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SULLI"N WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 9 TELEPHONE 688-2759
OWNER OF LANDDEPTH OF WELL
ADDRESS / `t STATIC LEVEL OF WATER FT.
LEGAL DESCRIPTION
DATE - Started Ended
PERMIT NUMBER
KIND OF FORMATION:
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MISCL. INFORMATION:
DRAW DOWN FT
GALS. PER HR
KIND OF CASING
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DRILLER'S NAME
�RJ lvl 1: KEY :1 1L, 1: -T- N-" F---- IFI P-4 0 bi (-I FT! bi���
DEPARTMENT pc HEALTH AND ENVIRONMENTAL -?UTECT%ON
825 STREET, ANCHORAGE, HK 9 J1
264-4720
PERMIT NO. ( 820724 )
APPLICANT BROTHERS ROSS CONST CO PO BOX 1234 E.R, 99577 688-]]85
LOCATION
LEGAL L6B3 BENITO LOT SIZE 999999 SQUARE FEET
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS FIRE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED.______-..._______...-..-.....-----------
APPLICANT BROTHERS ROSS CONST CO
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ISSUED V 4.
a
air t
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Anchorage necon<iil�� Pregirict, Alaska; and that the improve -
ti �aenb situated, t}Se�ari are• within the pro � arty line: and do
T, �, '► not over7*9 or'.*Uw"ch' on' the property lying adjacent then-
tb, that no rWatnezita . on Dzopsi ty lying adjacent thereto
encroach or t i► WMsa in 4uestion and that there are no
�• roadways, . taoass or otYiezvisible easements o0
maid Drop" t;'�t icat+sd heieoi2:
Dated aL Eagwt4 Yet" � Kiska r
i a thi..day►
` C Q
SCALE; Registered T and.Surveyar No: 880 LS
f Box, 45G;.Ea le River, Alaska'
t: Phane (947) Cip4-2643'
Municipality of Anchorage
Development Services Department
Building Safety Division = r'
On -Site Water and Wastewater Program 'Sm I T
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. _(Ynb-a-1a o 1a HAA#_IoLD9
Expiration Date:
1 GAN;E2Ah l(�tFORMATION Nf
,ne�nte4e �cPiel �rlAcrrin}inn. �// � S/z L 0T 4r, 844 C(Lj -
location (site address or directions) C/2C4.e ErE6'GF /?Wr✓Ere
C%Irferlt Property owner(s),B/Z44` 6225 D -S Day phone C7Z-34PVP
lillailing.adc3ress '�`7%� RF�j„f� �.9cJ Cf2Ct-/�
Lending agency Day phone
Mailing address
Real Estate Agent tTOE "C-a464CS
Day phone 3/7-4f 83o
Mailing Address '��G✓>RhGO /2E�
T�f
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site ❑
Individual Water Storage ❑
Individual Holding tank ❑
Community Class Well ❑
Community On-site ❑
S t ❑
Public Sewer
Public Water ys em
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, .
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, 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/vow/iLt Cil(' Phone
Address / 7.247 REQ 2 owu ei,2CzX
Engineer's Printed Name STE✓� F-�c._K Date
, OF At. Cdr.
S. DSD SIGNATURE
Approved for _ ! bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By, 9 w� �+► ` \L�. Original Certificate Date:
(Rev. OV02)
�� .eee.e
,
F
f s,, ,
�d t10 ►E 6256
_.:.�,O
Approved for _ ! bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By, 9 w� �+► ` \L�. Original Certificate Date:
(Rev. OV02)
. F 1
Municipality of Anchorage �E
Development Services Department N °;
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Boz 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: EFd(/ O s�A L Q7- 4. 4,Yejt _ 7 Parcel ID: OW 'o7a - IS,
A. WELL DATA
Well type Q If A, B, or C provide PWSID # _ Well Log (Y/N)
Date completed�4PZ Sanitary seal (Y/N) Wires properly protected (Y/N) Y
Total depth4/5—ft. Cased to AS—ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test 3r4PZ Q / 00
Static water level 9 ft. Ica ! ft.
Well production ZQ g.p.m. % g.p.m.7
WATER SAMPLE RESULTS:
Coliform O colonies/100 ml. Nitrate 4(,2Z mg./I. Other bacteria' Q colonies/100 mi.
Arsenic: — mg./I. \ Date of sample:/I s GCollected by: le(w. Est
B. SEPTIC/HOLDING TANK DATA 1Cj,) UG S
Tank Type/Material Date installed
Tank size Number of Com rtments /Hate
/N)
Foundation cle ut (Y/N) _ De7umpe(i
' n ver tank (Y/N) _arm (YIN)
Date of pu ping
C. ABSORPTION FIELD DATA PaBL(C S�j ,JEr2
Date installed Soil rating p.d/Monitorin
ZZ stem typeLength ft. idthft. Gravel below pipe ft.
Total depth ft. Eff sorption areaorin ube Depression o r field _Date of adequacy test ' F r _ bedrooms
Fluid depth in ab rption field before test r added_ gal. New depth_ in.
Elapsed Ti _min. Final fluid deAbsorption r >= g.p.d.
Any r ' venation treatment (past 12 mo.) (Y/NIf yes, give date
D. LIFT STATION /-V31-(C Sr`e�j
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at i High water alarm level a in.
Datum Cycles tested Meets alarm & circuit quirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /f 4
Absorption field on lot Nf-1
Public sewer main
i
Sewer /septic service line ZS t
On adjacent lots /UO (1, -
On adjacent lots /00 rf-
Public sewer manhole/cleanout 100'4-
Holding
00'rHolding tank At14
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK
Building foundatio Property lin/e--
Wells
Water main Water servion jacent lots
ON LOT TO: PU161 fc. 46—'49iR,
Absorption field
Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: %r1614C S6&j4e
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehic} storage
Curtain drain Wells on adjacent l0 1
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / have determined through field inspections and
review of Municipal records that the above systems are in r: ,
conformance with MOA HAA guidelines in effect on this date. r;
Engineer's Printed Name S7—CVC E..�T
Date
y
HAA Fee $ Y-310 Waiver Fee $ _
Date of Payment C - f Date of Payment
Receipt Number D 0 Receipt Number,
(Rev. 12/01)
OF Ar
Stevenjanq .44
PE 6256 .•wr
11-12-04 06:06PM FROM -CUE ESI, SGS ENV SERVICES 9075615301 T-967 P.04/05 F-06'
Matessu Test Lab of Alaska
4t Water Quality Testing
E
Mile a.7 Parmer-WasNla Hwy. P.O. Bot 7749
Midtovn Community Business Park Palmer, AN. 99945
Paone:19071746]005 imail: Qiatauteeneb®rooerstara com Fax: (907)74&3010
Client: SGS E:nviromental
Attn.:
Forest Taylor
Client ID:
Bear Paw Circle -1047344001
PWSID aN
I3ENr7'-V ,S/Q L ( �3
Source:
M.S.T.LA
200411793
Sample Matrix"
Comments:
Method
Parameter Units
SM 4600-NO3-E
Nitrate -N mg1L
Legend: MRL = Method Report Level
MCL • Max Cuisammat Level
9 Preasm In Method Blank
E . Esurnatad Vasco
H °Above MCL
D = Lost to Dilution
Reprted By Jon Pout Campbell
Lab Supervisor
4.29
Date
0.50 1119/04
Date Arrived: 11/5/04
Report Date: 11/9104
Sample Date: 11/6104
Sample Time: 0800
Collected By:
Date Analyzed MCL
11/9104 10.0
(�-'s /-
/YB9 0,fB ZS"�✓
�B9 °sBrs+u� siB6
ASBUILT SMIARD &ASSOCIATES LAND SURVEYING 04-0829
1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE!
FOLLOWING DESCRIBED PROPERTY �\
DATE. p.�� O ... (.I
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: '
EASEMENTS, COVENANTS, OR RESTRICTIONS iv�sz�'�`�..., A
WHICH DO NOT APPEAR ON THE RECORDED SUBDI— Duan* Mark Seward
jr
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' f LS -8918 ±�'w
�.'•.
ANY DATA HEREON BE USED FOR CONSTRUCTION ��`'f �'� 41'"�,••,��
OF FENCE LINES, OR FOR ESTABLISHING BOUND- .yn�„X
ARY LINES. DRAWN f ta% �.
r,
APPLY NT FILLS OUT UPPER HAI " ONLY
Property Ow,ier
Phone
Ti
Dat
Mailing Address
z ;, - , Zip Code
Buyer
Date
Address
Zip Code
Lending institution
h
Phone
Address
Zip Code
Realty Co. & Agent
Inspector
Phone
Address
Zip Code
( ) DISAPPROVED
Legal Description
( ) CONDITIONAL APPROVAL'
Street Location
Type of Residence
DATE
Single Family
BY `
Multiple Family
No. of Bedrooms
❑ Other
Well To Absorption Area
Water Supply
Septic Tank Size
Individual
Well to Tank
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
❑ Individual
Year Individual Installed:
Public Utility
When Connected to Public Utility:
Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Ti
Dat
Dat
Date
Date
h
Inspector
Inspector
Inspector
Inspector
Field Notes:
( 41j'APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY `
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72-023 (3182)