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Home My WebLink AboutKNIK HEIGHTS BLK F LT 4KnI*k Heights Block F Lot 4 #017-371-04 Municipality of Anchorage Page —/—of �. DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report 0 15001--r Permit Number: k51_ PID Number: Name. 771�in�S w. �C,�P/Sil�l� � BU��r��,D Wastewater S stem: New DUpgrade Systern: c 003 / jEfi dit5'40ST. �'�i SoZ. /� ABSORPTION FIELD Phone' No. of 8 dreams. eep Trench El Shallow Trench D Bed El Mound C Other LEGAL DESCRIPTION Soil Rating D _ Total Depth from original grac Lot. Block r /Sub'division/ / 4—r al gra� Dep:n to pipe bottom from origine. Gravel depth beneath pipe W467/ j%�% Ft. Ft. Township. _lam-�/�l� Rarg._ Section Fill added above original grade. r Gravel length. / 6 FL Ft. _ WELL: New ®O Upgrade Gra fel width �/ Number of lines: Distance Cz'f•5 lines /� Ft. t Ft. CClllaass.sif�ca�lmnn (Private. A,B C Total Depth � Cased /To Toal absorpi ^- a, la Pipe material ralo E72�= ( /� I ✓/T / G '2 / d Fl :/V FI (� (O SO FI. 4-57-? 1 ✓.c Driller. Da e Drilled SM!Ic Water Level Ic'a-ler S�rv�zs Date Installed Yield P�,Selat Gasing e^!Above Gmuno TANK GPM FI SEPARATION DISTANCES p IIjldx 1 STEI` I .. � .. ,'.- .'.,-i..: C iFa: 1_ ,gal tans �lJ From Tank, 11 Well 7 7 Number of Comparlmen6 2- aeF l /ao — — LIFT STATION Water wat _- — — Lo) , �� / `-" — �.-- J . - tf:t', IOr': �.1wuulacturer Line /� FOLlnda: 01 F_" level at Hign ware, curla"r � / / / ---:�+ake8;"' ElectriCa' Inspections performed by Drain Remarks: -711 BENCH MARK a'lon and Description: i os Assumed Elevation. !oD— ENGINEER'S SEAL t, r S & S ENGINEERt0 17034 Eagle River Loep, 0041l 204 � Dates: Inspections performed by:Ees1,�,e"&ska,99577 1st Q 2nd Z91I )fi •' kOL'et'1 A. iCI � �,+.�{," Department of Health and Human Services approval rCJfIP + '+.so '�° '4''^` S-;sll 5 Reviewed and approved by. �)c"Q (n4- Date: 72-013 (Rev. 9/91) MOA 25 SW930017 Page 2 —Of 2 t Permit No. - 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 KNIK HEIGHTS SUBDIVISION, BLOCK F, LOT 4 01737104 PID No.: Legal Description: rJC__ I C01 CO2 85.9 FINAL NEW 54"11 GAL 81.6' S.T. N.T.S. —'1 100' WELL RADIUS TBM (TOP OF WELL) 4 BDRM HOUSE UNDER CONSTRUCTION T.P. (BIRCH _--10' UTIL. ESMT. A NO WATER POUND 1,5o0 GAL r 4R�-��i-\�••llT �i ! 9,r1 ;Zi, �: Fi I �r�' Ydaslaa bODVMd3pOa<o��c•+'. I"€ ,.may 'Ko art A. hu .' f No. 1457 SWING TIES B _A FCO 1' 34' Cot 9' 33' CO2 19' 28' CO3 30' 13.5' C04 25' 26' C05 26.5' 36' C06 70' 52' C07 70.5' 56' C08 73' 61' MT1 53' 33.5' MT2 50' 39' MT3 50' 48' DV 24.5' 26' �on Col -NEW TRENCHFG / cos ✓/ . ` , P "! u ��i� MU Y'C tiJ1.Lt.^,Ar:✓ °.SF\: •5CC^?1�2i.��1��1 � JUY }�•J� ••.'•1 {,n .:• . LVYTq V.�04 ¢nf+n.u�+t3�4iV khWfu c 1,5o0 GAL r 4R�-��i-\�••llT �i ! 9,r1 ;Zi, �: Fi I �r�' Ydaslaa bODVMd3pOa<o��c•+'. I"€ ,.may 'Ko art A. hu .' f No. 1457 From ; ALPINE DRILL 507 345 0202 LOCATION OF WELL 41HInCtl XS®ySb�Y:YiQ�uWrtC:'C-7'•'*'-••��;;�ur JtiltApttiYs.' BOROUGH fiVSDI�Vi 4oNr+//y, LUT KOPK LOCAYION15KVIV-1: DEPTH: MEASURED VROM;Dcasing top nground surface BOREHOLE, DATA: Depth Nlatedel Type and Color From To 4 K o P d02- Jun. 13. 1953 C13: 31 At9 P02 STATE OP ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION Of WATER WATCH WELL RECORD 815CYiON OW WELL OWNER: 6ECTIOhi TOWN0J� RP,UE MERIDIAN WELL t71:PTH: DATV OF COMPLETION Llopm of hole:„ DEPTH TO 9TATIC. WAT13A LEVELt top of cesing M ground surfaoe -1�--�5`---- y R1ECtlb7 or DRILLING.i �-4,air rot--wy E,7 cable tool USE t9f- WELL; est iio le; tic: (� irripatlon E,7 monitor .a t_.1_tibViy.Sur:»l.r..� othrr.�m.__.--...w..n.� -�--•�-�- - ----.� C/1Si�C7 bill'".•' : —�_ it. Man): in. to ft In. to 0 ft r� WELL INTAKE UIIENINrii TYPE; opan on sor�aned ?. f'� ,` E,7 periorated C) upon hole lr;pthi of n cn'n 1; _ 4t r;f ft£E td 'f Y P#:: �? _ U:i+rn; _ in. Slettntecn OKIWE,. :[.t-) (. �I lume \.ser;._vIDepth to top: 0110UT TYRE; r� _• Volume: Depth: horn T_ �ft to _ _ it I�EVEicill; EEd�ftiiLT,HUCt: i Duratiu:r n P:IMPIU� LINA.1, AND YIELD: I SW_ it atter _ �hrs pumping, Z Lo— —gpm PUMP INTAKE OLPiH; TM ft Horsepower: _ WELL UISJVVk,'(;TCD UPON COMPLVI`ION? d,YES D NO CONTRACTOR INFO lATION: usinessii a 9'., pn,lure n utFor ze espre tatry T iia'te y REMARKS: PLEASE NIAIL WHITE GOF�Y OF LUG TO: DNR/DIVISION OF WATER PO BO)" 772116 LAC9Lk RIVC11 AK 99677.2116 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 WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930017 DATE ISSUED: 2/22/93 DESIGN ENGINEER:S & S ENGINEERING EXPIRATION DATE: 2/22/94 OWNER NAME:BULLARD THOMAS W & CHRISTINE H OWNER ADDRESS:8031 SEAVIEW ST. ANCHORAGE, AK 99502 �U PARCEL ID:01737104 LEGAL DESCRIPTION: KNIK HEIGHTS BLK F LT 4 LOT SIZE: 43500 (SQ. FT.) NUMBER 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 343-4329 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: A DIVERTER VALVE MUST BE USED TO SPLIT THE EFFLUENT FROM THE SEPTIC TANK EQUALLY TO EACH TRENCH. RECEIVED I ISSUED BY DATE: DATE: G71—.i1�-1ti 11:3G I— p1v111lf nap -.+ blvrlN valve i 1 BMW NM 040dw valve Blom i 1 I . 1 4.1111, I�E.(D' �, 1. ,�,,...... �,..� • �•t mol LOW', I'. Leech Fllld 'i Plelp t �• v 1 de'u' n �e. A P.I 'i. YAANKNN b T#"I drift IAMI lY•F1" SPECIMATION GUIDE,, N3 N4 w O so TANK N6 M c LANK REMOVE INNkIt 6' 16 0. 0�0 YUKN IIA OM 0 OAP t]At' TANK TANK OUJ CLOSED POSITIN STOP ION N g "Cl(v■ QWRCL Tddlvnt flow, lull wisp h"MA end Itrn Valve nam, Afe6w/ 6MW flow Mllllm• To 0/11hil flow Nom MI eulloll, lu+t rem vt "Iva atom I?oln eueMDty' WARRANTY An Nos vi dwis No ju ennatel el dWeto n4rl itbl Irani 611hn4 le? lobe? eine aad MW 4910341" n9Wr" le tWm 11iWWnU kelp the r ie?eol rlll 1.0I be sdvmC ►+y M Me fwf nebMny fv KmIf4A to ("WoF ont of yaodlmla �ngy1i�11 by l'IpE Nba UlaelW4. Inw.re Fil 01 -.Sb -1 Ci 11;131 1 - APR -M-192 - APR-M-'92 ®9x55 IDtWESTM4 UTILI711:S 75L NO.2W- 722-9477 spECInCATION GUIDE � �ii�rrfir yr DiVERTER VALVE NOW AVAILABLE IN p,V.C. +NDS 675 NDS 675P bbd9 M/02 For septic tank leach fields, irrigation and father applications Here's the %Implest, etnmgeat, most economical fivettOf VGIvG ever Invented for ank leach elds and other applications In dralnagetic tand IOUs - lion Us -tion systems. Made of lough ASS molded plastic that will not shatter, band, rust or corrode. Lighter In weight. Sasser to handle and out. Less expensive to ship. With diverter valve stem, you can control the Indl. viduals and up to three outlets, In any combinatlon. WI1h 0 three.way vatve stem, you divert Ilow to any two outlets. 7o permll flow through all outlets, Just lift the valve stem Out of the aeeembly. ' ' To drain Install, luplings sort Plastic standard 4" regular reducer fittings to Inlet and oullats on the four-way distributor box. (unwanted outlets may be sealed by Installing outlet cap.) Out diverter shield to desired depths and Install In top %leave of distributor box. Insert dlvertervatve stem. Cover with diverter shield cap. 4N .N VAS Dr'c%ERTER VALVE Here's the simplest, strongest, and most economical diverter valve ever invented for septic tank leach fields. It is made of tough molded plastic that will not shatter, bend, rust, or corrode. It is lighter in weight, easier to handle and cut, and less expensive to ship. V�'Mlwj FUNTIONAL The diverter valve stem flow may be controlled to individual or multiple fields; (up to three) in any combination. With a three way valve stein, flow may be diverted to any two outlets. To allow flow through all outlets the valve stem may be removed from the assembly. EASY TO INSTALL Connect 4" plastic sewer and drain pipe to inlets and outlets on the four way distribution box. (Unwanted outlets may be sealed by installing outlet cap). The Aiverter shield which houses the diverter stem may be cut to desired length. CLOSBD 1 2 3 13 11C3 0 TANK 6 f20flN C+4 GAP T TANK ADAM TANK PGS DESCRIPTION PART NO, PKG. QTY. MATERIAL LIST PRICE EA. UIVERTER VALVE mverterva1ve " 4"Aiverter valve 575Y 4 ADS 83.50 VDiverterWive 575 4 PVC 83,"50 1-1., YIAPMO Listed iol j 5puilinaon: NI35 Y575P, S7S PVC or AHS iNverte Vnive, Multi Ou11e1 Pones Vaivc Si�ro and blvrnu®SLickl. �ti E (807) 883.3315 440 WEST 40TH AVE. P.O. BOX 92162 ANCHORAGE, ALASKA 99509 To: WESTERN UTILITIES SUPPLY CO. of ALASKA DISTRIBUTORS OF WATERWORKS AND SEWERAGE SUPPLIES There is a FAX message on the way from: Western Utilities Supply Co. P.O. Dox 92162 Anchorage, Alaska 99509-2162 i90'j-4F.'d-xRlKl�avif6A7_R�7-77'PR1 FAX NO.: - .,54/zL- —6 COMMENTS:e�� DATE:Avvjs- PAGES: � TIME: (includ ni g lace sheet) January 26, 1993 ROBERI SHAFER. P F ROGER SHAFER. P CIVILENGINEERS (907) 694 2979 FAX 694- 121 ' HEALTH AUTHORITY APPROVALS Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES SEWERS WATER 825 L. Street MAIN EXTENSIONS Anchorage, Alaska 99501 SEWER & WATER INSPECTION REFERENCE: Lot 4, Block f, Knik Heights Subdivision Request you issue a permit to drill a well and install a septic system to serve the proposed 4 bedroom house on the ENESTUDIES referenced property. Attached for your review is an ANDD REPORTS application for permit, soil logs, and a site plan/design. As can be seen from the site plan, there exists sufficient room on the property for the original and at least one WELL INSPECTION FLOW TEST replacement leachfield. S I lWe do not: anticipate any adverse effects on neighboring !properties by the installation of the proposed system. SITE PLANS iIf you require additional information to complete your review !please contact us. ;Sincerely, ROAD DESIGN SOI -TEST PERCOLATION TEST STRUCTURALS MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ROGER J. SHAF R, P.E. 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 I" = 40' SITE PLAN —j sooY�'°N�R r i '� Gi • n o v rrl Y P9 0 "� ; • o ® -VI rp i Y Municipality of Anchorage 4 DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR:_`=l-Ll—c��1 DATE PERFORMED:s�l� Imo' LEGAL DESCRIPTION: L-4- 0,1S, Township, Range, Section: H SLOPE SITE PLAN 1 jFET)) 2 DO 3 / 4 5 6 d 7 8 / 9 10 11 . 17 18 19 WAS GROUND WATER t� I ENCOUNTERED? S IF YES, AT WHAT L O DEPTH? P E Depth to Water Alli Monitoring? FYO Date: Reading Date Gross Time Net Time Depth to Net Water Drop V5 Ito to *"5's(o _ Ito Ito 20 PERCOLATION RATE 9�4 (minutesnnch) PERC HOLE DIAMETER TEST RUN BETWEEN Is FT AND V FT COMMENTS PERFORMED BY: LEN G 1 N U-3UC.; CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Fn qFn le Rivcr Leta'IPGU ACCORDANCE WITHJ{ I§E(IV if�I�qI ,N If A IL,E�1h7�.rIN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) J'J 7 a� Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST y � •� r,c,t_Lt� 1. r�11n�Ela ° ��, to 8215 a ti 061° .<<i' 7 ®®��➢a�`��DBBa eoJ OGe�at�� PERFORMED FOR: f,--0 —DATE PERFORMED: LEGAL DESCRIPTION: �� IGPJ I fs 7 • Township, Range, Section: 1 Q PTH SLOPE SITEAN 17 - 18- 19- 20 COMMENTS "SOI -4 WAS GROUND WATER Depth to Net Water Drop ENCOUNTERED? '2 - S L IF YES, AT WHAT 0 DEPTH? P E Depth to Water Aller Monitoring? :1��/ Date: S L . ___-T Reading Date Gross Net Time Time Depth to Net Water Drop '2 - PERCOLATION PERCOLATION RATE 3/ (minutesnnch) PERC HOLE DIAMETER TEST RUN BETWEEN 5 FT AND G FT PERFORMED BY: 5 & 5 ENGIINEE:RING 1 2 J CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle Rivor Loop Road No � �Z.a cl ACCORDANCE WIydP.�}I�` E[�l}�I�I��L GUID�I SIN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) �3'v Municipality of Anchorage Development Services Department Building Safety Division U Onsite Water and Wastewater Program 4700 South Bragaw Street 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 Parcell.D. 017-371-04 HAA# /25DgD4 Expiration Date: If—'19 —O6- 1. GENERAL INFORMATION Complete legal description Lot 4 Block F Knik Heights Location (site address or directions) 12920 Shelburne Road, Anchorage, AK 99516 Current Property owner(s) Thom & Christine Bullard Day phone 345-7176 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 12920 Shelburne Road, Anchorage, AK 99516 Day phone Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners. 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 less than 30 days old. 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. (tn, 11W) S. 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 Health Authority Approval Guidelines for 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 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Ena. Svc. Phone 272-8218 Address _P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date Engineers Comments: In conducting an adequacy test,/ attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of 4.6k the test, and separation distances measured to readily identifiable features. The operational life of all i GJ,.•' wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions arc ' outside the control of the evaluator of this em. All cyst systems eventually fail and satisfactory test results i do not guarantee future performance of the system, nor do they guarantee that there arc no hidden defectma„1._...". , or encroachments. PES can therefore not provide any warranty for future performance nor give any j Ste estimate of how long the system will continue to meet the operational requirements of the ADEC or # C 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 . 1 whatsoever. 1. _ 6. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Additional Comments Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory )en R. Pon No. CE 814 bedrooms, with the following stipulations: WATER AND PROGRAM Maintenance Agreements Supplemental Engineer's Report Other p By: l /z11� �• Original Certificate Date:l Expiration Date: Reissue Date: (R„ 11M) Municipality of Anchorage • Development Services Department Building Safety Division On-SRe Water and Wastewater Program 4700 South Bragaw Street P.O. Box 195650 Anchorage, AK 99519.6650 www.ei.enchorege.ak.us (907)343-7904 A. WELL DATA Wen type P HEALTH AUTHORITY APPROVAL CHECKLIST If A. 8, or C provide PWSID # Date completed 4128/1993 Sanitary seal Y Total depth 212 ft Cased to _Zg$_ft FROM WELL LOG Date of test 4129MO93 _J'&P Static water level aw l'73 It Wen production 10 9 -p.m WATER SAMPLE RESULTS: Coliform -&—cokmies1100 ml Nitrate 1.58 mg/I Well Log X Wires properly protected Y Casing height (above ground) min. AT INSPECTION 5/542005 185 It 3.1 9 -p.m Other bacteria 0 coloniesl100 ml Date of sample: 81512005 Collected by: Laura Pannone Arsenir NIA mgll B. SEPTICIHOLDING TANK DATA Tank Type/Material Anchorage Tank Steel Date installed 4128/1993 Tank sae 1500 gal Number of Compartments $ Cleanouts X Foundation cleanout X Depression over tank tj High water alarm NIA Date of pumping 81442005 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 4429M993 Soil rating (g.p.d.lflz or fe/bdrm) Q�'A. System type Deep Trench Length 141 ft Width __ It Gravel below pipe ,¢_ It Total depth Lit Effective absorption area iMle Monitoring tube y Depression over field � Date of adequacy test 81342005 Results (Pass/Faiq Pass For 4 bedrooms SeEa �UT5SGc-T(OA) Fluid depth in absorption field before test 011010 in 4 Water addedol gal. - v New depth2al/O in. Elapsed Tone: 1440 min Final fluid depth 011010 in Absorption rate >= ¢QQ_+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) _1Q If yes, give date (Rev. 1 trop) D. LIFT STATION Date installed "Pump on' level at Datum Manhole/Aocess in High water alarm level at _ in Meets alarm E circuit requirements? _ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanklllR station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public ewer main 100+ Public sewer manholetcleanout 100+ Sewer /septic service line 60+ Holding tank 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 8 Property line _ f" Absorption field 10 Water main 100+ Water service line 60+ Surface water 100+ Drainage 100+ Wells on adjacent kris 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 100+ Water Service Ane 60+ Surface water 100+ Driveway, parkinglvehide storage _ 20+ Curtain drain 100+ Wells on adjacent lots00_ F. COMMENTS G. ENGINEER'S CERTIFICATION QIP' 44%� - , U:,,,14 -� 0 .• I certify that I have determined through field in spectlons and review of Municipal records that the above systems are in _ conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Steven R. Pannone. P.E. �? =ti to en ac e o rl r;�. Date 3��S�t2S ��"�� 4�....... HAA Fes S.� Date of Payment Receipt Number (Rev. I IN9) Waiver Fee $ _ Date of Payment Receipt Number S� °OZ 00 �E. 935.00 6-�Ec ) > S994.72YWE,0S) O m b",76 0WOP,) /45.00 MEC.) J6 �1 No a rrL a J �- �t SON L I� r _4 . 0. �v1 NS� r D IQ I N � o ° n O I D O Cr)y /45.00 <C'Ec S, 0002, w "E. <b<rsis) 1 i441.8G <P O S sfico. ,� 5'HEG �U�C /t/E �'OAO 96 m Is A C (D o. DH 05(1• h (D N :4 O a F W Wmr•r o Wrr a'O rtW ((D N N El °rano N a C O.N �.:1o(D rr O e+1 W C: cMILO m (D ft (D WN'J En O rr (D maGfD ma0o' ar (A rr K E m M 0 a ? N fD £ O0r rr a a H. PI m nr E H r• rr m 0 m 0 fDawrr a rr H f9aa .`ri a, rr fDam rr r, a D+ o ct ?r(D w rr m nmm a a 0 N r o \ � r � O �•� n i w s� v v �°' � D� N o' I Q� • • 1 20 1 m: •to •��` f� D m �Gl �' � o. p � i a'a � w �e � �3� ��S •�4 r lO r I� H pp�"2.u 1 rl V A V- a M M O • `� o v •-.. o a s w n a o r Ln � V• a 0 M � A M � � � � `1 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 1. D. #1- Q HAA # enc' -1 c) GENERAL INFORMATION Complete legal description Lot 4; B!?ock "F"; Knik He'ghts Subd.vv.i5ion Location (site address or directions) 12920 She2bewne Road Anchoitage, AK Property owner Torn BuUan.d Day phone 271-2700 (w) 345-7171 (h) Mailing address __ 12920 Shabwme Road, Anehokage, AK 99516 Lending agency — Day phone _ _ Mailing address-- Agent ddress— Agent — Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well XXX 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 WASTEWA T EIS DISPOSAL: Individual on-site XXX 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 n21 5. STATEMENT OF INSPECTION BY INNGINEER 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 funtherverify 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 iDsnection. Name of Firm Address 5 & s ENGINEERING Engineer's signat&VIe River 2 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for in Additional Comments bedrooms. Phone71 Date-2-9--9�/- bedrooms, with the following stipulations: ?�.`.",x{"ry' %� §."' ,..' $r;�`.# _ s r41f'f�{ai ilftke% y� ` Via. d?„u eFssi low-, + - s<_ar �r Y+.�',1"G� ii 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 courtesyto 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) 7aCk MDA.: L. Municipality of Anchorage AAL NZA Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo -r 4 &ocK F KJIK NFir SS Parcel I.D. A. Well Data Well type 12!VA7�_ If A, B, or C, attach ADEC letter. ADEC water system number_ /VIA Log present (9I) _Y_E,�_ Date completed —4/Z 'd i3 Driller &LPii,.1F O'21wy6 E0 T, Total depth _ Z I Z ' Cased to Zoy'_ Casing height Sanitary seal (j)N) YES Wires properly protected((Y N)__E� Date of test Static water level Well flow Pump levell FROM WELL LOG AT INSPECTION - y/23 We _NEW LL-. 1�3' SEC Lc)G z)Ai7-,q, —�ZQ—9-P.M. UK SEPARATION DISTANCES FROM WELL TO: 2' Septic/taatdiag tank on lot IIS ' On adjacent lots _// 00 �1 Absorption field on lot I % On adjacent lots , / OU it Public sewer main r%S �f Public sewer manhole/cleanout /QO _ Sewer service line ZS r� Petroleum tank /VON E KA Ly_j u WATER SAMPLE RESULTS: Coliform Nitrate D, L 6 1Other bacteria O Date of sample: 3 - 3 ,5 Collected by: T S G, �,, I (—Cx Jy B. SEPTIC/ -TANK DATA Date installed �I/ Z_ q 3 Tank size �SQD 6AL Compartments Cleanout(Y/ ) - f -E 5__Foundation cleanout Y&) _'KL_S Depression High water alarm (YO Vy Alarm tested (Y/N) Date of pumping YSE1_1A C. 1 y6Ai C OL() Pumper SEPARATION DISTANCES FROM SEPTIC/WGt-9+l4&TANK TO: Wells on lot 9 ' O f f J� --On adjacent lots.. /h(� �f' Foundation To property line 5,7 Absorption field_ i� Water main/service line Surface water/drainage _�Q� 9- 72•026(W3)•Front CONTINUED ON BACK PAGE C.LIFTSTATION NoOe P9ESC—.!-U Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DIST Well D. ABSORPTION FIELD DATA LIFT STATION TO: On adjacent lots Manufacturer Manhole/Access (Y tested off" Level at Surface water Date installed 41 2Y 19 Soil rating (GPD/Ft2) D, 4S— System type T-Z6AJC Length. 4� r , Width -:3/ Gravel thickness S r Total depth �1 Total absorption area 1410 Cleanout present &/N) �S Depression over field (Y/@) --Ua Date of adequacy test 5YSZM /- I Y6AfC vUD Results (pass/fail) —for —Bedrooms Water level in absorption field before test /U After test _ /)//4 _ Peroxide treatment (past 12 months) (Y/N) IUOtiJE Af1U6C-J/J If yes, give date _ IUTA _ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: r Well on lot /17 —On adjacent lots Z It Property line /01 �_ r To building foundation a� —To existing or abandoned system on lot AJ6M6 PIZ6 SEp.JL On adjacent lots Z -O r r _CutbankWater main/service line /0 Surface water Driveway, parking/vehicle storage area /4- _ Curtaindrain MoLL Woc-- iy E. ENGINEER'S CERTIFICATION I certify that / have checked, verified, or Signature1T5 Elves Engineers Nta E:a ' r Lao Goad No. Date Eagle River, Alask 457'7 -F— to all MOA and NAA guidelines in effect on the date of this inspection. HAA Fee $ Date of Payment "PA (� Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number COMIVIEPICIAL TESTING & H-4NIGINEURING CO. L.Am-QF�ATCRY SERIIIC-As AL IL - ), P,�) o t D r'-, ik Cllr: Ai-, a I s TL. L-.-=__ -'-- 1�_omll JK- RFAD - BZFO,�L (--,LL1:;- r,` C5"fill aF U -B L I C IV A If Z R S Y S T.F,% IT LD, .�A-N-�PLF DATE. V TYP�: T ter .-j Relpear. (t -or routine: with lab rer. no. spec;a! Pur-po�-. Collcctc� SANa'LE LOCATION e c, �ad Sv 2..0! 0 C) B, A c T El1 - L 'i -L YS TS L 0 C, 1 V,'A T E R A --";A LY S T S RE C 0 D TMG - VAU G R e s,:!,: "rota; C c:; 1 -1: LTJB BGB Fec2i Col"11-m T;=e CC . PART ONE OF TWO: s G S REMAINDER TO FULLOW sa s f �i Fa,^ 17sp. too long in U��— be :)N - r -,?j �rc;l rs c t nd�ca. sa-', 4� t!�c� Rcrce-,k S7 B, A c T El1 - L 'i -L YS TS L 0 C, 1 V,'A T E R A --";A LY S T S RE C 0 D TMG - VAU G R e s,:!,: "rota; C c:; 1 -1: LTJB BGB Fec2i Col"11-m T;=e CC . PART ONE OF TWO: s G S REMAINDER TO FULLOW LtiL !�N�t 906 CT&E Ref.9 Client Samplc 1D Matrix (_'.lientNhmQ Oidercd Dy Projec(Nume Projectfi PW81D Commercial Testing & Engineering Co. Environmental Laboratory Servietts LABORATORY ANALYSIS REPORT 94.1247-7 IA 13 'IF" KNIK IW[Ggf`; S/D WATER S & S ENG1NEJ1IktNU R. SIDU"ER UA — ---------- tiamp I c Remarks: ROTTFINE SA�IPU C01 I EC IFD lltr! S S. Paramet%,-r WORK 0! der 76883 Vtiot&d Date 6, 12: ID hrs. Co I lected D-ttc ')3/23/94 !a? 20! 0 0 hrs. Receivedl)atc 03/24/9-1 !�,j 09-.3o hn. ledwical L)itc,,.tur 1;TEP1ITN C. ! DF 'RCIULS�A Lill, ()C: &auln Q1181 Method o.66 mg/T- LPA. 1532/100.0 Allmvrible Ro. Lm,qs DoI Xy, C Iflif. Ste Special hiitmalons Above t IA :Urwvai!UVjle se4a saiiipleRwiwfkq Above NA -Not Analyzed limit, L'(=Less qlw11 �q D = Seco nclary (lilution GT= Uealei Than 6 H33 6 Street, Anchoreigo, AK 996113-1600 Tel: (907) 662-2343 Fax'. (M) 61-6301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA