HomeMy WebLinkAboutHYLEN CREST #3 BLK 4 LT 1Hylen Crest
#3
Block 4
Lot 1
#050-474-15
Municipality of Anchorage Page of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
�
Permit Number: SW 96033- PID Number: 050 - 41 %y - /5
Name:
Wastewater System: New ❑ Upgrade
r
Address:
�o zEqziih Rt v ez- 19,57-7
ABSORPTION FIELD
Phone:
No. of Bedrooms:Deep
(1{Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
SoiilRating:
�, Z
Total Depth from original grade: 7
GPD/Sq. Ft.
Lot: Block: Subd...on:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
Ft.
61Z Ft.
Township:
Range:
Section:
Fill added above original grade:
Gravel length: G
-
Ft.
/ Ft.
WELL: New El Upgrade
Gravel width:
z
Number of lines:
/
Distance between lines:
Ft.
"V/} Ft.
Classification (Private A,B,C):
Total Depth:
C ed To:
Total absorption area:
r T
Pipe material: /
Ft.
Ft.
SQ. Ft.
�B�U L? 30 $z -F
Driller:
Date Drilled:
Static Water Level:
Installer:nn -- /
CCC 57✓[
Date installed: p
FL
C�h -c CI707t_.
Yield:
Pump et at:
C ng Height Above Ground:
�/
TAN i�
GPM
Ft.
Ft.
SEPARATION
DISTANCES
Septic D Holding D S.T.E.P.
To
From
Septic
Tank
Absorption
Field
Lift
Station
Bolding
Tank
Public/Private
Sewer Lines
Manufacturer:
,
AAte— -,, j AN IL
Capacity in gallons: _
15 0 o
Well-
f
Zvo 4
/
2004-`
—
r
zDJ -�
Material:
Number of Compartments:
Z
Surface
/UD +
/Uo
LIFT VATION
Lot
Line
r
/ U +
—
—
r
/O 4
Size in gallons:
Manufacturer
Foundation
r
/ U -F
/U
/ -�
—
v
IL) -r-
"Pump on" level at:
"Pump off" level at:
igIn water alarm at:
Curtain
NO//G
OW /7
Pump Make & el
Electrical Inspections p04ormed by:
Drain
Remarks:
BENCH MARIA
Location and Description: II jj
Assumed Elevation:
JVD
ENGINEER'S SEAL
Aw 9X
Inspections performed by: N rcrtr Dates: 1s /o ze v ..� .�v�:.° ° .°...0..�
2nd e .°..a .. ...;...IV
3�2/Kenneth M. D s ��
Department Heal Human �® s� CC ),b
of t and Services aprNroval o°
Reviewed and approved by: Date: 4:_- /-Zz®®F OFF$ 10NP®�
72-013 (Rev. 9/91) MOA 25
A-D=19.8
B -D=13.4
A -E=29.8
B -E=9.6
A -F=44.4
B -F=17.8
B -G=34.1
C -G=28.5
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit SW960327
PID#050 474 15
HYLEN CREST S/D, #3, LUT 1, BLOCK 4-----
Note, Property Served By PubUc Water
0
IWi, a a oo wo
� J
Q U VV
= 100,31
CA
CA
W INSULATION FILTER
a
�o
N 1500 GAL
SEPTEJ IC 95.28
o , / I TANK
A <6 of ALA lk
I QA
t
A
KENNETHFFU' /
CE -71 6 wA7
/AtiApr
hYons910N �w
PREPARE
SEWER AREA
(ORIGINAL GRADE
SEWER ROCK
39'
MICHAEL QUINN CONSTRUCTION
P.O. BOX 772641
EAGLE RIVER, ALASKA 99577
SCALE I" = 50'
0
u
SCALE: NTS
VARIES
1
T
0.26'
_L
81.02' BOB
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
aTE: 3/9/97 DRAWING If
;ALE AS NOTED 96082 -Si
KIND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
Project Name
November 12, 1996
SW960281
Municipality of Anchorage
' ,, V E D
Dept. of Health & Human Services
On -Site Services Section
NOV '14 1996
196650
Alaska 99519-6650
sHealth
AliGhoar.Ancchoage
1l
"'Pt & FumanBl,,
SW960103
Subject: Incomplete on-site construction projects
Gentlemen:
As of this date we have several on-site septic and well permits which have not been
completed for various reasons. This letter is to update your department on those
projects and the reason for the delays in the submittal of the final inspection reports.
Permit #
Project Name
Status
SW960281
T14N, RiW, Sec 6, NE4SW4
Winter shutdown, Upflow filter system
installed; Well drilled; No foundation, no
electricity
SW960103
Woodridge Sub, Blk 2, Lot 1
Well and Septic installed; Have not received
survey as -built or well to
SW960097
Glacier View Hts, Blk E, Lot 3
Well, Septic, and Foundation installed; Have
not received as -built survey or well to
SW950400
Hamann Sub, Lot 5A
Well, Septic and Foundation installed; Have
not received as -built survey or well to
SW960195
River View Est, Blk 3, Lot 1
Well and Septic installed; Foundation not
done, no as -built survey, no well to
SW960226
100 Hills 1st Add, Blk 4, Lot 8
Well, Septic and Foundation installed; Have
not received as -built survey or well to
SW960264
Knik View Est, Blk 3, Lot 14
Septic and foundation in; Have not received
as -built survey
SW960325
Rouse Sub, Lot 1
Well and Septic installed; No foundation, no
as -built survey
SW960327
Hylen Crest #3, Blk 4, Lot 1
Septic installed; No foundation, no as -built
,survey
Respectfully submitted,
1KHD Engineering
Kenneth M. Duffus,
PAGE 1 OF 1
f�d ,[Lim io �Jd/'r6 g r�yJ`ov
MUNICIPALITY OF ANCHORAGE Jro�. °%3(96 G i/•'�o nth
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502�LY>`
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960327
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:HYLEN CHARLES S
OWNER ADDRESS:10215 STEWART DR
EAGLE RIVER, AK 99577
PARCEL ID:05047415
LEGAL DESCRIPTION:
HYLEN CREST UNIT 43 BLK 4 LT 1
LOT SIZE: 20005 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 9/25/96
EXPIRATION DATE: 9/25/97
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 (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
RECEIVED B
ISSUED BY:
DATE:
DATE:-
l��
K14D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
11 - l
(907)696-6111/FAX (907)696-8111
September 30, 1996
RECEIVED
Municipality of Anchorage
Dept. of Health & Human Services SP 0 1996
On -Site Services Section Municipality of Anchorape
P. O. Box 196650
Dept. f-lealth & Fluman Services
Anchorage, Alaska 99519-6650
Subject: Sewer/well permit - Lot 1, Block 4, Hylen Crest S/D, #�
Gentlemen:
The owner has requested that we modify our original permit to increase the
number of bedrooms from 3 to 5. Accordingly we have modified our site plan and
calculations to accommodate this change. Our design assumes a total depth of the
trenches will not exceed 12.0' from original grade. A single 39' trench will be
installed, and additional fill will be added to insure a total of 3' of cover over the
system.
If you have any questions regarding this application, please contact me at 696-
6111/FAX 696-8111.
Respectfully submitted, ,i ,;.i/ ✓L
JUAD Engineering
(L� F
Kenneth M. u fus, P.E.
attachments: Modified Wastewater Absorption System Details/Site Plan
KND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
September 18, 1996
Municipality of Anchorage
Dept. of Health & Human Services
On -Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Sewer/well permit - Lot 1, Block 4, Hylen Crest S/D, #"r Y
Gentlemen:
Attached are soil test and water monitoring results for the above lot. A total of two
holes were found on the property to date. A copy of the soils information and
water monitoring form the other soils test is included for your reference.
Our water monitoring results show no water present. Previous soil tests/water
monitoring show the testholes to be dry including our most recent inspection.
Therefore our design assumes a total depth of the trenches will not exceed 12.0'
from original grade. A single 32' trench will be installed, and additional fill will be
added to insure a total of 3' of cover over the system.
There are no surface water sources within 100' of the proposed design. Drainage
along Stewart Drive will be carried west along existing right-of-way ditching. There
are no known curtain drains within 50' of the proposed trenches. The
development of this lot will not negatively impact lots surrounding Lot 1.
If you have any questions regarding this application, please contact me at 696-
6111/FAX 696-8111.
Respectfully submitted,
KIVID Engineering
Kenneth M. Duffus, P.E.
attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WASTEWATER ABSORPTION SYSTEM DETAILS & SITE PLAN
HYLEN CREST S/D, #4, LOT 1, BLOCK 4
OF AZ4
/ (��,' fir' o
/*gTH* ' �
0 KENNETH M. D S /
CE -7116 �
w
\�404e
dW
4 ()PBSSI()O' AV
Note: Property Served By Public Water
DESIGN CRITERIA
1. 5 BEDROOMS X 150 GAL./DAY/BEDROOM = 750 GPD
P. SOILS RATING1 2 MINJINCH = APPL. RATE 1.2 GPD/SF
3. 750 GPD/1.2 GPD/SF = 625 SF
4. 625 SF /(2X8) = 39 'L
5. MIN. DESIGN SIZE = I TRENCH - 39' LONG x 2' WIDE x 8' DEEP
6. DEPTH OF GRAVEL IS 8' BELOW PIPE PLUS 0.5' ABOVE PIPE.
7. TOTAL DEPTH OF SYSTEM IS 12.0' FROM ORIGINAL GRADE,
8. 2" HD INSULATII]N REQUIRED EVER FIELD <3' OF COVER
9. 2" HD INSULATION REQUIRED OVER TANK <4' OF COVER
10. CONTRACTOR TO VERIFY AND INSURE MAX 27. GRADE FROM HOUSE,
MICHAEL QUINN CONSTRUCTION
P.O. BOX 772641
EAGLE RIVER, ALASKA 99577
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
ITF: 9-13-95;R2V 9-27-96 (DRAWING II
of
Municipality of Anchorage ®fx osr��N
�» DEPARTMENT OF HEALTH & HUMAN SERVICES •° ° °•.°e°e°. +o. o®o.eo.n°n.0
825 " L" Street, Anchorage, Alaska 99502-0650 .e°.aaa .a: .. ... .. 10
SOILS LOG — PERCOLATION TEST a 'q. Kenneth M. I U; ? ��
�� .o CE 7116
M I Y u I()VI DATE PERFORMED:�®���
PERFORMED FOR: ����1 �� ul-1 V1 VA /I l-- _62A QTY CA
LEGAL DESCRIPTION:_I`If,(q�A � ���(���d?� I Township, Range, Section �'/ — 9 (o
PIETT)
OOSLOPE SITE PLAN
1
2 N
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
5ariC"y gra\A w�5om�
51/t`,JCo661e�j 6 1e"
$M lensesl(' cke- 3
Of qr-. �50-V\,C(
Course)qr, Sa n
60 (r�ryI
MDI 5 11 WAS GROUND WATER /�
ENCOUNTERED? A
'BOR
S
IF YES, AT WHAT L
DEPTH? N14 O
P
E
Depth to Water After n
Monitoring? 0" �._
PERCOLATION RATE
�
(minules/Inch) PERC HOLE DIAMETER
r/
TEST RUN BETWEEN
FT AND _.7— F1
PERFORMED BYL4_m-t) � L' 1_�LL7� I e CC I-( S CERT IFYyllllA'ly/THI9T�EST WAS PERFORMED IN
ACCORDANCE W11 ALL STALE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DAIE DATE —./..--.!._- 1 w--------------
72.008 (Rev 4,8)1
FENT HY:MICHAEL GUINN CONST 8-30-96 4:07PM J 907694 5-j
KND; t# 2
MunkipNlty of Anch _
DEPARTMENT pr•t9E t OMAN SERVICE"
825 V Street. Anchorage, Aleske 99502-0850
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: C''Lt VA,%L-V -v6V `Lo
LEGAL DESCRIPTION 1 94- 14,1 6, &L&t
DEPTR P nim
(FEET)
11 1 114, Imo„
2
a
I
I 5
I 8
I
7
I
i
8
i�
9
10
11
12
9 13
i
- ..14
1e
18
17
18
1®
20
COMMENTS
S►t.+oV g gsIeL
Lq TwKr sILr'
_ DATE P
Range, Sectlon; SEIrq Sf3 TIgN R1W
PLAN
WAS GROUND WATER 0
ENCOUNTERED? N
8
IF YES, AT WHAT r p 1-4
DEPTH? P
E
wth is WMu Aur Z^ 894
PERCOLATION RATE ? Urinwb Imh) PERC HOLE DIAMETER JO. -
TEST RUN BETWEEN 5 FT AND 4 -FT
}p� PprFORMEO 8Y; v - I GHRTIFY THAT T JH18 TEST WAS PWOFi M NM
N,I ACCORDANCE WIT LL STATE AND MUNICIPAL OUIgELINEE IN EFFECT CN TOMO BATIL MTIi: f �31��
�'. i 72-M (Aw, 416)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
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
oo-�i�y- 15
Parcel I.D. COSA# ()SC a l DYp
1. GENERAL INFORMATION Expiration Date: �3 ' D — /
Complete legal description HYLEN CREST #3; BLOCK 4 LOT 1
Location (site address) 10215 STEWART DRIVE *EAGLE RIVER, AK 99577
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
HAL BLAIR
Day phone
10215 STEWART DRIVE *EAGLE RIVER, AK 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 5
Day phone
Day phone
301-4129
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
l�
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 affixed hereto and as of the validation date shown below, f 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. 1 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.
Engineer's Comments:
In conducting this evaluation, GEG, LfD. 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. fest, 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.
5. DSD SIGNATURE
Approved for 57 bedrooms.
Disapproved.
337-6179
Date
Qo�Op
4
OT
4 9s;40Q J�• TH* L -0
0.:... .... ...........1
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
C.�
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Nitrate Advisory Other
By.
(Rev. 11/05)
Original Certificate Date: 3 a /�2_
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
D 5"U- q 7q -/s -
Legal Description: HYLEN CREST #3• BLOCK 4 LOT 1 Parcel ID: 959�354-35-
A. WELL DATA
Well type
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE RE!
PUBLIC WATER
If A, B, or C provide PWSID# _ Well Log
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
Wires properly protected
Casing height (abo n
AT IN &TION
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
Ic: ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 10/28/96-3/21/97
Tank size 1500 gal. Number of Compartments 2 Cleanouts MN) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N)NS High water alarm (Y/N) N/A
Date of pumping Z (a l "- Pumper S
C. ABSORPTION FIELD DATA
Date installed 10/28/96-3/21/97 Soil rating (g.p.d./ft2o /bd 1.2 System type DEEP TRENCH
Length 39 ft. Width 2 ft. Gravel below pipe 8.26 ft.
Total depth *12.37 ft. Eff. absorption area 625+ ftz Monitoring tube YES Depression over field NO
Date of adequacy test 3/21/12 Results (Pass/Fail) PASS For 5 bedrooms
Fluid depth in absorption field before test 71 in. Water added 1043 gal. New depth 88 in.
Elapsed Time: 1004 min. Final Fluid depth 72.5 in. Absorption rate >= 750+ g,p,d,
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N0,45 k>J Dwd If yes, give date N "a"
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off' level High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on
Public sewer main
Sewer /septic service line
On adjacent
On adjacent lots
Holding tank
manhole/cleanout
Animal ant areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 100'+PVT/200'+PUBLIC
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 1C+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent Iotsl00'+PVT/200'+PUBLIC
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that f have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSH guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 3,/2 (,b7-
COSA Fee $ y O
Date of Payment 31�'I I17�
Receipt Number 041—M iii
(Rev. 11/05)
Waiver Fee $
Date of
Receipt Number
09/23/2012 13:15 FAX 9076943332 Laurie Blair 10002
f'Er�,y�T
wo
�r✓.9L
ASBUILT SEWARD &ASSOCIATES LAND SURVEYING 69z
SCALE. ��aw
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY- "<<C.OF . �a
f/l�iY �f.'r�al�, ui✓irug tni �%� / DATE P • S a
AND THAT NO ENCROACHMENTS EkIST EXCEPT AS i t� y t^ •
INDICATED. IT IS THE RESPONSIBILITY OF THE � * ;
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID 0,0
ee •'
EASEMENTS, COVENANTS, OR RESTRICTIONS 0
WHICH DO NOT APPEAR ON THE RECORDED SUBDI' F� .+ ? t5 s k B er
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD �r # r,. to
ANY DATA HEREON BE USED FOR CONSTRUCTION �A
OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN.
ARY LINES. �nrs
IN A MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section`
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1
Parcel I.D. #-rJ50 HAA # J (� �l 1 l nQ
1. . GENERAL INFORMATION
Complete legal description O.&2
Location (site address or directions) /6,7—/5
Property owner -Ml ae-16tl�nv- Ca��fvue irs�y Day phone
Mailing address ho Box 77Ziaell -IL4,o AK- 4957 -7
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. - 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.
4. TYPE OF. WASTEWATER DISPOSAL: ;r
Individual on-site
Holding tank n, j
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 (flay. 1191) - Front - MOA 121 - -
5. STATEMENT OF INSPECTION BY ENGINEER.
As certified by 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 KND En:gineedna Phone 1296 —4�// /
Address 20441 Ptarmigan Blvd.
._ —R,
Engineer's signature Date 3 z
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6. DHHS SIGNATURE `pwww®.�® io�9°�•.....•..••'°•����
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.�._. Approved for bedrooms. %
Disapproved.
Conditional. approval for bedrooms, with the following stipulations:
Additional Comments
By — Date 4
CAUTION
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
professionai 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-M (Rev. 1/91) Back. MOA #21 - - - -
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: 1114& �feSZ &W110f Parcel LD.: 050 -Y%�%�/J`
A. WELL DATA A
Well type r� �1l If A, B, or C, attach ADEC letter. ADEC water system number �'il �
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date completed
Cased to
FROM WELL LOG
Date of test
Static water level
Well production _ZZ g.p.m.
WATER SAMPLE RESULTS:
_ Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Coliform Nitrate Other bacteria
Date of sample: ZZ Collec by:
B. SEPTIC/HOLDING TANK DATA
Mom
Date installed Tank size /SUy Number of Compartments Z_ Cleanouts (Y/N) y
Foundation cleanout (Y/N) / Depression (Y/N) N High water alarm (Y/N) N
Date of Pumping A/4 Pumper
C. ABSORPTION FIELD DATA
Date installed /4 ZB Soil rating '.p.d./V or4tgbd=) / z System type Lee I �e vtc
Length 39 Width Gravel thickness below pipe 0,2& Total depth
Effective absorption area Monitoring Tube present (Y/N) Depression over field (Y/N) /V
Date of adequacy test _ /VA Results (Pass/Fail) Z For , bedrooms
Fluid depth in abso tion field before test (in.);
Fluid depth (ins) Minutes later:_
Peroxide tr atment (past 12 months) (Y/N) _
72-026 (Rev. 3/96)*
after
Absorption rate =
gal. water adyred (in.):
If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
Size in gallons
"Pump on" level at'
High water alarm level at' 'Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tatn lot 206 / On adjacent _
Absorption fielff on lot
Public seder main
/septic service line
"Pump off" level at'
On adjaq6nt lots
Publics er manhole/cleanout
Public
station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /0 �-/- Property line /U + Absorption field /O f
Water main/service line �/O t Surface water/drainage /00 � Wells on adjacent lots 200 f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Building foundation /O '* Water main/service line /O '--
Surface
Surface water / 0O f Driveway, parking/vehicle storage area /D '-
Curtain drain //D//,�- X-14/0m//Y Wells on adjacent lots 200 1 -4-
F.
-F
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
SignE
Engir
Date
HAA Fee $ `/ 0-2) ' 60
Date of Payment L/z-�//� / l
Receipt Number —Z/-/
72-026 (Rev. 3/96)"°
Waiver Fee $
Date of Payment
Receipt Number
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