HIGHLAND PARK BLK 5A LT 1C1

Press Alt + R to read the document text or Alt + P to download or print.

/ 4

Entry Properties
Modified	12/28/2016 7:56:50 PM
Created	9/25/2000 9:23:34 AM
Template
Onsite Files
Fields
Parcel ID	012-065-51
Subdivision	HIGHLAND PARK
Block	5A
Lot	1C1
Legal Description	HIGHLAND PARK BLK 5A LT 1C1

The URL can be used to link to this page

Home My WebLink AboutCRESTWOOD LT 21 GREA'~cR ANCHORAGE AREA BOR~GH Department of Environmental Qualitv 3330 C Street Anchorage, Alaska gg§03 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCAT,ON ~8'~ ;-~ _~-r. L~G^L DESCR,PT,ON ~O /-- ~ / cresT' ~d ~./~>- SEPTIC TANK: DISTANCE FROM WElL INSIDE LENGTH MANUFACTURER -~YA-"~'~'"~'~_ MATERI AL INSIDE WIDTH ""~"~ LIQUID DEPTH NUMBER OF "~_ COMPARTMENTS TILE DRAIN FIELD: DISTANCE FROM WELL NUMBER OF LINES ABSORPTION AREA FOUNDATION DISTANCE BETWEEN LINES SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE ~' / MATERIAL BENEATH TILE ~'T IN. ABOVE TILE ( NEAREST LOT LINE ~:~ /"1/~ TOTALoF LINEsLENGTH'.~ ~--~ Fo© ,N. TYPE_ CONSTRUCTION DEPTH DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION LOT LINE__, SEWER LINE__, TANK__ SYSTEM CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY: ~ PIPE MATERIAL: _~O~' ~0/'//~ LOT SLOPE: REMARKS: 5[/. - I~-A DIAGRAM Of SYSTEM DATE ~//~'/,,~ ? APPROVED 1// Form LQ-032 PERMIT NO. f-lL.l[4 ! E: ! F'FIL_ J T"¢ C~F R~4E:HC~F:RI.SEZ DEPARTMENT OF HEAl_TH AND ENVIRONMENTAL PROTECTION 825 "L' STREET, ANCHORAGE, AK. 9950i. 279-25it L-IEEE 7732:8 ) Fir-4[:, C~-4--S I 1-E SE[-~EF-: F"EF-:f-1 I -r' APF'LIC:RNT LOCATION LEGAL FOREMOST HOMES BRIEN ST L21 CRESTWO0[:, SUB[:, 2523 E:RIEN LOT SIZE 279-3644 .-.-.-':5000 '_=;QURRE FEET T'¢PE OF SOIL ABSORBTION SgSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT,.-'BR)= t25 THE REQUIRED SIZE OF THE SOIL ABSORPTION S~STEf'I IS: E:, E F' T H = 1 2 L E [-~ 13 qr- H = 3:6 ~3 F:: R '-.." E: L E:. E: F' qr" bt =: 7 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR [:,RAINFIEL[:'. THE DEPTH OF H TRENCH OR PI]' IS THE DISTANCE BETWEEN THE ':;L~RFHCE OF THE GROUND AND THE E:OTTOM OF THE EXL:A'.,,'ATION ,.'.'IN FEET::,. THERE IS NO SET WIDTH FOR TRENCHES. -' -" ~F.M,EL BETNEEN THE OU]-FF~LL. PIPE '['HE ~',F..M,.EL. DEF'TH IS THE MINIMUM [:,EF'TH OF -' -" AND THE BOTTOM OF THE E::-:',CA',.,'ATION ,::IN FEE'['::,. F~:: E ,]:-.~ Li I F-: E [:, S. E F' T I C T R N K '_:; I 27 E = :t 2 5 ~-_-E~ ,.S R b. b ,2, N S -F L-~ C~ ( 2 ::, I ~-~ $ F' E C: T T C~ ~-4 S Ft F-: E F-: E l;.~ L.! I F-: E BACKFILL. ING OF ANY S'¢STEM NITHOUT FINAL INSF'ECTION AND APPROVF~I_ 8'Y' THIS [:,EPRRTMENT NILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A NELL AND ANY ON-SITE SEWAGE DISPOSAl.. S¥S"FEM IS t00 FEET FOR A PRIVATE NELL OR 200 FEET FOR A PUBLIC NELL.. WELL LOGS ARE REQLIIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 [:,Ab'S OF THE NELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALL. ATION F'EF-: f-1 I T "-.."RL_ I E:, FC, F-: C~[-~E ~'r"ERF-: FF-:E~f'I I '-~;'--=; IJ E']_ I C:ERTIF'T' 'THAT 1' I 8M FAMILIAR N ITH I'HE REQUIF.:EMENTc; FOR ON-':;ITE SENERS AND WELLS RS SET FORTH B~' THE MUNICIPALIT'¢ OF ANCHORAGE. 2' I WILL INSTALL THE S'¢STEM IN RcCOF.:DRNCE NITH THE F:FE:,ES. .-...':- I UNE:,ERSTAN[:, THAT THE ON-SITE SENER S'¢STEM rdR'T' REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 E:E[:,ROOMS. SIGNED: APPLICANT FOREMOST HOMES ISSUE[:, BY ...... [)RTE ..................... GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456! Cc., SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. INSTALLATION LOCATION ~ ~~L INSTALLATION OF: SEPTIC TANK ~ TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS ./~I~-~ SEEPAGE PIT DRAIN FIELD OTHER TO BE INSTALLED BY NOTE= THIS PERMIT IS NOT VALID WITHOUT ~OIL 're:si' COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE MINIMUM DISTANCES, REQUIREMENT~ FOUNDATION TO SEPTIC TANK FOUNDATION TO SEPTIC TANK TO SEEPAGE PiT WALL DRAIN FIELD SEPTIC TANK ~ , SEEPAGE PIT . DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK /&)O i SF=~I~E--PIT~/4~"J~ /dO DRAIN FIELD ALSO CONSIDER AREA WELLS, WATER MAIN TO SEPTIC TANK /~ { SEEPAGE PIT DRAIN FIELD ....... DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFII=L '/2- -~ '/~ ~ ~ CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. G.A.A.B. OR LICENSED DESIGNER DIAGRAM OF SYSTEM 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. FORM NO. E~-01 $ Performed For Foremost Homes teoal ~escrintion: Lot 21 Block This Korm Renorts Soils Loa Mes "One ~ is ~o~h · th~sand o~i.ions" 2204 Cleveland Anchorage, Alaska 99503 Date Performed 5/23/77 Subdivision Crestwood Perc0]ati0n Test ~enth Feet Soil Characteristics ~" pmmt & h" R~d~imh Silt ._ Gravelly Sand 10-- 14--. Sandy Gravel 16-- 18 20 .,. Bottom of Test Hole iii Was Ground Water Encountered? No If Yes, At what Denth? I , : i IReadinq Date Gross Time Net Time Depth to H20 Net Dron [ ' Percolation Rate Uinute Prnposed Installation: SeenaQe Pit Drain Field Deoth of Inlet Denth To Bottom Of Pit Or Trench Cn~ENTS: 125 Sq Ft drainaq~ area req~iro~ per bedroom from i to 7.5 feet. 100 Sq ~t 'drainage area required per bedroom fr__o~ !:~ t~ 1__5 ~t~ __ Test Performed B¥~ ~~~'-~-. _ Data Certified BY:CONSTRUCTION TESTAB "bavid Paul ~ Date: 5/23~77 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & 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. 015-061-24 1. GENERAL INFORMATION Expiration Date: _ ?- ° Complete legaldescript[on CRES'P, VOOD SUBDIVISION; LOT 21, Location (site address or directions) 9651 BRIEN STREET * ANCHOEAGE, ..AK 99516 Current Property owner(si Mailing address Lending agency Mailing address Real Estate Agent Mailing address ELLEN INGRAM Day phone (907) 842-5287 P.O. BOX 355 * DILLINGHAM~ AK 99576 Day phone PATI'I HIGGINS w/ PRUDENTIAL VISTA Day phone 4241 "B" STREET * ANCHORAGE, AK 99503 360-2561 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 [] [-'] Public Sewer [] The Municipality of Anchorage Development Services Departmen[ (DSD) issues Certificates of Health Authority Approval (HAA) based only upcn 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 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 er B wells or a public water system. The Municipality of Anchorage is not responsible for errors 0r omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ to closing for the engineering sen/ices provided. at, or pdor 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 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. Name of Firm ALASKA WATER & WASTE'WATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 29 * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. CARNESS, P.E. 537-6179 Engineer's Comments: In conducting this evaluation, AKWWC, Inc. affempted 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 cond2ions encountered at the time of the test, and separation distancos measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, 9rounclwater 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 e valuator 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. AKWWC, Inc. can therefore not provide. any warranty or future estimate of how long the system will continue to meet the operational requirements of lhe 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 z, bedrooms. Disapproved. Conditional approval for ~ bedrooms, with the fllowing stipulations: NOTE: The well for this p_ropertv meets exi~tfn? ~tate & Municipal cod~. Th~r~ ,~'~ nitrates present. It is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate concentration Ss 6.2~~m concentration is 10.0 m~/1. More ~nformation on n~trates On-site Services Program at 343-7904. Attachments: HAA Checklist !~ Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort .. Well Flow Advisory Other Original Certificate Date: (Rev. Municipality of Anchorage Development Services Department Building Safety Oivlslon On.~lte Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196550 A~chorage, AK g9519.6650 www.ci.anchorage.ak.us (907) ~3-7g04 Legal. Description: A. WELL DATA HEALTH ~,UTHORITY ~.PPROVAL CHECKLIST , ,CRESiWOOD SUBDNISION; LOT 21 , Well type pRNA'i~ Date completed, -9/1977 Total depth ,78.5 fL If A, B, or C provide PWSII:~ ,N//A Sanitary seal (Y/N) _YES Cased to 78.5 ft. FROM WELL LOG ~ ,. 20 ,, fl. ~:0 g.p.m. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform __ Arsenic: . Parcel ID: 015-061-24. Well Log (Y/N) , , ,YES, , Wires properly protected (Y/N) . ~ Casing height (above ground) ,12' AT INSPECTION .... 3/7/2003 55, ff, 5.75 g.p.m. 0 colonies/100 mi. Nitrate 6.23 m~3J~--, Other bacteria O 3/~//200~ "' N//A mgJl.. Date of sample: 5/7/2003 Collected by: . AKWWC~ INC. SEPTIC/HOLDING TANK DATA *INSIDE FOUNDATION. UNE SNAKED BY McDONALD'S PUMPING TO VERIFY THAT IT WAS A USA~ILE CLEANOUT. Tank Type/Material ,.. PLASTIC/f,~-,~.~ Date installed , 6//B/,1977 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N), , , N//A Pumper CHUGACH PUMPING PBELOW FINAL GRADEI Soil rating (g,p.d./ft=or(~ 125 System type TRENCH Width 3 ff. Gravel below pipe 7 Total depth .lo.13, ff. Eft. absorption, area 504. fi2 Monitoring tube*L~YES Date of adequacy test . 3/7/2003 Results (Pass/Fa~) PASS Fluid depth in absorption field before test 18.5 in. Water added B 11 gal. Elapsed Time: 9 min. Final fluid depth 1,6.5 in. Absorption rate >= Any rejuvenation treatment (past 12 mo,) (Y/N & type) , NONE KNOWN *SUMP EXTENDS ONLY 4.63' INTO THE SEWER ROCK. Foundation cleanout (Y/N) *YES Date of pumping 5//7/2005 ABSORPTION FIELD DATA Date installed , S/8/1977 , Length _. 36 It. in, , colonies/100 mi, Depression over field NO, For,, 4. bedrooms New depth 42.5 in. 600+ g.p.d. If yes, gNe date - DJ LIFT STATION Date installed Size in gallons Man~ "Pump on" level at in. "Pu~ High water alarm level at in. ~ ~ Cycles tested. Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Fo Septic tank/lift station on lot100'+ Absorption field on lot t00'+ Public sewer main ' N/A Sewer/septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/'A Water service line 10'+ Wells on adjacent lots '100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ COMMENTS G. ENGINEER'S CERTIFICATION Absorption field 5'+ Surface water. 100'+ Water main N/A Driveway, parking/vehicle storage 10'+ 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 Date JEFFREY ~ GARNESS HAA Fee $ ~ Date of Payment Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number S 8~O~g'o,,O~ t ~00.00' N ngO§g'oo"w 900.00' THE INFORMATtON HEREON IS FOR THE U~E OF LEN01NG INSl'I~JT1ONS SPECIFICALLY TO SHOW ANy CONFUCTS BETWEEN EX~ST1NG STRUCTURES AND P!.ATTED LOT LINES OR EASEMENTS AND tS NOT TO BE USED FOR POSITIONtNG ADOITIONAL STRUCTURES OR FENCEUNES, NO CORNF. R$ SET TH~S DATE SCA.LE:I' s 40' I HEREBY CERT1FY THAT I HAVE PERFORMED A MORTGAGEE'~ INSPECTION OF THE FO~.OWINO DESCRI-SED PROPERTY. LOT 21, CRESTWOOD SGS Re£# Client Name Project Name/# Client Sample ID Matrh 1031267001 AK Watcr & Wastewater Consultants Inc. Cr~stwood L21 Crestwood L21 Drinking Water All Dates/Times are Alaska Standard Time Printed Date/Time 03/10/2003 17:02 Collected Daterrime 03/07/2003 14:56 Received Date/Time 03~07/2003 1~5:25 Technical Director. / Stephen C~,~e Sample Remarks: Allowable Prep Analysis Parameter Results PQL Units Method Limits Date Date Init Waters Department Nitrate-N 6.23 0.200 mg/L EPA 300.0 (<=10) 03/07/03 .IS Microbiology Laboratory Total Coliform I I OB, No Coil col/100mL SMI8 9222B (<=!'} 03/07/03 KAP CT&E Environmental Services Inc. Laboratory Division 200 W. Potter Drive Drinking Water Analysis Report 'for Total Coliform Bacteria ^.nhora.o,AK 99519-1605' Tel: (907) 562-2343 RE~ID INSTRUCTIONS ON REVERSE SI~gE BEFOR2? COLLECTING SAMP£E Fax: (907) 561-5301 " MUST BE COMPLETED BY WATER SUPPLIER El ,PUBLIC WATER SYSTE1H I.D. # .. [llllll' PRIVATE WATER SYSTEI~[ ~/~end Results ¢q Send Invoice vi Sencl Result$ El $~nd lnvolce SAMPLE DATE: ~ l~lonth · SAMPLE TYPE: t3 ,/Routine t~ Repeat Sample (for routine s~mple with fab ref. no. ) tn Special Purpose SAMPLE LOCATION. ~c~.,o~d ~'~1 Day Year Treated Water Untreated Water Time Collected Collected By' TO BE COMPLETED BY LABORATORY Analysis shows this .Water SAMPLE to be: /~ Satisfacto~ O Unsati.sfactor~ El Sample over 30 hours old, results may · be unreliable o Sample too long in transit; sample should '. not be over~Onours old at examination .to indicate reliable results. Please send new. sample via special delivery mail. ~aten.ceived ~,.2 7-~J TimeRccelved ' '/~ qO Analytical Method: ~ Mcmbrane Filter ' o MMO-MUG Comments: ~0 ml. 1031 631 -14~ Result' Anal,st Scot to A.D.£.C. Anch FbLs Jun Date: Time: Client notified of unsatisfactory resulis: Phontd Spoke with Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD biMO-I~IUG Result: Total Coliform ~'. Coif blembrane Filter: Direct Count ~~-~..~O Colonies/100 mi Verification: LTB BGB COIJIFIRM Fecal Coliform Confirmation Final Membrane FilterResu~4s ~~...~ Reported Bye-- ~ff/~~ Date //~ ',~'qC?)r Coliform/lO0 mi Time /~ ~/~) hfs Fazed [] Fazed ~,~ S~-~ Member O! the SGS Group {Soci6t~ G~n~ra e de Surveillance) ENVIRONMENTAL FACILITIES IN ALASKA, CAUFORN1A, FLORIDA, ILLINOIS, MARYLAND. MICHIGAI. MISSOURI, NEW JERSEY, OHIO. WEST V%RGINIA 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 1. GENERAL INFORMATION Complete legal description Lot 21; Cr~twood S~bdivisionl Location (site address or directions) Property owner Mailing address Lending agency Mailing address Lemi~ ~: Li~.~an M~<~.n Day phone 965! B~Zen ~ee~ ~e~e~ag~, 4~ qq~16 Day phone 561-5055 Agent Address Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: 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. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer 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 Sm 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. S & S ENGINEERING Name of Firm 17c=4 =..=;V- p;v~r Loc~ Read ~,,. 20~. Phone Eagle River, Alaska ¢~9577 Address Engineer's signature Date DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 DH HS 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /,~./L ~. ~; (,3 ~..~-~--~ 8 Parcel I.D. A. WELL DATA Well type ~ If A, B, or C, attach ADEC letter. Log present (Y/N) ~, Date completed Totaldepth "'7 [~:~ ~ '' , Cased to ~ 0 Sanitary seal (Y/N) ADEC water system number ~ ~..- Z.o- '7 '7. Driller I ~ Casing height Wires properly protected (Y/N) L/ FROM WELL LOG Static water level _~,, ¥ · Pump level Absorption field on lot Public sewer main Public sewer service line SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot { _~'~C) 'lL g.p.m. ,,+ AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank !oo ' IOO WATER SAMPLE RESULTS: Coliform --~*J~{~'f"Rc----']L~'ut Nitrate Date of sample: ~ ~ 'Z ~:) - ~:~ [ B. SEPTIC/HOLDING TANK DATA Date installed ~- _~- ~-. ~ Cleanouts (Y/N) ~ High water alarm (Y/N) Date of pumping Tank size I ~- ~'~ ? ~ I Compartments ~-- Foundation cleanout (Y/N) /kJ Depression (.Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I Ot~ '~ Onadjacentlots [ ~0 Y' Foundation To property line (~ ~ Absorption field ~ Water main/service line Surfacewater/drainage I (~0 ~' ! 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed '~.'X~ Manufacturer Size in gallons % Manhole/Access (Y/N) ~ Vent (Y/N) __ . ~ "Pumj~' level at .... "Pump off'. level at High water alarm level "~,.. ;/~ Cycles tested g__ Meets MOA electrical c~des (Y/N) ,~_)~.~. ' Well on lot On adjacent Iots"~ Surface water Soil rating ./ ~ ~-- ~:~/1~~ System type Gravel thickness · ~ Length ~ ~" Width Total absorptionarea Depression over field (Y/N) Results (pass/fail) ~P~ ~ PeroXide treatment (past 12 months) (Y/N) D. ABSORPTION FIELD DATA Date installed ~' ~ - ~ Cleanouts present (Y/N) Date of adequacy test for /-~ If yes, give date Total depth bedrooms t SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots ~0 Surface water Curtain drain On adjacent lots ! ¢3 0 ~ , Property line / ~ '/' -J' To existing or abandoned system on lot /~J/J~ Cutbank /~J / ~ Water main/service line [ 0 ~-~' Driveway, parking/vehicle storage area ~ ~ '~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect o~e of this i~ection. Signature ~Tn~ ~aa~e River ~p Road Eagle Riv;r, Alaska 99577 HAA Fee $ I~O, Waiver Fee: $ Date of Payment ~- ~O - ~ I Date of Payment Receipt Number ~ ~ ~ ~ / ~ ~ ~ ~ Receipt Number 72-026 (Rev. 3/91) Back MOA21. CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING ---~_ ---~------~ ---------~z~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE for WORKozdez# 34406 Date Report Printed: MAY 22 91 @ 18:49 FAX: (907) 561-5301 C:ient Sample ID:L21; CRESTWOOD S/D Collected MAY 20 91 ~ 15:0~ hzs kece:ved MAY 2t 91 ~ 14:35 h:s Preserved with :AS REQUI~ED Clxent Name :S & S ENGINEERING Client Acct :SNSENGP BPO $ PO $ NONE RECEIVED Req t Ordezed By :R. SHAFEE Completed :MAY 22 91 Send Reports to: Laboratory Supervisor :STEPHEN C EDE 1)S & S ENGINEERING Chemlab kei $: 912146 Lab Smpl ID: 11 ~at:ix: WATER Allowable Parameter Tested %esult Units Method Li~tts NITRATE-N 4.0 mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: R.D.J. Remarks: Tests Periormed ' See Special Instructions Above UA-Unavailable None Detected '* See Sample Remarks Above Not Analyzed LT-Less Than, GT-Greate~ Than MUNICIPALITY OF ANCHORAGE DEPARTME~._~F HEALTH AND ENVIRONMENI~,~PROTECTION 825 L Street, Anchoraa~. Alaska 99501 264-4720 Date Received: September 20~ 1977 #1: Time 1:30 p.m. #2: Time #3: Time Date 9-2~-77 ~d~ Date Date Insp A,~/7~1~2 Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Alaska Pacific Bank Mailing Address: 601 West 5th Avenue 99501 Phone: 276-3110 e Property Owner: Mai~ing Address: Howard Smith/Foremost Services 2523 Brooke Drive Phone: 278-3644 3. Legal Description: Lot 21 Crestwood Subdivision 4: Single Family Residence: (x) Multiple Family Residence: ( ) Number of Bedrooms: Three Number of Bedrooms: Se Well System: Permit # Individual Well (x) Community/Public System ( ) Depth of Well 78'5" Well Log on File Construction Bacterial Analysis Sewage Disposal System: Permit # Septic Tank Size Absorption Area On-site System (x) Public Utility ( ) Installed 1977 Installer Manufacturer Soils Rate Material Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line 'Page Two ~ Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 21 Crestwood Subdivision Comments: Affadavit Attached Disapproved: Letter Attached: ( ) Date: Department Worksheet: OF ANCHORAGE Type of Inspec!ieq: CMRO _VA Owner: How~[r~[ Stol_th DBA; Foremost * Mailing Addre~s: 25~} Brooke Dr. ' ~'x , ~ , Day ~aiting Address: Name of kendin~ Institution: Mailing Address: ~ 60~ Name of Realtor or Agent:_ Mailing Addre~:_~~~ . OF HEALTH AND ENVIRONMENTAL PROTECTION ,~or Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES FHA Services Day Phone: _ Phone:~6-.311 0 Phone: 272-057'1 ype of Facility to be Inspected: ~/Vater ,.gu ply _ No. Bdrms. Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well .. Disposal S~stem Type bf System: Public Utility If In~lividual, date of installation. 6-1(.:)-?? .Individual one _ I nd ividual (o~-site) DATE RECEIVED - ~ -"' iNSPECTiON APPOi NTMENTS ~'~ TIME , \ ,~ akj~)~ TIME :TIME DATE DATE DATE MUNIClPALI~ OF DEPT. OF J~'"L'~ ~ & ~UNIOIPALITY OF ANOHORA~E E~IRONME~-~t,~,~ ; ~ECTION 825 L Str.t-Anchor,~, Alaska ~01 I'~AY ~ 5 1980 ENVIRONMENTAL SANITATION DIVISION Telephone 264~720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES OIREOTIONS: OompleTe all parts on page 1. Incomplete r~u~ will not be procad, Please ~llow ten (10) days for pr~essing. MA~G ADDRESS PROPERTY RESIDENT 2. BUYER PHONE MAILING ADDRESS 3, LENDING INSTITUTION PHONE MAI LING ADDRE~ 4, REALTOR/AGENT ~ PHONE' MAI LING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY NUMBER OF~BEDROOMS [] One ~-- Four [] Two [] Five [] Three [] Six [] Other * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ~ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE i--I OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY G ~'-~ Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: ) '~-~"~ If Tank is homemade SOILS RATING give, dimensions: ~, ,~.._.~'" TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AR EA MATERIAL Absorption Area to nearest Lot Line 5. COMMENTS [~]~PPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompa~cate) [] DISAPPROVED //' 72-010 (Rev. 6/79)