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HomeMy WebLinkAboutGLACIER VIEW HEIGHTS #4 BLK 2 LT 8U) M A Z-O-mz mzo D D z M m -Di mmc O0'(� CM = P ca N O ;a-00 JoZ O (n( Mm C D^ mmr-wm> OMCWC>WO (nC �Z oZ> S7O �W r" mcommr Mwmzcczco _� s O� ="OOm-DI Z�W -C -C >X mm0-VDr �ZMOOMM-<MZU) Or II p�D-m{X-1 0" O n I �n 0m FAn�5 .ZmlmOrmfmrmT 2 --jw Na ��Z-C�r=Tt Cn�� O� O �M Z �O�m�(nOOZ-�fC(Dj-CC:U U' O �l�r �D O I O 3' CO-C�r- -058mZOy ZCZm� >O O O U) OM>LnZ(nK �N -< O vO O-{-N{Om OCA -<0—<-i -{ zm(nU7=O -rOD m Z MAKVWO M�WDCc 00-wwo L<� *� p *� t-iT OOD � D�� U p (n��m� Zm=Dwoo�a)zw -�D Z rn m F-.4 --i m D ��rn-z �� __ U Z Ommx� ��D=3'mZ�rip0 Z o (n 9: DDS ''' m O Zc Z� m ����� 11 O 1�7W>(n nm 0 m Ln m OO -< O� DO > ��ozmp D3 p D m zoDOr�* m 0 O O O Fi -n s�� • �� jFri C) tn (n a AUW IN o' con / RAMP J O O � C ,� I Z O; Fnox 1 Foy v Z s ? ¢O IV CA --► RAMPCl > Nrn r Sys• ZS �, v n > m10 m 5r o Q Ir g U) 50 O�p 0 y m m loo -� m � s CA �- II 0 Municipality of Anchorage Page I .of DEPARTMENT OF HEALTH AND HUMAN SFRVICES 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: S'k'"" 9 '501 '9 0 PID Number: ©to Name:Wastewater System: Et'New [] Upgrade '3"o~, ,.-, -Do,.... Address: Phone: No of Bedrooms ~ Deep Trench [] Shallow Trench [] Bed [] Mound [] Other LEGAL DESCRIPTION soil Rating: Total Depth from originalgrade: O , 8 GPO/Sq. Ft. [ O ' Lot: Block: Subdivision: Depth lo pipe botlom from original grade: Gravel depth beneath pipe Township: Range: Section Fill added above.~r original grade: Gravel length: Ft 55 ' Ft. WELL: [] New [] Upgrad~ //-~ Gravel width: Number of lines: Distance between lines: 4' Ft. I ~ Ft. Classilication (Private. A.B.C): Total D~ ~ased To: Total absorp*n a,ea: Pipe material: r-,,~ ~ Ddller: ~ate Drdled: SlaVic Water Level: Installer: Oate installed: Yield: ~ ,' [ : Casing Heighl Above Ground: ~, ~_ ~,. TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. TO Sephc Absorphon Ldt Hold,rig Public/Puvat6 Manufaclurer: Capacity in gallons: From Tank Field Slalion Tank Sewer Lines ~ G~ ( CO O ~ Material: Number of Compartments: SurfaceI [ ¢1OO' LIFT STATION Water ~O/ + ~OO~ ~ Lot . Size in gallons: I Manufacturer: ~ ~ ./ Line ~0 +.,~' ~ ~ ~O ~ ¢u '~'--' Highwateralarmat J ~ Pump Make & d¢¢¢ Electrical Inspections performed by: GurlainDrain 4 ~O' .NCO' ~50 Remarks: BENCH MARK Location and Description:  Assumed Elevation: ~OO ~ ~, ~NGINEER'S SEAL Inspections performed by: Dates: 1st ~-~-93 ~,.~~,~,,)~,, , ~,,,,~ ~,,,.,~:. Department of Health end Huma¢ Cervices appr~val/ ~*',':~*".~,.,(~:.~ ¢""' ~*, Reviewed and approved by: Date: '~k~,~(ph~ta.,.,~:~¢ 72 013 {Rev 9/91) MOA 25 Permit No. ~vu950~9° Page ~' of ?-- Municipality of Anchorage DEPARTMENT OF HEALTH AN[:) 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 PIDNo.: 050 So 13~ .... io0 ~ 72-013 A (2/91) MOA 25 '"~ 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 WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930190 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:DOMBOVY JOHN K OWNER ADDRESS:P.O. BOX 772504 EAGLE RIVER AK 99577 DATE ISSUED: 6/29/93 EXPIRATION DATE: 6/29/94 PARCEL ID:05050138 LEGAL DESCRIPTION: GLACIER VIEW HEIGHTS #4 BLK 2 LT 8 LOT SIZE: 43565 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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: THIS IS A RENEWAL OF PERMIT NO 880240. REF ORIGINAL SITE PLAN AND SOILS LOG. DURING CONSTRUCTION DEPTH OF TEST HOLE MUST BE EXTENDED TO/A DEPTH OF 16~ FT. ISSUED BY: ~.JC3t~ ~L%4 '7-7-~ DATE: / / ? ? ABSORPTION SYSTEM DESIGN DETAILS--STANDARD TRI~NCH SCOPE OF PROJECT: The lot received a permit to construct: a septic system in 1988 based upon a design and soils test performed by us. Tile soils were visually rated at 140 sf/bedroom; a 4-bedroom trench design system submitted to DHHS which required an 12' deep trench, 8'of rock below the pipe, 35' long. A new owner wishes to build a three (3) bedroom house on the lot. A perc test at the existing soils test site yielded a soils rating of 0.8 gpd/sf. ABSORPTION A/~EA CALCULATIONS: Minimum Required: 3 Bedrooms x 150gpd/bedroom = 450 gpd capacity Soils rating, proposed addition, 0.8 gpd/sf Minimum sizing: 450 gpd % 0.8 gpd/sf = 562.5 sf absorption area Use 3'W x 47'L x 6' D = 562.5 sf minimum for trench Trench depth: Bottom = 10' Below grade, w/ 4' cover IMPACT ON ADJACENT LOTS: The proposed absorption system has no adverse impact upon any adjacent lots as shown on previously approved site plan. 0¥ T~NUH D~IGN DETAIL~ WASTEWATER ABSORPTION SYSTEM LOT 8 BLOCK 2 OLACIER VIEW HTS ADD #4 SUB PREPARED FOR: MR. SAM NEWBY 338-2045 ANCHORAGE, AK, 995 NOT TO SCALE DRAWN BY CAL CONSTRUCTINO ENGINEERS346-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 6-8-93 DRAWTNG # 95-S2-06-5 Municipalily ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: L~ ~ (~.(~,~V~c.~,.j/-~ ~¥ Township, Range, Section: 2 3 4 5 6 7 8 9 10 11 12 13- 14 15 16 17 18 19 2O COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT ------ O DEPTH? p E Depth Io Waler Aller monitoring? ~ ~¥ Date: ~° ~' ~ Reading Date Gross Net Depth to Net Time Time Water Drop ~ ,o~,,~ ~c>....- ~?~" 1 '/~ Z ~o~.,~ I~,.~ ~ V~" I'(~' T ~ ~o~ %"~'l~' ~'1~" PERCOLATION RATE ~ (mmutes/~nch) PERC HOLE DIAMETER TEST RUN BETWEEN 7 FT AND 4~ FT PERFORMED BY: ~-'"~*f~' ~¢~/¢~'"~ _~ )'¢"~2-¢'~ I C ~~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~' ''"~--~ 72-008 (Rev. 4/85} Tom Fink, Mayor unicipality of Anchorage Department of Health and Human Services . 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 January 9, 1989 Glacier View Investment/John Dombovy PO Box 772554 Eagle River, Alaska 99577 Subject: Lot 8 Block 2 Glacier View Heights Subdivision #4 Permit ~880240, P.I.D. ~050-051-38 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1988. Pe~rmits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the orginal as-built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. When applying for a new permit, the fees are: $90.00 for an on-site sewer permit; $50.00 for a well permit; $140.00 for a combined sewer and well permit. If there are any further questions, please call this office at 343-4744. Sincerely, Daniel J. Roth Acting Program Manager On-site Services Section DJR/ljw enc: Copy of Permit J. (,;lii:F:~ t .t: F:: Y { I'li:~ t ','. ]. a;di"~ i :'::iiflJ. ] .~.~::d ],.'.l:i. I'..["~ T..i'u~:.:, ['E)(::lL.t:i.i"t:,ill(;?ti'~'..!E~ {'C:H" C:H"~'""!i~;i Lc.) !~H:.)t',J(.:'l".~ ~'~H'"~cI ,,:~ ',..~ b'y' l:..h¢.:, I"h..u*~j.t:::j.l:~aJ:i.'Ly of ~:~l'~(:l'~(::>t"ag~;' (I"K:)~.~) ar'id :, ~ ,,..: ~: ~,'~..., Lc:~ ;':.~.:J:t ['"lC)f.~ ar~(::i ~kLa'L(...? ot ~.)~].a':dr:.l::i:'.,. i'e:,~C:lL..&Jr'c~n'v:.zrYL% f(::)?' 'Lh(~ ~(.~.)'t. back , : .j :;y%Lr.':m~ ,.::u~ l'l'~.~s o[' ::ti'vy ac:l.ji~xc::(~;nTL or' i'/(.:,a:&l"l::)y :; ~ ~ (,', ~: ' ~' ~:~'!. &'~l') d 'k ['l a ~:. '~i h J, ~ I::) ~ t" f'l} J. 'L :i, E~ ',/a ]. J. c] { C) 1" a ('fi a )i J. ia :}. ~,'~ ~uui~::~P~t:.ar'lcl !.'..['~aL I:.l-m) c.: a l::) a c:: :i. 'L ,y (:)~ 't..l'~(~):) 'L(:)'t..:::~]. ~'~wLc~::)m J.~ 4 ba~(:l['c:~(::)m% ar'id ~ ................ ............ , ....... .................... ...... U::h,.: ~ : T c:: -~, ',/IF:~,',~ I I'[VI:~:~:FI',/,:fCII" I's D 31¥ PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17 18 19 2O SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT ~,~ ,, DEPTH? Oeplh Io Water After Moniloring? t%~ *~''~ SITE PLAN i ' Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN (m~nutes/mchl PERC HOLE DJAMETER __ FT AND PERFORMED BY: ~"A'~'~Y ~Jl~'~ ~ ~1~ ' *t~'"~P-,~ t ~'~% ~- ? ~"~ ~ ~,,~ L~,~¥'~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE ANO MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE: SULLIVAN WATER WELLS P.O. 8OX 272, CHUGIAKr ALASKA 99567 · TELEPHONE688-2759 S'DiT~.C LEVF. L OF WATER DRAW DOWN FT. GALS. PER HR / ~' O KIND OF CASING: Ft, to _Ft. Ft. to ...... Ft.. From From - MUNIC/PALITYtoF AN Front .... l't, to D ....... ~C.d~ ..... evl, OF HEALTH ENVIRONMENTAL PRO1 ECl-i© From Ft. to __, ,~ ' From ....... FI:, lo Ii ~'~F C~.Z~ From From From From __ From .... From -- From From From From___ ,Ft. to ..... Ft .... From ....... Ft, to ...... Ft ........................ DRILLER'S NAME __./~_'. ~~ ............. MUNICIPALITY OF ANCHORAGE Development Services Department ,.- ry Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-501-38 1. GENERAL INFORMATION Expiration Date: 10 ` '�— Z©ZO Complete legal description GLACIER VIEW HEIGHTS #4 BLK 2 LT 8 Location (Site address) 22825 Eagle Glacier Loop Eagle River AK 99577 Current property owner(s) DIETRICH DALE & FOX RUTH Day phone 907.696.4739 Mailing address 22825 Eagle Glacier Loop Eagle River AK 99577 Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 7 1.2.EO Waiver Fee $ Date of Payment ' /F I Z02,0 Date of Payment Receipt Number 02� (0 Receipt Number COSA# 0SC,201392 Waiver# 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, based on procedures outlined in the Certificate of On -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 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Eklutna Engineering, LLC Phone 907.355.9820 Address 19162 Mountain Rd Chugiak AK 99567 Engineer's Printed Name Curtis Townsend, PE Date 7/7/2020 6. DSD SIGNATURE _X_ System #1 Approved for -3 bedrooms a System #2 Approved for Disapproved Conditional approval for bedrooms `�,�'��®F t4CgsA�� .• sHv� eeeoe�larUa T ••°.•. e FG',�jJ'. No. 11904 .a�r� ®�00PRo�ssioN� bedrooms, with the following stipulations: \�J` nLr AITTW !:r,�- 1AIATCO AW-) iso Original Certificate Date: 7 —2.CZ0 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Adviso Other Ago Legal Description: GLACIER VIEW HEIGHTS #4 BLK 2 LT 8 If more than 1 septic system on tot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 411984 Total depth 120.7 ft Cased to 120.7 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 31 in. Date of flow test for COSA 6/2312020 Static water level at beginning of test 49 ft. Comments B. TANK DATA Age of tank(s) 27 years Tank type/material septic Sfieel Measured operating fluid level in septic tank 50 Al Standpipes/foundation cleanout per record drawing Date of pumping Sept 10, 2019 D. ABSORPTION FIELD DATA Which system tested (date installed) 1993 ❑ ALL standpipes present per record drawing Total measured depth from grade 10.9 ft (max) Measured depth to pipe invert from grade 3.25 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 050-501-38-000 Structure served by this system Well production at time of test 6.2 gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L R Arsenic less than MRL (ND) Collected by Curtis Townsend f Date of Sample 612312020 C. LIFT STATION ❑ Required maintenance com Age of lift station y Lift station material Comment Adequacy test date &2312020 Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test 38 in Water added 466 gal New depth 50 in Elapsed time 1200 min Final fluid depth 35 in Absorption rate ' 450 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 0 Yes Community Sewer Manhole/Cleanout > 100' f7./Yes if No ft Q Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No ft Absorption Field on Lot > 100' R(l Yes if No ft Holding Tank > 100' P/1 Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' Q Yes if No ft 7 Yes if No ft if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft � Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No 6 ft Surface Water > 100' ® Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' F,71 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with�Q,�®� MOA COSH guidelines in effect on this date. pr COSA Checklist yellow sheet .;4 �••49 ` H Date za c tao. CE 1'1904 a > o�PR0FE5510�A -� so Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 201312 Subdivision: Glacier View Heights #4 Block 2 Lot 8 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 27 years old. Typical replacement costs range from $8,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. Mailing Address P ;O Box 196650 * Anchorage,`Alaska 99519 6650 *www mum org s Parcel I.D. # 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner -~:~¼,~ -~w,~o~l Mailing address Day phone Lending agency Mailing address Day phone Agent Add ress Day phone e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATI=R SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA ¢121 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 C~-,'.s"~t~<-~,',~; ~l~,e-.,~.~ Phone Address A~.cko.c,~q,_~ 2~!¢. -995 )G ~\~_ ~¢.¢,-, .~., Engineer's signature~//~¢//'~ ,~r..~ ~ Date DHHS SIGNATURE ¢'// Approved for .~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given tn 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lg f~'L. C_~l~c~ cv ~c~../ ~'~ Parcel I.D. A. Well Data Well type ¢~ ~d;C~E I! A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot II L~' Absorption field on lot 17-9~ Public sewer main +-/~.~ o' Sewer service line ~ ~o' g.p.m, g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout -)--Z.~o ' Petroleum tank +t ~-'-o ' WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~--o\ ~ \ _9.9 ~. Tank size ) ©0 o Cleanouts (Y/N) Higl~ water alarm (Y/N) Date of pumping Compartments Foundation cleanout (Y/N) "/ Bepression (Y/N) (A Alarm tested (Y/N) <¢"¢ <~%--~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot II (2 On adjacent lots Foundation To property line -~o' Absorption field ~" Water main/service line Su dace water/drainage 72-026 (3/93)' From CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manhole/Access (Y/N) ~ ."~um 0popop~ Level at le~ tested Meets MOA electrical codes (Y/N) ~-~-" SEPARATION DISTANCE FRO.~PLd~STATION TO: Well on lot ~ On adjacent lets Surface water D, ABSORPTION FIELD DATA Date installed ;:3-',~/~I \ ~ ~ 3 Soil rating (GPD/FF) Length 3~ Width ,~- ' Gravel thickness Total absorption area ~o?_4 ~ Cleanout present (Y/N) Date of adequacy test ru~J <J¥ ~l-ff~x. Results (pass/fail) Water level in absorption field before test N' (q Peroxide treatment (past 12 months) (Y/N) Y /~ ¢~ for -- After test If yes, give date System type q-~'~ [~N c t4 Total depth Depression over field (Y/N) ~ Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1%9' To building foundation On adjacent lots Su trace water Curtain drain '~FI (DO' On adjacent lots Property line To existing or abandoned system on lot ~J Cutbank -p~ oo' Water main/service line Driveway, parking/vehicle storage area I'~-' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guide/ines in effect on the date of this inspection. Signature HAA Fee $ ,J '~ p ~ r/'D Date of Payment ~j"-~//'/~ ~ ~ Receipt Number "~-~'~// ~FT~) ;i~ ~ ~"~~~ :::::;: .... ~ ::::~ '~:'~' ~ffi"*:'~° ' '(~i' Waiver Fee $ Date of Payment Receipt Number