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HomeMy WebLinkAboutDELUCIA LT 34'~' ' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ',~ ~'.~ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAIU~G ADDB[SS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well [ Absorption area Dwelling PERMIT ~ ~,S~A.C. ~o: ~ ~ ' ~ ~ Manufacturer Mator ~o. of compartmen~ ~ ~ ~i~. ca0aciW in Callons Inside length Width ~iquid depth ~O~ O- IF HOMEMADE: ~ ~ Well Dwelling PERMIT NO. ~ ~ Z DISTANCE TO: O ~ ~ Manufacturer Materiat Liquid capacity in gallons D Well Foundation Nearest lot line PERMIT ~ ~ DISTANCE TO: ~ I-~ ~m~ No. oflines / Lengthofeachlin~. Totallengtho~li~es, Trenchwid~ Distancebetweenlines Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption aFea ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building faundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER I SOlE T[ST B[MA~KS I I _ I APPROV /~ DATE LEGAL -013 (Rev. 3/78) Russell Oyster 694-2774 O & E ENG,,4EERING & DEVELO~ ,¢IENT CO. Performed for: Name: i/: ',~ z'_ Mailing Address: Legal Description: ~ ~> 7~ :; "'/¢' Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 888-2280 SOIL LOG Tel. No. Earl Ellis 688-2280 Depth (feet) Soil Characteristics 0 1 6__ 7__ 9__ 10__ 11 12__ 13__ PLOT PLAN PERC. TEST 14__ 15__ 16__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No /"'~- If yes, what depth Drain Field Performed by: Date: 'rHF'C,c- i~; NO SET !4[D'FH FO? TF:E%CHE O & E ENG,NEERING & DEVELO~ ,VIENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name: SOIL LOG Tel. No Mailing Address: Legal Description: /-~' Earl Ellis 688-2280 Depth (feet) 0 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ 11 Soil Characteristics 12 13__ 14__ 15__ 16 Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No~ ~"/,,~ ' If yes, what depth Drain Field.__ PERC. TEST Performed by: RETURN TO: Dtvislon of Geological and 300t Porcupine Drive (Tel~ Anchorage, Alaska 99501 ~ystcal Surveys (DGGS) 277-66]5) WATER WELL RECORD Drilling Company Name STATE OF AI~SKA DEPARTMENT OF NATURAL RESOURCES U.S.G.S. Local No. Drilling Permit No. LOCATION OF WELL J Please complete either la, lb, or lc. M.U.L. la. ~orough Subdivision Lot I Block lb. Fraction Section No. Township Range Meridian 1c. Distance and Direction From Road Intersect;ohs 3. OWNER OF WELL: Address: S~reet Address and Area of Welt Location ,, 2. WELL LOG Feet BelOw 4. WELL DEPTH: (completed) Surface Elevation Date of Surface Completion Material Type Top J Bottom ft. I 6. USE: r~Domesti¢ ['-'~Public Supply [-']lndus:ry I r-1 irrigat~oo K-lRecharge ~co~i~, ~T~s~ ~ ~O~h~r: J 7. CASING: ~Threaded ~Welded in. to ft. Depth Weight lbs/Ft. [ i ~n. to ft. Depth - 8. FINISH OF WELL: l  Slot/Mesh Slze: Length: ~ Set be~en ft. and ft. ) -- Fit:Engs:  9. STATIC WATER LEVEL: ft. ~A~ve ~Below land surface Type of Measur~nt: 10. PUMPING LEVEL below land surface ft. after hrs. pumping g.p.m. ) ~ ft. after ~ hrs. pumping ~ g.p.m. 11. WELL H~D COMPLETION: ~ In Approved Pit ~Pitless Adapter ~ inches ~bove grade 12. GROUTING: Well Grouted: ~Yes Materl~l: ~Neat Ce~nt ~ Other: 13. PUMP: (if available} HP Length of Drop Pipe ~ ft. ca~city ~ g.p.n Type: ~Sub~rsible ~Reclprocating 14. REMARKS: 5. WATER WELL CONTRACTOR'S CERTIFICATION: Thls well was drilled under my jurisdlctlon and this reoort is true ~o the best of my knowledge and bellef: Registered Bus;ness Name Contract License Number Address: Signed: Date: Authorized Representative Form O2-~R Copy Distribution: WHITE - State DGGS, PINK - Driller, CANARY - Customer RETURN TO: Division of Geological and ' lysical Surveys (DGGS). 3001 Porcupine Drive (Tele, ne: 277-6615) Anchorage, Alaska 99501 WATER WELL RECORD Drilling Company Name LOCATION OF WELL Please complete either la, lb, or lc. U.S.G.S. Local No. Drlliing;Permit No. A.D.L. No. STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES la. Borough Subdivision �LoSt� Block 11b. Fraction / Section No. Township N/S [R�71EIW Meridian Ic. Distance and Direction from Road Intersections Street Address and Area of Well Location 3, OWNER OF WELL: Address: 2. WELL LOG Feet Below Surface Material Type Top Bottom 4. WELL DEPTH: (completed) ft. Surface Elevation Date of Completion 5, ❑ Cable tool - Rotary Driven Dug ❑ Auger ❑ Jetted ❑ Bored ❑ Other: 5 6. USE %, Q.Domestic Public Supply Industry Irrigation ❑ Recharge ❑ Commercial Test Well F1 Other: 7. CASING: Threaded Q Welded In. to ft. Depth Weight lbs/ft. in. to ft. Depth B. FINISH OF WELL: Type: Diameter: Slot/Mesh Size: Length: Set between ft. and ft. Fittings: 9. STATIC WATER LEVEL: ft. Above Q Below land surface Type of Measurement: 10. PUMPING LEVEL below land surface ft. after hrs. pumping g.p.m. ft. after hrs. pumping g.p.m. 11. WELL HEAD COMPLETION: In Approved Pit QPitless Adapter inches above grade 12. GROUTING: Well Grouted: Yes .,n No Material: ❑ Neat Cement ❑ Other: 13. PUMP: (If available) HP Length of Drop Pipe ft. capacity g.p• Type: Submersible ❑ Reciprocating. Jet ❑ Other; 14. REMARKS: 15, WATER WELL This well Address: Signed: CONTRACTOR'S CERTIFICATION: was drilled under my jurisdiction and this report is true to Registered Business Name the best of my'knowledge and belief; Contract License Number Date: Authorized Representative MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIOt~ DiViSION OF ENVIRONMENTAL HEALTH CERTir,CATE OF ~i;:.:r E .~T O., FOR HEALTH AUTHORITY APPROVAL ., ~N-ol L .t. ;Li' F.h,D WATER FACILFFY 264-4720 A~pi~cat~on Date ~_~%~__::~:'. GEI'4ERAL INFORMATION TYPE OF RESIDENCE : ' 'd :.-,,-~'"'T .1, , WATER SUPPLY ~i.: . ~; '.: ~d, '~,;:-r; ...' ~., :_,~ [:'.,',ir t~ [tt{.~ - [.',. '- . ;:: ', .:~': '. , ' .'. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, F~LE SEARCH, DATA AND iNFORMATiON · .- ~ ~., ,o,¢, ~ L',3!ow, I \'erif7 that ray 'w~3t ~h,.~n. cd lms Hea~th ; s c¢:;-t f:ed by ~ sea: ~ffix~d herc'to and as of the vahdat~on date ~''~ ~'~ 5, ~, h or t/A ;c p~' L,.'a 5h ~:ws that thc ~L: r,.-s~te w&ter supply and,,'o~' wastewater d sposal s},ste m is safe, func~iona', and adequate ~ ,~,,~ ~.c~ n,_;~'; t~e: c~ :~eCr,3oms and ~;/~'~ of structure ~' ~: :' '~' herc;;n. I further vea:y tha~ based on the u'ffoi'm~:~t~on obtaineo t':'c~ the M;:,c~,aht/ of Anchorage ~es and from ;'r,y :'"~' ....... ' ' , ~od~a~,on and inspE~ct~orh U'~(e on-s:,te water supply and,,'or :,a~e,,~ater c:2;..o_.a~ ~),~tem ,s ~n compliance w~th ail t~unt~p~ and State ..... ,~.~ o-~ ,--~ ....,.. ,.~_,u~ o, ~., ~: k. eo, arid ;'egulaticns in effect on ~ ~-- - -f'eiephone CAU'Tq Or.4 . .- ..... :---.- ~ :-, ::' sc',¢qy :;[:,::n the '.r' ....... . CHEP .... " . ':~': . ir . .' ~ ; : 'L MUNICIPALITY OF ANCHORAGE Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC251350 Parcel ID 051 -141-14 Legal description DELUCIA LT 34 Site address 22823 NEEDELS LOOP Expiration Date: 5/19/2026 Current property owner(s) PEDERSEN STEVEN L & KAREN J X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: By: Original Certificate Date: 8/15/2025 This Certifi a of On -Site Systems Approval (COSA) is intended to demonstrate the subject system is/are in substantial compliance with municipal code. The Municipality of Anchorage, Dev opment Service Department (DSD) issues COSAs based upon representations provided by an iildependent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory X Tank Age Advisory Arsenic Advisory Other UNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 0 n� c 1,4L !iTXA IVA +L On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel 1. D. 051-141-14 Complete legal description DELUCIA LOT 34 Location (site address) 1 22823 NEEDELS LOOP CHUGIAK, ALASKA 99567 Current property owner(s) PEDERSEN STEVEN & KAREN 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: � Private Well serving # 1 dwelling units F-1 Other Non-public well as regulated by MOA E] Water Storage R Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: RN Private Septic R Private Septic serving 2 dwelling units 0 Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: nN Steel n Plastic n Concrete n Fiberglass Age 19 - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: E] AWV\fTS ❑ Bed RN Deep Trench R Wide Trench R Seepage Pit Waiver request for: Expedited review requested: F Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $_ 60 Date of Payment COSA # Waiver Fee $ Date of Payment Waiver # COSA Application_Apr2025.doc COSA Checklist_May2025 .docx COSA Checklist Legal Description: DELUCIA LOT 34 Parcel ID: 051-141-14 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA * Well log is filed with Onsite (or attached) Date drilled *1981 Total depth *245 ft Cased to *245 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 7/28/25 Static water level at beginning of test 31 ft. Well production at time of test 2.3 gpm Water storage tank volume NONE gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 12.3 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 7/25/25 Comments *Well log in MOA documents is not legible, data per previous inspections. The area in general has high & increasing nitrates. The well was scoped and appears satisfactory – See attached Sullivan letter. _ B. TANK DATA Measured operating fluid level in septic tank 50" Date of pumping 5/19/25 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 8/27/1981 ALL standpipes present per record drawing Total measured depth from grade 12.5 ft (max) Measured depth to pipe invert from grade 5.8 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective. (ED) If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 7/28/25 Results Pass Fluid depth prior to test 0 in Water added 500 gal New fluid depth 7 in Elapsed time 30 min Final fluid depth 0 in Absorption rate 450 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 72 in (MOA 6’ ED) Effective depth used 0 in (Final Fluid Depth) Effective depth remaining 72 in Comments/Deficiencies: COSA Checklist_May2025 .docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10’ Yes if No ft Field to Foundation > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 08/12/22025 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. 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, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 08/12/25 Date: 8/11/2025 P.O. Box 670269 Chugiak, AK 99567 P: (907) 688-2759 F: (907) 688-2259 Brent Western First Water Consulting Services RE: 22823 Needles Loop, Chugiak Well Camera Inspection The well is steel cased beyond 60’ with a 2’ Stickup. All welded joints look good with no leaks. The Casing is in good condition with no holes, cracks or leaks. The pitless area appears to be sealed and in good condition. There is a perforation at 42 feet, producing around 2 gpm. MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT �� i— 907-343-7904 On-Site water and wastewater Section Fax: 343-7997 www.muni.org/onsite —% Nitrate Advisory Certificate of On -Site Systems Approval # OSC251350 Subdivision: Delucia, Block: , Lot: 34 A water sample revealed a nitrate concentration of 12.3 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. S89 °59' 00"E ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: DELUCIA SUBDIVISION LOT 34 PLAT 67-134 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shoull any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. WORK ORDER NUMBER: DATE: SCALE: E—MAIL: AUG 14, 2025 1 "=30' schullerak®gmail.com 25-103 DRAWN BY: CHECKED BY GRID NUMBER: BOOK/PAGE: JLS N W1259 250314 �,®.;®M®®NN SU ® OF ®® vL L A R�� �.........AL � o� �. sir ® 4 9TH •.� r .�..:. ....................:..i .® JOHN L. SCHULLER.- s �. LS -10408 `�� ® 1831 Talkeetna Street •�di'ls� .'�,, d Anchorage, Alaska 99508 ' �\ �® ° fAlwssiona� �' ® (907) 227-1455 office e �®®� ® (907) 274-4992 fax \ I A WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: Well Classification Well Log Present ~,~N) Total Depth ~--,~-~-"- ' Cased to Static Water Level ~ -~ ' Casing Height Above Ground Electrical Wiring in Conduit~N) Separation Distances from Well: To Septic/I ',o',dlng Tank on Lot To Nearest Edge of Absorption Field on Lot \ ~"~ ~'~ To Nearest Public Sewer Line _ , Cleanout/Manhote Water Sample Collected by ~.~ ,¢,r If A, B, C, D.E.C. A~proved (Y/N) Date Completed ~"//(~ ! Yield ! Depth of Grouting Pump Set At Sanitary Seal on Casin~;~J~/N) Depression Around Wellhead. ,¥~1) Water Sample Test Results ' On Adjoining Lots · On Adjoining Lots To Nearest Public Sewer r~ /A __ To Nearest Sewer Service Line on Lot c224~(', t/'~ ~z ~_~(-, Date Comments B. SEPTIC/~TANK DATA Date Installed 'U~,/1:¢., I Standpipes~N) Depression over Tank (Y~ ~//~ · for Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) m'~//4.? Separation Distances from Septic/J~ Tank: Size / ~_:'z~C:? No. of Compartments Air-tight Cap.s~) Foundation Cleanout Date Last Pumped To Water-Supply Well ____/.~--z~ To Property Line ~/b ~'Y~ To Water Main/Service Line Course /,~ 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(1~,,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: Type of System Design Length of Field "~ Depth of Field I ':Z- Gravel Bed Thickness '7 Standpipes Present. N) Date of Last Adequacy Test To Water-Supply Well To Building Foundation Lot ¢'J/,~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parking Area, or Vehicle Storage Area ! ! 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 Dimensions Manhole/Access (Y/N) j,~l "/~ m P Off" Level at A Vent (Y/N) ! / Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** 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 inspection. Signed ~, ~ E' ~",~C,:N'-~:''~' Date Company ~: ............ ,,, ,~--,~,,,~ ~;.~ . Page 2 of 2 Receipt No. Date of Payment Amount: $ 72-026 (11,84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Genera/ Information Application Date . //,~/~>cf / (a) Legal Desc~iption (include lot, blogk, subdivision, section, township, range) Location (address or directions) ./z , 6 Z~.':~ o Buyer ~ ; Other ~-~ (explain); tution ?-~ ; (d) Lending Institution ~ !2 ~ l 6'c.~u Telephone Address (e) Real Estate Co. & Agent Address Tel,ephone (f) ~-~a~iq the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms Multi-Family Other (describe) 3. Water Su~i . .. Note: If community well system, must have written conf~rmation from the State Department of Environmental Conservation attesting to the legality and status. 4. pewage Disposal Onstte~ Public ~ Community ~ Holding Tank ~-~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th& legality and status. [Page 1 of 2] E__n~ineering 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 w~astewater 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 obtain~ from the M~anicipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all ~nicipal and State codes, ordinances, and regula- tions ~n effect on the date of this inspection. Name of Firm Address Date D_HEP Approval Approved for ~z~/"~Jbedrooms '~ Disapproved Approved telephone Date / ,? - ~/ '~-~/ Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRO~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ,tNALYZE DATA BEFORE A CERTIFICATE I$ ISSUED. THE M[~ICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4Iej/D18 [Page 2 of 2] 7-19-84 ae WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION OEO(; RECElYED.. z:Pe/ c, Well Classificat~ S F Well Log Present~) Total Depth 2 ~- ! Cased to Static Water Level ~ ' Casing Height Above Ground ~ ~/~' Electrical Wiring in Conduit ~Y~) Separation Distances from Well: ! TO Septic/~4~3--Tank on Lot /'~ ~- If A, B, or C, D.E.C. Approved(Y/N) Date Completed ~/~/ Yietd~r~. ~ 2 ~Z~'- Depth of Groutinq ~ ~t At ~ ~ Sanitary ~al on Casing ~pression ~ound ~l~ead ; ~ ~joining Lots /~ ; ~ Adjoining Lots/~ To ~est Public ~r To k%arest Edge of Absorption Field cn Lot/~b TO Nearest Public Sewer Line /J / # Cleanout/Manhole /3 / ~ To Nearest Sewer Service Line on Lot Water Sample Collected By ~ .~ ~%~ .Water Sample Test Comments SEPTIC/HOLDING TANK DATA Date Installed ~~/~ / Size //~Q~D C) No. of Compartments ~__ Standpipes !Y~/~ Air-tight Caps~ Foundation Cleanout (Y/N) Depression over Tank (~ Date Last ?umped /~/~/~ Pumping/Maintenance Contract on~/File (Y/~/~f- ; for Holding Ts nk High-Wate~ Alarm (Y~/J/~- Temporary Holding Tank Permit (Y Separation Distances from Septic/F~R~l{~3 Tank: To Water-Supply Well /450 To Property Line /D To Water Nm~n/Service Line Course To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Receipt ~ Date Paid Arno un t: ,. [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~//~ / Width of Field ' ~ ~ ~ ~ Type of System Design //~./~ Length of Field ~ / ~p~ of Field /2 ' Gravel ~d Thickness ~ ~' Square Feet of Absorption Area Stalndpipes Present (Y/N) Results of Last Adequacy Test ~'~,~ ~r; ~ ~,~c ~-o~/ __ Separation Distance from Absorption Field: To Water-Supply ~!1 /Z~O /~ To Property Line /fP To Building Foundation ~ ~ ~ To Existing or Abando~.~d System cn Lot /c~ ~ ~J ~ ; OD. Adjoining Lots ~ TO Water Mmi~n/Se. rvice Line c~0 ~ To Cutbapk(if present) TO Stream/Pond/Lake/ct Major Drainage Course /~; O ~_7 To Driveway, Parking Area, or Vehicle Storage Area ~ Conn~nts /{/ ~ ~'~ ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions MapJ%ole/Ac~ess (Y/N) "~f"/Level at __ VVe~'~/N) Pumping Cycles cl~ring Adequacy Test. ,~ee ts MOA Con~nents ** Check Permitted Bedroom Rating A(jainst H/~R Request I certify that I have checked, verified, or cc. nf©rn~d to all MOA HAA C~aidelines in effect on the date of this i~pection. Signed Company KBi/dL/s [Page 2 of 2] 2-15-84 .~ C~.'~ ~)~ '~"~"~. ,~:~L . RECEIVED , I~P~CTION APPOIN~M ENTS ~ ~,~:~ ~ c%~ (~ ' ~ C~ ~v~' - ~- -~ ~ ~ ~--' DATE ~ DATE [ / DATE INSPECTO~ , I J ~UNIClPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH ~ ENVIRONMENTAL PROTECTIO~ 825 L Street - Anchorage, Alaska 99501 MUNidrA_~ , CF DEP[. J ENVIRONMENTAL SANITATION DIVISION ENVIRONMENT:,L ~,~,cC,,ON Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER ~HONE MAILIN~ ADDfiES~ PROPERTY RESIDENT (If different frbm above) / PHONE 2. BUYER ~ / MAI LIN~DDRESS/ MAILING ~DRESS 4. ~EALTO~/AGENT I PHONE MA~UN~ ADD~eSS' ~ / STREET LOCATION 6. TYPE OF RESIDENCE ~ NUMBER OF~BEDROOMS [] One I---I Four ~' [] Two [] Five SINGLE FAMILY [] MULTIPLE FAMILY ,J~ . Three [] Six [] Other 7. WATER SUPPLY  I NDIVIDUAL* COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since dune 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM /E~] INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [~]Holding Tank Size:- /~)~ If Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED NUMBER OF BEDROOMS PERMIT NUMBER [] THREE [] FIVE [] FOUR [] SiX DATE INSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] OTHER Septic/Holding Tank IAbsorption Area ISewer Line INearest Lot Line 5. COMMENTS FOR -,C% BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE 72-010 (Rev. 6/79)