HomeMy WebLinkAboutGLACIER VIEW HEIGHTS #4 BLK 1 LT 2Glacier View
Heights #4
Lot 2
Block 1
#050-491-50
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: r5~,¢ 9/0 o~-/y PID Number: ~<5-~- ~¢'/-,.5--~_
Name:
Address:
Phone: No. of Bedrooms:
~- ~17~ ~ ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
LEGAL DESCRIPTION Soil Rating: Total Depth from ~riginal grade:
~' ~ GPD/Sq. Ft. ~ ,~- ~ /
Lot: Block: Subdivision: Depth to pipe boltom from odginal grade: Gr~vel depth beneath pipe
Township: Range: Section: Fill added above original grade: Gravel length:
Gravel ¢¢: Number of lines: Distance belween line~:
WELL: ~ New ~ Upgrade ~'¢~
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Levek Installer: Date installed:
Yield: ~.~/~L¢~ GPM Pump Set at: ~ Ft. Casing Height Above~ Ground:FL TANK
SEPARATION DISTANCES ~s.,ti~ uHolding U S.T.E.P.
TO Septic Absorption LIII Holding Public/Private Manutacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines
Number of Compartments:
Material:
Sudace
Water ~/., - LIFT STATION ~/~
Lot / Size in gallons: Manufacturer:
Foundation / / / / ~ / O "Pump on" level at: ;'~mp off" level at: Higb water alarm at:
CurtainDrain ~¢~ ~ ,~. Pump Make & Model Electrical Inspections performed by:
Remarks: BENCH MARK
Location and Description:
Assumed
Elevation:
Inspections performed by: ¢¢~¢' Dates: 1st ~/~/~ ':;',"~"' '
Department of Health ~Hu~n Servic~ approval ..'
Reviewed and approved by: ~/~~~ate:
72-013 (1/91) MOA 25
Permit No. SW910054
Page ~ of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Glacier View Heights #4, Lot 2 Block 1
PID No.: 05059150
N00'05'06"W 249.09'
NO NEIGHBORING
WELLS, SEPTIC,
OR STRUCTURES
+200'
NO NEIGHBORING WELLS, SEPTICS OR STRUCTURES +ZOO'
SCALE: 1" = §0'
ELEVATIBNS
(NOT TO SCALE)
100'
LEACH BED
GAL
SEPTIC TANK
/
/
15' GAS EASEMENT
NO NEIGHBORING
WELLS, SEPTIC,
OR STRUCTURES
+200'
MONITOR TUBE
SEWER CLEANOUT
WELL
LEACHFIELD
BASEMENT
1.7' A~DED FILL
2' -- LEVEL ~ 96,4' NO
9 WATER
97.6' 94.8' TABL[E3,4,
72-013 A (2/91) MOA 25
ENGINEER'S SEAL
( er ifiei Drilling
by
{DOC Co. dba
SULLIVAN WATER WELLS
P,O, BOX 6?0272, CHUGIAK, ALASKA 99567' · TELEPHONE 688.2759
OWNE~ o~ ~ANO /7]W.f~' c.2a,~r.'/(
ADDRESS ~/OP'.~J~o~ ('...~','it~,4LT~[
LEGAL DESCRI~ION~_ d ~1( I ~.ZnC, t~
DATE- Started _~/~/ Ended
/
PERMIT NUMBER
/ /I
,,E,,-i-. o~-WELL /% 7 re-
DP, AW DOWN FT.
GALS. PER HR
K[NI) OF CASING
S1-A'IIC LEVEL OF WATER FT. 7 ~
70/0
KIND OF FORMATION:
From 0
F'rom
From
Fromd 0~
From_
From~/~
From__
From/J<)''~'
From
From
From
From
From
From
From ~
Ft. to A Ft. (-J~Jl-fr,X/~ '--(Tt(,,~4OP. Fro,,,
Ft. to~Ft.~)U~ ~ gO~4~ Fro,n ~
Ft. to Ft. C: 0 ~ From
Ft. to ~. ~ cUdTE;- Fro,,
Ft. to Ft ~ From_~
Ft. Io Ft From
Ft. to~Ft From
Ft. to~ Ft. Front
FI. to~ Ft. From
FL Io Ft. From
Ft. to_. Ft.
Ft. to, Ft.
__ Ft. to Ft.
FI. to FI~
Ft. lo Fl
__Ft. to __.Ft.
__Ft. lo .Ft.
Ft. to.iviunlclp~t{t!t7 e~ ~nchOraOo
Dept. Hear ~ & Human services
Ft. to, ~Ft,
FI. lo__Ft.
Ft. to Ft
__FI. to__Ft.
__FI. to Ft.
FI. to_ Ft
MISCL. INFORMATION:
DRILLER'S NAME /,'~cA-,~ ,~'2 .....
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 AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910054
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:CLARK MARK J & DONNA A
OWNER ADDRESS:lB338 CLEAR FALLS CIRCLE
ANCHORAGE, ALASKA 99577
DATE ISSUED: 4/10/91
EXPIRATION DATE: 4/10/92
PARCEL ID:05049150
LEGAL DESCRIPTION: GLACIER VIEW HEIGHTS #4 BLK
1 LT 2
LOT SIZE: 51951 (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. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
Louis Butera, P.E.
Registered Civil Engineer
April 5, 1991
John Smith, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Lot 2 Block 1, Glacier View Heights #4
Narrative
Dear Mr. Smith,
The proposed septic system installation will have very limited
impact on adjacent properties for the following reasons:
The subdivision is of large lots (1 acre) with no
development on any adjacent lots so there are no well
setbacks considerations allowing adequate room for
upgrades on all lots.
2. Wells in the area are adequate.
3. Reserve space is adequate. Soil conditions are good.
Drainage will not be effected and is not a major
consideration in our design. This is a better area of
Glacier View Heights and is not in the low section.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
P.O. Box 773294 · Eagle River, Alaska 99577 · Telephone (907} 694-5195 · F~ (907} 694-3297
LEGAL:
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
Glacier View Heights~/Lot 2, Blook i
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this
specification.
3. All materials and workmanship shall meet the Anchorage
Department of Health and State Department of Environmental
Conservation requirements.
4. All soil tests are advisory to the design and are to be verified
or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified
or modified in the field by the contractor to meet Municipality
of Anchorage, Department of Environmental Conservation
requirements.
6. It is the responsibility of the owner to obtain all necessary
permits or easements and to locate any adjacent multi-family
wells.
7. The excavation is to be exactly in the area shown on the site
plan, any deviation requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot
line position and the location of any easements.
B. BED
1. The bed is to follow the natural land contour to maintain
uniform total depth of the bed bottom.
2. The bottom of the bed shall be level, plus or minus 1.5".
3. The total depth of the bed excavation is not to exceed 5' at
deepest point.
4. The bed gravel is to be covered with typar fabric material.
5. Soil or combination of soil and extruded board insulation to a
depth of 3' or equivalent is to be placed over the leachfield.
6. The area over the bed is to be finish graded to prevent ponding
of surface water runoff.
7. The septic tank and leachfield must not be closer than 100' to
any existing private well, 150' to any Class "C" well, or 200
feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS
TOTAL DEPTH = 4-5'
BED LENGTH = 47'
Soil Rating = 0.6
Bedroom Capacity =
Septic Tank Size =
GRAVEL DEPTH = 6"
BED WIDTH = 12'
3
1,000 gal.
NO NEICHBORINC WELLS, SEPTICS OR STRUCTURES 7200'
N00'05'06"W 249.09' .~ tO' MTA & MEA Eosement
~ ~ I~ 15' Gas easement
s~.uc~u.~ +200' ~
,~d'~
~9'~ ~ - TEST HOLE
· - MONITOR TUBE
o SEWER CLEANOUT
NO SURFACE WATER COURSES ¢ - WELL
PROPOSED LEACHFIELD
NO KNOWN CURTAIN DRAINS EASEMENT
S E P TI C S I m E P LA N
LEGAL; Glacier View lies.
OWNER: Clerk
CONTRACTOR:
dob ¢ 9o-~o51 DATE'
P, O. ~o~
EACLE RIVER, AK. 99577
(SO~) SS4-S~SS ~'AX;
EAGLE RIVER
ENGINEERING SERVICES
P. O. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
SHEET NO
1'-
Munlclpnflly of Anchorngo
DEPARTMENT OF HEALTH & HUMAN SERVICES
B25 "L" Street, Anchorage, Ala,~ka g9502-06fi0
SOILS LOG .-- PEI1COLATION l'ES'r
LEGAL DE$CRIPTIONL..~/;g'T ~.....,~..~j~.J Township. Rm/ge. Section:
10 WAS 6tlOUN0 WATER ,. I .,-,,'
IF YES, AT WHAT
~4 Roudlng Onte GroAl
~t Dopth to Not
line Wator Drop
· :. . ,. ~, :~, ~ ~' ~,. ,,,'~,~/~p~ ,,. ~.,~..,; ....... ~ ~ ..,
· :'¢ ', ;" 1,3
18 ......... ) ........
~ ~4~, u~,.~ ~dl PERCOLATIONRATE
TE~T RUN BETWEEN ~ F~NO // FT
........ 17034 Eogi. River Loop no~i ~o, ~n~ ~'~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Streat, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION: ,~ ~
'/'/d~-
0
WAS
w ENC[
IF YE
DEPT
Louisa ~ulera ~ ~
PERC
8
9
10
11
12
13
14
15
16
17
18
19
2O
SLOPE
SITE PLAN
GROUND WATER S
ENCOUNTERED? .''Z-/'~ L
O
,~,~, ~,~ Pi
;, AT WHAT ? ~-,/~ r E
Reading Date Gross Net Depth to Net
'rime Time Water Drop
I ~/~ ~'~ ~ /~,~ ~,-'~,', ~ '~
LATION RATE ~' ,~-- (minutes/inch) .~ O. ~ c.,,'.~...~, .~
TEST RUN BETWEEN Z/ FT AND__-~ FT
COMMENTS
PERFORMED BY:
72-008 (6/79)
Eagle R!vcr En0Jnoerlng Services
P. 0. P~x 77~a4
E~!e R;\'er, AK 99577
69~5195
CERTIFIED BY: ~-
Municipality of Anchorage
Development Services Department
Building Safety Division r `:
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING t
Parcel I.D. 050-491-50 HAA #y�LA
y
Expiration Date:
'1. GENERAL INFORMATION
Complete legal description Lot 2. Block 1. Glacier View Heights Subdivision No. 4
Location (site address or directions) 22434 Eagle Glacier Loop
Current Property owner(s) . Alvson Pvtte Day phone 264-0760
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
22434 Eagle Glacier Loop Eagle River, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ' Well
Public Water System
Three 3
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an Independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or 13wells or a public
water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER 4 ' °
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined In the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functionat and adequate for the number of
bedrooms and type of structure Indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone 522-7773
Address P 0.13ox 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 8/2012003
5. DSD SIGNATURE
_j�..Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
WASTEWATER
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date: " a- (o - D 3
(Rr. IM
Municipality of Anchorage*A4
• Development Services Department
Building Safety Division On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.cl.anchorage.ak. us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot & @lock 1. Glacier Vlew Heights Subdivision No. 4 Parcel ID: 050.491.50
A. WELL DATA
Well type pr<v to If A, B, or C provide PWSID #
Date completed 51111991 Sanitary seal (YAC y
Total depth 141 ft. Cased to __9,Q., 8.
FROM WELL LOG
Date of test 5/x11991
Static water level N ft.
Well production 12
9—
p.m-WATER SAMPLE RESULTS:
Coliform —L-colonies/100 ml. Nitrate -J_ mg.A.
Date of sample: 8/512003 Collected by: MEA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Senge/Steel
Tank size 1.000 gal. Number of Compartments j
Well Log (Y/N)
Wires property protected (Y/N) Y
Casing height (above ground) 36 n.
AT INSPECTION
MM03
80 ft.
¢,75 9—
p.m-
Other bacteria 3 colonies/100 ml.
Date installed 0112/1991
Cleanouts (Y/N) Y
Foundation cleanout (Y/N).y Depression over tank (Y/N) y High water alarm (Y/N) N
Date of pumping_ 811112003 Pumper JITs Pumping
C. ABSORPTION FIELD DATA
Date Installed 0112M991 Soil rating (g.p.d./112 or ft2/bdm7) .8 GPpISF System type Shallow Bed
Length 49 ft. Width 12 ft. Gravel below pipe .5 ft.
Total depth i3 ft. Eff. absorption area 118.fl? . Monitoring tube y Depression over field jv_
Date of adequacy test 8/3/,03 Results (Pass/Faiq Pass For 2 bedrooms
Fluid depth in absorption field before test P_a in. Water addedo gal. New depthgry in.
Elapsed Time: ¢6_ min. Final fluid depth Ra In. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) N If yes, give date
i
D. LIFT STATION
Date installed Size in gallons
'Pump on" level at
Datum
in. "Pump off" level at _in.
E. SEPARATION DISTANCES
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 2100'
Absorption field on tot 2100'
Public sewer main WA
Sewer /septic service line 225'
C
Manhole/Aocess (Y/N)
n
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots 2100'
On adjacent lots 2100'
Public sewer manhole/cleanout NIA
Holding tank WA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line }S Absorption field 3-5'
Water main >10' Water service line 210' Surface water >100'
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 210' Building foundation 210' Water main 210'
Water Service line 270' Surface water >100' Driveway, parkinglvehicie storage >10'
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION •1
I certify that I have determined through field inspections and 49th ` •
review of Municipal records that the above systems are in ' .... ......•• - • • - '�
conformance with MOA HAA guidelines in effect on this date.
MICH11El r -
w ERSON
Engineer's Printed Name Michael E. Anderson. P.E. 1No. CE-47e1��
Date 812012003 .......... ��•
HAA Fee $ 104 a�J /}/r' Waiver Fee $
Date of Payment 012Date of Payment
Receipt Number Receipt Number
(Rev. 12100)
A
f�
r
�r x
Jforic" STJPJvG A�/JrES
s
B
K
0 20
SEWARD >k
ASSUILT-NO CORNERS SET THIS DATE. SCALE=
'1 HEREBY CERTIFY THAT I HAVE SURVEYED THE 1•4 a 40'
FOLLOWING DESCRIBED PROPERTY+ Lot 21
Block 1, Glacier View Heights, Unit NO. 4 DAT$ 14/91
AND TTHE
THAT NO ENCROACHMENTS EXIST EXCEPT A5
INDICATED• IT 1S THE RESPONSIBILITY OF
pWNFR TO DETERMINE THE ORSR IC i IONSENCE OF Y GRIDS,W59
EASEMENTS, COVENANTS,
WHICH O NOT APPEAR ON THE RECORDED SUBD1. FV
23-b1
VISION FLAT.' UNDER NO CIRCUMSTANCES SHOULD
D
NUCTION
OF FDATA HEREON ENCE LINES, OR FOE USR ESTABFOR �SHIINNG BOUND- DRAWN
ARY LINES.
DMS
l0 'd 8L90 V9Z L06
® `"'—•—
•:'� O� ALS �•
Oveee Merk sewed
!'•,• .1S-6918 I
sanw 21��"l3dd� ud £0:60 IES tOONZ-Ong
ANDERSON ENGINEERING
Telephone:9D7'-=-7773 Engineering Services
PO Box 240773, Anchorage, AK W524
Date: August 3, 2003
Legal: Lot 2, Block 1, Glacier View Heights
Well Depth: 141'
Static Level: 80'
E Single -Family
Type of
❑
Type
System Tested:
Multi -Family
Test Performed:
rn Well Flnw Onlv
of
rn
cantle A&a tt w Only
Fascimile: 9075225779
PmjectN: 02-261
Inspector: S. Gilbert
S Bdrms. 3
❑ Commercial
an Reith
Time
Flow
Flow
(gpm)
Volume
(gals)
Cum
Volume
(gals)
Wen
Static
Level
(ft)
ST
Liquid
Level
(IM
MTN1
Liquid
Level
(in)
MTS 1
Dena
(in)
MTS2
Liquid MTS2
Level Dena
On) (in)
Meter
Reading Corrrnents
2:21
N
Yes
❑
W
49"
0
Yes
❑
171870 Start
2:35
7.14
100
100
126.5'
49`
0
171970
2:48
7.14
100
200
126.5'
49'
0
172070
3:05
6.88
110
310
126.6
49'
0
172180
3:21
6.25
100
410
126.6
49'
0
172280
4:34
726
530
940
126.6
49'
0
172810
534
6.83
410
1350
126.6
49'
0
173220
6:52
6.15
480
1830
126.5'
49'
0
173700 End Well Flow
6.75 I Average Ga"In WeN Fbw
Does septic tank need pumping?
Is well wire in conduit?
Is wells sanitary cap installed?
Elevation of well casing above ground level:
ADEC Code
ComnAance:
�c a
__-
a
Yes
❑
No
N
Does septic tank need pumping?
Is well wire in conduit?
Is wells sanitary cap installed?
Elevation of well casing above ground level:
ADEC Code
ComnAance:
a
Yes
❑
No
N
Yes
❑
No
0
Yes
❑
No
>2
Ft.
PWS ID S S NA
Is this system currently in compliance? 0 Yes ❑ No
Test Results: 0 Passed ❑ Failed
Reviewed By: 7 V 1 't a Date: _
❑ NA
❑ NA
❑ NA
8-zo-0.3
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH 8. 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. # 0S0-411 . `sd HAA #.44.6 99D (mob S
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 6rC-a2 IPJ/�P
Property owner /,/1 ti 7/PLR DY Day phone
Mailing address .
Lending agency
Mailing
'Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well x x
Community well
Public water
Day phone
Day phone
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
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(Rw.1/91) Front MOAA21
5.
J.
0
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 �% 7 y
17034 Eagle River Loop Road No. 204
Address Ennie River.Ai
Engineer's signature
DHHS SIGNATURE
A Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
IIITIC
Date / A Id 0/ q-7
:D F
ROBERT C. COWAt4 �?
IcCt� CE -8801 :\i•�
BOJ ;•' ;•'CCN
bedrooms, with the following stipulations:
Date / -4 -ao
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 courtesyto 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(R..1A1) Back MOA621
Municipality of Anchorage _
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health AuthorityApproval Checklist
Legal Description: rZ�L—arg / 6C�FG/�2 ✓ / &t4 k1r_s Parcel I.D.:
'#-g
A. WELL DATA
Well type /Q / VLF � If A, B, or C, attach ADEC letter. ADEC water system number
Log present CON) Date completed
Total depth Cased to 40 f Casing height (above ground) 2
Sanitary seal aN) / � Wires properly protectedgN) E s
FROM WELL LOG AT INSPECTION
Date of test
Static water level 7 s / 7
Well production 14;7 g.p.m. g.p.m.
fl 411 46- L/f-7/7Z�D 2WY PUHP
WATER SAMPLE RESULTS: 5'oMe— Got✓ VOLUM& /f.S&HVL-O �1 S�
Coliform 4/ Nitrate Other bacteria
Date of sample:/ 2�115- '9Collected by: S Slur /NCS/N�
B. SEPTIC/HOLDING TANK DATA
Date installed 2 /Tank size Number of Compartments z CleanoutsdgN)_S�fi
Foundation cleanout N) Depression (Y/to High water alarm (Y/N) N
Date of Pumping // 9 Pumper C�� S
C. ABSORPTION FIELD DATA 2
Date installed lJ Z / Soil rating �r ft2/bdrm)y System type
Length _Width I Z — Gravel thickness below pipe rP r Total depth
Effective absorption area Monitoring Tube presentAN) CS Depression over field (Y/ 1� Mo
Date of adequacy test Results (Pass/Fail) �5 For %!>`Aei5-t55— bedrooms
Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.): y �4
Fluid depth (ins) Minutes later: Absorption rate = f�s� g.p.d.
Peroxide treatment (past 12 months) (Y/N) APN& 11/V AI If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /00?/- On adjacent lots
"Pump off" level at*
Absorption field on lot Ino f On adjacent lots /d 0
Public sewer main N /4 Public sewer manhole/cleanout ZA
Sewer /septic service line Zs -/–
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /0/"– Property line �4- Absorption field t
Water main/service line zS Surface water/drainage IeV f Wells on adjacent lots AO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line Building foundation Water main/service line /
Surface water l�� /G Driveway, parking/vehicle storage area
i
Curtain drain /1// Al'-- SCA/OZ✓A/ Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
1 certify that 1 have determined thru field inspections and review of Municipal
in conformance with MORA HAA uidlines i�n effect on this date.
Signature
� F
Engineer's Name C• Co W q/ 11
Date
HAA Fee $ �� (,-0 � Waiver Fee $
Date of Payment
Receipt Number �T
72-026 (Rev. 3/96)*
Date of Payment
Receipt Number
Tl 1 ROBERT C. COWAN
are
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Glacier View Heights 1t4
Lot 2, Block 1
Location (site address ordirections)
22434 Eagle Glacier Loop, Eagle River
Property owner Donna Clark Day phone 696-7177
Mailing address 22424 Eagle Glacier Loop, Eagle River, AK 99577
Lending agency
Mailing address
Northland Mortqage Day phone
11421 Old Glenn Hwy., Eagle River, AK 99577
694-7872
Agent N/A Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well xx
Community well
Public water
NOTE:
If community well system, provide written confirmation front State ADEC attest-
ing to the legality and status of system.
TYPE OF WAS'rEWATER 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.
?2-025(Rev. 1/91) Fronl MOA #21
o
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seaJ 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 ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Eaqle River Enqineering Services Phone 694-5195
Address P.O. Box 773294, Eagle River, Ak 99577
Engineer's signature
Date
DHHS SIGNATURE
Approved for
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72q)25 (Rev. 1/91) Back MOA~I
Municipality of Anchorage ~ E',,~
DEPARTMENT OF HEALTH & HUMAN SERVICE~' lJ (-- t: / V~'~)
Environmental Services Division
825 L Street, Room 502, Anchorage, Alaska 99501° (~.7)
Health Authority Approval Oheckli bore9e
Legal Description: ~¢dE/~ ~'/~0 ~ZS' ~ _ Parcel I.D.: ~ ~O,-
Well type ~V~ If A, B. or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~ Date completed
/
Total depth
Sanitary seal (Y/N) Y~'~
Cased to //¢'~'/ '~ /' Casing height (above ground)
FROM WELL LOG
Date of test
Static water level
Well production /~.-
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTICII-li~a~iG TANK DATA
Nitrate
Date installed
Foundation cleanout (Y/N). ~/~,~
Date of Pumping /0/~
C, ABSORPTION FIELD DATA
Date installed 0 ~///9 /
Length /--/: ~2 ' Width
Effective absorption area
Date of adequacy test /o .-.//-
Wires properly protected (Y/N)
AT INSPECTION
c.,
g.p.m. ~ ,,.¢-
g.p.m.
~"/ /~//'/- Other bacteria '~;~'
Collected by:
0 ~.///~/ Tank size ~0~
Depression (Y/N)
Pumper
Number of Compartments ~ Cleanouts (Y/N)
/¥/~ High water alarm (Y/N) /
Fluid depth in absorption field before test (in.);
Fluid depth ~ (ins) Minutes later: ,¢
Peroxide treatment (past 12 months) (Y/N)
Soil rating (g.p.d./ft2
er- ...... kin) O, '~ . System type
/ /
Gravel thickness below pipe Total depth
Monitoring Tube present (Y/N)/v/_~..~ Depression over field (Y/N)
Results (Pass/Fail) /~..~'~ For ...~ '~ bedrooms
Immediately after z/5~. gal. water added (in,):
Absorption rate = _ ¢/¢,~'o g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed S iz~e~ir~..g alldh'~
Manhole/Access (Y/N) ~-~P mu~"p (~n" level at* "Pump off" level at*
High wate~*~'~'~ *Datum
C..~.ea-te~t e d
E. SEPARATION DISTANCES
Absorption field on lot
Public sewer main
8ewer/septic service line
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/C-~Iding tank on tot //~/'//
/
//5
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOL-DtNG TANK ON LOTTO:
Foundation / / Property line ~;'.~ Absorption field
Water mai'n/service line ////-,) Surface wateddrainage /~/~,'0 / Wells on adjacent lots
/
-/-/OO '
/,//4
//~-/
SEPARATION DISTANCE FROM ABSORPTION FIELD ON I.OTTO:
Property line ~ 0 ' Building foundation /z/ ~ Water.,.maLq/service line
Surface water ~/00 /
Driveway, parking/vehicle storage area
Curtain drain /~/~/'¢E ,'~°~,d,g--CF, A/'T Wells on adjacent lots '/'-/(2/_.) /
ENGINEER'S CERTIFICATION
~ cer#fy ~at ~ ~ave determined ~r~ f~e~d ~ne~ec#on~ ~,~ r~v~e~ o~ Mun~c~p~ recor~e~:~ ~ ar~
~n conformance w/th MOA HAA gu~debnes tn effect on this date.
~.,,~ ~. . '., ~ :..: ~ ' ..~
S~gnature ,~ ~
HAA Fee $.
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Parcel I.D. #
'1.
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
O5O49150
GENERAL INFORMATION
Complete legal description
Glacier View Heights #4, Lot 2, Block 1
T14N R1W Sec.16
Location (site address or directions) NHN Eaqle Glacier Loop, Eagle River
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Mark J. & Donna A. Clark
Day phone
18338 Clear Falls CLrcle, Anchoraqe, AK 99577
Federal Home Administration
Day phone
701 C Street, Box 64, Anchorage, AK 99513
696-7177
N/A Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well X
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, 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/orwastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein, lfurtherverifythat 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 Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eagle River, AK 99577
Engineer's signature
Date
DHHS SIGNATURE
/¢k.~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date
The Municipality of Anchorage Department of Health and Human SeA/ices (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~F21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /~-¢;)- ,d~/,/'F/ ¢¢'/'~ ¢/ ¢',- ~'/¢"¢ '¢/"~ 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 ..5-/'¢/ Driller
Casedto /~/~ '-7 '/ Casing height
,/V' Wires properly protected (Y/N) )'"
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p,m,
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /o/¢' /
Absorption field on lot //
Public sewer main
~ sewer service line ¢ 5- /
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
AT INSPECTION
MUNICIPALi~ OF ANCHO~GE
~R~L SERVICES DIVISION
~,~ ~. 9 199[
RECEIVED
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ,~//?
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size / ¢¢¢ ~ '~ ~' ' Compartments ~
Foundation cleanout (Y/N) ~v Depression (Y/N)
_ Alarm tested (Y/N) /vi?
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
// t
On adjacent lots ~'/~'~' ' Foundation
Absorption field /-~- / Water main/service line
72-026 (Rev. 3/91) Front MOA 21 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)
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DA'rA
Date installed 2~-/¢ /
Length z~/¢ / Width
Total absorption area 5"-~'~ _c~..
Depression over field (Y/N)
Results (pass/fail) "¢./'~
Peroxide treatment (past 12 months) (Y/N)
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
System type /5%,¢(
Total depth
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots 7~ ?¢¢ Property line
To existing or abandoned system on lot
Cutbank /u ,/~.
Water main/service line
Well on lot //5-
To building foundation
On adjacent lots
Surface water "¢/~/ Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, orconformed to all MOA and HAA guidelines in effect
ate of this inspection.
Signature
Engineer's Name
Date ~,,'~ ?//~ /
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 {Rev, 3/91) Back MOA 21