HomeMy WebLinkAboutHYLEN CREST #1 BLK 3 LT 10Hyl
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lock
Lot 10
050-474
-06
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 e Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
. Permit Number: ~ I¢--~ C~ ¢~'4~::D 1 ~ h~ PID Number:
~"~;,~.~_,~0_.c.~,% L~ ~~ ~ ~astewater System: ~ew U Upgrade
Address:
~o ~ ~~~, ~~ ABSORPTION FIELD
Phone: ~' 1~1~ No, o~o~: ~eepTrench U Shallow Trench ~Bed ~Mound ~Other
LEGAL DESCRIPTION Sog.~t~n~: ¢'~ GPD/Sq. Ft. Total Depth from origin~l ~r~de:
L. ot~ ~ ~BI°ck: ~ ~~Subdivisi°n:~~ / Depth to pipe botlom Irom original ~ Ft. Gravel depth beneath pipe ~ /Ft.
Township: Range: Section: Fill added above original grade: / Gravel length:
WELL: ~ New ~ Upgrade Gravel~:~l ~ Ft.
~lassification (Private, A,B,C): Total Depth: Cased To: Total absorption area: ~ Pipe materiah ~ I~
Driller: Date Drilled: Static Water Level: Installer: Date installed:
Yield: Pump Set at: Casing Height Above Ground:
e.~ ~,. ~,. TANK
SEPARATION DISTANCES ~,t~c u ,o~in~ u
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons:
From Tank Field Staiion Tank S .... Lines ~*~ ~
Well ~¢+ ~,~ ~ ~ ¢~t~ Materia~¢~ Number of C~artments:
SurfaCewater /~¢~ /0~ ,+ ~ _. ~ LIFT STATION
LineL°t /~ I~ /~¢~ ~ ~ ~ Size in gallons: Manufacturer:
'--Foundation- /¢1 / ¢1 ~ ~ ~ "Pump on" level at: ~~' I~el at: ~i~i water alarm at:
/I
~.- - C~rtainDrain ~ ~[0~ (~0~[ ~ ~mp Make & ~,~ ~ctr~al Inspections performed by:
Remarks: BENCH MARK
Location and Description:
I Assumed Elevation:
Inspections performed by: -~ ~ ~d ~¢~t~Dates: 1st_ d-ioz 9¢ ~ '"-'-'<"'¢'" ......
Department of Health~dcHuman Scryices approval '¢-~ ~. --
Reviewed and approved by' Date' Z,~
72-013 (1/91) MOA25
Permit No. ~ [,'-.J ~ ~ J 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
Legal Description: '~/["~'~ C--~T'~ I ~".~[~:~,J/-~ '~ L.O'T )0 PID No.:
N
72-013 A (2/91) MOA 25
;EAL
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES /~.~6.
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PAGE 1 OF
PERMIT NUMBER:SW920010
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:EAGLE RIVER VALLEY DEV
OWNER ADDRESS:12801 REATA ROAD
ANCHORAGE, AK 99516
DATE ISSUED: 1/31/92
EXPIRATION DATE: 1/31/93
PARCEL ID:05047406
LEGAL DESCRIPTION: HYLEN CREST #1 BLK 3 LT 10
LOT SIZE: 20025 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
DATE:
DATE:
ROBERT SHAFER. P.E.
ROGER SHAFER. P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694 1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
January 28, 1992
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, AK 99519-6650
REFERENCE: Hylen Crest Subdivision #1; Block 3; Lot 10
We request you issue a permit to install a septic system to
serve the proposed 3 bedroom house on the referenced property.
The approximate locations of the test holes and proposed leach
field are located on the attached site plan. The ground water
monitoring tube within the hole has been checked and found to
be dry.
This property is served by a Community water system. There
are no protective well radii which encroach upon the property.
As can be seen from the attached site plan there is sufficient
area for a septic upgrade. We do not anticipate any adverse
effects on neighboring properties by the installation of the
proposed septic system.
If you have any questions, or require additional information
for your review, please contact us.
Sincerely,
Sh~fer, P.E.
RJS/lsu
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER. ALASKA 99577
SCALE
Omlr~
Septic Design
z
oz >~
mo oo
7~ o~
7-<
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION."~I._~LOC'~AE"-- ,t,~ Lx~.-i- IL'5') Township, Range, Section:
10
11
12
13
14
15
16
17
18
19
2O
SLOPE
IF YES, AT WHAT
DEPTH?
Depth Io Water_A~.r..
SITE F'LAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
S & SENGINEERING
t703~ P-.agie River Loop Road J~O,-, .~ -- ,~-- t
PERFORMED BY: Eagle River: Ala~l~a
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev, 4/§5)
PERCOLATION RATE i ~ (minutes/inch) PERC HOLE DIAMETER ,,~ II
TEST RUN BETWEEN (~ _FTAND '~]~ FT
CERTIFY THAT THIS TEST WAS PERFORMED IN
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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 FAMILY DWELLING
Parcel I.D. 050-zt?zt-06
1. GENERAL INFORMATION
Complete legal description
Expiration Date: G- ~..c~_/~
HYLEN CREST #1 BLOCK 3, LOT 10
Location (site address) 21309 LOWLAND AVE., EAGLE RIVER, AK 99577
Current Property owner(s) MICHAEL & MARY MONTGOMERY Day phone
Mailing address 21309 LOWLAND AVE., EAGLE RIVER, AK 99577
Lending agency,
Mailing address
Real Estate Agent
Mailing Address
Day phone
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBEROF BEDROOMS: 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 E~]
[] Public Sewer E~
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 sample results. (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 vedfy 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 06/22/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a ' .~~i.'...'
system will function satisfactory for current or future ~.:~i'::~2:~ ~.
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist. :.;~' ;~':~" '"' ~ F~?~-~::~.'~.
DSD SIGNATURE '!~!'
g'/'/' Approved for ~.~ bedrooms. ~.~.:~.~.-:':~:'.'~:,~.~'
Disapproved..' :'~~"'.'" . '
Conditional approval for bedrooms, with the following stipulations:
0N,SITE
WATER AND
WARTFWATFR
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Date completed
Total depth f.
Municipality of Anchorage
Development Semices 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 CHECKLIST
Legal Description: ]-]YLEN CREST #1 BLOCK 3, LOT 10
A. WELL DATA,
Well type PtTB[,I¢ IfA, B, or C provide PWSID #__
SanitarY seal (Y/N)
Cased to f.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/10OmL Nitrate
Arsenic: __mg/I Date of sample:
B. SEPTIC/HOLDING TANK DATA
mg/L
Collected by:
Well Log (Y/N)
Parcel ID: 0~0-47~4~6
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
Tank TypeAdaterlal Septic/Steel Date ir~talled 3/10/1992 Tank size 1000 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) N Date of pumping 6/20/11 Pumper ~
C. ABSORPTION FIELD DATA
Date installed 3/10/1~)2 Soil rat. ing (g.p.d./ft2 or ft2/bdrm) 0.8 System type Deep Treach
Length 41 f. '..Width 3 ft. Gravel below pipe 7__ft. Total depth 11.35 ff. (Measured 6/20/11)
Eft. absorption area 57z~ ft2 Monitoring tube Y
Date ofadequacy test 6/20/11
Fluid depth in absorption field before test 58.2 in.
Depression over field N
Results (Pass/Fail) Pass For 3__ bedrooms
Water added ~10 gal. New depth 76.2 in.
Elapsed Time: 1415 min. Final fluid depth 63 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N___lf yes, give date __
LIFT STATION
Date installed
"Pump on" level at __
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at __
Cycles tested
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
Manhole/Access (Y/N).
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
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'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line :10'+ Building foundation :10'+
Water Service line :10'+ Surface water 100'+
Curtain drain 50'+ (No~e Know~)
F. COMMENTS
System operating in the upper third of the cffeetivc depth.
Absorption field 5'+
Surface water 100'+
Date of Payment
Receipt Number ~-~1::~
(Rev. 11/05)
Date of Payment
Receipt Number
G. E.GI.EER CERn.CATION
cet'J'/Ty
I that t have determined through field inspections and
review of Municipal records that the ebove systems are in
conformance with MOA COSA guidelines in effect on this date
::::n:~P:lnted Name :K:ENNF. TH M DU]rFU$
COSA Fee $490.00 Waiver
Driveway, parking/vehicle storage 10'+
Wells on adjacent lots 200'+
Water main 10'+
Municipality of 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 HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D, 050-~47-406'
,%
· "~i C.~/nplete legal deScriPt.ion Lot
"' "Location (site addr~ss'b'r directions)
~urrent Prop~r~y'owneFis) ]~ nb ~I n
· '";. 'Mailing address.·., s am e
lO;
Expiration Date:
Block 3; H¥1an Crest Subdivision #1
21309 Lowland Ave. Eagle River, AK 99577
Callaway Dayphone 696-0220
Lending agenby
Day phone
Mailing address
Real Estate Agent
Day phone
..Mailing Address
"~]nless otherwise requested, HAA wi//be held by DSD for pickup.
'2. NUMBER OF BEDROOMS: 3
¸3.
TYPE'oF wATER SUPPLY:
Individual Well
· Individual Water Storage
community class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
3[~] Individual On-site .~](
[] Individual Holding tank []
[] Community On-site .ri
[] 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 4 by an independent professional civil
engineer registered in the State of Alaska. 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. (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 p~Jblic water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
STATEMENT OF INSPECTION BY ENGINEER
As cedified 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 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.
NameofFirm ,S & S Engineering ~ Phone 694-2'979
Address 1703/4 N. Eagle' River Loop STP_. 20/4 ~.~1'~,
Engineer's.Printed Name 'Robert C. Cowan
DSD SIGNATURE
~ Approved for ,_'~
Disapproved.
Conditional approval for
bedrooms.
River, AK 99577 Da.te ~/!
z~ CE
cE.88o
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
By:
Original Certificate' Date:
(Rev. 01/02)
i MuniciP,a,lity of Anchorage
DevelopmentServices DePartment
.... ' Builcl'in'g Safety Division ·
On-Site wat'e~ & Wastewater Program '
~: 4700 South BragawSt. '.
P.O. Box 196650 Anchorage. AK 99519-6650
' www.~;i.anchorage.ak.us ,
H
: ' . :(907) 343-7904 : , . ; ~!';
EALTH AUTHORITY APPROVAL CHECKLIST
LegalDescrip!ion: L.,.IO :,T~ '~ ;' .iL..j ',,~i/~,x~ O,~_p~:~-.. ~:: paic
· ,*' '! I:~"' , v - - ~' ::';!,1,';~ '
A. WELLIDATA: . ; ,,'.: i '~. .. . '", , ,2 .?
Wellty~e [?~ ~[ IfA a orCg~o ePWSID~ ' : ' WellL0g'(Y/~ . .
Date completed, _ . San~lq' seal ,~/N) . ' W~res properly p;~ected (Y/N)
Total depth ;. ,~ ". ft. . ~se, Jto . k E. ; : . ' Camng hedge(above ground) -In.
, :!;~ :~;~ '- FR( M~ELLLOG '~,i:' ' ' ,ATINSp~cTIO~~:
], ,. . ., ff. :
Well production '/ ~ , . ~ ?~.].p.m. ', :: .' ~ /. ' ,' ;:{~ r~.p.m.
WATER~SAMPLERESULT ;' .,, ,; ~;~ ~' ': . . / ~, : . :~,; '
Cohfor~ ~ ,~ I;~. '~lonies/100 mi. Ntrate i ' ~ 'mD.Il.. ../' :..Other bacteri[, .colonies/100 mi.
ArseniC:'~ I::l :/mg.,..,.,. . . . Date*f.~am~le:,' ~'Collected;:ky:~''~_;
B. SEPTIC/HOLDING TANK DATA t . :~i~ ' - ....
Tank~ype/Matetial~ '.' · 5~ ~ ~' h~' : ', ~, ' - Dateinstalled~:~/lO/~Z
~,~[, ~_. ...... ~", , ,t' , . ~ .- .'"r~: '..,
Tank s~ IOPO:' gal..' ,:: ,~MEerof~o~pad~ents: ~. : ..Cleanout~'(Y~) - Y~
Foun;;t;dn '' : (;N), ~. '~;,~ssi;~/~;er,iank (Y/N) ~ ~;Highwat~;'al~rm (~/~ ~.o
C. AasoRP, TIONFIELOBATA~, .'.':~;~ ; : ~'~ .:.' ' ' ' ;.?.~;~
Date installed ,f.3/I fag , Soil rating ~orft Ibdrm)' ~ _System type~ ~
Length'~ ~ l- ft. '; · WidthS, ,L,')" -~ fl.' ' Gra~l~iow'pipe ~
' ' ? '~ ' ' ' ~ : .... '~i'" ' '
.~ , ~ . , J ~ ~ ' . ,, . - , , ~ ,~, ,
Total depth,~ti J;~t.. .'Elf. absorption area~?~ ft Monitoring tube~ V ~.:Oepression over field
Date of adeq~acY test ~/~/0~' [ ,? ~. JResults (Pass/Fail)~~ - . {.~ ~[~, ..For ~ bedrooms
Fluid depth in absorption field before test ff~;'in. ~ .Water added ~gal.~. 'j'.'i.~... New depth~ in.
Elaps~¢~T,;:~'i~°° min.; '.~. Final fl'u,d ¢~p~t'h'-~in.~ ' ~: Absorpt,o~ ra~ >=.: ~ g.pd
Any reJuvenation treatment (Past 12 mo.) (WN & type) ':;- ~ ; : .If ~s give date
D. LIFT STATION
' Date instailed
"pUmp on level a~7/_~ in.
Datum ~/' .
E. SEPARATION DISTANCES
Size in gallons
"pump off level' at~
Cycles teSted '
in.
Manhole/Access (Y/N)
High Water alarm level at
Meets alarm & circuit requirements?
SEPARATION DISTAN(~ES FROM WELL 'ON LOT TO:
septic tank/lift statiOn On lot'. / '~
Absorption field on lot ....... . /
J
On adjacent lots.. /i
/
On adjacent lots
HoldingPUblic sewertank manh°le/~0ut'
Public sewer main : ,
Sewer/septic service line ="
SEPARATION DISTANCES FROM SEPTIC/HeL-BiNG TANK ON LOTTO:,
AbsorPtion field
Surface water
I
Building foundation
Water main I (~ ~--f- .Water service line t (~ ~.,L
Wells on adjacent lots ~/-~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water Service line
Curtain drain
F. COMMENTS
Water main
lO' ~ '/' '. Surface water ,/0 0 /
Drive. way, Parking/vehicle storage
~'~ ~o,~ ~ ', Wells on adjacent lots ".
in.
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 HAA guidelines in effect on this date.
Engineer's Printed Name .~.t
Date " ~, // ~/4) ~ '"':',
.AA'Fee $
Date of Payment
Receipt Number
(Rev, 12/01)
Waiver. Fee $ '
Date of. Payment
Receipt Number
06/14/2004 00:46 ' 5521674
·
.I
3 A~ C~m PAGE 02
A~I3UJLT .
I MERRily' ¢£RTIFY .TH-AT I I. IAV'£ SURVEYED THE
FOLLOWIN~ DESCRIBED PROPERT'r~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~) ~C~) - ~-t~t-~- ~C){.p
1. GENERAL INFORMATION
Complete legal description Lot
10,~ Block 3; Hylen Cr~st ~ U J
Location (site address or directions)
Property owner Bethard ConstructiOn Day phone
Mailing address 12801 Reata Road, Anchorage, Alaska 99516
345-1615
Lending agency
Day phone
Mailing address.
Agent Day phon. e '
Add ress ' '~
Unless. otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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 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
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alasl<a 99577
Engineer's signature
Phone
Date
DHHS SIGNATURE
Approved for ~/,-~ %//~_,,~ be d ro o m s.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: . Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based onty 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.
724)25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: _~ C::) ~L.-~. -2~ .~Parcel I.D.
^. w.L, D^TA''/ t
Well type /~ If A, B, or C, attach ADEC letter.
Date completed
Log present (Y/N)
Total depth Cased to
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
ADEC water system number
Driller
~<21 ,p
Casing height
MUNICIPALITY OF ANCHORAGE
Wires properly protected (Y/N) ENVIRONMFhjT,~ ~. ........
......... ~'.-~zo uWISION
AT INSPECTION
t992
RECEIVED
g.p.m, g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts ~g)/N)
High water alarm (Y/N)
Date of pumping
Tank size \ C:~¢;~:~ Compartments
Foundation cleanoutd¢~) "'/ Depression (Y/4~
Alarm tested (Y/N)
Pumper
SEPARATION DIST~AI~CES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I~/~ On adjacent lots "~'¢;>C;> I''~ Foundation
To property line I~::'~ ~ Absorption field ~.~ Water main/service line
Surface water/drainage / <:;l~I Jo
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at'
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length '¢::~ ~. ~ Width
Total absorption area
Depression over field (Y~
ResultS/fail) ~~-'/
Peroxide treatment (past 12 months) ('~j~_
Soil rating
Gravel thickness '"'7 I
Cleanouts present. N)
Date of adequacy test
for ~
~ ¢'~::>~ Sys t e m ty p~~ ~_.t,~.
Total depth
bedrooms
If yes, give date
SEPARATION DIS?ANCE FROM ABSORPTION FIELD TO:
Well on lot ¢/~' On adjacent lots /.~...~¢>~ I...~ Property line 1 ~t
To building foundation ~.~l ~/~.
To existing or abandoned system on lot
On adjacent lots "~ "'~ Cutbank I~ c~ ~-~ Water main/service line ~?::~ I j~
Surface water \ 6::::~~ ~m Driveway, parking/vehicle storage area 2..42:~/"~
Curtain drain k_~ ~::~.~'~ ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect o.~ the date of this inspection.
~,'.:.-2~ .,:~ ~r-;,~
S & $ ENGINEERING ¢;.,, ,.:,,. ,.~. /, % ,. q-.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment .~//~-'~ ", ~ ~
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number