Loading...
HomeMy WebLinkAboutATELIER BLK 2 LT 7 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: 'E~'/ qL/C).~5"7 PIDNumber: Name: ~o p~_, ~ [~t~ Wastewater System: D New ~ Upgrade Address: ~ AT~L~ ~- ABSORPTION FIELD Phone: I N°' of Bedrooms:  Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from original grade: LEGAL DESCRIPTION so~,~ti.~: .~ ~/s~.~. ~-/~ Lot: 7~ B~k: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe ~T~I~ ~ ~ ~ ~ Ft. ~ Ft. I Section: Township: Range: Fill added above original grade: Gravel length: WELL: ~ New ~ Upgrade Grave~ width: Number of lines: Distance between lines: ~( Ft. I ~ Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: ~ Pump Set at: I Casing Height Above Ground: ¢ ' TANK JO GPMI ~~ Ft,I ~ Ft, SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank SewerLines ~ . ~[ J Well )[ ~ ~ ~ ~ __ ~ __ Material: 5 ~ Number of Co~rtments: Surface Water ~ I1~+ LIFT STATION Lot Size in gallons: ~ Manufacturer: Line ~ "Pump on' level at: "Pump off" level at: j High water alarm at: Foundation ~ ~ O I Curtain ~ Pump Make & Model ~ Electrical Inspections performed by: Drain ~0 ~ ~ I Remarks: BENCH MARK ~~/ ~ ~~ ~~ 1 ~ FI, Inspections performed by: ~; Dates: 1st '¢,/, M Department of Health and/Hum vices approval 72-013 (Rev. 9/91) MOA 25 TOBBEN SPURKLAND P.E. LOT 7 BLOCK 2 ATELIER 203 W 15TH. AVENUE ANCH. AK. 99501 SEC. 6 TI2N R2W DATE: NOV. 2, 1994 (907") 279-3916 A. WILLIAM SAUPE SHEET: Z/Z GRID: 2142 BENCH MA£K TOP FOUNDA FION ASSUktED ELEV. lO0. O0 Fl'. Standard Trench: 65 F! ?oral Lengfh I0 F! Tofol Depfh 6 Ff. Effective Rock Depth Mira fi ~ 40 6 f~ of Septic Rock Cleonoufs NO SCALE TOBBEN SPURKLAND P.E. 203 Wl5th Ave Ak 99501 LOT 7 BLOCK 2 ATELIER SEC, 6 TI2N R2W A. WILLIAM SAUPE S/D SEPTIC S ST M AS .ILT DATE: NOV. Z I994 SHEET: GRID: 2! 42 PAGE 1 OF 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:SW940357 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:SAUPE A WILLIAM & OWNER ADDRESS:9300 ATELIER DR ANCHORAGE, ALASKA 99507 DATE ISSUED: 9/22/94 EXPIRATION DATE: 9/22/95 PARCEL ID:04103129 LEGAL DESCRIPTION: ATELIER BLK 2 LT 7 LOT SIZE: 67989 (SQ. FT.) N73MBER OF BEDROOMS: 4 THIS PERMIT: 4 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 (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 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: ENGINEER SHALL VERIFY CONSISTENCY OF SOILS AT THE END OF THE ABSORPTION TRENCH AT THE TIME OF CONSTRUCTION AND REPORT THIS ON THE AS-BUILT INSPECTION REPORT. RECEIVED BY: ,~,~/~, _ ,n ~' ~ ['"'-~~'>~ DATE: 203 W 15th. Avenue, Suite 203 Anchorage, Alaska 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 7 BLOCK 2 ATELIER S/D A. WILLIAM SAUPE No Ground Water or Impervious Layer to 16 ft. Use Standard Trench Soil Rating. From test 3/24/94 4 min/in = 1.2 gal / sq. ft. Use 6-15 min per inch -- .8 gal / sq. ft. No. of Bedrooms 4 Required Area per Bedroom: 150/.8 = 187.5 sq.ft.. Total area required: 187.5 x 4 = 750 sq. ft. Finish Floor Elevation: 776+ Ground Elevation at Absorption Field Testhole Total Depth 16 Less 6 feet 10 Less 3 feet Cover 7 Rock Depth 6 774- Length of Trench 750 / 12 = 62.5 [FT.] SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 63 FT. TOTAL WIDTH 2 FT. TOTAL DEPTH 10 FT. ROCK DEPTH 6 FT. COVER 3 FT. SEPTIC TANK/Z,a~3AL. -- _ The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 7 Block 2 Atelier S/D Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ,.5~' (ENGINEER'S SEAL) DATE PERFORMED: Township, Range, Section: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? 7 S L IF YES, AT WHAT I ~.. pO DEPTH? Depth to Water Alter j ~ ~/.~ Monitoring? Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND __ FT COMMENTS PERFORMED BY: I 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) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~ ~ ~Tes 1. I I~.1~ (ENGINEER'S SEAL) Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E SITE PLAN Depth to Water Alter Monitoring? Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN .ETWEEN 7 . COMMENTS PERFORMED BY: I 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: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER!S SEAL) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PERFORMED: Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ~.L t_l~ ENCOUNTERED? . S L IF YES, AT WHAT O DEPTH? p E Depth to Water Alter Monitoring? .D~,-~/ Date: Gross Net Depth to Net Reading Date Time Time Water Drop I' ,o F', Jt PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~_~,_ FT AND 7 FT COMMENTS PERFORMED BY: I 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: Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS DATE PERFORMED: Township, Range, Section: SLOPE SITE PLAN WASGROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? s L O P E Deplh to Water After Monitoring? Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN __ FTAND FT PERFORMED BY: I 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: 50 O 50 100 150 pO0 O 0 / TOBBEN SPURKLAND P.E. LOT 7 BLOCE 2 ATELIER S/D SEPTIC SYSTEM DES/ON 205 ~ I5[H. AVENUE gNCN AK. 99~0~ SEC. 6 [I2N R2W DATE: SEP[. 6, 1994 OZ] 27~-~ A. WILL/AW SAUPE SHEET: ~5 OR/D: 2~42 N TOBBEN SPURKLAND P.E. LOT ? BLOCK 2 ATELIER 203 W 15TH, AVENUE ANCH. AK. 99,501 SEC. 6 TI2N R2W DATE: SEPt. 6, 1994 (907~ 279-}916 A. ~ILLIA~ SAUPE SHEET: ~/Z OR~D: 2142 ? .'?/? I0¢ Ioo o o Standard Trench: 65 Ft Total Length ~0 Ft Total Depth 6 FL Effective Rock Depth Cleonouts 4" L o~ co,or 1250 gal septic tank NO SCALE TOBBEN SPURKLAND P.E. LOT 7 BLOCK 2 ATELIER S/D SEPTIC SYSTEM DES/ON 205 Wl5th Ave DATE: SEPT. 8, I994 Anohoraoe Ak 99501 SEC. 6 TI2N R2W 279-59~6 A. W/LLMM SAUPE SHEET: 5/5 OR/D: 2142 M-W DRILLING, Inc. P.O, Box 110378 · 10330 Old Seward Highway (907) 349.8535 ANCHORAGE, ALASKA 99511 94-148 DRILLING LOG Well Owner, .William Saupe ._ Use of Wen Domestic Location (address of: Township, Range, Section, if known; or distance main road , LOt ._7~_.Block 2 Atelier Sub Stuckagain His are,a, A~cho~aga Size of c~Mg- 6 . ._Depth of Hole_ 85 feet Static water leveL.. 13 ~_t, (~Jt~"~i'"' fbelow) land surface. Screen ( ); Perforated ( ~ ), ":" N/A Describe scr~n or perforatio~ ~ ..... Wen pumping teat a~ga~ ~ (~) of drawdo~ from static ~l,,.: ~.:~; ' ;'.. Date ot completion 0ctobe~ 2.~/:. ].99~_ C~ed Finish of well (check one) (minute) for ~ As built note: __~,. WELL, LOG Depthin feet from ~?.:. '. '~ :, . ,, j , ~:.(: ,4 ' ground surface GiVe"detal~ Of/orrnatlons penetrated, _. o..TO. 2 Csg...~ .... ..[5 _TO. 35 ..~ open end ( X ); .,hours with 100% well dry grouted with 2 sacks of Bentonite C, ranules size ,of material, color and hardness ~-'~,,~f~ ~ ~',, .~ ' ;[~%'ase;L; '.ma_~l. _ siltvZ~t_ zradin~ ._cleaner with tach ---_~TO 85_ . :._To. , TO Post'_ItTM brand fax transmittal memo 7671 TO/ , ~ Certified' Conh'ac~ox. Certificate ;No's, 814 & 973 1 - CU~.TOMfR • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 041-031-29 Expiration Date 1. GENERAL INFORMATION: Complete legal description ATELIER: BLOCK 2, LOT 7 Location (site address) 9300 Atelier Drive *Anchorage 99501 S A F E T Y Current Property owner(s) Linda Smith Day phone 830-6603 Mailing address 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 ❑ Waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ �{ 2, w COVID Waiver Fee $ Date of Payment 8 11 202 O Date of Payment Receipt Number 0 5� 3 y C Receipt Number COSA # OSC 2D j 9 2 ( 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. 6. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for 7�' Jy A. GcIrness: CE—,795,b kZ_rofessxol�_1 11 \�,\?NUTi' op t,,, 4 oN s do �. W r ATE �qST=•�,�'�ND m^ 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other�ov� E OA, Legal Description: ATELIER; BLOCK 2, LOT 7 If more than 1 septic system on lot: COSA Checklist # 1 of A. WELL DATA © Well log is filed with Onsite (or attached) Date drilled 10/28/94 Total depth 85 ft Cased to 84.2 ft X Sanitary seal is functioning correctly ❑Q Wires are properly protected, Casing height (above ground) 12+ in. Date of flow test for COSA 6/17/20 Static water level at beginning of test 12.6 ft Comments B. TANK DATA Age of tank(s) 26 years Tank type/material SEPTICSTEE Measured operating fluid level in septic tank 51 X Standpipes/foundation cleanout per record drawing r Date of pumping ZGly D. ABSORPTION FIELD DATA DEEP TRENCH Which system tested (date installed) 10/13/94 0 ALL standpipes present per record drawing Total measured depth from grade '10.08 ft (max) Measured depth to pipe invert from grade 3.8+ ft (min) ❑ N/A — pressurized field © Monitor tubes go to bottom of effective. If not, state depth into effective V Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced N/A gallons Comments/Deficiencies: 'AT MONITORING TUBE COSA Checklist yellow sheet Parcel ID: 041-031-29 Structure served by this system 1 Well production at time of test 3.2+ qpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes F111 Nc 15"Coliform bacteria is Negative Nitrateol mg/L IN Nitrate less than MRL (ND) Arsenic ug/L 5] Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 6117/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: N/A Adequacy test date 6117120 Results Q✓ Pass For 4 bedrooms Fluid depth prior to test 51 in Water added 681 gal New depth 60 in Elapsed time 130 min Final fluid depth 55 in Absorption rate 600+ gpd Any rejuvenation treatment (past 12 months) If yes, enter date N/A NONE 44 .— 1 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 Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft ❑✓ Yes if No Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' E Yes if No Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' 0 Yes if No Neighboring Absorption Fields > 100' Water Main > 10'✓❑ if No Animal Containment > 50' Fv� Yes if No ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft✓❑ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) ft ft ft ft ft Building Foundations > 10' ❑ Yes if No *51+ ft Surface Water> 100' ❑✓ Yes if No ft Property Line > 5' ✓❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓❑ Absorption Field > 5' 121 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10'✓❑ if No 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' Q 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'✓❑ Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' ❑ Yes if No **95 ft F. ENGINEER'S COMMENTS *MET CODE AT TIME OF INSTALL **WR#090053 TANK APROXIMATELY 3" SHORT ON COVER - SEE EMAIL FROM OWNER REGARDING FREEZING G. ENGINEER'S CERTIFICATION l certify 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. COSA Checklist yellow sheet 9T .... v*..O0� .�.... ...................� .J ey ess. CE -795 �p ���professio�°oo . #AECC884 Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 201421 Subdivision: Atelier Block 2 Lot 7 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 26 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. F. Ma�hng Address P O Box 196650 *, Anchorage, Alaska 99519 6650 www muni or Sonja Blewett From: Janelle Pfleiger <janellepfleiger@gmail.com> Sent: Monday, August 10, 2020 4:28 PM To: Sonja Blewett Subject: Fwd: Freezing and septic system Here you go Sent from my iPhone A. Janelle Pfleiger Associate Broker, CRS, CLHMS 2016 National RRC President RE/MAX Dynamic Properties 3350 Midtown Place Anchorage, AK 99503 907.242.0076 Begin forwarded message: From: Janelle Pfleiger <janellepfleiger@gmail.com> Date: August 10, 2020 at 5:17:41 PM PDT To: Linda Smith <lapollol5@gci.net> Cc: Erik Widger <erik@garnessengineering.com> Subject: Re: Freezing and septic system Thanks Linda! Sent from my iPhone A. Janelle Pfleiger Associate Broker, CRS, CLHMS 2016 National RRC President RE/MAX Dynamic Properties 3350 Midtown Place Anchorage, AK 99503 907.242.0076 On Aug 10, 2020, at 5:07 PM, Linda Smith <Iapollol5@gci.net> wrote: Dear Erik, I am writing to advise you that we have never had any issues with freezing with regards to our septic system at 9300 Atelier Dr. It has performed flawlessly throughout our time there. Please call Or text to let me know you have received this letter at your earliest convenience. I 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 Parcel I.D. # O 1. GENERAL INFORMATION Complete legal description LoT -1 Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone w e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER 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#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/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat 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 t c=~ ~?v, Phone Engineer's signature DHHS SIGNATURE ~ .. Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date ~Z'- .5-- ~",.~-" The MUnicipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~21  Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L 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 I O/z.,9//q L/ Driller 'IH" ~ ~ Cased to c.Q) Cl/o I ..~ Casing height /~'/ y 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 I I [ Absorption field on lot I ,~- c~ Public sewer main g.p.m, g.p.m. Sewer service line 7---~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) "/ Foundation cleanout (Y/N) High water alarm (Y/N) /"///,~ Date of pumping Compartments Depression (Y/N) Alarm tested (Y/N) iW/'/F--~ Pumper ~'/F-~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot II I On adjacent lots To property line ~ C~ Absorption field Surface water/drainage ~ ,.~' '~ Foundation Water main/service line 72-026 (3/93)* Front 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) SEPARATION DISTANCE FROM LIFT STATION TO: Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Well on lot On adjacent lots Su dace water D. ABSORPTION FIELD DATA Date installed I0/1"¢ / ~ ~ Length ~ ._~ Width Total absorption area 7 ~ Date of adequacy test ~'-///~, Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) ,-" ~ Gravel thickness Cleanout present (Y/N) 7 Depression over field (Y/N) Results (pass/fail) ~ for Z-/'/ (f'/0,~ ~/~_) Aftertest If yes, give date ~/"/~ System type / ~ c ~/ Total depth ~ ~ ~ C) /,,.,! Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~ 2- ~ Property line To existing or abandoned system on lot Cutbank I"'./e~ ~ e._ Water main/service line Driveway, parking/vehicle storage area ~ .2 E. ENGINEER'S CERTIFICATION Date of Payment Receipt Number 72-026 (3/93)* Back I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on ttce'~.~h~ inspection. Engineer s Name ~l ~<~ o~[~ ~-~. ............... ~':"~ ............; ~ ' ................. '-,'"- 4". 'U', ':'e CE-2225 Date 1 q, Iff ~ ~ ,,,,,, ,,,.... o,,. ~.,~ ,~ H~ Fee $ ~OO - ~ Waiver Fee $ ~~~ ,, Date of Payment ~¢~/~) Receipt Number