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HomeMy WebLinkAboutFOX HILL BLK 1 LT 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION FNVIRONMENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ~ , I~HONE ~W -~"~/-~ OtC /~/l,,~//~¢~.f' C ~'~/~Z,J,"~'' ~_.~,~¢/i-_~..¢~"'~¢~ [] UPGRADE .~./ O' ~ ! Dwelling . ~/~ PERM O. Manufacturer ~ ,~- .~ ~ Ma~ No, of compartments Liq. caJ)a~it~]n gallons ............ Inside length Width Liquid de Manufacturer //~ ~ Material Liquid capacity in gallons We Fouadat on Nearest lot line PERMIT NO. DISTANCE TO: I b/ I No. or ,n~, I Length of each hne ~ ~tal length of hnes I Trench width D,stance between hnes ,o grade / terial beneath tile Total effective absorption area inches Type of crib -- Crib diameter Crib depth I Total effective absorp¢~ area ~,. we z.. / Buidingfo~nda~pn/~ I Nearest lot I ne l~ /~ DISTANCE TO Buld~ng~at~o~ 8e~r me 8eptlctank Absorpbonarea s OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER R EMA~.~S DATE OWNER OF LAND ADDRESS Ar ` irb 43rttttnt Y[ti by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 DEPTH OF WELL STATIC LEVEL OF WATER FT, LEGAL DESCRIPTION DRAW DOWN FT. F DATE, - Started Ended GALS. PER HR PERMIT NUMBER KIND OF CASING KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. Ft. from Ft. to From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. Ft. From Ft. to Ft. From to From Ft. to Ft. From Ft. to Ft. From_ Ft. to Ft. From Ft. to F F ANCHORgpE From Ft. to Ft. From Ft. to F DEPT. OF HEALTH & , TAL PROTECTION From Ft. to Ft. From Ft. to Ft. MAR 21 1985 From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. RF M it C n 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 MISCL. INFORMATION: DRILLER'S NAME S2!!!!; L., :il;]"i:~i:EET., I::lt'.,ICl, rEll:;i:l::lGliii:., I::IK ~i)~i~5~ii)::[. PERM I'l" NO: f::,FIT[}; I L'::;.C:;I..Ilii::[:,: I::IPF'L. ! C'F:ff',FI~: (~:C~N TI:::IC T PHI]NEi:: [..OT i.~!; :[ 2%: L..OT L.OE':FtTZON: t"IFI;:.:: ',,"El'U'.':., FIK :i'~;C HI...IC Hh'IFIN COI",ISTR. E~i...Cu]:K: :l. L Z :!~:;"I'tEI:::' E:E]....OI.,.! I:::IRE "i"l'"ll!i: OF:'T ]: OI",IS F:I',,,'F:I :[ L.I:::E:]I...E 'TO "r'[)U ]'. l",l I}[i]~ I Gl",[ I I",[I]i "r'OUFi: :ii;IEF'T I C :~!i;"¢:iSTE]'I. CHOO:!!i;E TI"JE: OI:::"T .[ ON THI'::I'T' E',E:.~i;T I:::'IT:5 "¢OL.II:;i: :.I,::+: !:::,IEI:::"T'I-.! 'T'O F' :i: F'!E 13OT'TOH .:::: ::!i:. 5 F'T'. REL::!L.I t' I:;.:E.':'~; I I'.,l:i!i;I...ll....FIT I ON :.l.,:+: [:,EF:']"H TO I:::' I I:::'IE E',OTTOM 'C 4. ~;!!i FT. HF:I'.r' RtEg!U t' RE FI 1.... I FT ?T'FIT I ON :+::.]': GRI:::I',,,'I:!!:L. LEIq(::iTH }. 7'5 F:'T. F;'.EL.'TgJ]:t';;:ES MI...ILTIPLE I:~:IjNS ,::NOT E::'.','CIEE[.':,ING 75 FT. EFICH) :+::.1.: TFINK h'll..J:i~;T HI:::I',,,'E I:::IT !....I:i!:F:I'.~i;'T' THO I E:ERT I l::"-r' "I"HI:::IT: :l.. t F:IM F::'FIMII....II:::ff;;: HITH 'T'hI[E RE:~:;:!U:I:REhlEIqT~.i; FOF.: OI'.,I-:E;ITI]~: :~;Et.,.IEI:~::!:; FtN[:, t.,.IEL. L.'.':~; FI:E; '.F;ET FORTH E',"r' THE:. HI...IN Z C I F'FIL. I T"r' OF' FINCHOF.~'.F':IGE ':.' HOFI ::' i:::fi",lE:' ]"HE STI:"'ITE 01:::' I::II_..F:I~'~;I<I:::I. ;;:i:.): HIL..L I t',I:!STI:::ILJ_ 'l"l'"lli~: '."~;'.r'?r'EM ].'N RCCORB, FINC:E: I.,.lI'l]"'l t::ILI.... MOF:I CO[.':,E:'.:~i; F:IND F.:'.EGULFITI'ON:i':;., I::11'.,I1:::, I N COMPL. :!: FINCE H I TH THE DE:E; I GN Cl-;i: I TI;'Zi::;.': I I::I 01:::' "1"1'"11 :~; PEFd"I I '1". :ii:. ~. HILL F:I[:,HEI:;;'.E 'TE) FILL. HOF:~ ~::':I1'.,!1:::, STF'ITE OF I::II....FIF:]I<FI REE..'!UIREMEi'.,IT:!..q FOR THE :~:SE'I" BF:H.']K [.':, I :ii;]~FiNC[~:r!i!; I.':.'I:;i:OH FIN"r' E?, I E;T I NG HE:L[ .... I.,.IF:IL::;TEHF:ITEF:t [:, I ':'~;1:::'O'.'51::I1... :5'¢F~;TEkl OR I:::'I...IE:I.... 1' C :ii:;EH[!:RF:IG,E:: :5"RSTIEM ON "r'HI:~!; (]r~: F':ff',t'T' Ft[:'JFICENT OF;'. NEF:IRE:"r' L. OT. 4. I LINE:'['~];~::E;'T'I::II",II:) THF:I]' TH ];:E; F'EI;;i'.M I T I :Fi; ',,,'I::IL.. I D FOR I::'I MI:::I',:'::I MUM OF .3: E:IEDROOM:.E; 1:'t1"4[::' I::IN'¢ ENI....FII:~'.(:ii[::]'"ilENT H I I.J... RE(;:!U ]: RE!: Ri",I FI[)[:, ]: T Z OI",II::IL PERM I T. ]: F:' FI I... ]: F"T' :~:!;]"I:::I'T' :t: ON t ::!; :1: I'.,I:E;TFIL. L..EE:, I I".1 FIN I:::IRER CECv'EREI} E:'¢ I'"101::i Ei:U I L.D I NG C:OI}E:~:.';., THEI'.,! ,:: ::L ::, I::ll'.,I EI...EC:TR I CFIL. I:::'ERM :1: ]" FIN[) I Iq:!!q::'EC]" I O1'.,I MUST [!!:['~: OEFI"f':I ]: t',tE[:,.~ ,:: 2] ::, F:I:.:.';...-BL.I I [...T::']; H I L.L. I",tOT [3E I::II::'PI:~:O',,,'E[) 1,.I I TH[]i...tT l:::lh,I EL.[ii)2TI:;i: :[ C:I::IL :[ N:!'];I::'EC]" :!: Eq",l I:;i:EI::'ORT.= FIND ,:; ::ii: ::, THE EL..ECTRtCI"]L HORK HLI:!~;T' E:E: [)Efi",IE: I::!:Y F'I I...:t:CEi'.,I:ii!;IEE:, [!!]...ECTRICIFIN. ]:::lf::'t::'t... :1: E ]:::IHT ' '" ' ..... ':: ' cZ.', [::} 'y/]. ':: ..... -' '" '*'-' '1 :': '1 .... 1~",1:5]"1::' .v/ PERFORMED FOR: LEGAL DESCRIPTION: [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST 5 6 7 8 9 10 11 12 13 14 15- 16 17 18 SLOPE TE PLAN Gross Net Depth to Net Reading Date Time -rime Water Drop MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this �r Day of (\1\0. of 20 9 3 , by .and between -lo C ,herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as BioCycle located at (legal description) Fog Hill Blk 1 Lot 10. 22314 Woodcliff Court, Chugink, AK 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) �,%' Throughout the term of this Agreement, the .Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in .p accordance with the equipment's approval for operation in the Municipality. d- It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This l includes an annual maintenance fee (typically $400 to $600). oz� Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. �G71 Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. d-!7srOwner acknowledges that the Municipality may request records of maintenance and (�- repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. i Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions .of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. OWNER: By: (signature) Date: Iq mAV 2-n3 �rrL4 Srpyt,&—! j f L, to 4�6� (print name) STATE OF—A1,A9YiA) The foregoing instrument was acknowledged before me this ffday of 2 QZ�, by OTARY PUBLIC FORtk-�j rf� My Commission expires: JT—/�b Q t86 E �l JULIAN EASTER d Notary PpbUc - Arizona ' Pima County a o Commission #f 570693 ae °? M9 Comm. ExPIM9 Oct 13, 2x23 MUNICIPALITY: r _ BY: M-�. (signature) Date: L� L, s I-�A, n (print name) Title: C t (P 6- MUNICIPALITY OF ANCHORAGE Development Services Department t Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-073-28 Legal description FOX HILL BLK 1 LT 10 Site address 22314 WOODCLIFF CT Chugiak AK Current property owner(s) DEREK HAGLER Expiration Date: U Z 3 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: M Ci Original Certificate Date: 5 3 2-o-2-3 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-073-28 Complete legal description Fox Hill Block 1 Lot 10 Location (site address) 22314 Woodcliff Ct. Chugiak, AK Current property owner(s) Derek Hader Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑✓ Plastic ❑ Concrete ❑ Fiberglass *BIOCYCLE Age *19 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ✓❑ AWWTS ® Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ _6 0 Date of Payment 511ch,-3 COSA # D S c., 23 it 31 Waiver Fee $ Date of Payment Waiver # COSA Application—June 2022 COSA Checklist Legal Description: _ _ Fox Hill Block -1 Lot 10 Parcel ID: 051-073-28 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑// Well log is filed with Onsite (or attached) Date drilled 4/1984 Total depth 141 ft Cased to 140.5 ft ✓❑ Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) 23 in. Date of flow test for COSA 4/27/23 Static water level at beginning of test 114 ft Comments B. TANK DATA Measured operating fluid level in septic tank NA* Date of pumping 4/21/23 ❑✓ Required maintenance completed, ifAWWTS Comments: *BIOCYCLE D. ABSORPTION FIELD DATA Which system tested (date installed) 6/7/04 P/1 ALL standpipes present per record drawing Total measured depth from grade 3.75 ft (max) Measured depth to pipe invert from grade 3.25 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ✓❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies COSA Checklist June 2022 Well production at time of test 5.4+ _g pm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑✓ Nc ✓❑ Coliform bacteria is Negative Nitrate 4.44 1 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ✓❑ Arsenic less than MRL (ND) Collected by Arcterra C onsu tino Date 4/27/23 C. LIFT STATION ✓❑ Required maintenance completed Age of lift station 19 years Lift station material Plastic/BIOCYCLE Comments Adequacy test date Results 0 Pass Fluid depth prior to test Water added 450 gal 4/27/23 0 in New fluid depth 0 in Elapsed time 10 min Final fluid depth 0 in Absorption rate 450+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 6 in Effective depth used 0 in Effective depth remaining 6 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' © Yes if No ft Community Sewer Manhole/Cleanout > 100' QYes if No ft ❑✓ Yes if No Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25'✓❑ Yes if No Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100'✓❑ Yes if No Neighboring Absorption Fields > 100' Animal Containment > 50' ✓❑ Yes if No ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ✓❑ Yes if No ft ❑✓ Yes if No ❑ N/A — Served by Community Well (not on lot) or Public Water ft ft ft ft ft From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ./❑ Yes if No I ft Surface Water > 100' ✓❑ Yes if No ft Tank to Property Line > 5' © Yes if No ft Field to Property Line > 10' ❑J Yes if No ft Water Main > 10' ✓❑ Yes if No ft Water Service Line > 10' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' 21 Yes if No ft ❑✓ Yes if No ft If tank or field is under driveway comment below G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Arcterra Consulting Phone (907)-696-6111 Engineer's Printed Name Kenneth Duffus Date A 3 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. Th flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the yea and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluatc of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. COSA Checklist June 2022 WOppCI.IF �UR� o �15' T&E EASEMENT v ) —� WELL _ O J �� y<. ' f RETAINING WALL 2 N POST & RAIL FENCE 84.1 ' Zc" Lot 11 Lot 9 SHED 3.0'x4.5' Z TREATMENT POD I cam$, HOUSE DETAIL Scale: 1"=30' — T — — — S 89'57'40"W 157.19' — — I 6.0, 3 KENNEL Lot 1 I I } MORTGAGE SURVEY X_ SCALE _ 1" 50'_ GRID __NW_1458 Project No. 11500 Daryl Avenue, Anchorage, 907 522-6476 Phone Lang Associates, Inc. c > SEPTIC PIPES4.0'x5.2' PORCH o �OU jonothanOlongsurvey.com trovisOlongsurvey.com 2.0' PROW CANT N ���,'��! , mac.' LOT 10, BLOCK 1, FOX HILL SUBDIVISION (PLAT No. 83-555) j*; 49TH Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a Q O representation of the conditions that were found on the date the survey was performed. This does not boundary is to inaccuracies • • . ' • • • • ' • • survey constitute a survey and subject any that a subsequent boundary survey may disclose. The information contained hereon be to fence, 26.3' Lot 10 2.2'x4.3' CANT t A h Al Dated this the __ �0___ Day of ancorage, Alaska r--- -----' 40,091 S.F. 2.2'x5.0' STORAGE covenants, or restrictions which do not appear on the recorded subdivision plat. 2.0' CANT — T — — — S 89'57'40"W 157.19' — — I — — — Lot 1 I I MORTGAGE SURVEY X_ SCALE _ 1" 50'_ GRID __NW_1458 Project No. 11500 Daryl Avenue, Anchorage, 907 522-6476 Phone Lang Associates, Inc. c > Alaska 99515-3049 kenOlangsurvey.com Professional Land Surveyors pF A� jonothanOlongsurvey.com trovisOlongsurvey.com t ' ' • . ,4\l 5 , I hereby certify that I have surveyed the following described property: ���,'��! , mac.' LOT 10, BLOCK 1, FOX HILL SUBDIVISION (PLAT No. 83-555) j*; 49TH Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This does not boundary is to inaccuracies • • . ' • • • • ' • • survey constitute a survey and subject any that a subsequent boundary survey may disclose. The information contained hereon be to fence, / shall /j 9. KENNETH G. LANG e� Fp not used establish any structure, or other improvements. 0.5202 t A h Al Dated this the __ �0___ Day of ancorage, Alaska r--- -----' k F p ..... • ' S�Q�_i ll � ROfESSIONA��P,`.� It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 H87-0460A ~051-073-28 Application [;)ate GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 10 Block 1 Foxhill Subdivision ( T15N R1W Section 4) Location (address or directions) Woodclif f Circle (b) Property Owner Fannie Mae AK Telephone: Home 561-0828 Business Mailing Address 3201 C Street, Anchorage, Alaska 99503 (c) Lending Institution Fannie Mae AK Telephone Mailing Address 3201 C Street, Anchorage, Alaska 99503 (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followinq address: or: Check here L-J, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family I~x Number of Bedrooms three(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 the legality and status. SEWAGE DISPOSAL Onsite:[~:× 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. Page 1 of 2 72-025 fRev 8/861 Fronl ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or 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 Jn compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone Address Date _ Enqineer'sSeal This department has received written confirmation from the engineer regarding the Conditional Approval of January 5, 1988. The corrections have been accomplished and an inspection has been completed by the engineer. The subject property meets with Muncipal standards is now approved. DHHS APPROVAL Approved for three ( 3 )bedrooms by Approved XXXXXXXXX Disapproved Terms of Conditional Approval Conditional 1988 CAUTION The Municipality of Anchorage Department of Health and Human Services fDHHS) 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. Page 2 of 2 72-o25 CRev 8/86) Back MUNICIPALITY OF ANCHORAGE ,-1 t~ / DEPARTMENT OF HEALTH & HUMAN SERVICES ~j DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 H87-0460A Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 10 Block 1 Foxhill Subdivision (T15N R1W Section 4) Location (address or directions) Woodclif f Circle (b) Property Owner Fannie Mae AK Telephone:Home 561-0828 Business Same Mailing Address 3201 C Street r Anchoraqe f Alaska 99503 (c) Lending Institution Fannie Mae AK Telephone Mailing Address 3201 C Street, Anchoraqe, Alaska 99503 (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followine address: or: Check here [] if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family [~x Number of Bedrooms three(3) WATER SUPPLY Individual Well E~×Community [] Public [] Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~:× 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. Page 1 of 2 72-025 trey 8/86~ Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or 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 Telephone Address Date This certificate supersedes approval H87-0460 granted September 18, 1987 for Lot 10 Block 1 Foxhill Subdivision. Engineer's Seal DHHS APPROVAL CONDITIONAL Approved for ~nree ( ~)~drooms by Approved Disapproved Terms of Conditional Approval Monitor qroundwater coliform bacteria per letter to Dale Potts dated November 12, 1987. Test Conditional XXXXXX levels and sample for fecal Merrell, P.E., Besse Epps and results are to be delivered ther... DHHS no later than June~. CAUTION 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. Page 2 of 2 72-025 (Rev 8/86~ Back 3Aunicilc lity ANC¼,~RAGE, ALASKA 99519-6650 (907) 343-4200 Anchorage MA YOR DEPARTMENT OF HEALTH &'HUMAN SERVICES November 12, 1987 Dale R. Merrell, P.E. Besse Epps and Potts 2220 East 80th Avenue Anchorage, Alaska 99507 Subject: Lot 10 Block 1 Foxhill Subdivision Dear Mr. Merrell: This letter is to advise you that the department has no objections to the construction of the proposed curtain drain on Lot 10 Block 1 Foxhill Subdivision. It must be understood, however, that this measure is in lieu of the installation of a holding tank. Should the curtain drain fail to perform adequately, the department will then require that a holding tank be installed. In order to confirm that ground water integrity is maintained, we will require that a monitoring tube be installed and water levels taken at one month and again at six months after installation. We will also require that the curtain drain outfall be tested for fecal coliform bacteria at the end of one month and again at six months to ensure that the ground water discharge is not affected by septic effluent. I wish to thank you for your cooperation in this matter. If you should have any questions or wish to discuss the matter further please call this of~e at 343-4744. Robert W. Robinson, Program Manage]: On-site Services DB/RWR/ljw cc: Gus Andress, P.E., Manager On-site Services/Water Quality Lee Browning, P.E., Manager Environmental Services MUNICIPALITY OF ANCHORAGE ENVIROt ,vq N rX, L PROTECTION ~ tJR V_[~]' 0.~ (;;ERTIFICATION I HEREIY CERTIPY THAT I HAVE SURVEYED TH[ PBOP[RTY DI$CRIIED ON THIE PLAT AND THE IMPROVI!~klENTS IITUATED THEREON ARE LOCATED A~ .sown oR rHIB PLAT. LEGEND Ix!O',/ '~ '_i ~'>"' 0 LOT CORNERS ,OUNDA'r,ON RECEIVED DRAINAGE ARROWS NOTES' h E, IT BHALL BE THE flEBPOH$1BILITY OF TIlE BUILDER OR OWNER TO VERIFY THA BUILDINg LOCATION BltOWN MEETO ALL IUODIVIOION COVENANTa AND ZONINO ORDINANCEI. IT lB THE REBPONSlRILITY OF THE ~UILOER TO VERIFY A~L ELEVATIONS WITH R[IPECT TO ALL UTILITIE~t 8 DRAINAGE, THII PLAT REPMEBENT8 THE PARCEL OF PROPERTY DESCEIBED ~ELO~ TAKEN FROM THE ~ECOEDED PLAT UESCHI~IHG THAT PARCEL. IN~TRUMENT~ ~ECORD[D PRIOR TO OR AFTER THE FILINg OF THE RECORDED PLAT ARE HOT IHOWH ON THI~ PLAT. THE INFORMATION ON THIfl PLAT I~ FOR THE UB[ OF LENDING INSTITUTIONS SPECIFICALLY TO ~HOW ANY CONFLtCTI PLATTED LOT LINES O~ EASEMENT~ ~ THE PLAT I~ NOT TO DE UaED FOR POBITIONING ADDITIONAL aTRUCTUR[~ OR FENCEI, 349-6452 b. AW, BESSE, EPPS POTTS 2220 E. 8Bth. AVE. ANCHORAGE~ ALASKA 99507 CHK. BY' /-I ,~ SCALE, /~-" ~-~' C-C ual[, //,~.t,61 rLD. BK., 349-6454 NO. MUNICIPALLY' OF ANCHORAGE ·., :-ROTECTION ENVIROr v'"' ,N,- L ~!0\~ ~, l:l' RECEIVED MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTFI AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application [)ate GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, ran9e) Location (address or directions) l/Jo O ~ C ~-/ ,~ r~ ~ I /:. ~ ,~.::~ (b) Property Owner ..-~,.,z.-'z~ /~"/'"~-~-- //' Telephone: Home .5%./- o..'32Z Business Mailing Address 'Dg.~/ ~ t, ~r (c) Lending Institution ,.~,.t¢'~ .,,4',.~ ...4-~;o ¢'~'- Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followina address: or: Check here if hold for pick up. List contact ~erson and day phone number below. TYPE OF RESIDENCE Single-Family/~3 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 the legality and status. SEWAGE DISPOSAL Onsite ~' 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. Page 1 of 2 72-025 IRCv 8/861 Fro,~t ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply end/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. ~-'; Telephone - L,.:- ~.,:7/ Name of Firm :_.,,'~ . .' .... .. .. Address ............ ' , < ( -- ,'- Date DHHS APPROVAL Approved for /~_,-/~¢Z~C~_z'/bedrooms by Disapproved Approved Terms of Conditional Approval Engineer's Seal CAUTION 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. Page 2 of 2 72-o25 trey 8/86) Back MUNICIPALITY OF ANCHORAGE (MOA) HEALTH~,,T~I, ORITY APPROVAL (HAA) ., ,.~,{ O~CI~8~IO?FEBRUAF:~Y 1984 Nktl~\C\'~ ~r'~'¢ h,t SG'-'J\~'~'~264-4744 ~:~~'O¢>m''' ~ , ~n'~ I / / ' 3 ~ ~ ~JO Lega Description: WELL DATA .~ r'; ~ ~ 'g Well Classification '~JP/Y~ ,,-D~: If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) ~ Date Completed :~ , ~: : Yield Total Depth /'/'/ ' Cased to "" ' ~ Depth of Grouting Static Water Level .//'%. :~ ~/'~ / ~'~/ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole /: Water Sample Collected by //)/>~.' / / ¢. .... .-, Pump Set At .... ¢ ' r ' ~'' ' ) Water Sample Test Results Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots /< r ~ /?)'- ; On Adjoining Lots ,":'~- To Nearest Public Sewer To Nearest Sewer Service Line on Lot '?' ,' > ; Date "~ ~;/,>," / Comments B. SEPTIC/HOLDING TANK DATA Date Installed ,.. ¢ /' ! Standpipes (Y/N) "~ / Depression over Tank (Y/N) /~.~/ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) / ,". Separation Distances from Septic/Holding Tank: To Water-Supply Well /'~?:-" ¢ /', To Property Line /:¢" To Water Main/Service Line :" Course ,""' Comments I',)z- ," y:, "; :',. h, ~., ,.,,., ~., > /,~ · Size ¢ (..": ~* '~ No. of Compartments - Air-tight Caps (Y/N) 'Y Foundation Cleanout (Y/N) Date Last Pumped "-%'¢,/*"4 ?/~ /¢ ~/~ ; for Temporary Holding Tank Permit (Y/N) >///~ _ To Building Foundation ;" (- ':"'r To Disposal Field "'; t" To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72 026 fRev 8'86~ Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field , Square Feet of Absorption Area Depression over Field (Y/N) "* / Results of Last Adequacy Test Separation Distance from Absorption Field: To Building Foundation L,.r To Water Main/Service Line "%*.? To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ' :' ,' ' :"' Type of System Design Length of Field "~./~.~" Depth of Field ~;; Gravel Bed Thickness ,/o Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line /4~/:} To Existing or Abandoned System on ; On Adjoining Lots ' .4 ;' , To Cutbank (if present) /',,.; o,,~,"- D. LIFT STATION Dimensions Manhole/Access (Y/N) _ , .... "Pump Off" Level a!__~ " Vent'(Y/N) Pumping Cycles during Adequacy Test. Meets MOA Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that,~;,.. ;~ '1 have.check, d. ;..'ve[ified'~'r~' conformed,: to all M CA and H/AA guidelines in effect on the date of this inspection. Signed /?:'" ~',' . ; ~' ,, ,? Date ~": ' ~' Company.?¢ ..:,7¢ ~:~. i':-7~-;i ?':' MOA No. Date of Payment ¢////~ 2 Amount: $ '~¢ (~ ~ ~'--~ Page 2 of 2 72-026 trey 8¢861 8ack /0 ~IRVEYOR'$ CER'rlFICATION IHEREIY CERTIFY THAT I HAVE SURVEYED THE PROPEHTY DEIIORIEED ON THIN PLAT AHD THE IMPHOVEM~'flTI EITUA'rED THEREON ANN LOCATED &E IHDWN OH THIN PLAT. CATED T,~E ff" CaY oP 5'~.~'r' ,~t..~..Z. LEGEND 0 LOT CORNERS FOUNDATION DRAINAGE ARROWS NOTESt I, IT SHALL BE THE NEI~POt~SIBILITY OF THE .UILOEfl OR OWNER TO VERIFY THAT IUILDIHg LOCATION 8HOWH ME[TI ALL IUIDIVIEION COVENANTI AND ZONIN~ OROINANCE~, ~. IT I~ THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL E~EVATION~ WITH REtPECT TO ALL UTILtTIEI~ D~I~OE. ~, THI~ PLAT REP~E~ENT~ THE PARCEL OF PROPERTY DEICRIBED ~ELO~ TAKEN FNOM THE RECORDED PLAY DESCRIBING THAT PARCEL. IN~TRUMENTI RE~O~ED PRIOR TOOR AFTER THE FILINg OF THE RECOROED P~AT ARE HOT IHO~N ON THtB PLAT, 4. TH:' INFORMATION ON THIG PgAT 18 FO~ THE U~E OF kENDING INITITUTIONI ~PEClFICALLY TO ~HOW ANY CONFLICT~ BETWEEN EXI~TIN~ ~TRUCTURE~ AND PLATTEO LOT LINE~ OR EASEMEHTt , THE PLAT I~ NOT TO BE U~ED FOR ~O~ITIONIN9 ADOITIONAL ~TRUCTURE~ OR FENCE~. L$49-64§2 ~*Aw. mY, J~ CH~. DY. /,4 ~; BESSE, EPPS 8~ POTTS 2.220 E. 88'th. AVE. ANCHORAGE, ALASKA 99507 $49-64§4 BESSE, EPPS & P(~fTS 2220 EAST 88 AVENUE ANCHORAGE, AK 99507 (907) 349-6451 WATER WELL TEST Subdivision: Lot: Block: Client's Name: Address: Initial Reading on Meter: DRAW D O~N T I ME GPM GALLONS A VOLUME GALLONS TOTAL VOLUM~ METER READING NOTES: .... ~ : .... ~ ...... ; ' Gallons Production RaLe: 7'; /) ,¢:,'i ~'=- ......... :"~""'-: .... i ....... 600 UNIVERSITY PLAZA WESI, SUII-E A FAIRBANKS. Al ASKA 99/09 907 479.31 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378 Besse, lgpps, & Ports 2220 E. 88th Avenue Anchorage, Alaska 99507 Date Arrived: Time Arrived: Date Sampled: Time Sampled: Date Completed: 9/03/8? 151.0 9/03/8? :L:L00 9110/87 Source: L 10, B 1, Fox Hill Sample ID~: A090387-21 Para:meter Unit Result AI)EC MCC* Nitrate-N mg/L 0.79 10 Reported By' Z/~/~,~z/~ /~-~' ~' Pate: 9/10/87 Carol J. Garrison, Vice-President ,* MCC = Maximum Con'~aminant Concentration 11 O 3--'V-CA 0 -0.0 to -4 -4-V-W-4 x:; a -� 20mew � __-- a s�®tn Ozom -� FAmnm Z-4M:l ®r0 -4'> om-' 2000 r-4-ar q 3.02IP -4m r $a V 0 3, I Zrr2 p6 F� -qam-' -gam �m� aCA �o� y, r -a >cz y -V -loam s-4 {, `�3 X 2< r o m -4'Mr2 -a = m Ori mw Yr:y 2m 2 z z A 1 $ a te r r m 2", rms _4 -4 _$ ®O ��g z 0 -9 1 -4Acar Q- c ra - W ? S 4m= m= my-4«� -� mr Camra a-" O -m D. m®r 0$ I r S ,o -0.0 to -4 -4-V-W-4 x:; oaq or >a2 2mm 5 m 2C -� FAmnm tWO0 to ®r0 om-' 2000 r-4-ar q 3.02IP -4m r $a Zrr2 p6 F� -qam-' -gam �m� aCA Ar 4o0 y, r -a >cz y -V -loam s-4 {, `�3 a oa02 r o m -4'Mr2 -a = m mw maw qp mmm CT 2m 2 z z A 1 $ a te r r m 2", rms _4 -4 ��g z -4Acar Q- c ra - my-4«� -� mr Camra a-" O -m D. m®r 0$ 5 -4 O 2a � o (} OP4 psr A -4V ® r-4 2 P�W2 �r C A--44� ®C 2-zf" 0)pX O ZX Z ®®r Opp r OZ z OZO Jolza > 00 r -4mzZ C-4— mCa r AI"® A IMc A s 0A-4 - Osr Y 7 No o m -4 73 S D A O g O Go � Z $OA 2 d ® 2 Z -4 2a aA 49 m r S � 4 , 1 ��;77 .r'- ��-77 ,o a � � 4 , 1 ��;77 .r'- ��-77 NORTHERN TESTING LABf Ra-[O[fllES, NC. 600 UNIVERSITY PLAZA WEST, SUITE A 2505 FAIRBANKS STREET FAIRBANKS, ALASKA 99709 ANCHORAGE, ALASKA 99503 907-479-3115 907-277.8378 Hesse, Epps, & Ports 2220 g. 88th Avenue Anchorage, Alaska 99507 Attn: Andy Ports Source: Fox Iii]./ Subdivis:[on, LiO,B1 Smnple ID#: A052488-10 Date Arrived: Time Arrived: Date Sampled: Time Sampled: Date Completed: 05/24/88 :L503 Various Various 05/25/SS Par~mnet er Unit Result ADEC MCC* 5.3 Ni trate-N mg/1 10 MUNICIPALITY OF ANCHORA~)~ DEPT. OF HEALTH & ENviRONMENTAL PROTECTIO~ JUN 6 ~988 p,[CE VED Francois ]tod:Lgari, Anchorage Operations Manager * MCC :.: Maximum Contaminant Conceni:rai:ion 600 UNIVERSITY PIAZAWES] SUITE A 2505 FAIRBANKS STRELT FAIRBANKS ALASKA 99709 ANCItORAGE, ALASKA 99503 907-479-3115 907-277-8378 Quality Control Report Client: B.E.P ID#: A052488-10 Listed below are quality control assurance reference seunples with a known concentration prior to analys:i.s. The acceptab]e limits re. present a 95% confidence interval established by the Environmental Protection Agency or by our laboratory through repetitive analyses of the reference sample. The reference samples indicated below were analyzed ut 'the same tlme as your s~unple, ensuring the accuracy of your results. Sample # Parameter Unit Result Acceptable Limit EPA 378-12 Nitrate-N rog/1 7.58 7, ].7 --- 8.01 Francois Rodigari, Anchorage Operation Manager MUNICIPALITY 0~' ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPA~.~ENT OF HEALTH AND ENVIRONmeNTAL PROTECTION APPLICATION FOR RF~LTH AUTHORITY APPROVAL CERTIFICATE I. C~e~ neral ~I2~f~o~r~t.~ip_~n Application Date ~.~ ~ (a) Legal Description (include lot, block, subdivision, section, ~ownship, range) Location (address or directions) (b) Applicants Name ~'~/~-~-~L~ ~ ~a±e non__one Business Applicants ~dress ~ ~ '; ~ ...... (c) Applicant is (check one) Lending Insti~ution ~ ; ~er/builder~'~ (d) Lending Institution ~7~ Telephone Address (e) Real Estate Coo & Agent Address (f) Telephone ~.~t~e HAA to the following address: 2. T.~e of Residence Single-Family ~ Number of Bedrooms 3o Water S_.qupR_lji Individual Wel 1 ,~ Multi-Family ~ Other (describe) Community ~ Public Note: If community well system, must have written comfirmation from the State Department of Environmental Conservation attesting to the legality and status° Onsite ~'~. Public Community Holding Tank Note: If community well system, must have ~.rritten confirmation from the State Department of Enviroo~uental Conservation attesting to the legality and status. [Page 1 of 2] ineerin I J_r~ Pcovidin? Ins ections Test~a~_I~ile Searcha Data and Information :z!"'~l As, cer~ffied by ~ se~ affixed hereto aud a~ of the valida~ioa date sho~ below, I verify that my irn~stigation of this Health Authority Approval shows ~ha~ ~he on-site ~ter supply and/c~r ~stewatar disposal system is safe~ f~ctional and adequate for the number of bed~cms and ~ype of structure indicated herein~. I further verify chat, based on the i~o~gion obtain~ from the Municipality of ~chorage files and from investigation ~d inspection, the o~'site ~ter supply and/or ~stewater disposal system i~ in c~p/iance ~th ~1 Municipal and S~ate codes, ordinances, a~ regula~ tions in effect on ~e date of this inspection. Name of Firm~~.~ Address Da~e Approved for Approved~. Telephone Disapproved Condielona~~ Temns of Condigional Approval CAUTION THE MUNICIPALITY 0F ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON T~iE REPRESENT- ATIONS GIVEN IN PA~h~GRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN %~Ig STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND Sqi~TE REQUIRE~ MENTS. EMPLOYEES OF DHEP 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. (DHEP SEAl,) RR4/e~/D18 [Page 2 of 2] 7-19-84 ae MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification I~IL2./&'~ Well Log P~esen~Y,'.'.~. Total Depth /~TL/ Cased to Static Water Level //,~ ~ NUNICIPALITY OF DEPT. OF HEALTH & NVIRONMENTAL PROTECTIOI~ ,RECEIVED Legal Description: ,~/~ Pump Set At Casing Height Above Ground ~ ~) /' Electrical Wiring in Conduit~Y.'~ Separation Distances f~cm Well: To Septic/Ho2]zl~ Tank on Lot //~'- / To Nearest Edge of Absorption Field on Lot //0 ' Sanitary Seal on Casing (Y~_~__ Depression A~ound Wellhead((~"//N,...)/ ~joining Lots /O~ ~' Adjoining ~ts... /OO (~ To Nearest Public Sewer Line ~J //~ To Nearest Public Sewer '/,/' . TO Nearest Sewer Cleanout/Manhole /3 .~ Service Line on Lot Wate~ Sample Collected By,__5'.~./~ ~//~/~/; Date r ,~ ~//~ ~ Wate~ Sample Test Results ~_~>A -77 -~ /c W4 ( ~_z-o ~ c Cc~ents ~ I-'re. ~ i~ ,/~ B. SEPTIC/HO~ TANK DATA Date Installed //./~ a./ Size ./~OL) No, of Cc~,ga~tments "~- Standpip~ ) Ai~-tight Cap ) ' FOundation ~Cleanout ) ~p~ession o~ Ta~ (Y~) ~te ~st P~d ~'~ 6~ P~ing~intenan~ ~n~a~ ~ File (Y~/~-. ; for ' ~ Holding Ta~ High-Wate~ ~a~ (~J//~ ~a~y Holdi~ Tank ~r~t (Y~/~ Sep~ation Distan~s ~ ~ptic~ Tank: ( To Water-Supply ~11 To ~ilding F~ndation ~L~--' ( To P~operty Line /0 To Water Main/Service Line Course Comments TO Disposal Field /L3~- / -/- TO Stream, Pond, Lake, c~ Major D~ainag~ /u- , [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/ Width of Field ~ .~ Square Feet of Absorption A~ea Depression over Field (Y~] Results of Last Adequacy Test Length of Field _ ~L,-~ Depth of Field ~. ' Gravel Bed Thickness . ~" Standpipes Present ~) Date of Last Adequacy Test /(-J~f? ~'j Separation Distance frcm Absorption Field: To Water-Supply Well //~ ~ To l~operty Line / To Building Foundation 4~._~'- ~ To Existing ~ ~ndo~d System ~ 3 ~ ~joining ~ts ~ ~ Lot /~ ~ ~ ,__; ~ / TO Wate~ Main/~vi~ Line /O ~, TO ~t~(if pre~nt) To St~e~ond/~ke/~ Majo~ ~aina~ C~ /~ ~ To ~i~way, Parki~ ~ea, ~ Vehicle St~a~ ~ea ~o Co~nts /~ ~ ~"~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions MaPJ~ole/~cces s (Y/N) /~ Olf"/~vel at Pumping Cycle~' du~ing Adequacy Test. Meets MOA Comments ** Check Permitted Bedrocm Rating Against HAA ~equest I certify that I have checked, verified, or conformmd to all MOA HAA Guidelines in effect on the date of this inspection. Signed , SR[~ 19S)~ Co. any PH. KB1/d5/s [Page 2 of 2] MOA No. ~_f--i ~353 ~ 2-15-84