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Home My WebLink AboutHYLEN CREST #1 BLK 2 LT 8 Municipality of Anchorage Page / of ~ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~ O~' PID Number: ~'¢ ~/-/',~Z- Neme: Wastewater System: ,~New [] Upgrade Address: p) ¢?~¢~ ~ ~ ~5~ ABSORPTION FIELD Phone: No, of Bedrooms: ~5~ ~ ~ Deep Trench ~hallow Trench ~ Bed ~ Mound ~ Other L E G A L D E S C R I PTI O N sci, ...n~'. from original grade: ~, ~ GPD/Sq. Ft. Block: Subdivision: Oepth to pips bottom from original grade: Gravel depth beneath pipe ~o,:~ ~ /tY~ 6~/ ~ ~,. ~ Township'. /~ Range: /~ Section: ~ Fill added above original grade: Gravel length: WELL: O New D Upgrade Gravel~ ~/0~ Number of lines: Dis[ance between lines: Classification (Private, A,B,C): Total Depth: ~ Total absorption area: Pipe materi~l: Driller: ~ ~ Drilled: Static Waler Level: Installer:.,__ Date installed: Ft.~ ~ ~ ~/~ ~/ Yield: ~ Pump Set at: Casing Height Above Ground: TAN K ~ ~"MI Ft. Ft. __ SEPARATION DISTANCES ~ Septic ~ Holding ~.T.E.P. TO Septic Absorption Lilt Holding %blic/Privale Manufacturer: Capacity i~ gallons: From Tank Field Station Tank Sewer Lines ~C~ ~ Well ~/~ ~/ ~0/ ~/~ ~/~ Materiah ~ ~ Number °f C°mpartments: ~ Surface w~t.~ ~lA 7 LIFT STATION Lot Size in gallons: Manufacturer: Line /~/ /~/ ~ ~ Foundation /~ I ~ / ~/~ "Pump on"¢~/,level at: "Pump off"~level,/ at: High water~//alarm Pump Make & Model Electrical Inspections performed by: ~" 5d~s/ /~s~ ¢~ ~ BENCH MARK Remarks: ~W~, ~P~ ~b~7 ~¢l v~rZlF/~ ~4¢¢~ 1~¢ CR~ ~ ¢~4/~ ~0~ ~/1¢ %g~ Location and Description: Inspections pefformed by: ~,¢~Y~ ~ Dates:lst ~//~/~'/ ~"-~~'"'"'" ...... 2nd I~1~/~'/ ,,~ ........ ~ Department of Health and Human Services approval %?~{;.'*':&~L,;,¢,:'::"' 72-013 (1/91) MOA 25 Permit No. ~ 3 O~-/-~-'~ Page ~.~ of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION '" P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report 98', ASSUH£D ELEV = J00.0 (NBT TB SCALE) II III I t5'-4' II /,, 35PS[ INSULATION II G~T 8 169 9[PTN (RECORd) RECORD DRAWING ' 8000 GAL SEPTIC TANK W/LIFT STATION SWING TIES, A - g = 33,! $ - D : 74.7 A - E TM 86,0 $ - E = 50,4 B - F = a8.4 C - F = 7.3 MONITOR TUBE SEWER CLEANOUT KEYBOX LEACHFIELD EASEMENT 2" 55 PSI INSULATION WATER LINE 72-013 A (~/91) MOA 25 To: Halmar Electric PO Box 1864 Palmer AK 99645 Ph. 745-8883, 696-8883 CCC Construction POB 770647 Eagle River AK 99577 Date: 03-08-95 Ref: Lt.8, Blk.2 Hylen Crest This is to certify that on site sewer lift station at above mentioned property has been wired in accordance with the National Electrical Code and manufactures specification. Systems were checked and performed as specified in the systems manual. Halmar Electric Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 34%4744 November 14, 1994 Mr. Bradley Gerken P.O. Box 770493 Eagle River, AK 99577 Subject: Lot #8 Block #2 Hylen Crest gl Permit #SW930266, Parcel ID #050-472-77 Dear Mr. Gerken: The subject permit, issued August 2, 1993 by this office for a single family well and/or on-site wastewater system, has expired as of August 2, 1994. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If the on-site wastewater system has been completed and a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as-built inspection report must be sent to this office for review, approval and docmnentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new pen-cdt, the fees are: $320.00 for an on-site wastewater permit; $120.00 for a well permit and $440.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Y, Program Manager On-Site Services JC/kb cc: JeffA. Garness, P.E. PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930266 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES OWNER NAME:GERKEN BRADLEY E & MELANIE M OWNER ADDRESS:P.O. BOX 770493 EAGLE RIVER, AK 99577 DATE ISSUED: 8/02/93 EXPIRATION DATE: 8/02/94 PARCEL ID:05047277 LEGAL DESCRIPTION: HYLEN CREST #1 BLK 2 LT 8 LOT SIZE: 20041 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SE.PTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: SOLID PVC PIPING FROM LIFT STATION SHALL CONNECT TO PERFORATED PIPI~AT MID/~7 (40 FT. FROM EITHER END). RECEIVED BY: ~ J/~/~-~(/\ldll~--- - DATE: Alaska Water & Wastewater Services July 1,8~ 1,993 Municipality of Anchorage [)epaFtment of Healtln and Human Services Division of EnviFonmental 8ecvices On-Site Services Section P.O. Box 196650 Anclno rage, Alaska 99519-6650 "Preserving the Last Frontier" Hylen CFest .~TE). divieion. To ~hom it may concern- Attached is 'the application, site pi. an and design . rep the subject septic system replacement. Comments regarding tine pcoposed system are as follows: 1. TRENCH DESIGN: As can be seen from Feviewing tine attached percolation test results, the so~l "perked" at 26.7 minutes/inch in the upper 5 feet ef soil and minutes/inch :i.n the 5-10 foot soil layer. "ro be/ c::onsenvative, I am using the 26~7 minut, e/inch pencolatio~/ Fate fo~ the design. For a trench system¢ this co~ X~t:O an applicatien rate ef .6 gpd/fb2. Since Based upon this, the minimum amount of absoFption aFea l~~ ftz, 'rise pfc)posed lsr-enoh is 8 feet deep and 80 fee~ ],on~ pPeviding an absoFption area of 1280 fta. This design ,~'is conservative. 2. LOCATION OF CLEAN-OUTS: I-he olean-outs, nermally Fequired immediately downstream fFom t. he septic tank, will not be provided if a STEP tank is used s~nce they weu].d not be functional, l'f a separate lift station :i.s pFovided a'fteF t, he septic tank, the clean-outs ~ill be pr'ov~ded. 5. TOPOGRAPHY: 'The subject tr'ench will be installed on a slepe ~h~oh has an approximate gFade of 50~. Since theFe rio aFea on the property ~hich has slepes ].(:}ss than SOt an alter-native site cannot be selected. Consequently, r"eques~,ing a ~aiveP to the 25A maximum slope requirement. I will require the vegetatien of all slepes doNnhill from t, he trenches to minimize tshe potential for wasi:,eNate r ll. eachir~g c)ut the side of the hill. Furthermore, I be].eJ, ve thab the mastewaber 'from the trench will move downward rather rapidly through the sand layer Father than migrating horizontally to khe hillside. Telephone - Fax 338-$246 · 8471 Brookridge Drive · Anchorage, Alaska 99504 4. Absenoe of Surfaoe Wabers & Subsided Groundwater: /2fJe ~;/td¥'~' af'E~ areas ~h:ch ~ou]d norma22y /'¢av~' ¢'Uf~f'~J:~ff ~8~'~'~' ~'~ ~'/'~d'l¢~ bu~' d~'d' OU~'t'et~ly d~'>', Zn addition, khe dry ~eather may have signi'fiicantly altered the normal gr'ound~ate r profile, Oonsequen~ly, ~,~ ~,s poss~,ble bhat future ground~a~er monitoring on ~his pr'oper~y may ind~.ca~e bhe presenoe of ~a't;er o],oser to the ground sur'l:ace. .ii: am unaware off any impa¢;ks that. impose on adjacent water), or septic systems. call me a 557--6,1.79. this ins't;allat:i, on wou~/,d (neighborhood is on community If yotl have any quest.~,on, p16;ase Ge rkenl. N P,'i!; LOT t~ L. oT' I0 CE-7953 CE-7953 Municipality of Anchorage ' DEPARTMENT OF HEALTH & HUMAN SERVICES 8.25 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG-- PERCOLATION TEST LEGAL DESCRIPTION: ~r,~/....~_~ Cv'Z.~c/'[-' ~/.~> ~,o~pe~D ... t,4 5Po'S'5 1 2 3 Township, Range, Section? /"J/,~ SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S ~donltorlnD? __l-(' O _ 18 19 20 " Gross Nat ' I~opth to Reading Data Time Time .'- Water Drop PERCOLATION RATE .-~ ' 1(~ (minutes/inch} PERC HOLE DIAMETER 4,,o &,E' : TEST RUN BETWEEN c~0~ FTAND /~3. FT /::)il ER ORMEDB : , CE.T, THAVHiSTmWA .poR O,. ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE: '7/1~/'~i~.~ · . 72-008 (Rev. 4/85) PERFORMED FOR: LEGAL Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 8,25 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG-- PERCOLATION TEST 19- 20- DESCRIPTION: · ~ ~,:,. ....... .::;b,~.~ , / DATE PER FOF~M'~ Township, Range, Sectioni' ~/,,~, ~- '~x:)$~- i,o u'f'f'~2' SLOPE SITE PLAN / /, J,, J~ /m C1 WAS GF~OUND WATER ENCOUNTERED? DEPTH? Oeplh lo Waler Alter Monllorlng? IFYES, ATWHAT / ,.~ (~ P Gross Net · Depth to Net Reading Deto Time Time Water Drop z zo ~o ~Vz g 3~ lO ,. ~V& ':OMMENTS PERCOLATION RATE 4' "7 (minutes/inch) PERC HOLE DIAMETER TEST "UN "ETWEEN '~'~FTAND V'~) FT ' PERFORMED BY: ~ ~J~ I ~_~:~'~"~ CERTIFYTHAVHIS~STWASPERFO.MEDIN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON T~IS DATE. DATE', '7,/17/c72 ' 72.008 (Rev, 4/85) • 567 970 ••- j;"" Municipality of Anchorage °• �� • On-Site Water and Wastewater Program tFi i ; (907) 343-7904 ��. `Y 4 Certificate of On-Site Systems Approval ` hw C� 01 6 8 L Parcel I.D. 050-472-77 Expiration Date: � Z.3 - ( 1. GENERAL INFORMATION Complete legal description Hylen Crest #1 Block 2 Lot 8 Location (site address) 10255 Silvertip Circle Current Property owner(s) Ray & Becky Quenneville Day phone Mailing address 10255 Silvertip Circle Eagle River, AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: O Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System Q Public Sewer ❑ WaiverNariance request for: Distance: Received b � V Date: _ COSA to be released`o the enginee, I e erwise requested b th engineer. COSA Fee $ Waiver Fee $ Date of Payment S/ZQ 117 Date of Payment Receipt Number 6Tl cl`9 Receipt Number COSA# C 17lA3cl 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. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 5/24/2018 OF Aq‘kk 6. DSD.SIGNATURE V. / /& System #1 Approved for 5 bedrooms 'ceven R. Pannone: fa g.•. CE-8149 ." System #2 Approved for bedrooms s , .• Disapproved � � `-9) nOFESSu ,, . Conditional approval for bedrooms, with the following stipulations: ectrA 'e( S e, <<` �s 20 . n 1..)) Q��\�,I nF /ajvCryG . N P ER E\NMER O. �W PROGRAM C- fin'?c ,_�,�0�t\C• By: �•_..(-.- Original Certificate Date: C —( 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 blue sheet_f ,. If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system 1 Certificate of On-Site Systems Approval Checklist ) Legal Description: Hylen Crest #1 Block 2 Lot 8 Parcel ID: 050-472-77 A. WELL DATA Well type Public If A, B, or C provide PWSID# AWWU Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) in. FROM WELL LOG AT INSPECTION Date of test _ Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material S.T.E.P./Steel Date installed 10/1994 Tank size 2000 gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) Y Date of pumping 5/23/2018 Pumper One Stop Pumping C. ABSORPTION FIELD DATA Date installed 10/1994 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.6 GPD/SF System type Shallow Trench Length 128 ft. Width 5 ft. Gravel below pipe 4 ft. Total depth 7.0 ft. Eff. absorption area 1280 ft2 Monitoring tube Y Depression over field N Date of adequacy test 3/2/2018 Results(Pass/Fail) PASS For 5 bedrooms Fluid depth in absorption field before test 16/6 in. Water added 750 gal. New depth 19/10 in. Elapsed Time: 120 min. Final fluid depth 16/6 in. Absorption rate >= 750+ g.p.d. N Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date D. LIFT STATION Date installed 10/1994 Size in gallons 2000 Manhole/Access (Y/N) Y "Pump on" level at 42 in. "Pump off' level at 38 in. High water alarm level at 43 in. Datum Bottom of Tank Cycles tested Meets alarm&circuit requirements? Y E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS Survey on file. �� `\kv G. ENGINEER'S CERTIFICATION -hi7oFt I certify that I have determined through field inspections and �'<P• ,, •• 4 review of Municipal records that the above systems are in 01 • .` !- %\ *-fir conformance with MOA COSA guidelines in effect on this date. 0••• �I Steven Pannone •` • ••/ Engineer's Printed Name i •Sleveri 13. 'annone: l Date 5/24/2018 ��9s.•• CE-8149 COSA canary sheet_2-6-15.doc MUNICIPALITY OF ANCHORAGE ............. (Development Services Department h+ T On-Site Water 8,Wastewater Section :� Phone; 907.343-7904 , ter. Fax: 907-343-7997 Lift Station/Pump Vault Maintenance Log Owner 0 eN e. Street Address rJ Septic Tank: S /o,Qeo �.Zyar�". "Sludge level inches -Pumping: required Ll $ o Y s -Pumping completed ns "Pump basket cleaned Cat no -Effluent filter cleaned ALDs2 �� -Control floats cleaned pa no -Proper float settings confirmed nq 'Operation satisfactory fit$ SEs 'Dedicated electrical alarm circuit no -Audible and visual alarm Inside dwelling -Alarm system operation ! � -=J�i�i�'i •t .ti a . Mnho(e Riser -Ground water intrusion at riser to tank connection yes -Ground water intrusion aroundtine penetrationsye �� 'Weep hole functional lid no 'Manhole ilcf: Functional (I rip Insulated a no Properly Secured . , n• MT: er -All manufacturer required inspections and maintenance completed iiitg Lam men .1 uaeci A FiflAairtt�pancergylger: Tpchrtici$6----Th__c_. 2._._ca Date of msintenancei Company Signature . �� Date2.4 /$ rviliiuvl Af1dr:'s; P. 0. 8c t 1913Gbo'Anci,craqn.At.?sE•:;r 9i1'.519•(TG5;1's „'�,.owtri.oro :.:' '" .' .... . j,,'"~"~: : '/MUNICIPALITY'OFANCHORAGE :'~'":;:."'~;?:: '~'/~[t'~!?~!?"-r~F:?':':' '!/.. _.: ~ .- :(~ ':" '~' ~?':~'~'d~;~'-:'::~;;~::.~(~:~? DEpARTMENT~OFH~LTH &"HUMAN SERv CE8 - ~"; ~'~ ................... ....... P,O, Box196650 Anch'orage;'Alaska~ · _ ~ a'_:-:. '-': , :" ' ~:j.,,' ;.~;.~:~..:3'.~:.'~.2:'.~ .... ,;~47~ .;:?::: ' :'- - ':-' '"'")./:~:~PPROVAL FOR ASINGLE FAMILY DWELLiNg"'7 '~'.--- 'Parcel I.D.~ '050-472~77~'~: ' ::'/::'73'/' -; ~ i-:.~;~5~;j?' :':-:'.::' H~ '.-Fl AqCo] o~ -.- '. -- '.~. · . . ~.:...~..,,.. ...... ~ ..... ZZe C est ~Z .. ~ 8,,,BZ~ 2 ............. ~.~. %~?} x... :'...,.¢:~:~ :,Location (s~te address or dlrect~ons).~~'~ ~-' . ...... ~ ........ ~, ProRe~owner. 7 Da hone - 7 ........... .:.5.,'/-.:.-:~h:-;:.~:~2~a[hng add[ess '. r P :O' ~X''770493 ~ Eagle Rzver, ~ ' 99~77 ' · ' ' -' ~ -'-' :--:'vF'----":"~':?;~:vC(/.' ~- ?.- -:-: :.?.-,, .¥:.r~*:,,.- .7 -,.~:*r..,,~ -'..~:-.-~. -¢~-/A~.~,-_-. /z,: .:..':e ~h%'.- ".'q ~ :?',:?r:r:.:. ;Z' -."~ 7 ;: ........ ." ":~' ~" ~' ""-~ ~:?' ;';X4~ ~;~:e?::~?'~. '-'"~:' ': :?~': Lending agency~' '"~':~::2~'' -' ........ " ' Davphone ' ' · '"~:'"'~'~::'~'~'~'~'. ..... ' '. ;;'" ' 4.'"':t 'OF ' ' DISPOSAL.' * :.:~'.', ..'.':. ',~:h':'.': : : ' :'-' ;,_,,, ] ~:-~'F~ ,, .:F:.-~..r:,,, ?'.2' ..... . .,-:.. ,~ ......... , ....... Pub csewer..~ .... ~ ..,~ , · ~ ........ ] ~., .. "~.,: .'- :c:: ~::~: ':;:? '~',-/, : : . :,~:-; ~ %': fi;;,:.:~.~z~'-~':. :~ ~ ' :': : ',~ '~?~¢;'-"' '-'*.'~.~:~,~?~?~?F :: . - -:,.'. :-:: -,. :;.:: :: NOTE: ::':~ If commum~ was~atersYstg~,',provide wri~en COnfirmation from State:~DEO ,~:,;~:~::: .- ' : :.' :. a~estmg to the legah~ and status of system.' : ~. ¢ ::::~':~:' .::: ::::. :¢:.-s;,-:;;?';':_,:;:;: ..: :: 12~(R~, 1~1) Fro~l ~OA~I .' ': ": ' :. .: :': ': ': :::: : .... · 5. STATEMENT~OF INSPECTION BY ENGINEER -~ ..... ..--~ ...... ~,-.~ . .... · ...... '-'. '-*-'.~'~¥..-~, ?' As cerhhed by'my seal,affixed hereto and as of the v~li~la~i0n ~Jate sh6~r¥.b~l~3~, l, ~/~['lfY ·that my and type of structure indicated herein. I further verify that based on the information obtained, from .~ ~.: the MunicipalitY of AnChorage files and from my inves!i_gation and inspection; the On-site '. :.. -' . supply and/or waSteWat~i~Idisposal system is'in C°rn pliance with all Municipal 'and State codes, ....... ~-.~.~= 6~.~,.:, DHHS.,SIGNATURE -?{ ~ '~' :': ~¢ ~(~p~OVal'~e~i[i,~: ¢~' only Upon the loP[eScOrt ons gi~e~ 0,, p~ragrap~::~..~bb~ej.~i ~9,} ~depend.e~f:~)~;}~? :: ~ ~.~ ~ ~. pfe sona'e~ ~r~ ster~ ntheStateofAlaska. TheDHHSdoesth sasacou~ytopurch~emo homes'~%;~:~ : ;: "-:? ::'.';:)~:~d~t~'ih~$~t eries '0'~-~:~h~i~e"data before'a Ce~iflcate ~is issu~::,lhe ~ufiicipali~bf,:~Afi~horage;is:~not :~:~?~ ,~ ~,?~mspons b e for errom or om ~lons in the prof~lonal engln~ffs wo~. ~. ::~.,;,~ :,; ~¥,~ ,.., ;,. ~.~ .,~;~;: ~<.~, ~,:?,, ,.~:,:.~;~ ~. :~,,~:-:~.. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type ,PuCL./¢_.- Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test ¢,/2,8¢~' ¢// Parcel I.D. 0¢(,2 ~'~ If A, B, or C, attach ADEC letter. ADEC water system number FROM WELL LOG Static water level Well flow Date completed Driller Cased to Wires properly protect~/~N~''~ight ,~,NSP ECTIO N Pump level1 SEPARATION DISTANCES FROM WELL~: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line/~ WATER S~ RESULTS: C~_ ~ Nitrate /B'ate of sample: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria B. SEPTIC/H~L-DING TANK DATA Date installed /D/<~ Y Cleanouts (Y/N) Y~ High water alarm (Y/N) Date of pumping /~/A Tank size ¢.O420 Foundation cleanout (Y/N) Compartments )/~¢ ~ Depression (Y/N) Alarm tested (Y/N) ,/'///C- Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ./"//~ To property line /~ ! Surface wateddrainage On adjacent lots ,/'//,4 Absorption field ~ / J Foundation Water main/service line 72-020 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons ~0 Vent (Y/N) )/¢ ~ High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) L/'~ ¢' "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot /'//,4' On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed / Length ./~...~' (r~,¢,~) Width Total absorption area Date of adequacy test /"//,4- Soil rating (GPD/Ft2) ¢, ~ System type ~/¢/¢£/..Db2 ~",-e~,~,~.) Gravel thickness /?b ~r~ ,o ~,..¢ Total depth Cleanout present (Y/N) ~¢5 Depression over field (Y/N) '~ Results (pass/fail) /¢~ ~ ~c~ for ~ Bedrooms Water level in absorption field before test /"//-'¢ ¢ /'/¢ ~ After test /',//g- Peroxide treatment (past 12 months) (Y/N) /'7./.4 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ]'//,'¢ To building foundation / ~- / On adjacent lots -/' Sudace water //V///~ Curtain drain On adjacent lots ,/"J//~ Property line To existing or abandoned system on lot Cutbank /V'/~ 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 ofthN !n~pecfion. En ineer's Name DDt/5 ~7~, ~ · HAA Fee $ r~ ~ ~ Waiver Fee $ Date of Payment ~ ' ~ ~ '~'/'J --., Date of Payment Receipt Number 7',..{-~C/ ( /~ /~ ) Receipt Number 72-026 (3/93)* Back -~