HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 1 LT 5�I�1-
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BILL 8& COLE
ULLIVAN WATER WELLS
P.O. Box 670269, Chugiak, AK 99567 688-2759
www.suilivanwaterwells.com
Well Drilling Permit Number: SW Date of Issue
Parcel Identification Number: 0 51-. yS � - 5 G
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page —[—of�
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,lC10 PID Number: o�l-e I j5O
Name:
O � t LAS
IF•� w tewater System: :,/_New ❑ Upgrade
Address:
ABSORPTION FIELD
Phone:
� 3g
No. of Bedrooms:
❑Deep Trench ❑Shallow Trench -Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
6•8
Total Depth from original grader
GPD/Sq. Ft.
Lot: Block:Subdivisio
G44 -LAS
Depth to pipe bottom from original grad:
Gravel depth beneath pipe
`r (
r
Ft.
Ft.
Township:
Range:
Section:
Fill added above original graded
Gravel length:
Ft.
Ft.
WELL: New El Upgrade
Gravel tlefltM. ► �I
Number of lines:
Distance�twfen lines:
Ft.
Ft.
Cla ' ' ation (Private, A,B,C):
Total Depth:
Cased To:
Total absorption area:
Pipe material:
A--orri—iJ
+ \/A-cgj
Ft.
Ft.
57:�SQ. Ft.
Driller:
Date Drilled:
Static Water Level:
Installer:
Date inst led:
Ft.
d
Z tZ
Yield:
Pump Set at:Casing
Height Above Ground:
',
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
>65eptic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer: ' Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
Well
Material: Number of Compartments:
Watere
1t�4'
►�`
—
—
—
LIFT STATION
LotSize
l
(0 `-!'
"-
in gallons:
Manufacturer:
Line
t'�f-l-
Foundation
��
_��
"Pump on" level at:
mp off" level at:
High water alarm at:
Curtain
I
Pump Make & Model
Electrical Inspections performed by:
Drain
�S
Remarks:
BENCH MARK
Location and Description:
'ID �
Assumed Elevation: o
-
t vd Ft
ENG;N`k%$SEAL
so
�* �� %
S 8 S ENGINEERING
9
Inspections performed by: 17034 Eagle River hoop Road, No. s: 1st
♦""" "'"'•"' ••••• ••
�'
Eagle River, Alaska 99377 2nd
• ' ' ' ••
fit
ROG R J SHAFER
��j
Department of Health a H rvi approval
s,�; .•• No. 15 •�� may.
I
`e�F�pROFESSIONP..~..
Reviewed and approved by: Date:
72-013 (1/91) MOA 25
Permit No. W Ci201 SIO
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
Leaal Descriotion:4;Z;1L-4>G�/-- Lrdr 151 PID No.: G�-�14f�15d
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72-013 A (Rev. 9/91) MOA 25
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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 AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW920190
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:CORNERSTONE BUILDERS INC
OWNER ADDRESS:17510 SNOWCREST LANE
ANCHORAGE, ALASKA 99516
PARCEL ID:05148150
LEGAL DESCRIPTION: CHUGACH PARK ESTATES BLK
T 5
LOT SIZE: 54525 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1 L
PAGE 1 OF 1
DATE ISSUED: 7/20/92
EXPIRATION DATE: 7/20/93
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE: % ZO A /
DATE:/ -2 - ,Z22_
001
June 8, 1992
HEALTH AUTHORITY
APPROVALS
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
SEWER &WATER Anchorage, AK 99519-6650
MAIN EXTENSIONS
SEWER & WATER
INSPECTION REFERENCE: Chugach Park Estates, Block 1, Lot 5
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
ENGINEERING STUDIES We request you issue a permit to drill a well and install a
AND REPORTS septic system to serve the proposed 3 bedroom house on the
referenced property.
Two test holes were excavated and percolation tests performed
WELL INSPECTION on the above referenced property. The approximate location of
&FLOW TEST the test holes are located on the attached site plan.
This property has enough area for future septic upgrades,
which can be seen on the attached site plan. We do not
SITE PLANS anticipate any adverse effects on neighboring properties by
the installation of the proposed septic system.
If you have any questions, or require additional information
ROAD DESIGN for your review, please contact us.
Sincerely,
SOILTEST
Roger J. S fer, P.E.
PERCOLATION
TEST I RJS/ 1 su
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
50'
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Municipality of Anchorage C;:"
e DEPARTMENT OF HEALTH &HUMAN SERVICES :�i
825 "L" Street, Anchorage, Alaska 99502-0650 ` 4R.... ` •.`�., s .. ` "�" `♦
SOILS LOG — PERCOLATION TEST
ER k;
G" w
PERFORMED FOR: ��%�✓ C— 451741"4e L157 DATE PERFORM����Jea '
G4 I'Ll G 'ACJ -t 1L .QST .
LEGAL DESCRIPTION:-,2t,OL° 1= I. F LO -T- z:�Township, Range, Section:
SLOPE SITE PLAN
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1
10-
• �J"e
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.v
2 .o
3
0 ��
= 6
e-
4
5
6
'
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8-
9-
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10 WAS GROUND WATER 1
ENCOUNTERED? 1\ r
11 '
IF YES, AT WHAT
DEPTH?
12 �.G;�•
13-
14-
15-
16-
17
314151617
81920 18-
19-
20
COMMENTS
w
Depth to
Monitoring?
Depth to
==MM Water
"'2
r�
PERCOLATION RATE v (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED BY: S & S ENGINEERING CERTIFY lJ , CERTIFY THAT THIS TEST WAS PERFORMED IN
17034 Eagle River LOOP Koad No. b4r--
ACCORDANCE WITH j3dgEffRh!bANM ft"I MM U I DELI NES IN EFFECT O THIS DATE. DATE:
72-008 (Rev. 4/85)
"'2
r�
PERCOLATION RATE v (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED BY: S & S ENGINEERING CERTIFY lJ , CERTIFY THAT THIS TEST WAS PERFORMED IN
17034 Eagle River LOOP Koad No. b4r--
ACCORDANCE WITH j3dgEffRh!bANM ft"I MM U I DELI NES IN EFFECT O THIS DATE. DATE:
72-008 (Rev. 4/85)
,e- OF A
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG PERCOLATION TEST
PERFORMED F0R: DATE PERFORMED:i�
f,nship, Range, Section:
LEGAL DESCRIPTIO -0
Pf.$T H L -OT SLOPE SITE PLAN
(FEeT4e
2 N
3
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5
01
6
Lot •
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9 - 0
10-
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15-
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18
19
WAS GROUND WATER t"L
ENCOUNTERED, —
IF YES, AT WHAT
DEPTH?
Depth to W*j
Monitoring? � Date:
20lul PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
.1
TEST RUN BETWEEN 14.1-5 FT ANDZ�?, FT
COMMENTS
3 & 5 ENGINEERING
PERFORMED BY: 17034 Eagle River Loop Road NO. - CERTIFY THAT THIS TEST WAS PERFORMED IN
Eagle River, Alaska 99577 (,2— ( 12 -
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECION THIS DATE. DATE:
72-008 (Rev. 4/85)
Depth to
Water
mow
20lul PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
.1
TEST RUN BETWEEN 14.1-5 FT ANDZ�?, FT
COMMENTS
3 & 5 ENGINEERING
PERFORMED BY: 17034 Eagle River Loop Road NO. - CERTIFY THAT THIS TEST WAS PERFORMED IN
Eagle River, Alaska 99577 (,2— ( 12 -
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECION THIS DATE. DATE:
72-008 (Rev. 4/85)
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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 (UPGRADE) PERMIT
PERMIT NUMBER:SW930044 DATE ISSUED: 4/01/93
DESIGN ENGINEER:DUMMY COMPANY EXPIRATION DATE: 4/01/94
OWNER NAME:MUNDELL MARY D &
OWNER ADDRESS:19375 CHUGACH PARK DR
CHUGIAK, ALASKA 99567
PARCEL ID:05148150
LEGAL DESCRIPTION: CHUGACH PARK ESTATES BLK 1 L
T 5
LOT SIZE: 54525 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
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:
RECEIVED BY: ✓�
ISSUED BY:
DATE: V'- $L- L3
DATE: 4- 1,93
ENTRY ' C,
f9
Y«.
40ADiF
P
WELL
L-Z40.T2•
95.6' I
p3
1
O M
o
i 0
N
I i,rr%9 rcpAR
w/cAr-LS-4.11'
5 g4' 23' 20.2'E
PA �K Z8.74'
-5-93- REVISE STREET NAME. SAG VE
AS BUILT I hereby certify that I have surveyed
the property depicted above and that
GASPALDI LAND SURVEYING no encroachments exist except as indi-
Jeff A. Gastaldi,R.L.S. cated. It is the responsibility of the,
4726 West 88th Ave. owner to determine the existence of any
Anchorage, Alaska 99502 easements,covenants or restrictions
which do not appear on the recorded
ph. 248-5954 subdivision plat. Under no circumstan-
ces should any data hereon be used for
GRID DATE construction or for establishing boun-
NW 1160 11-25-92. dary or fence lines.
F.B. JOB NO. ANCHORAGE REODRDING DISTRICT, ALASKA
9L-IZ
�Q.F- �F .....gs�5�
•49TH
1 i
•
a�
CHUGACH
PARK ESTATES SUBD.
LOTS-, BLOCK
(4,
Zoo Y'/
SLY t/�'0 REMR 5 89'
23' 20" a
127.81 f,.N• Its"
C_
w/cA/ Ls•�•!i"
00A9(bRNr)
10' UTIL. ESMT•
40
O ctlCL`
G
ti
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N
LOT 5
��"
54,525 5•F.
5f rrlt
SYST EeA
i
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SET %9 MAR
EXISTI Nb
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85i
w%AP-LS-4611•
/L'$UILPIN6
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(IN 4RAVfl
ROAV)
GRAVEL ROADWAY
r.
S.W.11
61 cA"T•
ENCRo/ICHES
/SI V��.
ENTRY ' C,
f9
Y«.
40ADiF
P
WELL
L-Z40.T2•
95.6' I
p3
1
O M
o
i 0
N
I i,rr%9 rcpAR
w/cAr-LS-4.11'
5 g4' 23' 20.2'E
PA �K Z8.74'
-5-93- REVISE STREET NAME. SAG VE
AS BUILT I hereby certify that I have surveyed
the property depicted above and that
GASPALDI LAND SURVEYING no encroachments exist except as indi-
Jeff A. Gastaldi,R.L.S. cated. It is the responsibility of the,
4726 West 88th Ave. owner to determine the existence of any
Anchorage, Alaska 99502 easements,covenants or restrictions
which do not appear on the recorded
ph. 248-5954 subdivision plat. Under no circumstan-
ces should any data hereon be used for
GRID DATE construction or for establishing boun-
NW 1160 11-25-92. dary or fence lines.
F.B. JOB NO. ANCHORAGE REODRDING DISTRICT, ALASKA
9L-IZ
�Q.F- �F .....gs�5�
•49TH
1 i
•
a�
DEC 0 7 iJ15 rn
• Municipality of Anchora 6
On -Site Water and Wastewater Program e c °
(907) 343-7904 << i C� S A F E T Y
0/
Certificate Of On -Site Systems Approval
Parcel I.D. 0517481-50 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Chugach Park Est. Block 1, Lot 5
Location (site address) 19375 Chugach Park Dr.
Current Property owners) Mary Mundell & David ZUck Day phone
Mailing address PO Box 671587 Chugiak, AK 9956.7
Real Estate Agent - Day phone
2. TYPE OF DWELLING:
F Single Family (w/waADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
`''
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER,OISPOSAL:.
Individual Well
El
Individual
lX l
Individual Water Storage
❑
Holding Tank-
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
— ❑
WaiverNanancerequest for:
- Distance:
Received by: Date:
COSA to be released tothe engineer; unless otherwise requested by the engineer. -
COSA Fee $ 60 Waiver Fee $ .
Date of Payment 1Z/ 711- Date of Payment
Receipt Number 3bf� 01, Receipt Number
COSA # n g'5 1(a (2 I Waiver #
5. STATEMENT 1 CTION 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 CertificateofOn-Site .Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system. is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the informafion obtainedfrom the Municipality of Anchorage files and from.. my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are) in: oompliance with all applicable Municipal and State codes, ordinances,- and regulations in effectat
the time of installation. - In conducting an adequacy test I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of thetest,
and separation distances measured to readily identifiable features. The: operational life of all wells and septic systems depend. on thelocal soil
condition, ground water levels that may fluctuate: during the year, and the water usage of the: family: being served by the system. These conditions
.are outsidethecontrol ofthe evaluator of this. system. All. -systems eventually fail .and satisfactory test results do not 'guarantee :future
_performance of the system, nor do they guarantee that there are no hidden defects or encroachments.. Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above. -
-Name of Firm Pannone Engineering Services LLC -'Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 817/2015
. - „�•�~►\\moi\
- 6. DSD S NATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
• ,•,� : Jam_
By. Original Certificate Date:
The Municipality of Anchorage Development Services. Division. (DSO) issues Certificates of On -Site -Systems Approval (COSA) based only "
upon the representationsgivenin paragraph 5 by an independent professional civil engineer registered in the. State of Alaska. The Municipality.
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X. Nitrate Advisory `
Septic System -Advisory Arsenic Advisory
Well Flow Advisory Other
COSAbluesheer t '- :., c
If more than 1 septic system is on the lot:
COSA Checklist # +_of
Structure served by this system
Certificate,of On -Site Systems Approval Checklist -
Legal Description: Chugach Park Est. Block 1, Lot 5
A. WELL DATA
Well type Private If A, B, or C provide PWS IQ # Well Log MN) Y
Date completed Unknown Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 285 ft." Cased to 234ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test Unknown 7/28/2015:
Static water level 165 %ft 169 ft
Well production 2.59.p.m. -1.7 g.p.m
Parcel ID: 051-.481-50
WATER SAMPLE RESULTS:
Coliform O colonies/100mL Nitrate 014tf41g/L
Arsenic D ug/L Date of sample: f Z Z
Collected by: i" e"e-
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel- Date', installed 7/25/1992
Tank size 11000 gal Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N)) N , r High water alarm (YIN) N
Date: of pumpingI, + Pumper
7--T
C. ABSORPTION Flab -DATA -
Date
7/2511,W2 x x 0.8 GPD/SF $
installed Soil rating (g.p d./ft or ft /bdrm) System type
Length 32 ft.. Width 18 ft. Gravel below pipe 0'5 ft.
Total depth 5:3 ft... Eff, absorption area 5716 ftz Monitoring tube Y_ Depression ower field
Date of adequacy test 712$/2015: Results :ail) pass For 3 bedrooms
Fluid depth in absorption field before test 0in. Water added 463 gal. New depth 0 in.
Elapsed Time: 200 - min. ' Final fluid depth 0 in. Absorption rate >= 450+ g,p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &,type) No If yes, give date
;I
D. LIFT STATION
Date installed_
"Pump on" level at
Datum
Size in gallons
in. "Pump off' level at
Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100+
Public sewer main 75+
Sewer /septic service line 25+
Animal containment areas 50+
Manhole/Access (Y/N) _
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Holding tank 100+,
Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parkinglvehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
in.
F. COMMENTS'
Original well decommissioned per code. See attached well log.
G. ENGINEER'S CERTIFICATION
I certify that l have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone:
Date 8/7/2015 .
COSA canary sheet 2.6-15.doc
:KIND OF FORMATION:
_From Ft. to ') Ft.
From__
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Ft.
'From Ft. to �i - Ft.
=' yr 4:4d0? V c c -J ._
-: From.
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Front Ft to Ft.
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From
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ininn date Fl h n f` ' t
ASBUILT SEWARD & K
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE
FOLLOWING DESCRIBED PROPERTY:
_ DATE=
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID=
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES. ®/tell
ie/B9�ZZ Z4 w
z� �y
ism>�/�
� �6 �
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. # C (� L�f-yz HAA # I-\ fi�yl nr)Q�
1. GENERAL INFORMATION
Complete legal description Lot 5; Block 1; Chugach Park Subdivision
Location (site address or directions)
19375 Chugach Park Drive
Property owner David tuck and Mary Mundell
Mailing address
Lending agency
Mailing address
Armn+ --
A A.4.o��
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
Day phone
Day phone
Day phone
258-2534
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:
Individual on-site XXX
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 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 s & s ENGINEERING Phone
17U:54 ngle Faver LOOP Read No. 204
Address Eagle sliver. A;iaska 99577
Engineer's signature
6. DHHS SIGNATURE
Y _ Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Em
By:
Date lZ-IU-,�z
ur
,ON.N��N WeOs N�wY.• � ;
"itd6Y.11 r�•a'• • •i�� •.t M i
bedrooms, with the following stipulations:
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 & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: �t t-1� - 1 G�kl� Parcel I.D.
A. WELL DATA
Well type N If A, B, or C, attach ADEC letter. ADEC water system number
Log present4�71N) !4 Date completed (o- 1--112 Driller -54-5' VfZIL-LJ.,1�5
t
Total depth Ste, Cased to 2 612 Casing height
Sanitary seakV�N) _ Wires properly protectedON) -
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
12 f+
AT INSPECTION
g.p.m.
SEPARATION DISTANCES FROM WELL TO: n
Septic/beld+rrg tank on lot l20 ; On adjacent lots
Absorption field on lot }�'4' ; On adjacent lots �r-4- C `�
A
1^ N
Public sewer main Public sewer manhole/cleanout / �
f
Sewer service line �G�' "� Petroleum tank
WATER SAMPLE RESULTS:
2
Coliform
Nitrate Other bacteria
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed �'2S' `�� Tank size 1 c�C, Compartments
2-
Cleanouts (QN) Foundation cleanout&PN) v Depression (YAW c='
High water alarm (Y/N)
' l Alarm tested (Y/N)
Date of pumping 1J N r✓lN Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 1 ��r On adjacent lots
Foundation
To property line t p Absorption field Water main/service line
Surface water/drainage N (-_� -1-
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
M
oz_
�D
r
Cn 0
M T
< Z
� c)
W _
00
< D
�M
O rn
Z
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Manufacturer
Manhole/Access (Y/N)
"Pump on" level at "Pump off" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
Cycles tested
Surface water
Date installed -7 '�� ' `�� Soil rating o•y' P�System type ��
Length '222 Width l v Gravel thickness Total depth 05
Total absorption area `727 L, Cleanouts presentA17N) `�
Depression over field (Y�W Date of adequacy test A
Results (pass/fail) for bedrooms
Peroxide treatment (past 12 months) (Y�W1-- If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
- r
Well on lot On adjacent lots Property line_
S
To building foundation `2-� r To existing or abandoned system on lot
On adjacent lots �`�� Cutbank 4�5 C_�,t + Water main/service line_
Surface water t-ILE 'I Driveway, parking/vehicle storage area
Curtain drain 1J
E. ENGINEER'S CERTIFICATION
I 1.4,-
I certify that t have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & S ENGINEERING oklt .0.;Aior
Signature 'et1 e4 Eagle
Rases �� Road No. 204 % 49 ���+�♦
�r�te�a+N��ri�+» M�s• �,
77
Engineer's Name / /A t
Date
12-1(0_92
HAA Fee $ /70c(90
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $ —
Date of Payment
Receipt Number
ROGER J! SHAFER
No. 8215 .
P90FESS10,�
00