HomeMy WebLinkAboutANGELS PLACE LT 1A1
Jan_09.2023 05:41 PM Anchorage Well & Pump Service Inc 9072430742
#5571 P 1/ 1
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Lag
Well Drilling Permit Number: Date of Issue:
Parcel Identification plumber: 017_11268
Legal Description Block Lot Property Owner Name & Address:
SALDIVAR RANDY L & HOLLY
ANGELS PLACE 1AI 15210 EVERGREEN RIDGE STREET
ANCHORAGE AK 99516
Pump Installation Date: 01 _ 09 _ 2023
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name: FPS
Pump Model: 7FR07P4-3W230
IPump Size: . %rJ _ _ hp
175 feet
Pitless Adapter Burial Depth: 14 feet
Pitless Adapter Manufacturer's Name: MARTI NSON
I Pitless Adapter Installer:
Well Disinfected Upon Completion? Yes A No
Method of Disinfection: PALLETS
Comments:
Pump Installer Name: _
ANCHORAGE WELL & PUMP SERVICE
Company: 7640 KING STREET
ANCHORAGE, AK 99518
Mailing Address:........-.__-.- 907-243-0740
IlCity: State.• Zip:
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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
Name:
I,-~PrY-4~ I,V~UCA~I~/(..~ Wastewater System: ~New ~ Upgrade
Address:
~/~ ~ ~l~ ABSORPTION FIELD
o. e roo s:
Phone:~,[~ U DeepTrench ~ Shallow Trench ~Bed ~Mound ~Other
Total Depth from original grade:
LEGAL DESCRIPTION Soil Rating: -~ GPD/Sq. Ft. O
Lot: [ ~ ~ Block: ~~Subdivisi°n:~ Depth to pipe bottom from original~,~grade: Ft. Gravel depth beneath pipe ~ Ft.
Township: ~ Range: ~ Section: Fill added above original grade: Gravel length:
I
I
WELL: ~New ~ Upgrade Gravel width: ~ Ft, Number of~lines: Distance between~ lines:Ft.
C~sification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Yield: ~e~ GPM II ~mp Set at:~ Ft.II Casing Height Above~ Ground:Ft. TAN K
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons:
From Tank Fie,d Station Tank Sewer Lines ' ~ ~ [, ~
I Material'
. Number ~f Compartments:
Surface
Water ~ ., -- LIFT STATION
Lot I / Size in gallons: I Manufacturer:
Foundation ~ ~ I ~/ ~[~ , , _ "Pump on" leve~ "Pump off" level at: High water alarm at:
CurtainDrain N~ ..... Pump Make & Model ~ Electri~ions performed by:
Remarks: BENCH MARK
I Assumed Elevati;;;,_,L~O Ft.
Inspections performed by: ~o~ ..~ ,::
Department of Health~uma~¢rvices approva~ ........ "' ~'
Reviewed and approved by . Date:
72-013 (Rev 9/91) MOA 25
Permit No. 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: Prnod~[~ P(~-: (.~o'f'- 'lPrl PI_D No.: C'l~r' II~-&~
:i EASEMENT
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72-013 A (1/93)'
(~4-22-1994 08:25 9975638453 PARKNAV ATRIUI'I BLDO
,, ,.. ...... .
' ~TATE OF A~8~
, DEPARTM~T OF NAYU~L RE~OURC~
, DIVISION OF WAT~
~ ,~ WAT~ W~k RECORD
lOT BLOCK MOTION Gl'Il e~TION TOWNIHIP RANOE MI~JDIMI
~~ ~ : ON DE
~ I II
LOCATIONIIK~CH~ WELL O~ER~ r,
, .. I '~ ~ ' V D~TE OF COMFL~iON
DEPTH6 M~SURED FROM:~Melng top ~grou~ lu~acl W~L DEPTH:
IOR~OLI DATAt , D~th Oep~ of ~l~~tt~~
Mater~il ~pi ~nd C~ From To
/ M~HOD OF DRILUN~ ,~ elf ro~ry ~ oeble ~ol
~ ~ USE DP W~L~ ~ dominic ~ I,l~811on, ~ monitor
~' / WELL INTAKE OPTING TYPE:' 0 open end
/~ /' SCREEN. TYPE: Diem: _In,
G~VEL PACK TYPE:, _.
QAOUT ~Pl= Volume:
..... ~' ' PUMPING LWEL AND YIELD:
Municipality of ~nchorage
~MP INTAKE DEKH: ~ ft Horse~er:
WELL DISINFE~ED UPON COMPL~ION? ~ YES ~ N0
II I II II . I I ..
CONTR>OR INFORMATION: REMARKS:
, ,-~ ~ , ,_..',~ ' ,
F- , -- ,, , PLEASE MAIL WHITE COPY OF LO
PO BOX 77211 $ ,",
EAGLE RIVER AK 99E77.2118
MOUNTAIN ENGINEERING
3868 Shannon Circle
Anchorage, Alaska 99508
(907) 562-1500
AS-BUILT NOTES
Project Scope:
On-Site Septic System Installation Notes & Design Revision
Legal Description: Angels Place, Lot lA-1
Date of Report: April 30, 1994
NOTES
During installation inspection of the septic system on the above referenced lot, we found
soils that appeared to be less permeable than those encountered in the earlier test holes.
For confirmation, we performed percolation testing at two additional locations on the
bottom of the bed. The attached sheet, dated 4/27/94 presents the results for Percolation
Hole #3 and #4. The percolation rate in both holes was 33 min/inch, resulting in an
increased bed size. The application rate became .3 GPD/SF. For a four bedroom home,
the required area thus became 600/.3 = 2,000 SF.
In expanding the bed, we were limited to the north by the property line, and to the south,
by test hole #1. We also did not want to make the bed significantly wider (east or west).
We chose to make the bed 2 FT wider, and extend the bed to the south in order to obtain
the required area. We reasoned that the test hole was installed last year, and we feel that
any significant settlement that might occur had already taken place. Further, during
installation and test-pumping of the well, the contractor discharged the well water into
and around the monitoring tube. The addition of this water would also accelerate
settlement.
Because of the weight restriction currently in place for the roads on the hillside, the
contractor has requested that he be allowed to place the remainder of the 3 FT cover in
the spring. The system currently has approximately 1 FT of cover over the gravel, and is
in no danger of surfacing or freezing. The access road north of the property is also
presently unusable due to mud. If it meets the departments approval, funds will be
escrowed for the performance of this work.
Please contact Mark Pearson at 562-1500 with any questions.
MARK W PEARSON ~{;/~c/.:t
~,~,o. ~ CE - 7760 ,~ .;:'/~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930472
DESIGN ENGINEER:MOUNTAIN ENGINEERING
OWNER NAME:MULLINGS G LAKE & HELEN J
OWNER ADDRESS:2204 WEST NORTHERN LIGHTS BLVD.
ANCHORAGE, ALASKA 99517-3344
DATE ISSUED:il/08/93
EXPIRATION DATE:il/08/94
PARCEL ID:01711268
LEGAL DESCRIPTION: ANGELS PLACE LT iAi
LOT SIZE: 41976 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD / 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 (iSAAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 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. TWO FEET OF SAND WILL BE PLACED PRIOR TO GRAVEL
INSTALLATION.
2. INSULATION OVER SYSTEM WILL BE REQUIRED.
3. OBSERVE 3:1 SLOPE ON FINAL GRADE OVER MOUND.
PAGE 2 OF 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
4. IF LIFT ST.~A~I~~REQUIRED, DESIGN MUST BE AMENDED.
RECEIVED BY:~~_ DATE:
ISSUED BY: ~ ~-~ DATE:
RECEIVED
NOV 2 1993
Munic~pahty ol Anchorage
Dept. Health & Human Services
MOUNTAIN ENGINEERING
3868 Shannon Circle
Anchorage, Alaska 99508
(907/) 562-1500
DESIGN CRITERIA AND NOTES
Project Scope: On-Site Septic System & Well Design
Legal Description: Angels Place, Lot IA-1
Date of Report: October 29, 1993
DESIGN CRITERIA
This permit request is for a new septic system and well on the above referenced lot. The
proposed home is a four (4) bedroom single family home.
Two test holes were excavated at locations indicated on the attached site plan. Percolation
rates were 7.7 mb/inch in test hole #1, and 11 mb/inch in test hole #2. Water was not
encountered during the testing in test hole #1, and a seep was encountered at 9 FT in test
hole #2. At the end of the ground water monitoring period, the water level was at 8 FT in
test hole #1, and 7 FT in test hole #2. Further monitoring on October 28 revealed
groundwater at 4.5 FT in test hole #1, and 4 FT in test hole #2. The system will therefor, e,
be a mound to ensure groundwater separation. 3~ 9,-t ~ -¢t'l-~ ~
Based on four bedrooms, the daily design flow is 4 X 150, or 600 gallons/day. The
application rate (for a bed) at test hole #1 will be .5 Gal/Day/SF. The required area is thus
600/.5, or 1,200 SF. With a 25 FT wide mound, the length required would be 48 FT,
rounded to 50 FT.
The topography on the lot in the area of the proposed septic system slopes at
approximately 5% to the west.
EASEMENT
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MOUNTAIN ENGINEERING
3868 Shannon Circle
Anchorage, Alaska 99508
(907) $62-1500
DESIGN CRITERIA AND NOTES
Project Scope:
Legal Description:
Date of Report:
On-Site Septic System & Well Design
Angels Place, Lot lA-1
September 29, 1993
DESIGN CRITERIA
This permit request is for a new septic system and well on the above referenced lot. The
proposed home is a four (4) bedroom single family home.
Two test holes were excavated at locations indicated on the attached site plan. Percolation
rates were 7.7 min/inch in test hole #1, and 11 min/inch in test hole #2. Water was not
encountered during the testing in test hole #1, and a seep was encotmtered at 9 FT in test
hole #2. At the end of the ground water monitoring period, the water level was at 8 FT in
test hole #1, and 7 FT in test hole #2.
Based on four bedrooms, the daily design flow is 4 X 150, or 600 gallons/day. The
application rate (for a bed) at test hole #1 will be .5 Gal/Day/SF. The required area is
thus 600/.5, or 1,200 SF. With a 25 FT wide bed, the length required would be 48 FT,
rounded to 50 FT.
The topography on the lot in the area of the proposed septic system slopes at
approximately 5% to the west.
LEGAL DESCR,Pt,ON:
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 & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Waler Alter ,O/Date:
Monitorino? "~
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~f~i :~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN~ETWEEN ~-- FTAND (¢ .T
COMMENTS
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: ~ (~i~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: ~[N'(~J...~ ¢('~¢'~/ ~)1~ {r~-I
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
.. ~ter Alter "~,1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
Township, Range, Section:
SLOPE
S
L
o
P
E
Dale:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE [ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~ FT AND /'3/" FT
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
AGt :86
Munid'ali of Anchorage
On-Site Water and Wastewater Program "r
(907)'343-7904 SAFETY
Certificate of On-Site Systems Approval;
Parcel I.D. 017-112-68 Expiration Date: 10�r!
1. GENERAL; INFORMATION:
Complete legal description Angels Place; Lot 1A1
Location (site address) 15210 Evergreen Ridge Street *Anchorage, AK 99516
Current. Property owner(s) Helen Mullings Day phone 345-8685
Mailing address 15210 Evergreen Ridge Street*Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4.. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
:.:_.individual Well ® Individual
Individual-Water Storage ❑ Holding Tank
:Community Class' Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550 • DO Waiver Fee $
Date of Payment ` 3 j a Date of -Payment
Receipt Number �`YO`-r-1 Receipt Number
COSA# _. sCi��.�a ._ _ ..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.
Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date:
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the system/s on the date/s of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit of the person/party that retained GEG to
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
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6. DSD SIGNATURE
System #1 Approved for bedrooms ``,�ob
O �
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
_ bedrooms, with the follg st1��l�aio�'A(ER
�P0nG?
ifjJ ENT
Original Certificate Date:
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
Septic System Advisory
Well Flow Advisory
COSA blue sheet 10-10-12.doc
Nitrate Advisory
Arsenic Advisory
Other �rcL
Legal Description: Angels Place; Lot 1A1
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1/6194
Total depth 206 ft
Cased to 105 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 6/15/19
Static water level at beginning of test 47.2 ft.
Comments
B. TANK DATA
Age of tank(s) 25 years
Tank type/material sept"""el
Measured operating fluid level in septic tank
51"
Al Standpipes/foundation cleanout per record drawing
Date of pumping �t / 1II f.3
D. ABSORPTION FIELD DATA
Parcel ID: 017-112-68
Structure served by this system
Well production at time of test 2.7+ qpm
Water storage tank volume n/a gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate mg/L $0 Nitrate less than MRL (ND)
Arsenic ug/L (Arsenic less than MRL (ND)
Collected by GEG, LTD.
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comment
Which system tested (date installed) .1994
Adequacy test date 6/15/19
❑ ALL standpipes present per record drawing
Results QPass For 4 bedrooms
Total measured depth from grade *5.1 ft (max)
Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 3.58 ft (min)
Water added 659 gal
❑ N/A - pressurized field
1
New depth in
❑ Monitor tubes go to bottom of effective. If not, state
Elapsed time 15 min
depth into effective •
❑ Code -required soil cover over field
Final fluid depth 0 in
[:1 System presoaked
Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) no
date of test)
Gallons introduced n/a gallons
If yes, enter date '
Comments/Deficiencies: @MTS
COSA Checklist yellow sheet
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'
❑ Yes
if No *5+
Community Sewer Manhole/Cleanout > 100'
M Yes
if No
ft
171 Yes
if No ft
Neighboring Tank > 100' Yes
if No
ft
Private Sewer/Septic Line > 25' Yes
if No ft
Absorption Field on Lot > 100' Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
**
ft
Animal Containment > 50' 0✓ Yes
if No ft
❑� Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Q Yes
if No
ft
El Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No *5+
ft
Surface Water > 100'
❑✓ Yes if No ft
Property Line > 5'
Q Yes
if No
ft
Wells on Adjacent Lots:
Q Yes
Absorption Field > 5'
Q Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
Q Yes
if No
ft
Community Wells > 200'✓❑
Yes if No ft
Water Service Line > 10'
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'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q Yes
if No
ft
Private Wells > 100' Q 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
*Met code at time of installation
**With caveat - septic system on Fairmount Sub. Lot 1 is not documented. Confirmed 100'+
separation to closest septic pipe found. Possibility for an encroachment exists.
G. ENGINEER'S CERTIFICATION
OF A
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with Com: g
MOA COSA guidelines in effect on this date. : , , • „ , , , , , , , , , , , , ; , , , 00
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Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC191284
Subdivision: Angles Place Lot 1A-1
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 25 years old. Typical replacement costs range from $6,000 to $9,000.
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.
HEX
)9517
)hOne
IMBER'OF
TYPE OF WATER SUPPLY:
Individual well
Cc
~E OF WASTEWATER
NOTE:
~Re~:11/91) Front ' MoA'#2~ :' 4: '?:,:
STATEMENT= OF INSPECTION BY. ENGINEER
certified by mY~seal affixe(~:~ereto 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 d~'posal sYstemis safe, functional and adequate for the number of bedrooms.
and type of structUre indicated herein. I further verify that based on the information obtained fr~'m
the Municipality of Anchorage files and..f~6m'! my: inveStigation ,and.inspection; the on-sitewater'~,~
supply and/or wastewatei~ d'isp6Sal'~(e'~"i~";i~i C6mpli~n~e,Wiih all MUrficipal and State CodeS,'"
ordinances, and reguiatior~s in eff~(~i.~'~' t6~i'~ate~f'thi'§ in~peciion~ '
,~'" h'I ? .':. .i.ii "F r., '~ ,':,
Enq ~ nee r inq ~: 7
i neer's s ig natu re'-
DHHS' SIGNATURE
P
'Additional'Comments
By:
::!~The MuniciPalitY of Anchorage Dep~rtment°f Health'and Humanse~i~iDRHs)issues Health!AathoritY
' :~ i ApPrOval Certificates based only upon the rePresentati°nS:given~in paragraph:5 above by an independent
· gistered in the state of Alaska. The:DHHS does thisas a cOurtesy to purchasers °f h°mes
~and their lending institutions in order to safisfYcertainfederaiandstate requirements; Employees of DHHS donot
inspections or .analYze data~ before~i:a ~ertific~t~!is;~issued, The MUnicipality of Anchorage is
or omissions:inthe profeSSional engineet'~work. ~ : · ~ ;ii
(Rev. l~91) Back MOA~I
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ~v-~
Log present (Y/N)
Total depth '?.,4~ ~
Sanitary seal (Y/N)
Parcel I.D. Ol
t"
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed I{/¢'lcJq' Driller Pc[~(~_~
Cased to I D~' Casing height ~- F~T
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
t..~, ~' g.p.m. ~,0
'?..O (¢, I
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot [ ?...%L /
Absorption field on lot j ,~ I
Public sewer main lk~eyY-~
Sewer service line
MUNICIPALITY OF ANCHOI<AGI:
ENVIRONMENTAL SERVICES DIVISION
g'.[~,.~'. -, 2 1994
RECEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: L+I~:>I cl ~r~
B. SEPTIC/HOLDING TANK DATA
Date installed
Nitrate
Collected by:
Tank size [i'Z'~-O
Other bacteria
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Foundation cleanout (Y/N)
Depression (Y/N) {~
Alarm tested (Y/N) N. (~-
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots '~' Z.o~D I
Absorption field [ ~
Well(s) on lot ~ '7--H' ~
To property line ~51
Surface water/drainage
72-026 (3/93) Front
Foundation I Ur /
Water main/service line N. cmy-~
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed ~ OY'.~- ~,, Manufacturer
Size in gallons ump~o" I Manhole/Access (Y/N)
evel at
Vent (Y/N): "P "Pump off" Level at
High water alarm level '~ Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT S
Well on lot On adjacent Iots'~ Surface water
D. ABSORPTION FIELD DATA
Date installed [.{-ICo~ [ c1L.{. Soil rating (GPD/Ft2) · ~
Length '~'~- / Width 7_.~ /
Gravel thickness
Total absorption area ~.07..~' F-r' 7._ Cleanout present (Y/N) "1'
Date of adequacy test I~,,,J 1~,{>_~1 Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N) ~ ~
System type
Total depth
3'-t4~ ~ s~,v~.~l
Depression over field (Y/N)
for Bedrooms
Affertest
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot [ ~-
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~' 2.-oo ~ Property line
To existing or abandoned system on lot
Cutbank [",[ ~ Water main/service line
Driveway, parking/vehicle storage area ~ ~ /
(L~/
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effeot-on~the'dat,e of this inspection.
~:'~' , ,', ;' , '~-':~,
Signature ~
Engineer's Name
Date %'-It l~ ~1-
HAA Fee $~>,~0 ~
/
Date of Payment ~--'~-c~
Receipt Number c~ ~-~>~'~
72-026 (3/93)* Back
~:;~ fi~...~ CE - 7/60
Waiver Fee $
Date of Payment
Receipt Number
zTL
CT&E Ref.#
Client Sample ID
Matrix
Client Name
Ordered By
Project Name
Project#
PWSID
Commercial Testing & Engineering Co.
Environmental Laboratory Services
LABORATORY ANALYSIS REPORT
94.1841-1
1A-A ANGELS PLACE
WATER
MOUNTAIN ENGINEERING
MARK PEARSON
UA
WORK Order 77781
Printed Date 04/28/94 ~ 16:59 hrs.
CollectedDate 04/26/94 ~ 12:25 hrs.
Received Date 04/26/94 ~ 13:00 hrs.
Technical Director
STEPHEN C. EDE
Released By:
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: B.E.
QC
Parameter Results Qual
Units Method
Allowable Ext. Anal
Limits Date Date Init
Nitrate-N
0.10 U mg/L EPA 353.2/300.0
10
04/27/94 CMR
* See Special Instructions Above
** See Sample Remarks Ab o v e
U = Undetected, Reported value is the practical quantification limit.
D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
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