HomeMy WebLinkAboutT15N R2W SEC 25 LT 61 S2T15N R2W
ec. 25
Lot 61 52
#051-282-10
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL
PROTECTION
ENVIRONMENTAL
0(*
ENGINEERING
DIVISION
825 L Street
- Anchorage, Alaska 99501
Telephone 264-4720
ON-SITE SEWAGE DISPOSAL
SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
�� c_ �Y�j'-S&KJPGRADE
MAILING ADDRESS
/e /`/-e /✓/( /%S-!�7
LEGAL DESCRIPTION
S/d Z, 7- 6-/ T - ws°r a s
LOCATION
NO. OF BEDROOMS
/
DISTANCE TO:
Well
/b,!�_
Absorption area
r
Dwelling /
A;_cS'
PERMIT NO.
',S—D.S--�6
UY
/
F Z
Manufacturer
Material
S'}P
No. of com' artments
wF
hie4 T�n/K
e-/
rn
Liq. capacity in gallons
Inside len tlh
Width
Liquid depth
/
IF HOMEMADE:
O z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= 2F
Manufacturer
Material
Liquid capacity in gallons
O
to
DISTANCE TO:
Well
Foundation f
Nearest lot line
PERMIT NO.
E
No. of lines
Length of each line
Total length of lines
Trench width/
Distance between lines
aSte`
�`
S
//q .
Top of tile to finish grade
Material beneath tile
e
Total effective absoQrption area
p3i�
-inches
Length
Width
Depth
PERMIT NO.
W
0
Q F
Type of crib
Crib diameter
Crib depth
Total effective absorption area
wa
to
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
to
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
>t A
ruvet�F /qt . 3U 3 �/ •p 7:i
SO(TEST RAIN G
INSTALLER
/�"
/—:3q
REMARKS
sF
_ r
p�t
of
K
I 00
P /J�e&� V
` elm � o � �
a rApj
m
i
G' ;
Louis A. Patera
o %
GE -6736
`
APPROVED
DATE LEGAL
10-:145f
s�
PERMIT NOa
DATE ISSUEDr
APPLIC,A' T2
ADDRESS:
CONTACT PHONEe,
L.EGAL_. DE:SCRIP,
101 IF ' flDh C3 EiE
DEPARTMENT OF HEALTH AND E.NVIRONME:NTAL. PROTECEIOh1 C
S5 I... STREET, ANCHORAGE, (-lK 99501
264-4120
d_::11'.1'......13 1:1-1.:,- :r_3[E-UJEECfy
850586
09/12/85
JACK BRADY
% P.O. BOX 77329A
EAGLE RIVER, AK 99577
694-5195
SUBDIVISION: NA LOT: 61 BLOCK: NA
SECTION! 25 TOWNSHIP: 15N RANGE 2W
LOT SIZE, 25A, (SUiFT.
OR ACRES)
MAX BEDROOMSe 4.
Listed below are the options
available to
you In designing
your septic
system. Choose the option
that hest fits
your site.
- - -
- - - - - - - -
- -I FR I_' 1 11 C__ �_l
3 En Tai A
54 13 F Z a_: a SE: 1x.k
DEP TI -f TO PIP='E BOTTOM (1=T.)
4.0
4.0
4.o
GRAVEL.. DEPTH (FT.)
4.0
0.5
..5
TOTAL_ DEPTH (FT. )
8.0,
11..5
7.5
GRAVEL WIDTH (FT..)
2 5
1.611()
5.0 /
GRAVEL LENGTH (FT.)
.43.0
:'.^::..p�=
. ?--:A6
GRAVEL.. VOLUME (CEI. YDS..)
1.8.0
:1.9.0
27.51
TANK SIZE(GALS)
1,250.0
1,250.0
1,250.0 *#.
SOILRATING (SC!,FT./BR)
85
85
85
4TANK MUST HAVE AT LEAST TWO COMPARTMENTS.
-- -- - - - _. - - .-- --
I. certify that,
1... 1 am familiarwith the: requirements for on-site sewers and wells as set.
forth by the Municipality of Anchor4ge (MOA) and the State of Alaska.
:.'. 1 will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. 1 will adhere to all MOA and St.at.e. of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system an this or any adjacent_ or nearby lot.
4. 1 understand that this permit is valid for a maximum of 4 bedrooms and
any enlargement_ will require an additional. permit.
IF A LIFT STATION IS INS'T'ALL_ED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AMID INSPECTION MUST BE OBTAINED; (.2) AS-HLEI:LTS"
L•Jl:l..L NOT BE APPROVED WITHOUT HOU}- AN..ELECTRICAL. INSPECTION REPORT:; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED ( DATE,
APFL_ I C
IS SUE::D
aNT, JAi'E: 1DY
Ta DALE, /
-1111..-----------
O
PERFORMED FOI
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
LEGAL DESCRIPTION: +� �`� Lot Ei T /S /✓ f�'� /.t,.
SLOPE
1
0
2
3 i
4
5 b. (7
6
D
7
8
0
9
10 b
11
�l
12-
13-
14-
15-
16
2131415 16
17 G
18 �V J,'<.
19-RQ'N
b
OR GA111 1
Gw
Sa.,,e 9 G 4 l
gs
so ti's —
aF Hole
a�p^
Louis A. Butera
CE -6736
•PROFESS)'JN�.t
X SOILS LOG
❑ PERCOLATION
TEST
DATE PERFORMED: 7`
G •� S
SITE PLAN
ionmEmSEENE
Date
Gross
Time
Net
Time
limomm7■■■I■
,I..'lmi,■■.I■
Net
Drop
■■I■
■1®111111■11■■EIN
'�:�■ILII
Elm\11M1MM1Mww!jJ
WE
MEEMEEMMEm
MEMINIMINMEMIN
WAS GROUND WATER I) L p
ENCOUNTERED. O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
4re/.
Rote
20 uj's . /
PERCOLATION RATE aS �'Z x (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMM1ENTSf liL4Ya o1¢ -e x,,r 11/�1
y/1A5 Cony lge�c'y 1A/nw �es�� 757&&I—
PERFORMED
57&&D—
PERFORMED BY: CERTIFIED BY: U
Eagle River Engineering Services / DATE: 7
Eagle River, AK 99577
694-5195
72-008 (6/79)
L of
s
ND OF FORMATION:
IOM........................FT• I
,FROM.. _:..... �.... ::FT.
s6
KV1R.....:
....s a� a
ROM.........
._ .-FT. 9
ou
39 �, 4
L:::.. FT. TQ :..............' FT.. - ............ FROM..........: _ .......FT. TO......................FT..
.......................... -
....FT ......................................... FROM.......... FT. TO ..................... FT ........................ . .
R...:.. .......: FT. TO.::.. ` .......:.- FT. - .............. FROM..::..... .:.......FT. TO:..: .......... . FT....... .. ........ F
ON:
FT...
.. FROM ......................FT.
TO........................
..............
........... 2.6
FT.......
PlAY_............... ' FROM ..........................
FT TO...........
....lr!P..� .....:: ........ t
_:.:...? 9
...FT.....:.
FROM
FT TO.. :. _....._..
i'T.: ........ : ....
water. 6gpa
... ..
FT .....::.
.:............... .. � - FROM.:............:..:
FT. TO.........................BT
._ .... .........
38
FT..
cement gravel
........ FROM ...... .......
..... FT. TO . .........
....i,T; ....... .. ... -
........... ...
.......
q
9
so 9 gravel firmOM.......................
:
-
.
- FROM- .......
.........FT. TO...... :...................
FT;....... ................ ....._ :...-.
.45
FT.....
Rook, *andStone FROM.. ....................
FT. TO..... ...
....... FT,................. ..
L:::.. FT. TQ :..............' FT.. - ............ FROM..........: _ .......FT. TO......................FT..
.......................... -
....FT ......................................... FROM.......... FT. TO ..................... FT ........................ . .
R...:.. .......: FT. TO.::.. ` .......:.- FT. - .............. FROM..::..... .:.......FT. TO:..: .......... . FT....... .. ........ F
ON:
Municipality of Anchorage .:
On -Site Water & Wastewater Program -
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-282-10 Expiration Date: �T f
1. GENERAL INFORMATION
Complete legal description T7 5N R2W SEC 25 S2 -9P LOT 61 5 2
Location (site address)
15912
CLINE STREET EAGLE RIVER
AK 99577
Current Property owner(s)
GLENN
& KATHLEEN BOULTON
Day phone C/O AGENT
Mailing address
15912
CLINE STREET EAGLE RIVER,
AK 99577
Real Estate Agent
CINDY W/
GREATLAND REALTY
Day phone 694-9125
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
E
Individual On-site
E
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ r - Waiver Fee $
Date of Payment .29113 Date of Payment
Receipt Number�� Receipt Number
/} J
COSA# V — �3` � Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, t 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. l 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.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, RE
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
System #1 Approved for bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
0
bedrooms.
Phone 337-6179
Date 7), 8 l
bedrooms, with the following stipu
OF
ON-SITE
WATER AND
WASTEWATER
Original Certificate Date: q - / _ 3
ThWMurAci#ali or Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
(R— ivasl
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: T1 5N, R2W, SEC 25, S2 9r LOT 61 Parcel ID: 051-282-10
A. WELL DATA *PER SURROUNDING WELL LOGS
Well type PRIVATE If A, B, or C provide PWSID# NIA Well Log (Y/N)
Date completed 10/65 Sanitary seal (YIN) YES
Total depth 45 ft. Cased to *40+ ft.
FROM WELL LOG
Date of test 10/65
Static water level 12
FOR
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
7/10/13
23 ft.
Well production 10 g.p.m. 4.30 g.p.m.
WATER SAMPLE RESULTS: 11 C(^lo" }`Ct t'Sarnptc fc-�.11�� b� Cot¢5�.11t�k.�
-3-
Coliform — colonies/100 ml. Nitrate` &� mg. /L. Collected by: GEG. Ltd.
Arsenic: AJOug./L. Date of sample: 7/10/13
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1500 gal. Number of Compartments 2
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO
Pumper 3 � r.s
Date of pumping Pum p
C. ABSORPTION FIELD DATA *RFI nw Fx1sriNa rean
Date installed 9/16/85
Cleanouts(Y/N) YES
High water alarm (Y/N) N/A
Date installed 9/16/65 Soil rating (g.p.d./ftor /bdrm 85 System type SHALLOW TRENCH
Length 52 ft. Width 5 ft. Gravel below pipe 3.5 ft.
Total depth *9.52 ft. Eff. absorption area 481 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 7/10/13 Results (Pass/Fail) PASS For 5 bedrooms
Fluid depth in absorption field before test 0 in. Water added 1 180 gal. New depth 9.25 in.
Elapsed Time: 1050 min. Final fluid depth 8 in. Absorption rate >= 750+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YM
"Pump on" level at in. "Pump off' level High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
f
Septic tank/lift station on lot 100 +
Absorption field on lot l() � +
Public sewer main N/A
Sewer /septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10/+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parkinglvehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t have determined through field inspections and
review of Municipal records that the above systems are in
confofmance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 113
(Rev. 11/05)
—7 53
7 I $I
a NOOD15 rE a
�
164.59
0/6'RESAR
SA'RERAn
1
30.5 l9.3LEACNINO FIELD
` INSTALLED- 3/20/95
- TE9TED - - S/22/96
1500 91L5EPTIC TANK
:—INSTALLED 912WO5
TESTED - -5/22/96
m
c
w
N
m s.d w
35.6
m
y C/O [mR
o
O W00D N
3.7'-3T11F$RAME Or?
•DECK
u -1
r
a.s'
try
- 67.5" DI
Ito I,1�
F/AJCE
N IG'2
O�WELL 9
WOODE TESTED SA2/oe
Oer FRAME
NOOSE Ct
W/FULL o
DECK
R4]Y'T
WITH RAIL
/1.0'
e1.4 / 12 0'
parce a
_NA'a
I., :.
UU
32 b' �i
*,CONCREjEt �' -
S D
.�ORIVF'l:. W/nnAYE
Y DAFADE
Q
0/9'ROAR
14'•
—
6/9'RE3AR
na
w
r
O
IN
O
ale REB"
NR-RERAR
DIME 164.61 STREET
FI
' RECERTIED 5 23 96 500 IS W
y}•.a.V1
SEPTIC AND WELL
DATASUB-I PROVIDACEED
DATA
.R �•r�/_ _S BY OWNER
�
=TLE ASBUILT
SI/2 LOT 61, SECTION 25
T15N R2W S. M.
SCALE I'R3o OR.BT. axe FILE NO
ORTE 9/24/ Cza ST .ig InV713 NnvwI?%R
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH R 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. # CJ - l - ? - 1CG
1. GENERAL INFORMATION
HAA# '�� r1"1SC\'I_,
Complete legal description S, of Lot 61• Sec. 25• T15N; 8.2.19; S.M.
Location (site address or directions) =5912 C.irie
Eagle River, AK
Property owner Jack & vera Brady
Day phone 696-2254
Mailing address 0.0- Pox 770 36 Eagle River
AK 99577
Lending agency
Day phone
Mailing address
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
°`tiP. �n
�Zn��'r
2. NUMBER OF BEDROOMS: 5
3. TYPE OF WATER SUPPLY:
:iiii:
Individual well
yea ? ��
i / ij7 LAS C
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. 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_ 1191) 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 f urther 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 S & S ENGINEERING
a Phone 69 _q-3 `i 7
Address Eagle River, Alaska 99577
1
Engineer's signature
6. DHHS SIGNATURE
X Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
Date S` /,;� 311%
cm
�t} �ROBERT C. COWAN f C
CE .8801
bedrooms, with the following stipulations:
Date C `/3 —��
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 theirlending 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 (Say 1/91) Back MOA N21
Municipality of Anchorage
e DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 a Anchorage, Alaska 995010 (90MEWED
MAY 2 41996
Health Authority Approval Checklist Municipalityy of Anchorage
Legal Description: .5 t12 6r-Lv-r G I Ste. ZS isd, iZWParcel I.D.: dept. Health it Human Services
A. WELL DATA
Well type P914AtE If A, E, or C; attach ADEC tetter. ADEC water system number —
Log present (2YN)
Total depth
Sanitary seal
Date of test
Static water level
Well production
Date completed Ocrooe�w, , 1965
46; t Cased to 40 +
WATER SAMPLE RESULTS:
Coliform
FROM WELL LOG
l0 /65
i
12
/O
g.p.m.
Nitrate 1.09
I
Casing height (above ground) 'Z .*
Wires properly protected ON)
AT INSPECTION
5 6Z -Z. b
zit
g.p.m.
Other bacteria 0
/ S & S ENGINEERING
Date of sample: 15 �1G / q6 Collected by: Lid over Loop Road No. 204
Eagle River, Alaska 99577
B.�[IOLDING TANK DATA
Date installed 9/16/135 Tank size I SO o Number of Compartments `Z Cleanouts (DI)
Foundation cleanout &N) Y Depression (YAJO tJ IIigh water alarm (YS) a
Date of Pumping 5A01-16 Pumper JP- 'A*PI A G -,
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./f 2 or Wlbdrm) 95 a System type 'frtcele4 CS o alta€)
Length 52' Width 6' Gravel thickness below pipe '3 • t Total depth $ t
Effective absorption area q61 44 Monitoring Tube presen 1(1) Y Depression over field (YA@ iJ
Date of adequacy test 5%7,Z�9b Results ass ail) @ASS For 5 bedrooms
Fluid depth in absorption field before test (in.); a Immediately after Seo gal. water added (in.): 1 la
Fluid depth n (ins.) Minutes later: /0 mod • Absorption rate = •76a 4" g.p.d.
Peroxide treatment (past 12 months) (Y/N) t4odE keJoad If yes, give date —�
D. LIFT STATION
Date installed
Manhole/Access (YIN)
High water alarm level at*
E. SEPARATION DISTANCES
,.Pump
Size in gallons
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic folding tank on lot /0C),
Absorption field on lot too 1.f,
Public sewer main � /PV
Sewer /septic service line 25 t
"Pump off' Icvel at*
On adjacent lots loo 1 .+
On adjacent lots /60 1 f
Public sewer manhole/cleanout M /A
Lift station /00,.+
SEPARATION DISTANCES FROM EPTI HOLDING TANK ON LOT TO:
Building foundation 6c t Property line 101+ Absorption field / tl 1.4-
Water main,tservice line ZS 1+ Surface water/drainage )oo l+ Wells on adjacent lots 1001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 001.4- Water main/service line 2� I +
Surface water l oo ' 'I' Driveway, parking/vehicle storage arca GO ,+
Curtain drain t Orifi VfJod,3 Wells on adjacent lots 1001+ Properly line to 1
F. ENGINEER'S CERTIFICATION
/ certify that / have determined thru field inspections and review of Municipal
in conformance with IOA 1/AA guid tines in effect on this date.
Signature _ -W�L- ' ,,,
Engineer's Name �8t A T C. CowR,)
Date
s/a3/-16
HAA Fee $ ,(�%% • 6Z
Date of Payment ZII:jp��/�f{o} 2, J
Receipt Number /c� o ��t7 S -
Rev. 8/95 OSS: liaa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
,./1
�0�t:�;,'.y Ok•FJ001 ; ��;'!
sy
05/21/96 13:42 CT&E ESI ANCHORAGE -> 9076941211 NO.374 P03
CTc&E Ref,#
Client Sample TD
Matrix
ME Environmental Services Inc.
Laboratory Division
Laboratory Analysis Report
961796.961796001 Collected Date 05/16/96
S 1/2,L61,SEC 25,T15N,R2W 101
Di ioking Water Technical Director: Stephen C. Ede
PVi'SID 0 Released By—
Sample Remarks:
Parameter
Results QC PQL Units
Method Allowable Prep
Analysis ]nit
Qual
Limits Date
Date
Nitrate•N
1.09 0.100 mg/L
EPA 353.2
05/16/96 EMD
Total Coliform
0 0 col/100mL
S1418 92228 (DW)
05/16/96 TAV
U - Undetected
LT - Less than
GT - Greater than
D Secondary Dilution
J - Below the calibration range
.- 200 W. Patter Drive, Anchorage, AK 99518.1605 — Tet: (907) 562-2343 Fax: (907) 561-5301
3180 Peger Road, Fairbanks, AK 99709.5471 — Tel: (907) 474-8656 Fax: (907) 474.9685
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN. MISSOURI, NEW JERSEY. OHIO, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
l> DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
{ DIVISION OF ENVIRONMENTAL HEALTH
i CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
254-4720
I t. GENERAL INFORMATION
i.
Application Date 9/ 6%S
(a) Legal Description (include lot, block, subdivision, section, township, range)
S$ Lot 61 T15N R2W Sec. 25
Location (address or directions)
fChu iak
(b) Applicant Name Jack Brady Telephone: Home 688-2258 Business 279-7671
Applicant Address C/o Box 77329LF Eagle River AK 99577
(c) Applicant is (check one): Lending Institution❑ ;Owner/builder�l ; Buyer El; Other El (explain);
(d) Lending Institution N/A Telephone
I Address
I; (e) Real Estate Company and Agent N/A
i Address
i
Telephone
(f) Mail the HAA to the following address:
Pickup by Engineer
I
I'.
l: 2. TYPE OF RESIDENCE
I
Single-FamilyJa Multi -Family 11Other
Number of Bedrooms 5
3. WATER SUPPLY
Individual Well ® Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite El Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verifythat my investigation of this Health
Authority Approval 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 Telephone
Address EAGLE RIVER ENGINEERING S RVICct
I:AULE RIVER, AK 99577
Date K M BOX 77499
694-5195
`c °. L .... .
Louis A* Puiera
CE -6736
0
6. DHEP APPROVAL
' _
Approved for bedrooms by
Approved Disapproved Conditional _
Terms of Conditional Approval
CAUTION
Engineer's Seal
Date `® ✓` ?y
The MuncipPty of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
-- - - ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) r 6 1985
IST -
FEBRUARY 1984
CHECKL
264-4720 RECEIVED
Legal Description: La 6/ T IJ IV ,e-4 w
sec ,-5`
A. WELL DATA
Well Classification %� f d,A r,6 If A, B, C, D.E.C. Approved (Y/N) IZ-114{ _
Well Log Present (Y/N) Date Completed Yield 'b' rG pM br e -Y
Total Depth �15� Cased to `/®t Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
a'
i
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
On Adjoining Lots /ao 71
To Nearest Edge of Absorption Field on Lot /'�'o ; On Adjoining Lots Io`)
To Nearest Public Sewer Line 11-1144 To Nearest Public Sewer
Cleanout/Manhole �'0'� To Nearest Sewer Service Line on Lot s
Water Sample Collected by L�> �� ��" ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA _
Date Installed Size �' 19 No. of Compartments
Standpipes (Y/N) y Air -tight Caps (Y/N) y Foundation Cleanout (Y/N) y
Depression over Tank (Y/N)
Date Last Pumped ye'�
Pumping/Maintenance Contract on File (Y/N) �� ; for
Holding Tank High -Water Alarm (Y/N) � Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well / o
/U t
To Property Line
To Water Main/Service Line
Course
Comments
Page 1 of 2
72-026(11/84)
To Building Foundation
/6
To Disposal Field
S
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
145
Soils Rating in Absorption Strata S5—, Type of System Design
Date Installed Length of Field S
Width of Field S� Depth of Field k
Gravel Bed Thickness
Square Feet of Absorption Area `z
Depression over Field (Y/N)
Results of Last Adequacy Test���
Separation Distance from Absorption Field:
To Water -Supply Well ' To Property Line
i
To Building Foundation 2 To Existing or Abandoned System on
Lot —O�w 3oOn Adjoining Lots 2 e)
To Water Main/Service Line led To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area 7—
— Standpipes Present (Y/N)
Date of Last Adequacy Test
/C) /
Comments Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access(Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
Icertifythatlhav the ked,verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company f� �S MOA No.
Receipt No.—.jG�Cj`��i
OF ;9 g
Date of Payment
_ / e
Amount: $ — 4.7`L Engineer's Seal
V 9
Page 2 of 2 Louis A. Buium
• N� °„
CF67'6(C ay
72-028(11184) 7J �jj G1.r