HomeMy WebLinkAboutCOLONIAL PARK BLK 3 LT 1 N2
· 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: ~<:~t ~ ~~' PID Number: O~x> --,~o 1
N=~: ~H k~ ~Rr~ ~V~ Wastewater System:
Address:
i~ ~~ ~~ ~-~., AE,~ P~,c ABSORPTION FIELD
Phone: /~ ~ NO. of Bedrooms:
~_]~ ~_~ ~ ~D~pTrench ~ Shallow Trench ~Bed
LEGAL DESCRIPTION Soil Rating: Total D~na,
grade:
GPD/SQ. Ft.
Lot: Block: Subdiv~ion: Depth to pipe bosom from original grade: ~ h ben,th pipe
Gravel width: ~ ~ Number of lines: ] Dis~nce ~n ]i~:
Clarification (Private, A,B,C): Total Depth: ~: Total absorpt~: Pipe materi~l:
Driller: ~ Drilled: S~c Water Level: Inst~ Date ins~lled:
I ~ing ~ight Above Ground: TAN K
~ GPM I Ft.I Ft.
SEPARATION DISTANCES ~Septic ~ Holding ~.T.E.P.
To ~mic A~omtion Lift Holding ~ubli~ri~te Manufa~umr: (~ ~ ~ Cap~city in gallons:
From Tank Field S,.,ion Tank ~r Lin. ~~ ~
We,~ ~ ~ [ ~ , , Numar of ~mpa~ment,:
Sudace
Water IOof+ ~ leot~ ~ LIFT STATION
LOt Z~l~ ~~ ~ ~ ~ Size in gallons: I Manufacturer:
t ~ vi ~ "Pump on" level at: I "Pump o~' level at: ~High water ala~ at:
Foundation I~ ~ ~[ ~ ~
J ~ Pump Make & Model ~ Electd~l Ins~tio~ pedo~ by:
Cu~ainDrain " . . ~ ~ ~ ~ OSj ~ ~ ~N
Remarks: BENCH MARK
Lo~flon and D~cription:
J ~um~ ~OO, ~ Ft.
Election:
~, ~/ ~N~NES~'S S~ ~L
Inspections performed by: m~ ~ m~so. Dates: ~st ~ ~ ~ ' ' ' ' '
2nd ~
Depadment of Health and.H~man Se~ices approval -~.~,, J:E-795~ ..~
~ ,~//~~
Reviewed and approved by:~ Date:/~-~ ~'~
72-O13 (Rev. 9/91) MOA 25
~ / /~, ~ ,~ .~' ~ 1
/ / ~
I I /' \
] SECOND STREET ~
.... ~ ..................... ~.-~--~~
~~ '~ ~' ~'t %,~., ~ ~ ,~o ~~ , , ,~
'a BDRM I I
i ~ SE~CE ~ [ ~ ,
~ ~ ~ ~ (~PROX. LO~TION) I
~e~ ~ ~2so ~o~ SSA~ON
~ WHICH PUWPS EF~UENT TO
~ ~ THE PUBUO S~ER ~IN.
~ ~ ~ =- ~- ~ ~ _ ~ I ~ ~ DAVID DRIVE
~OLONI~L P~K ~UBDIVI~ION; NO~TH 1/2 OF LOT
WPE OF WORK:
SITE P~N
~,s~ w~v~ ls~-~s/s~s-ssso . ..-'"
JAY AND
lO/5198 J.L.M. 1 = 50' 1 or 1
PERMIT NUMBER: AS BUZLT DI~k~ING PARCEL ID NUMBER:
TO' BE ASSIGNED = 050-501-50
~ SECOND .... STREET~/ ~
/ X~ ~S~ER SE~CE LINE
/ / ~ (.P,ROX. LOC*T, ON)
----~, ' ,. ~ , ~ '
,~ 5 BDRM
I ~&~ ~/ / HOUSE ~ ~, I
/- ~t A ~ ~ ~ I
I ~/ ~1 '~~ x
WHICH PUMPS EFFLUENT TO ~. ~
,u,,,c ) /
ST~ 30.8 25.2 -
ST2; 55.5 28.0 ~r- ~
MH 54.8 29.4 ~.~~ ~ ' ' =~.
7320 E. CH~ H~G~ ClRC~, ~OHO~ ~ 9~504
PHONE: (.0~) ~Z-~/F~: (.0~} ~-~
COLONIAL PARK SUBDIVISION; NORTH 1/2 OF LOT 1, BLOCK 3, '
, ,.
~PE OF WORK: I ~f~"~
~ ...... ~ .
AS-BUILT DRAWING OF SEPTIC TANK/UFT STATION DOCUMENTATION.
KRISTEN WEAVER 265-1495/696-8680 '~ r-.. ~ ...'.~
JAY AND
10/5/98 J.L.M. 1 : 30' 2 or 2
A B
ST1 .30.8 25.2
ST2 55.5 28.0
MH 54.8 29.4
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 , TELEPHONE 558-2759
I
DEl'TH OF WELL <:~'~ 'T' ~-
e~'~"'/"PST A TIC LEVEL OF Vl ATE R FT. ~ /
LEGAL DESCRIPTION/~'
DATE - Started
Ended
P£1LM IT NUMBER
DRAW DOWN FT.
eER HR
KIND OF CASING
KIND OF FORMATION:
From ~ -Fl. to ~2, .Fl.
From ~ _Ft. to__~Ft._
~_, .A-.~"~J(~ ,.~-! C~'IlO From .FI. to_ --Ft.
O~,l~~ From .... FI. to .Ft. '
t
From ~ .Ft. to ~ Ft._ ~a/4~ ' ~a~d,~ From _FI. to Ft.
Fmm~Ft. to~ .Ft._~(T~ ~0 f ~G From~Ft, to~Ft~
~m~~t. t~Ft.ya~n &~~ ~ ~ar~ ~om~ ~t.
From _Ft. to _Ft._ From . Ft. to
Fromm_ _Ft. to ~ ,.FL_ From~ Ft.
From _Ft, to _Ft. From .F~.
Fmm~Ft. to .Ft~ Fmm~ __Ft. tg_ .Ft.
From_ _Ft. ~ ,.Ft.~ From . ,Ft. to~Ft.
From_ ~Ft. to _Ft. ~ ~. ~
From ~Ft. to .Ft._
From~ ~Ft. to .Ft.~ Ftom~FL to
From ~Ft. to__Ft. From~Ft. to_ _Ft.
From~Ft. to__Ft.-- Ftom~Ft. to
MISCL. INFORMATION:
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Oct 29, 1998
Expiration Date: Oct 29, 1999
Permit Number: SW980422
Legal Description: COLONIAL PARK BLK 3 LT 1 N2
Design Engineer: 0003 S & S Engineering
Owner Name: Jay & Kristen Weaver
Owner Address: 19944 2ND STREET
EAGLE RIVER, AK 99577-8427
Parcel ID: 050-301-30
Site Address: 019942 SECOND ST
Lot Size: 13770 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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 ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Issued By:
Rick Mystrom,
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http://www.ci.anchorage.ak, us
343-4744
October 29, 1998
Jeff Garness, P.E.
Alaska Water & Wastewater Consultants, Inc.
7320 East Chester Heights Circle
Anchorage, Alaska 99504
Subject: Waiver Request for N½ Lot 1 Block 3 Colonial Park
Waiver Request #WR980076, PID #050-301-30, SW980422, HA980364
Dear Mr. Garness:
Your request for waiver(s) of the required 100 foot horizontal
separation of an on-site wastewater disposal system to a private
well has been approved. The approved separation distance(s) are
a private septic tank and lift station to the private well on property
is 65 feet.
This waiver approval applies to the existing on-site wastewater
disposal system to well separation only. Any future upgrade to either
will require all separation distances be met or another approval
from this department.
If there are any further concerns or questions regarding this waiver,
please call our office at 343-4744.
S~n~erely,
Daniel J. Roth
Civil Engineer
On-site Services Program
ljm:#6
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR~L~ij_~k~- PID# i~fS_.%f~,\-,%K~ HA#~%~%~ Permit ~
Date Received: October 15, 1998
Legal Description: Lot 1 N½ Block 3 Colonial Park Subdivision
Engineer: Jeff Garness, P.E., Alaska Water & Wastewater Consultants~ Inc.
7320 East Chester Heights Circle, Anchorage, Alaska 99504
Applicant: Jay & Kristen Weaver
Waiver Requested: Private well to the septic tank/lift station of 65 feet.
NOTE: Also, Paid for the sewer permit for the installtion of the septic tank and
lift station, this needs to be issued.
Cri%erla: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
Special Conditions:
3. Other:
Waiver is Granted: ~
List Conditions or Reasons for abo~
Rec #: 04272/6232
Amount: $.6:
fEET Oz~P. r~ts ~t Fe~T~re~ ~ ~'1 ~r r~/c~ ~ff~R OF 4
x=.~+ I
[.~RAI)O TOT'R,L
2. q
/.6
/7.2
Alaska Water & Wastewater Consultants, Inc.
7320 East Chester Heights Circle - Anchorage - Alaska 99504
(907) 337-6179 - Fax (907) 338-3246
Consulting Engineers
October 13, 1998
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref.' Waiver Request and Health Authority Approval for
Colonial Park Subdivision, North 1/2 of Lot 1, Block 3,
To whom it may concern:
The existing 3 bedroom house is served by a public sewer and a private well. On September 15
1998, we went to the referenced property to perform a well flow test. On our site visit, we found
a 1250 gallon septic tank/lift station in the backyard. It appears that this was installed with out a
permit. It is assumed that the li~ station was installed because gravity flow to the sewer main
could not be obtained. Attached an as-built drawing and a inspection report for the documentation
of the septic tank/lffi station. The size of the tank was verified by the pumping of the tank. We
request you issue a Health Authority Approval and grant a 65 feet separation distance waiver
from the well to the septic tanldlffi station. The following items are justification for the waiver:
· There is a audible higher water alarm (installed in the crawlspace) that will notify the
homeowner of a high-water condition before the system can overflow omo the ground.
· The ground surface elevation by the septie/lffi station is lower than the ground surface
elevation by the well so if any effluent would surface, it would have to travel uphill.
· The location of the septic tank/lffi station is in a very visible area so that if any effluent was to
surface, it would be noticed and the problem corrected.
The other path of comamination is subsurface migration wastewater should the tank begin to leak.
As can be seen on the attached well log, the aquifer is confined, with over 50 feet of hardpan soil
that would serve to inhibit the migration of untreated wastewater into the aquifer. Recent water
sample results indicated undeteetable nitrate levels (0.1 mg/L) and no bacteria. Based upon the
aforementioned facts, it appears that there is minimal risk associated with the 65 foot separation
distance.
If you have any questions, please contact me at 337-6179, or 244-9612. Thank you for your
assistance.
Sincerely,
.E., M.S.
Pres/debt
SULLIVAN WATER WELLS
P,O. BOX 670272, CHUQIAK, ALASKA 99567 · TELEPHONE 688-2759
OWN£R OF LAND Z~_ e ,qc-.~' b/',~ m
DATE - S~ed Ended
PERMIT NUMBER
t
DEPTH OF WELL C:~,~ 'T" ~'--
~f~--/~STAT[C LEVEL OF WATER ~*r .... ~ /
DRAW DOWN FT.
GALS. PER HR "
KIND OF CASING
KIND OF FORMATION:
From.~L~Ft. to ~ Ft.
From ~ _Ft. tO ~ . Ft.
From '~ .Ft. to '-%'--~"' Ft.
rrom..~_.._Ft, to O~ ¢~ Ft._
From ~'~ ...Ft. t~Ft.-'3'''~''at3 g~/q'O~'~.
From , .Ft. to _Ft.
From.~,Ft. to______~Ft..
From Ft. to , Ft. _
From._____.Ft. to , Ft.
From _Ft. to . Ft._
From---~---Ft. to ,. Ft.
From ,Ft. to~,Ft._
From ,. Ft. to Ft,
From -Ft. to~-Ft._
From ~ .Ft. to Ft.
From _Ft. to ..... Ft.
From , Ft. to Ft.
From
From
From.
.Ft. to~ Ft.
.Ft. to .Ft.
Ft. to , Ft.
Ft. to Ft,
Fl. to~Fl
Front .Ft. to ,Ft.
From~Ft. to~Ft.L
From ,.Ft. to_.__._.Ft.
From , Ft. to ...Ft.
From ,Fcto___..___Ft.
MISCL. INFORMATION:
DRILLER'S NAME / '~"~':'~
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 WELL SYSTEM PERMIT
PERMIT NUMBER:SW930235
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:HILL SAMUEL P &
OWNER ADDRESS:7021 DRIFTWOOD PLACE
ANCHORAGE, ALASKA 99518
DATE ISSUED: 7/20/93
EXPIRATION DATE: 7/20/94
PARCEL ID:05030130
LEGAL DESCRIPTION: COLONIAL PARK BLK 3 L~
2
1 N
LOT SIZE: 13770 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL 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 (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
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:
ISSUED BY:
DATE:
DATE:
COLONIAL PARK SUBDIVISION
THE N ~/~oF LOT I, BLOC K 3
REL. A"rlVE EL
$ ~ ~$&' 00" E
1='3~o IV~ As~,U I~ E C~ DATd~
'0
0
F
~£¢~
I I I. (::,o '
~ LbT
o LO]-
o
I II."/'7 '
I s'~. 5T'I~EET
IIII
PLOT PLAN ~ hereby certify tha~ ; have surveyed
~ the property depicted above and that
the proposed improvements and d:aZn-
GASTALDI LAND SURVEYING
age patterns are as shown he:eon. Zt
Jeff A. Gastaldi,R.L.S. is the responsibility of the
4726 'West 88t_b Ave. prior to construction, to verify the
Anchor~¢e Alaska 99502 proposed building location on lot,
248-545~ grade and utility connections and to
determine the ex±stence of any ease-
GRID DATE merits, covenants; or restrict±ohs
NW 6~ .~-9-~ which do not appear on the recorded
subdivision plat.
F.B, JOB NO.
. .o, -~.>;¢
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (~ ~'"~)''~OI ~0 -:,. NAA #. ~'~'~, ~'~ ~ (~ .~ ~'L'I
1. GENERAL INFORMATION
Complete'legal description ~___~o1,~o~ ~ ~~j ~ ~. _) L-~T- [O
Location (site address or directions) i c) <:) ~ "P_,JO ~'~
i
~.~X,A-~ ~' ~--:~,(-'r'~-.~ (-~J~-'~v'E"~Dayphone ;2-~-----/4--c~'''
Property owner
Mailing address
Lending agency
Mailin. g address
Day phone
Agent
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: -~ '~
Day phone
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:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
L~ ,-m-~ I/uP i,Ji l;)i.,,'~--~ i...: f==:'i--
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72,025 (Rev. 1/91) Front MOAI21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
. //.
Name of Firm ~ Phone
^dd es,
Engineer's signature Date !
DHH$
SIGNATURE
Approved for 3
Disapproved.
Conditional approval for
bedrooms.
bedrooms,
with the following stipulations:
Additional Comments
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 II'21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmenta Se~ ces D v s on
tree , oom · Anchorage, AI sR · (go7)
Legal Description:
Health 'Authority Approval Checklist
~:,~.oc,~ ~'~ '~_..o~.o~AL- ~O~,~,y, _~ ParcelI.D.:
A. WELL DATA
Well type (~:)~t ~/AT'E" If A, B, or C, attach ADEC letter. ADEC water system number
Log presenti~N) "I~P--.~ Date completed ~ /'::1 :~
Total depth ~J 'z-t Cased to cl'Z % Casing height (above ground)
Sanitary seal (~IIN) ' ~/F_....~
FROM WELL LOG
Wires properly proteCted (i~N)
Date of test
Static water level
Well production r
AT INSPECTION
g.p.m. (~' ~1/~ g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ Nitrate O. I ,~_~/L.- Other bacteria
Date of sample: ~t 2) Collected by: ~JA~r~'f~-- c::o,J.Su~'rAedT:~
B. SEPTIC/HOLDING TANK DATA ~ ~.~ ~ ~/ ~,c ~/
Date installed q~ Tank size I ~ Number of Compa~ments ~ Cleanouts
High water alarm(~)
Foundation cleanout(~N) ~'5, Depression (Y/~
Date of Pumping lO /~ /~j~ Pumper
C. ABSORPTION FIELD DATA ~~ ~~
Date installed Soil rating (g.p.d./fF or fF/bdrm) System
Length Width
Gravel thickness below '
Total depth
Effective absorption area
Tube
Depression over field (Y/N) __
Date of adequacy test
Fluid depth in absorption fiel~ test (in.);
Fluid d,~,.~~(tns)Min utes later:
P~x~oxide treatment (past 12 months) (Y/N)
Immediately after
Absorption rate =
If yes, give date
For bedrooms
;r added (in.):
72-026 (Rev. 3/96)*
LIFT STATION
Date installed et/~/~.,~
Manhole/Access ~N) '~.~
High water alarm lev. el at*
Cycles tested I,.I
Size in gallons
"Pump on" level at* ~,1[" "Pump off" level at*
*Datum ~ofl",~,,~. oF "['"~.~,d~
E. SEPARATION DISTANCES
Septic/holding tank on lot
Absorption field on lot .
Public sewer main
SEPARATION DISTANCES FROM WELL ON LOT TO:
I
~ OOt 4-
Sewer/septic service line ~-.~"
On adjacent lots
On adjacent lots '. IooI'f'
Public sewer manhole/cleanout
Lift station ~ "7 I.-'~
SEPARATION DISTANCES FROM SEPTIC/HO'cDtNI~r-~ANK ON LOT TO:
Foundation { ~/..4-
-- Property line 'Z.~/-.~--
Water main/service line I oI -f- Surface water/drainage Iool-f-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property..lin~ Building foundation
Absorption field ~--om ,~ u~ ~,'c'Y ~'~
Wells on adjacent lots
Water, main/service line--..~
Surface water ._.~.__._.~~ay! parkJng/vehi.cle storage area
Wells on ·
F. ENGINEER'S CERTIFICATION/~
I certify that I~d~~ru ~ield inspections and review
,n con,orm?e w~~LuiJelines in effect on this date.
Signature ~ ___
Engineer's Name
Date
HAA Fee $ / ~
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
CT&E Environmental Services Inc.
Laboratory Division
200 W, Potter Drive
Anchorage, AK 99518
Tel: (907) 552-2343
Fax: (907) 561.5301
ChemLa~ Ref. #: 98,5246 Client ~O#-:
Client Name: AK Water&Waetewater Cone. Printed Date/Time: 9.,'21198
Project Name; L1 B3 Colonial Park S/D Col:acted DateJTime: 911.5/98 1
Client Semi;la ID: L1 B$ Colonial Park $/D Received Date/Time: 9t15~8 t7:15
~atrix: Drinking Water Technical Dl~ect~)~: 8fel~hen Ede
PWSID n/a Released By:
Sample Remarks:
Allowable P,'ep Analysis
Parameter Reeulta PQL Unite Method Limitr, Date Date Init
Total Coliform (MI=) 0 ~ol/100 mi SM9222B 9/15/98 KAP
Nitrate 0.1U 0.1 mg/L EPA 300 10,0 9/15/98 GCP
80×I0'd ~0£S[_qS~06 ]E)~JOHDN~ IS] ]~.LD O~:SI 8GGI-~-c~S
ALASKA WATER & WASTEWATER
7~ F.J~r ~ H~GH~ ~ · ~ICHCX~E, ~.ASKA eeso4 · PHONE= ~7-elTi FAX:
llVEL L FL O~ TEST DATA
LEGAL DESCRIPTION-'
STREET ADDRESS'_- I~cl
CUENT: "~ ~,'1' k*~P ~-,g,~r~, ~x,~t~,,Je,,... ,,
NUMBER OF BEDROOMS ~ F.H.A. - FOUR HOUR FLOW TEST:
YEs /
TEST DATE START~ TEST DATE
WELL DEPTH (PER WELL LOG):
CASING DEPTH (PER WELL LOG):
WIRES IN CONDUIT: ~I~-NO ~ Iqeco 'T'oe
WATER SAMPLES TAKEN: ~ NO IF YES. DATE:
TIME
METER RE~
FLOWRAT E--'~'[~_ WATER LEVEL .
G.P.M. (BELOW TOP OF CASING)
~ ~.z _i___
DRAWDOWN
WELL PRODUCTION MEASURED
COMMENTS:
.~ -'TG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
HAA #
Location (site address or directions) --'-',--'
Property owner
Mailing address
Day phone
Lending agency
Day phone
Mailing address
Agent
Ad dress
Day phone
m
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm /~r~ ~) ~--'-/~O~J L~-'~/,J ~57[,f~ Phone ,~'~/~/'-
Address ~-0. ~O~ Z.~/077~ ~(:~O~~ ~
EngineeCssignature ~~ ~ ~ ; Date
approval for
DHHS SIGNATURE
/~'~ Approved for
DisapprOved.
Conditional
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 DH HS 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: /.o'r~ ~c~. ~. C~Co~ ,/14.. /~A,~/~.Parcel I.D.
A. Well Data
Well type
Log present (Y/N) "~
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~/~' Driller
Cased to q Z i
Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
g.p.m.'~'
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line ~'/~)
AT INSPECTION
F~..~ tv1 I~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ,~ ~/~'
m
WATER SAMPLE RESULTS:
Coliform Nitrate
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Tank size
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Foundation cleanout (Y/N) Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots
Absorption field
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).
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Date of adequacy test
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
On adjacent lots
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
Surface water
System type
Total depth
Depression over field (Y/N)
for
After test
If yes, give date
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that/have checked, verified, or conformed to a//MOA and HAA gu/~linesjZ~n ~11!~ of this inspection.
Signature ~ ~ ~ E~>~';'~;:'~:;~''''~*~'';%;~¥'':'
EngineedsName ~t~~ ~ ~O~D~
Date /-/*O/-/' ,,-<'~ ......... '~,,--
Bedrooms
HAA Fee $ ~
Date of Payment
Receipt Number
72-0~6 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LABORATORY .~ERVICE~
........ RE~RT of ANALYSIS
che~¢lab Raf.# :93.5720-1
Client Sample ID :L1 B3 COLONIAL PARK
Matri~ :WATER
Client NaCre :ANDERSON ENGINEERING
Ordered By :M. ANDERSON
Project Name
Project~ :
PWSID :UA
.5833 B STREET
ANCHORAGE, AK 99518
TEl.; (90?) 562-2343
FAX: (90?) 561-5301
WO~ O~ef :72569
Re~ Completed
Collected :10/25/93 @ 19:30 hrs.
Received :10/26/93 @ 08:10 hrs.
Technical Director:STEP[~EN C.
Sample Remarks: ROiFfINE SAMPLE CO[J~ECTED BY: t~. ANDERSON,
Qc
Parameter Results Qual Units Method
Nitrate-N 0.[0 U mg/L EPA 353.~/300.0
Allowable Ext. Anal
Limits Date Date Init
i0 ~0/27 LLH
See Special Instructions Above UA = Unavailable
NA = N~t Analyzed
See Sample Remarks Above
Undetected, Reported value, is the practical quantification l[~it. [./£ = Less ~han
Secondary dilution. GT -- Greater Than
~II'~B Memr~er of Ihe SG$ Group ($oci~t~ Generale de Surveillance}
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
ROd ££S'0N SBDIA~BS ~q 9t~±NBWNO~IANB B~I3 ~:60