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HomeMy WebLinkAboutALPINE WOODS BLK 2 LT 7A Ipin e Wood lock 2 Lot 7 015-234 -14 Municipality of Anchorage Page / of 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: ::~J~,~'~"~ PID Number: ~/~ ~ Name ~ -~ ~~~ Wastewater System: ~New ~ Upgrade ~~ ~~/ ~,/~ ~[~ ABSORPTION FIELD LEGAL DESCRIPTION ~o,,~,,~: ~. ~GPD/Sq. Ft Total Depth from original grade: Lot: ~ BIock:~ ~/Subdivisi°~:~ ~~ Depth to pipe bottom from origi~r~e: Ft. Gravel depth beneath pipe ~/ Ft. Township: J Range: Section Fill added above original grade~ Gravel length: Ft. Ft. Numbgr of lines: ~ Distance bel~een lines: WELL: D New ~ Upgrade Gravel widt,: .~ Ft. ~ I ~,. C,assification (Private. A B.C):~~. Total Depth: Ft Cased To: Ft. Total absorption ~DsQ Ft.. ~ Driller: Date Drilled: Stat,cWaterLevel:Ft. Installer: . ~'~'0 ~~ Date installe~/ Yield: ~ Pump Set at Casing Height Above Ground: ~,~ ~ ~t. TANK SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P. Capacity in gallons: To SepUc Absorp,ion L,fl Ho,ding Pub,lc/Private Manufacturer: ~~ / ~ Well ~ ~ ~ ~ ~ Material~~ Numberof~Compartments: Surface Water /~ /g~ ~ ~ ~ LIFT STATION .ot , ] Line /~ /~ ,~ ~ ~ Size in gallons: Manufacturer: ~OU,a~,io~ 15d~ /~.~t /-- ~ ~ "Pump on" level at: ~elat: High water alarm at: Curtain Drain ~/~ ~<~ _ ~ Pump Ma~Electrical lnspections performed by: Remarks: BENCH MARK Location and Descripb~: ] Assumed Elevation: /~, ENGINEER'S SEAL ~. '~;t~ :', , ,. S & S ENGINIERING t / ., I RspectioRs performed by'. ~~~17°34 E~le River L~ __R°~, ~.~lst, ~//~/~,~././1/~ ~ ~~~ ~:~' ~ ............ .................... L,~ Department of Hea Hum ervices apprqv ~2., ........ Reviewed and approved by: Date: ~ ~"" '~:'" "~' '~'?"~"'~' ' ~' I I ' 72-013 (Rev 9/91) MOA 25 Permit No. SW950084 Page 2 of 2 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: ALPINE WOODS, BLOCK 2, LOT 7 01,525414 PID No.: CO1 C02 102.4' NEW 1500 GAL S.T. /FINAL GRADE MT C04 N.T.S. 81.3' NO WATER FOUND · A B C C01 13.5 26.5 C02 18.5 20.5 C03 33.5 19.5 C04 57.5 60 MT 37.5 52.5 ~~ /NEW TRENCH L~$ BELOW BACK DOOR) ~ ~ 5 BDRM NEW 1500 G~L. SEPTIC T~K~ sc~ 1" = 40' EN C.~..N.I~E~'S SEAL 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:SW930084 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:DE VAS CONCELLOS HARRY S & OWNER ADDRESS:2720 LEGACY DRIVE ANCHORAGE, ALASKA 99516-2730 DATE ISSUED: 5/05/93 EXPIRATION DATE: 5/05/94 PARCEL ID:01523414 LEGAL DESCRIPTION: ALPINE WOODS BLK 2 LT 7 LOT SIZE: 40543 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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: 1. VERIFY CONTINUITY OF SOILS AT NORTH END OF TRENCH DURING CONSTRUCTION. ~--3' ~( ~/' DATE: RECEIVED BY: DATE: April 28, 1993 ROBERTSHAFER, P E ROGER SHAFER, P E CIVIL ENGINEERS (907) 694-2979 FAX 69,4-!211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, Alaska 99501 REFERENCE: Lot 7, Block 2, Alpine Woods Subdivision Request you issue a permit to install a septic system to serve the 5 bedroom house proposed for this property. Soil tests were performed on this property in 1987 and a previous permit issued for a 4 bedroom home. The soil test we performed on April 14, 1993 in the new area proposed for a septic system was essentially consistent with the previous soils reports. Ground water monitoring found no water within 18 ft. of the ground surface. Attached is a site plan/design. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have questions or require additional information for your review, please contact us. Sincerely, ROAD DESIGN SOl L TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ROGER J. SHAFER, P.E. 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 ~ll0o ~ r~ o L.~Z E--' LU u_ O 3At,tO HONId A3NA~o(~ ~-.. / / / / 0 / / / / / / / / NYqd 3liS ,0~ = ,,L Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 625 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O SLOPE SITE PLAN WAS GROUND WATER ~ ENCOUNTERED? ID IF YES, AT WHAT ~) DEPTH? P Depth to Water Alter_':'~, _'~-~1'~ ,~ Monitor ng? -'~7 Dale: _ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE I''zp'''~ (minutes/inchl PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND 7 COMMENTS PERFORMED BY' S & S ENGINEERING ~ · 17034 Eagle River Loop Road No. 204 ACCORDANCE WlTt-~l~r*~, ~I[Da~I~'GUIDELINES IN EFFECT ON THIS DATE. GERTIFY THAT THIS TEST WAS PERFORMED IN DATE: ~ --Z-~--~% 72-008 (Rev. 4/85) ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 7, Block 2, Alpine Woods Subdivision GENERAL: 1. The scope of this project includes the installation of a 1500 gallon septic tank and a deep absorption trench to serve the five bedroom residence proposed for the referenced property. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. page 2 Lot lB, Block 1, Stony Brook A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DR~INFIELD INSTALLATION: 1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed- up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. page 3 Lot lB, Block 1, Stony Brook INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. o The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ASS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. page 4 Lot lB, Block 1, Stony Brook e Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. ip tity P.O. BOX196650 '/N"~i"f~O & , ANCHORAGE, ALASKA 99519-6650 O~: ,'" : ~ ", (907) 343-4200 Anchorage Tom Fink, January 8, 1988 Martha Sundberg PO Box 91443 Anchorage, Alaska 99509 Subject: Lot 7 Block 2 Alpine Woods Subdivision Permit #870310, Tax #015-234-14 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1987. Permits 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.original Cs-built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. Effective January 1, 1988, a new fee schedule is in effect. When re-applying for a new permit, the new 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. S~cerely, Robert W. Robinson Program Manager On-site Services RWR/ljw enc: Copy of Permit TESTING ENG]NEEFiS TONY D. OARTER, P.E.~0461 HAMPTONORIVE ANCHORAGE~ ALASKA 99516 907-}4§-! ! 70 October 24, 1987 Warcl Constl'uction Al-f: Robin War~l P.O. ~ox 91443 Anchorage, Alaska 99509 Ref: Lot ? Block 2 Alpine Woods §ear Robin, Per your request, ! performed a soils analysis and percolation test on the above f'eferenced property. The percolation test resulted in classifying the soils as a well graded sand. Therefore, these soils are suitable for installation of a four bedroom residence. As required by municipal ordanince an alternate site was tested and identified. This lot is acceptable for obtaining an on-site sewer permit from the Municipality of Anchorage. The following is a listing of my time and charge.';, to accomplish the same. Oate Activity Billing O/14/87 Soils log/Percolation $200.00 0/21/07 Water monitor included 0/21/87 Site plan included Total Billed = $ 200.00 Total Received = ~ 0.00 Balanced Owed = $ 200.00 Sincerely, Tony l~arter, ?.E. PERFORMED FOR: LEGAL DESCRIPTION: ~--~'~ 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUI~IAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST I--~'/.,?_."' C, '"-,;-~' DATE PERFORMED~~ Township Range . ,Section:  SLOPE SITE PLAN 1 WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? ,_~,LO pO E Depth to Water Alter Monitoring? .JVL~ Date: ID-~I Gross Net Depth to Net Reading Date Time Time Water Drop I 2 ~: ~ , o ~ ¢ :08 4 ,rl,~ PERCOLATION RATE ~ (m,nutes/,nch) PERC HOLE DIAMETER TEST RUN BETWEEN 4~'~ FT AND ~,~ 0_. FT PERFORMED BY: 4, ~ I 4. ~~--J~ ACCORDANCE WItH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: I 0 --~"~- I~ ? 72-008 (Rev. 4/85) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O Municipality of Anchorage DEPARTMENT OF HEALTH & HU~IAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST COMMENTS -'r'/~ Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? ~ p E SITE PLAN Depth to Water Alter Moniloring? :.AQ ~ Date: Gross Net Depth to Net Reading Date Time Time Water Drop I /o-/,/ ~: qo 4 "~ ~:~ 5'"~ ' ' I ~ / ~:~z ~o ~ '~ I~ / PERCOLATION RATE ~ [mmutes/~nch) PERC HOLE DIAMETER ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: /0 -I~'' ~? 7~ SF ~TAc. /I \\ \ 119 5F ~ / o~ Ac 8~Ac. ~ I I Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-234-14 1, GENERAL INFORMATION Complete legal description Expiration Date: ALPINE WOODS, BLOCK 2, LOT 7 Location (site address) 6501 DOWNEY FINCH DRIVE, ANCHORAGE, AK 99516 Current Property owner(s) HARRY & GAIL DE VAS CONCELLO$ Day phone Mailing address 6501 DOWNEY FINCH DRIVE, ANCHORAGE, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address = Unless otherwise requested, COSA will be held by DSD for pickup. NUMBER ,OF BEDROOMS: TYPE OF WATER sUPPLY: IndividUal Well Individual Water Storage Community Class A__ Well Public Water System 5 TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [~ [] Individual Holding Tank E~ [] Community On-site E~ [] Public Sewer E~] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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. (Certificates may be reissued for a pedod of up to one year with valid water samples.) Certificates are valid for one year for properties served by ClaSS A or B wells 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 As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 01/28/2011 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. The 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 dudng the year'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 evaluator 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. DSD SIGNATURE ~/ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory By: (Rev. 11/05) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Repod Other I/~::-~-~,~'~~ Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ALPINE WOODS, BLOC~ 2~ LOT ? Parcel ID: 015-234-14 A. WELL DATA Well type CommunJ~ If A,B, or C A provide .PWSID # Z 1 35 98 Well Log (Y/N) Date completed Sanitary seal (Y/N) Total depth ft. Cased to ft. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Wires properly protected (Y/N) Casing height (above ground) in. AT INSPECTION Coliform colonies/100mL Nitrate mg/L Arsenic: __mg/I Date of sample: Collected by: B. SEPTIc/HOLDING TANK DATA Tank Type/Material septic/Steel Date installed 9/11_/1993 Tank size 1500 gal. Number of ComPartments_2 Cleanouts (Y/N) _~ Foundation cleanout (Y/N) ¥_~* Depression over tank (Y/N) High water alarm (Y/N) N Date of pumping 1/27/20~1 Pumper Isaac's N C. ABSORPTION FIELD DATA Date installed 9/11/1993 Soil rating (g.p.d./ff~ or ft2/bdrm) 0.8 System type Tzeach Length 60 ff. Width --3 ff. Gravel below pipe 8__ff. Total depth 12.33 ft. (,-casual 1/28/11) Eft. absorption area 960 ~ Monitoring tube Y Date of adequacy test 1/25/2011 Fluid depth in absorption field before test 0 in. Elapsed Time: 0 min. Final fluid depth Depression over field N__ Results (Pass/Fail) Pass For 5__ bedrooms Water added 750 gal. New depth 0 0 in. Absorption rate >= 750+ g.p,d. in. Any rejuvenation treatment (Past 12 mo.) N(Y/N & type) ~!f yes, give date __ D. LIFT STATION Date installed "Pump on" level at __in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off' level at ~ Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line Animal containment areas in. Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas Building foundation $'+ Water main 10'+ Wells on adjacent lots 200'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Property line 5% Water service line 10'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field 5'+ Surface water 100'+ Date of Payment Receipt Number (Rev, 11/05) Water Service line 10'+ Surface water 100'+ Curtain drain SO'+ (Nene Known) Driveway, parking/vehicle storage. 10'+ F. COMMENTS *FCO located inside crawl space G. ENGINEER'S CERTIFICATION I ce rtify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH ]VI. DU-FFOS Date 01/28/20~1 COSA Fee $490.00 Waiver Fee $ ~1~ (~/~1 Date of Payment I L-((~L'~ -'~ Receipt Number Wells on adjacent lots 200'+ Property line 10'+ Building foundation 10'+ Water main 10'+ // ? ? / / / ./° Ill MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HU MAN 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 '1, GENERAL INFORMATION Complete legal description bot.,,.7,:; N~o ok' 2 ~ :"~Alp/,.nP.: Woo ~ m Location (site address or directions) Property ow ner Mailing address Lending agency An~orag~. AK H~ry D6v~eonc~os · .,,.. Day phone 345-7149 6501 Downey Finch D~v~ Anehorag~, AK 99516 Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 5 '~ TYPE OF WATER SUPPLY: NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community On,site NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ~.-'. ~' , Public sewer 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 Name of Firm Address Engineer's signature BY' 'ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this H6alth 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 Anchoragefiles and from_ my investigation andinspection, the on-sitewater -~ ~. supply and/or wastewater dispOsal sYstem is in compliance with all Municipal and State codes, i' ;:, ordinances, and regula'tions in"eff~t on the date of this inspection. s & S' £NGIN£~ Phone '" ;-'-' ~' ' __ Date "~'"A~.~,~.q~."~~'' ,., ~.',; . DHHS SIGNATURE '~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with. the following stipulations: Additional Comments ":rl~"~'MuniciPality of.AnCh~orage Department of Health and Human Services (DHHS) issues Health Authority APproval Certific~.tes 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 .:~i~i~i~i~i~i~and the r lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not :}i~!~i!~ii.!~6nd'Uct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not %~/~:X.:i;~,,.-.'. ,. - .... ;~~..respons~ble for errors or omissions ,n the professional engineer's work. 72-025 [Rev. 1/91) Back MOA 1~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: L-o7 '7 A. Well Data Log present (Y/N) Total depth Sanitary seal (Y/N) /~Pe ~__ A/._~//L~- ~3:~c~.~ Parcel I.D. Date of test I~B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing h~ Wires properly ~ FROM WELLLOG ~ AT INSPECTION Static water level ~ ~l~Well flow SEPARATION DISTANCES FROM WELL TO: Septic/betdiag tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank .~ Nitrate Other bacteria Collected by: B. SEPTIC/I'IOL-DING TANK DATA Date installed ~/ Cleanout~N) .~_~.~ High water alarm (Y~") Tank size Foundation cleanout(~) Date of pumping ~,~ ~.~5 Compartments C/~ _~ Depression (Y~) Alarm tested (Y/N) j~/~/.'-J C.O~3T-'/~."I~(-M,J' Pumper J~'J///~ SEPARATION DISTANCES FROM SEPTIC/~TANK TO: Well(s) on lot_~O/'J~-/~'.'f.~,~"-On adjacent lots ~__.~0'¥- T° c~.~l~'~u¢c~/~ Foundation /,.~, _,.4-' / To property line /0 ~ Absorption field /~_.)/'Y--- Water main/service line Sudace water/drainage 72-~26 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer Manhole/Access (Y/N) vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE ~TION TO: Well on~--'''/ On adjacent lots D. ABSORPTION FIELD DATA "P~el at Length ~-c~O~ Width ~.~' Tota a so, tlon area Date of adequacy test /~]g/---/ ~g"/ Results (pass/fail) Water level in absorption field before test /L,//~F Peroxide tmatrnent (past 12 months) (Y~ /t-JO Soil rating (GPD/Ft2) (~' Gravel thickness Cleanout presen~_]~l)"7/d~ Sudace water After test /'" / A If yes. give date System type Total depth / Depression over field (Y~_.)~ .,4Jo for ,~'//-~ Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /t,]O/,JE /O~~On adjacent lots To building foundation /© On adjacent lots ~ Sudace water Property line To existing or abandoned system on lot Cutbank ~O~E ¢~Watermai~se~ice line D~eway, ~in~vehicle storage area /O r Curtain drain E. ENGINEER'S CERTIFICATION I cergfy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on thecta~of-this inspecb'on. 7!. · !:~ ~i::. :::' ~:":' .~::~.~ ::~i~i:~:~:: '::~: Signature Name;'7~;4~g;;~;'~lR°ad No. 204 ;7'e HAA Fee $ ~<S:~, ~ Waiver Fee $ Date of Payment ~ ~f Y-- } [ ~'~' ~ ~'"'~, Date of Payment Receipt Number ~-~--~' ~} [ ~ C~,~._ ~/~,,~'~ Number _ _ '-~ _ ~/ Receipt 72-026 (3/93)* Back