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HomeMy WebLinkAboutCHUGIAK GARDENS LT 2 Municipality of Anchorage Page 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: ~J~ lO '~-i ~ , PID Number: ~::~'-/~-(~ I Name: Wastewater System: ~ New ~Upgrade Addre'~ ABSORPTION FIELD Phone: ~No. of Bedrooms: ~Deep Trench D Shallow Trench D Bed ~ Mound ~ Other LEGAL DESCRIPTION so,, Rating: Total Depth from original grade: ~.~ GPD/Sq. Ft. ~' ~. Lot: ~ Block:~ ~~t ~ ~~Subdivisi°n: ~Depth to pipe bottom from original ~de: Ft. Gravel depth beneath pipe ~ I Ft. Township: /JJ Range: ~JJ Section: / Fill added above original grade:~ Ft. Gravel length: ~' Ft. WELL: ~Z [~~ D Upgrade Gravel~ , Number of lines: Distance between lines: ~ ,~ Ft. [ ~ Ft. Classification (Private,'A,B,C): I Total Depth: Cased To: Total absorption area: Pipe material: ~~ ~' Ft. ~0~~ Ft. ~7~ SO. Ft. ~ ~~ Driller: Date Drilled: Static Water Level: Installer: Date in~lle~ Yield: , ~ ~ Pump Set at: ~ Casing Height Above Ground: ~.~ TANK SEPARATION DISTANCES ~Se,tic ~ Ho~n, ~ S.T.E.,. TO Septic Absorption Lift Holding ~ivate Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~~ ~ Material: Number of Comp~ments: Surface Water [~t~ [~o'~ ~ ~ ~ LIFT STATION Line [O / / ~o1~ Size in gallons: Manufacturer: : '~ High water Foundation ~ ~' ~, ~ ~ ~ "Pump on" levet at~1 ~ at: atarm at: Curtain ~ I Drain / / / / / Pump Ma~ Electrical Inspections performed by: Remarks: ~[~~ ~ ~~ BENCH MARK Location and Description:l I Assumed Elevation: E~&~AL 5 & S ~GINE~ING Inspections performed by: 17~ ~;~= R~er [~p"~ ~ 1st ~'~-~ I ~ '~" ~: Y':~ Department of Health and Human Services approval ~ ~"' Reviewed and approved by: ~~ Date: ~-~ ~/ 72-013 (1/91) MOA 25 Permit No. 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: lOT' ~.. ~,~6iI~IX-_ ~__---.i~,P-_.~;::>~I~.~ PID No.: ~1~. G1;z~--. N 72-013 A (2/91) MOA 25 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 (UPGRADE) PERMIT PERMIT NUMBER:SW910215 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:FRIESEN JAY C & GWENDOLYN W OWNER ADDRESS:PO BOX 566 SEWARD, AK 99664 DATE ISSUED: 7/26/91 EXPIRATION DATE: 7/26/92 PARCEL ID:05126122 LEGAL DESCRIPTION: CHUGIAK GARDENS LT 2 LOT SIZE: 30927 (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 (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS ISSUED BY: ~ / ROBERT SHAFER, P.E. ROGER SHAFER, P.E. 3uly 24, 1991 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 SOl L TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF H~ALTH AND HUMAN SERVICES 825 L Stregt P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERkNCE: Lot 2; Chugia~ Gardens subdivision; PERI, lIT REQUEST NARRATIVE Requgst you rssue a permit for the upgrade of the on-site wastgwater disposal system located on the referenced property. The existing absorption trench installed in 1976 failed an adequacy tgst. It is proposed to upgrad~ this systgm with thc installation of a new absorption trench para~gl to the ~xisting trench as shown on the attachzd sit~ plan. In addition to the upgrading of th~ septic system an old well which is not currently in use, will b~ abandon in accordance wi~h cod~ requirements. An existing fiberglass s~ptic tan~ installed in 1976 wrll b~ excavated to verify its integrity, however, with the history of fiberglass septic tan~s and th~ age of this tank, r~placement of the tan~ is also anticipated. Sh~e~ I of 2 of the attached site plans shows th~ location of s~ptic systems and wells on th~ adjoining propgrti~s. As noted by this sit~ plan the upgrading of this system should not significantly affect th~ development of th~ surrounding properties. If you requirg additional rnformation, pleasg contact us. Sincerely, ~O~~NA~ RJS/gm 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 1" : 50' I NW856 i SCALE ER TI] SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 DATE PERFORMED: / SITE PLAN 10 ~-11 12 13 14 15 16 17 18 19 20 ENCOUNTERED? S L IF YES, AT WHAT ~ O DEPTH? p E DeplhtoWaterA~.~,~y Monitoring? Dale: _ / ~Gross Net Depth to Net Reading Date Time Time Water Drop ? /M~, d'-p ! '~ ' 1 Y.z.." z~ ' / s/.r/~ IO '~'~ / 'q~" ' '°'/:?,,, PERCOLATION RATE ~ (minutes/inch)PERC HOLE DIAMETER ~.~ COMMENTS $ & S ENGINEERING PERFORMED ~l. le River, Alaska ~5~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) GREA ER ANCHORAGE AREA BOR, JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LOCATION MAILING ADDRESS PHONE SEPTIC TANK: DISTANCE FROM WELL /[r)g INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPACITYI~Q0t~) GALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL NUMBER OF LINES_ FOUNDATION DISTANCE BETWEEN LINES NEAREST LOT LINE TOTAL LENGTH OF LINES ~' 7 TRENCH WIDTH_~ IN. TOTAL EFFECTIVE ABSORPTION AREA DEPTH: TOP OF TILE TO FINISH GRADE SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER ~- MATERIAL BENEATH TILE__ ~-~ IN. ABOVE TILE IN. WELL: ~ TYPE CONSTRUCTION BUILDING NEAREST NEAREST FOUNDATION LOT LINE_ SEWER LINE__ DEPTH SEPTIC SEEPAGE , TANK__, SYSTEM CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCE FROM: DISTANCES: DIAGRAM OF SYSTEM INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: REMARKS: DATE ?'/7~ G.A.A.B. Form EQ-032 i:::'l...Ei:l:::l:iii:l:::tl",t"!" 'v']:E:t.,.I [::,i:;i: i... ;':ii: C H I..1 I::!i :t: I:::11'::: (:ii F:Ii:;i: [)[ii:l",l:iii; GREATER AN~;HORAGE area BOJ~OUgh! DEPARTMENT OF ENVIRONMENTAL OUALITY 3~I30 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT · /, MAILING ADDRESS ,NSTALLAt,ON LOCAT,ON /'~--:'~'~'/~"/~-- ~'"/~ ~/ INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT , D Fl~LD THER ~, TYPE AND SIZE OF FACILITY TO BE SERVED fINANCED THROUGH TO be INSTALLED BY ~~ ~ __ ~INA~ INSPECTION: Z4 HOUR NOTICE REQUIRED. BA~ ITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTA~ QUALITY AUTHORIT~ WI~ BE ECT TO PROSECUTION. TYPe SEEPAGE AReA -- TYPE MINIMUM DISTANCES, REQUIREMENTS / FOUNDATION TO SEPTIC TANK ~-~-~ FOUNDATION TO SEEPAGE Pit ¢~T f~ DRAIN FIEL~ __ SEPTIC TANK TO SEEPAGE PIT WALL To NEARESt lOT LINE --~..~_ , ×~. WELL TO SEPTIC TANK ';~---'-'a~'~ ~ SEEPAGE PIT , DRAIN field ~ ~ ~ ALSO CONSIDER AREA\WElLS. WATER MAIN TO SEPTIC TANK //"~ '/ SEEPAGE PiT DRAIN FIELD ' SEPTIC TANK, /D~ r. SEEPAGE PiT ~,~ /~,~ DRAIN FIELD .~ TO RIVER, LAKE. STREAM. ~ / CASt IRON INTO AND OUT OF SEPTIC TANK ~ND INTO CRIB CROS/:ING GAP Of EXCAVATION 5 FEET INTO UNDISTURBED ~OIL, ~ / GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. G,A.A .B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE . APPLICANT'S SIGNATURE -- I FORM NO, EQ'OI 6 327 E~GLE STREET '- ANCHORAGE~ ALASKA' 99501' This P~ Rapo~:s a: ~o~1~ LoK '~ '-~rco!affion T~sz ....... Readinz Date Gross Time ~ = . . J_t Time Dapth 'To H20' N'e~: Drop P~o"osed 'Ins~al~Seepage Pit Dra'in Field . Depth Of ~nl~ ~ap2h To'Bot~o.~ Of ?i~ Or T~enc~: ' .......... ' ..... =:-/] ' .:._.:..,..~._. ..~_ ~ ~.~ . _:=- _ , ........ ~ ............ . ('- M-W DRILLING, INC. DRILLING LOG Well Owner Use of Well Location (address of: Township, Range, Section, if known; or distance main road Size of casing. ~:' .Depth of Hole Static water leve] [O0 ft. Screen ( ); Perforated ( Describe screen or perforation Well pumping test at 2+ gallons per (-t~l~) of drawdown from static level. Date of completion ::!~'~ Ju'!~ ] 976 :?50 feet Cased to !OO feet (below) land surface. Finish of well (check one) open end ( . ); ). (minute) for i hours with ~.0~'~)- ft. WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 .TO :'~ Casi~':g ~; ~ick.up .TO .TO .TO .TO .TO TO TO .TO TO .TO .TO __TO. ,TO TO !~edrock: ~::a?s iD J'frac'tur~2s: - - ~:,~M bv 175' 2 ' STATE DRILLING, INC. Well Owner DRILLING LOG .Use of Well Location (address of: Township, Range, Section, if known; or distance main road Size of casing ~) Depth of Hole'~r~'~''' feet Static water level -~. ft. (above) (below) land surface. Screen ( ); Perforated ( ). Describe screen or perforation Well pumping test at ~'~, gallons per of drawdown from static level. Date of completion Cased to ::6, :: feet Finish of well (check one) open end ( (hour) (minute) for hours with WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 7© .TO qL; Bou].,]er Grave] .TO ORY HOLE .TO TO .TO .TO .TO .TO .TO __,TO TO .TO ); ft. Bl, ue Cl~aq/Clavstone i 2 -- STATE M 8 W 5 R · L L I H .~ M-W DRILLtHG, Inc. 10378 e 10330 0 d Sewerd Hi~hwa7 ANCHORAGE, A,,.~S~ g~5~ 1 F:'. 0 1 DR~,LLING LOG Well Owner ~ation (ad~ of: Tow~hiP, R~;~e, ~tion, if ~own; or flbtance main roa~. Well No. 2, Lo~ 2 Chugiak Gardens Sub., Ckugiek, Alaska SEe (;,! casing-6'' Depth of Hole---350 ,feet Cued. to..~OB , feet 8~ticwa%erlevel ~' fi, (~': ~iow) l~ud surface. Fm~hofwell (checkone) o~nend ( ); ~een ( ); Pe~orat~ ( .X: )... 5'~,:PVC Liner perforated 'w/ 3/8" Drl. Holes (2/fu): De~cri~ ~ or perfor~tl'a~4.i~~ (minute) for_~- .... hou~ wkh ~ Jt Well pumFtng te~t et--~--~.-ga~lOn:~ pet (:~"r) of ~aw~own ~om ~tic ~Xel,, r~ : Depth in feet irom ground surface Oi~ d~,~.t~ of forma:ions penetrated, site of mater,al, cclor and hard~ne~ 0__~TO. 250 ..259~TO. 235 __~TO __TO_.= 325 _TO. 350 Exis~.In~ well g no~e: The old we]] had filled 1.n wi:.b ~e.qk,:.-c. hips at the bo~so'm of a p.a~- liner at 155 { ..... . .... Grey Sil, tstone; soft would not hold open hole. Po,si-It" brand fa)< transmittal nme"nc, 7o?,1 ['¢ m pag~,s ~ i ~o ~. -- ..... r,o--~-----~ '-L ......- .... - 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 AU'I~HORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # GENERAL INFORMATION Complete legal description Lot 2; ChU,qxak.Oa~dens Location (site address or directions) Property owner Mailing address 16439 p~easant View Chuqiak, AK 99567 Andy and Para Alkire 16439 Pleasant View Day phone Chugiak, AK 99567 277-6677 Lending agency Mailing address Day phone Agent Address Day phode m Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 'w TYPE OF WATER SUPPLY: Individual well Community well Public water X×X NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality anti status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: 72-025 (Rev, 1/91) Front MOA #21 Individual on-site Holding tank Community on-site Public sewer XXX If community wastewater system, provide written confirmation.: from state, .. ADEC attesting to the legality and Status of system. ' · · 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 inves.ti_gation 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 Phone c'~,~:'~'/-~ 5 & 5 ENGINEERING Address ; 70s4 Eagle River Lo .... Engineer's signatu~;~ale River, Alaska 9 Date DHHS SIGNATURE *; Approve. d for · .rDisapproved. · ~ · ::~ .: . ....... ..: ~. ~::~:.~:::~::' ,.~ bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ",} 0t41~ "--...~' t 'l'q-~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~..--,'¢ ~ ~-~,~t/~4_-- (..~~5 Parcel I.D. A. Well Data Well type '['P~-~J, Log present (~) Total depth If A, B, or C, attach ADEC letter, ADEC water system number Date completed ~ \ "Z.- -- ~'- ~'5 Driller t~ Cased to \c>,~,' Casing height .~.S.~nitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG Date of test \ Static water level Well flow Pump level1 AT INSPECTION g.p.m, b~. o MUNICIPALI [Y OF ANCHOiU~E ENVIRONMENTAL SERVICES DIVISION JAN - 4 t994 ' ECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ~ -2.--\ WATER SAMPLE RESULTS: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank '7.- Coliform ~ Nitrate \, ~t ~1 Other bacteria Date of sample: \'?---- ~ 7---~ .~l "5 Collected by: ~'~ B. SEPTIC/HOLDING TANK DATA Date installed ~ ~'~ -" ~ 'l Tank size ~ c~ ~ (-~ Compartments '7--- Cleanouts (~N) ~ Foundation cleanout (~¥N) '-// Depression (Y.~I.~ High water alarm (y/~l) ~ Alarm tested (Y/N) ~ ~- Date of pumping \\. ~ - ~ '5 Pumper '~.~ ~.<. ~% c~ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \~c:, ~ On adjacent lots To property line ~,O ~ ~' Absorption field Surface water/drainage J ~,L~O ~ ~'' Foundation ~" ~ ~" Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ycles tested Meets MOA electrical codes (Y/N)..._ ~- SEPARATION DIC:~Alq~E FROM LIFT STATION TO: WelCb'~ lot On adjacent lots Manufacturer ...---~ Manhole/Access (Y/N) ..--~-' ..----'"P~p off" Level at SurfaCe water D. ABSORPTION FIELD DATA Date installed °t ,'"l Lc ,) ~ .. 0¢ .~ I Length 23 i . ~'7 ' ! Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ Width Soil rating (GPD/FF) O, ~ ~f'¢~r z- System type 2, S' ' Gravel thickness .5-' ' Total depth ,// Cleanout present(~/N) 7 Depression over field (Y/I~ Results~ail) /~',~r~'.~ for ~ Bedrooms ~ After test ~,,J/~ i/-./J~ ~/~{ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots "~ Surface water Curtain drain / D o I On adjacent lots / L~ /' ~ Property line /0 ~/' 4.,. .To/existing or abandoned system on lot Cutbank /'}(~r Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checke~onformed to all MOA and HAA guidelines in effect on the.date of this inspection. Signature Engineer s Na~~ Date of Payment Receipt Number 72-026 (3/93)* Back HAA Fee $ <~O O ¢ Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 2; Chugiak Gardens Subdivision Location (site ad_dress,or directions) NHN Pleasant View Drive Property owner Maili~-g add~'ess Jay and Gwen Friesen HC 78Box 1023, Chugiak, Alaska Day phone 99567 Lending agency Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. Rae Hall/GREATLAND REALTY Day phone 694-9125 11411 old Glenn Hiqhwa¥, Eagle River, Alaska 99577~- 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: 3 Individual well Community well Public water 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 structu re indicated herein. I fu rther verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & S ENGINEERING 17034 Eagle Ri,vet Loop Road No. 284 Eagle River, Alaska 99577 Phone DHHS SIGNATURE /~ Approved for //~ ~_-~? bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~ ~_.~-~¢..¢.~z.Z'~¢ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~325 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~...o-v 'Z. ~.~Ao4.,,~/--- (..~.~(zu~5 Parcel I.D. A. WELL DATA Well type ~.~-t~ Log present ~/N) Total depth Sanitary seal ~N) If A, B, or C, attach ADEC letter. ADEC water system number ~l,~ Date completed ~J-'z~:>-'l~ . Driller ~ Cased to ~ c~ ~ Casing height ~'~- Wires properly protected i~;)N) FROM WELL LOG Date of test '1 - '~ --' ~,~ Static water level ~ I:~ ~ Well flow 'Z,. ~4- Pump level ~4, g.p.m. INSPECTIOI~ii1NiCiPALtTY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION Y, o 199! I .EE.E'IV E D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~/~" Sewer service line -~r ~. j ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform C> ~'"" ~/~c)o~,~ Nitrate Date of sample: ~ --ZL,,-'~/~ ~- '~ - c/I Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~-'~'"'~ ~ Cleanouts~/N) '~ High water alarm (~/~:) Date of pumping Other bacteria S & S ENGINEERING 1/-O~4 F..egie River Loop Road No. 204 EKIle River, Alaskn 99577 Tank size ~c)~c) Compartments Foundation cleanout ~ ~ Depression ~'/ ~ Alarm tested (~M~) ~/ '"'J/,4,. (/~ ~,,/)-"") Pumper Foundation Water main/service line SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot !/~ ~ On adjacent lots To property line lc) 1~ Absorption field 5' Surface water/drainage 72-026 (Rev, 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA ele~ S~ISTANCE FROM LIFT STAwell on iot TION TO: Manufacturer Manhole/Access (Y/N) ,~f" level at Cycles tested On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed '~-7~ Length ~.'7 ~ 5"7' Width Total absorption area DePressiOn over field ~ Results (pass/fail) Peroxide treatment (past 12 months) Soil rating System type Gravel thickness ~' ~ Total depth Cleanouts present~/ll~- y Date of adequacy test /~/'~ ~J for /'//,~, '~' If yes, give date ~'//A, 1/' bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot I, Dc:>~ To building foundation On adjacent lots '~c~ Surface water Curtain drain ENGINEER'S'CERTIFICATION On adjacent lots ~ *" Property line to To existing or abandoned system on lot ~ ,~, Cutbank ~ ~'- Water main/service line lo ~' Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date S & $ ENGINEERING Eagle River, Alaska 995~7 HAAFee$ /?D~O Date of Payment (~ ~0--?/ Receipt Number c:~'~ O ,,~ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ¢-1.~'~~ ~'.i- ;i.~.~¥ HAA# ~:\~'~5/..~.-~(~-~q 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Lo~ 2~ CHUGIAK GARDENS Location (address or directions) NHN P2~.~z~u~ ViPw (b) Property owner FARM CREDIT SERV. Telephone' (home) Mailing Address 248 East Dahlia Street, Palmer, Ak Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address 18550 Eagle River Telephone 694-4994 HERITAGE REAL ESTATE/Suzanne Cool Road, Eagle River, Ak. 99577 (e) Mail the HAA to the following address: (or check here l~,Y, if hold for pick up.) List contact person and day phone number below: $ & $ ENGiNEERiNG 170~4 Eagle River Loop Road No, 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family,~ Number of bedrooms ,~ 3. WATER SUPPLY Individual Well [~( Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-siteY~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 '~JOA~ s,Jaau!§ua leUO!SSajoJd aq~ u! SUO!SS!LUO JO SJOJJa JOJ elq!suodseJ 3ou s! a§EJOLIOUV JO X3!led!a!unl~ eq.L 'penss! s! a)eo!jF)Jao e aJojaq m, ep aZ~leUe Jo suo!)oedsu! ~onpuoo 3ou op SHHQ ~o see~oldLu~ 's3ueuJeJ!nbeJ e3e~s pue leJepej u!elJao ~jsp, es o~, JepJo u! suop, n)!)su! §u!puel J!eq) pue SaLuoq JO sJaseqoJnd ol ~sa~Jnoo e se s!q~, seep SHHO aq/ 'e~{Sel¥ jo e)e),$ eq~ u! paJa3s!§eJ Jaeu!l~ue leUO!SSajoJd )uepuadepu! ue ~q aAoqe ~ qde~§e~ed u! UaA!§ suo!~e~uesaJdaJ eq3 uodn,{lUO peseq pe~,eoU!Jaa I~^oJddv ~l!Joqln¥ qlleeH senss! (SHHQ) seo!^Jes ueuJnH pue q~,leeH jo ~,ueLu~Jedea e§eJoqouv jo/~)!led!o!unl~l eq.L leUO!~!puoo leAoJddv leUO!3!puoo jo SLU~a/ peAo~ddes.!o ~ paAo~ddv ~q SLUOOJpaq ~- JOJ paAo~dd¥ 'lVAOIddd~f SHHQ '9 arno ]'7¢66 e~selY 'jeA.~ elbe=. 'ON peo~l doo"l aeA!a el6e=j tT£OZI. ~NI~I~J~INION3 $ · $ ssaJppv · uo)ioadsu! s!4) jo aiep aU) uo )oajja u) suo!ieln§aJ pus 'saoueu)pJo 'sepoo G)8)S pue ledlolun~ lie qi)M eouelldwoo uI si weis~s mesods)p Jem~eise~ Jo/pus Xlddns JeleM ei)s-uo eq) 'uoIioedsuI pu~ uo~3~O~3s~Au~ ~ ~o~ pus saul e6e~oqouv jo Xl~lgd~o~un~ aq3 ~oJ~ peu~s3qo uo~mm~oju~ eq1 uo peseq ~eql AtpeA ~eq~n~ I 'u~aJeq pe~o~pu~ e]n~onJis ~o edX~ pus s~ooJpeq ~o ~eq~nu eql ~oj elenbeps pue" leUOllount 'e~es s! ~e~s~s lesods~p ~e~e~e3se~ ~o/pue ~lddns ~e)e~ e3!s-uo eq) )gq1 s~oqs leAo~ddv ~)uoq)nv qlleeH s~q3 ~o uo~3g6~seAu~ X~ 1eql X~eA I '~oleq u~oqs e~ep uo~lepueA eq1 ~o se pus ola~eq pexu~e leas X~ Xq peu~3~ao sv ,~..~G ,~'~ ~,.~ CHECKLIST- FEBRUARY 1984 ,~,"~ ~ ~ 343-4744 ~ A. WELL DATA Well Classification //J.i~l vr~ ~,,¢,~ if A, B, C, D.E.C. Approved (Y/N) Well Log Present~/N) 7 Date Completed '~'- ~O .- 7 ~. Yield G Ft4 , , Total DeP~h~ Cased to/ ~ Depth of Grouting '~ ' Static Water Level Casing Height Above Ground Electrical Wiring in Condui~i~TN) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot Pump Set At To Nearest Edge of Absorption Field on/Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Sanitary Seal on Casingd[~/N) Depression Around Wellhead (Yd~..l~ I ; On Adjoining Lots I co/+ ; On Adjoining Lots Nearest Public Sewer Cleanout/Manhole //~.4~//-~'~ ; Date Comments B. SEPTIC/HOLDING T~ANK DATA Date Installed ~//'7(,,P Size Standpipes ~¢"N) Depression over Tank Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) / ~ Air-tight Cap~(~/N) No. of Compartments y Foundation Cleanout(~N) "'/ ~/,~Date Last Pumped ; for SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: · To Water-Supply Well To Property Line To Water Main/Service Line Temporary Holding Tank Permit (Y/N) To Building Foundation ~-~C~ I'~'~- To Disposal Field ( 7 io To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field "~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~ Square Feet of Absortion Area '~--~/~ 'f'' Statndpipes Present (Y/N) Depression over Field (Y~;[~ /"{ Date of Last Adequacy Test Results of Last Adequacy Test ~//'~. ,/~./~'-'/~--~rT~-~,-./ ,-- .~'~'~:::~--~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~//~"~ TO Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ; On Adjoining Lots '"~ '/'~ [ ~ f"~ To Cutback (if present) To Property Line [ Q I,j.. To Existing or Abandoned System on Comments D. LIFT STATION Date Installed Dimensions Siz~allons "Pump O~,,,e.v.~.~ High Water Alarm Level-'~--~--..~_ Tested for Meets MOA Electrical Codes (Y/N) Comments Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Signed Company **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA inspection. $ & $ ENGINEERING 17034 Eagle River Loop Road No. 2.04 Eagle River, Alaska Date MOA No. Receipt No. c~/c~ ,c///% Date of Payment Amount: $ //2 ~ ~ r_../ 72-026 (Rev. 7/88) Back a~)..~'AA g__~L~j.~a~-~ffect on the date of this ~~ E~"t~'/"'~'~'~gineer'sSea. Receipt No. * -~:.,,,., Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order $ !3858 Date Report Printed: JUN 12 89 @ 11:56 Chent Sample ID:L2 CHUG~CH GARDENS PWSID :UA Collected JUN 6 89 @ hzs. 5eceived 3UN 7 89 @ [6:45 hrs. Preserved with :AS REQUIRED Client Name : $ & S ENGR Client Acer : SNSENGP P.O.$ NONE REC'D Req # Ordered By Analys!s Completed :JUN 9 89 ,. Send Reports to: Laboratory Supervisor :STEPHEN C. EDE I)S & S ENGR Released By : /,4 2) Special Instruct: Chemlab Re~ $: 5638 Lab Smpl ID: 3 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE~-N ND(0.10) m~/1 EPA 353.2 10 Sample SAMPLE COLLECTED BY RP Remaz ks: 1 Tests Performed * See Special Instructions Above UA-Unavailable ND= None Detected "See Sample Remarks Above NAr Noi~ Analyzed LT-L~s Than, GT~Greate~ Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# I I I -~;I,JPRIVATE WATER SYSTEM Name Phone No. Mailip.g .Address ~ City ' / State Zip Code Mo. Day Year TO BE COMPLETED BY LABORATORY AnalYsis shows this Water SAMPLE to be: ,~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received ~- 2-~c' ~, Time Received /~ ~..~- SAMPLE TYPE: .[~Routine [~' Check Sample (for routine sample with lab ref. no. [] Special Purpose .~ Treated Water ..~'-' Untreated Water Analytical Method: Membrane Filter * No. of colonies/100 mi. SAMPLE NO. / LOCATION 4 I 5 I Time Collected Collected By I '~ ~-;~.c I 1 I I Lab Ref. No. Result* ] Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter: Direct Count CoilformllOOml BEFORE COLLECTING SAMPLE Verification: LTB Final Membrane ~~t~ ~ Reported By ~ ~'~ ~__~,~ ~ BGB Date  . ~,F~311f°rmllOOml TNTC - Too Numberous To Count OB = Other Bacteria PART OF 2 REMAINDER TO FOLLOW MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) / Location (address or directions) (b) Property owner ~'O-///'~d., ~ ~, Telephone '(home) Mailing Address c~/'//~ _~:9~"°"~ ~t~~-'~ ~, Business (c) Lending Institution Telephone Mailing Address (d) (e) Real Estate Company and Agent Address /~-~ ~-~z~~~ Telephone Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING !703~. E,,=!e Ri.~'__ t ~p Ra~d Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-Family,S, Number of bedrooms WATER SUPPLY Individual Well [~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status,' SEWAGE DISPOSAL On-site'l~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 '>{JO~ s,Jeeu!t~ua IEUO!SSejoJd aql u! suo!sS!lllO JO sJOJJ{} JOj elq!suodseJ lOU s! a§~Joqou¥ jo ~,!led!o!u nlAi eq.L 'penss! s! e~,Bo!j!lJeO e eJojeq ~,ep eZ~l~U~ Jo suo!loedsu! ~,onpuoo lou op SHHQ jo see,~olduJ3 'slueuJeJ! nbeJ e~els pue leJepe~ u!e~,Jeo ~js!~s ol JepJo u! suo!lnlp, su! I~u!puel J!eql pue seLuoq JO sJes~qoJnd ol ,~se~Jnoo e se s!q~ seop SHHQ eqj. 'e>lS~l¥ ~o e~,el$ eq~, u! peJe~,s!l~ej Jeeu!§ue I~UO!SsejoJd ~,uepuedepu! u~ ~q e^oqe S qde~Se~ed u! ue^!8 suo!~ueseJdeJ eql uodn ,{lUO pes~q pe~,eo!~!Jeo le^oJdd¥ ~l!Joqln¥ qlleeH senss! (SHHQ) seo!^JeS u~LunH pue qlleeH jo lueLulJ~deQ e§eJoqou¥ ~o ~l!l~d!o!unlAI eq.L I~UOp,!puoo le^oJdd¥ leUO!],!puoo to swJe/ pe^oJddes!Q, '~ peAoJdd¥ /~q SLUOOJpeq ~. JO~ peAoJdd~f lVAOI:IddV SHH(3 '9 e~eQ MLJNICiP/~,LI I'~~ OF Al ! ~ ORAGE ENVli~,)NMr:N//xL ~f~r~i ,o, ~UNIOIPALITY OF ANOHO~AQE (MOA) .... ~'~'~'~'~ Health Authority Approval (HAA) ~ ~ ~ CHECKLIST- FEBRUARY 1984 ;': ~ ~ 343-4744 '~" ~-~ V ~ [~ Legal Description: ~ A. WELL DATA Well Classification Well Log Present ~:YN) Total Depth ~,~'o Cased to Static Water Level Date Completed ~ ~"~'lllb \of~ Depth of Grouting ~ Pump Set At If A, B, C, D.E.C. Approved (Y/N) Yield ~.,~ ~, f'c'd Casing Height Above Ground VZ~ Electrical Wiring in Conduit,~N) '7/ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot Sanitary Seal on Casing ¢~.N) Depression Around Wellhead (Y/I~) I'~ ; On Adjoining Lots I TO Nearest Edge of Absorption Fiel~.~o~Lot \ c:::=,c~ 'P ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~ t~ Water Sample Collected by ~~ ~l~~ ;Date Water Sample Test Results Comments ~ ~~ ~~ ~~' B, SEPTIC/HOLDING TANK DATA Date Installed '~1//~b Size ~ No. of Compartments Standpipes~)/N) ' y Depression over Tank (Y~ Air-tight Caps,(~/N) . . Pumping/Maintenance Contact On File (Y/.N) / Holding Tank High-water Alarm (Y/N) Foundation Cleanout:~YN) //p~ate Last Pumped /~ ; for -'---- Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/I'fOL-DtNG TANK: / O~ ! To Building FoundatiOn '/f 0 ¢-' To Disposal Field ! To Stream, Pond, Lake or Major Drainage Course To Water-Supply Well To Property Line To Water Main/Service Line 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field "~ Type of System Design Length of Field Depth of Field ! / Square Feet of Absortion Area Depression over Field (Y/(I:~ Results of Last Adequacy Test Gravel Bed Thickness "~'7 (P '¢Statndpipes Present (~/N) /"J Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot I--~ ~,/~ To Water Main/Service Line \ ~ 'Jr 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 /'-~-~c, 'J~ ¢/^ To Cutback (if present) Comments D. LIFT STATION Date Installed Size ~ "Pump On" Level at-'~'-"~ High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Pumping ~y Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspectionl Signed Company Date MOA No. S ,& S ENGINEERING 17034 Eagle ~,.v,~ L-.-.r- ~=~1~ Rive~, Alaska 995~ Receipt NO. /~' Date of Payment Amount: $ 72-026 (Rev. 7/88) Back -,P,F Receipt No. '~ Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. / ~~\- -~ ~-~ ~~~ ~-~~ .~""'t~,a'o~,~'~',~:;"% FEDERAL TAX ID # 92-0040440 NOV 2 9 1988 RECEIVED CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER RIVATE WATER SYSTEM Name ' w ' '~hone No. Mailing Address ~_ City / State Zip Code SA.,,, AT,: Mo. Day Year SAMPLE TYPE: __~outine hack Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO, LOCATION MuNlC/PALITy OF DEPT. OF HEALTH & ............. '~'~- rKUIl:CrlON IqUV ~.1 ~ IC7OO Time Collected Collected By TO BE COMPLETED BY LABORATORY Analys~s shows this Water SAMPLE to be: ~l"' Satlsf act cry [] Unsatisfactory [] sample too long in transit; sample should no, be over 30 hours old at examination to Indicate reliable results· Please send new sample via special~delivq/'y mail. Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No.. Result* J I I Analyst RECEIVED READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count ~ Coilformll00ml Verification: LTB Final Membrane ~~5 Reported By TNTC - Too Numberous To Count OB - Other Bacteria BGB Coilformll00ml Time: /~ a.m. p.m. PART ! OF 2 REMAINDER TO FOLLOW