set At Sanitary seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public sewer To Nearest sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed /~ ~/ Size /~D~ ~/ No. of Co~%~artm~nts Standpipes (Y/N) 7 Air-tight Caps (Y/N) .~/ Foundation Cleanout (Y/N) ~ession o~ Ta~ (Y~) ~ ~te ~st P~d P~ing~aintenan~ Con~a~ ~ File (Y~) ~/~ ; for~ Holding~ Ta~ High-Wate~ ala~ (Y~) ~ ~ra~y Holdi~ Tank ~t (Y~) ~p~ation Distan~s ~ ~ptic~olding Tank: To Water-Supply ~11 ~ '~ To ~ilding Foundation ~ To ~o~rty Li~ '~/~ / To Dis~sal Field /3- / To ~ter Main/~vi~ Li~ /~ ~ To S~e~, Pond, ~e, ~ Major ~aina~ Course /~ f_ Corm~nts [Page 1 of 2] 2-15-84 Ce ABSORPTION FIELD ~ATA Soils Rating in Absorption Strata Date Installed /~ ~ Width of Field 3~// Square Feet of Absorption A~ea ~ Type of System Design Length of Field ~ ? / Depth of Field ~ / Gravel Bed Thickness ~z/ Standpipes P~esent (Y/N) Depression over Field (Y/N) /t~ Date of Last Adequacy Test /D/~d~-/ ~, Results of Last Adequacy Test ~6/~ c~ ~, Separation Distance f~cm Absorption Field: To Water-Supply Wall ~3D 7~ To P~operty Line /~ / To Building Foundation ~co ~ To Existing or Abandoned System cn Lot /~_ ; On Adjoining Lots ~ w-/ TO Water Main/Service Line /m ~ To Cutbank(if present) /Z/~ C To Stream/Pond/Lake/c~ Major D~ainage Course ~'~ ~ To D~iveway, Parking A~ea, c~ Vehicle Stc~age A~ea ~ z C~-~nts LIFT STATION /~/..~ Date Installed Size in Gallons "PLm~ On" Level at High Water Alarm Level at Tested for Eleet~ical Ccdes (Y/N) Cc~nts Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles ~ing Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, c~ confc~med to all MOA HAA Guidelines in effect on the date of this inspectic~. Company ~/ J~/~/~/ /~ KB1/d5/s [Page 2 of 2] MOA No. 2-15-84