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HomeMy WebLinkAboutKNIK HEIGHTS BLK H LT 4I(nik H ight Block H Lo1- 4 #017-372-04 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: ~'-) t/k} q l 0~r_..q-I PIDNumber: Name: J]~ ~¢.~ E~ ~rv~ .(.¢~ ,¢~/ Wastewater System: ~New D Upgrade Address: ~.~ ~/ / ~)(~ / ~O ~-I ~' ~') (% [=~'/r ' ABSORPTION FIELD Phone: ~ C/~ ~ 7: ¢ ~No.o, Bedrooms: q ~ep Trench ~ St, a/Iow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTI ON so, Rating: ~ ~ 2 GPD/Sq. Ft. Total Depth from original grade: I. ot: ~/ Block: /~~. Subdivision: ~ ~ Dep~ht°pipeb°lt°mfr°m°riginalg~e:i Graveldepthbeneathpipe ~01Fb' FL Township: Range: Section: Fill added above original grade: [ Ft. Gravel length: ~-~ I Ft. Number of lines: Distance belween WELL= ~ew ~ Upgrade Gravel depth: ~' ~Ft. ' Cl~sifi~ation (Private, A,B,C): Total Depth: Cased To: ~ Total absorption area: Pipe material: I 1 ¢,, Ft. Ft. 4 Date Drilled: Static Water Level: [nsta(ler: Dateinsta[led: ~. ~ Yield: I~ GPM Pump Set at: ~ Casing Height Above Ground: ~,.~ ~ ~,. , TANK SEPARATION DISTANCES ~pti~ u Holding ~ S,T.E.P. Fro~ Tank Fie,d Station Tank SewerLines ~ ~ ~'~ ~ ~ ~.~ ~,. ~ :'" Material: 5~.~~ Number ol Compartments: Well I '~ ~ -' Surface _ W~r / //' LIFT STATION LineL°t (~1 t/~' I Size in gallons: ti ManufaCtUrer: ~ ~ "Pump on" level at~ "~" level at: High water alarm at: ,oun.t,on. CurtsiRDrsin ~el ~Eleo{ric~lnspec~ionsperlormedby: Remarks: ~OktS~ ~o~ ih ¢~.. y¢~ BENCHMARK Location and Description: Assurned Elevation: / 0 ¢ ENGINEER'S SEAL Inspections performed by: _,~h¢~or ~yd/~ Dates: 1st ff~' )~ ?1 Reviewed and approved by: /~ ~ Date:; -/~-?~ "' ""*~ ~*'~(E,';;::::,'-"'::' ' ':': 72-013 (1/91)MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN ENVIRONMENTAL SERVICES DIVI$1~ P.O. Box 196650 · Anchorage, Alaska 99519-6650 · "F_e'_~hone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LegalDescription: ~0/~/ ,~/106,~ /L/ J,~y)'~k 7~.~J/4.5 PIDNo.: 72-O13 A (Rev. 9/91) MOA 25 PermitNo. ~2~) C~I0'~'~-'I ~) Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box ~96650 · Anchorage, Alaska 995~9-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report PID No.: C' 0 '- 72-013A (2191) MOA 25 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SWg10251 DESIGN ENGINEER:ROBERT KNIEFEL, P.E. OWNER NAME:EMMEL JAMES N & OWNER ADDRESS:12741 SHELBOURNE RD ANCHORAGE,AK 99516 PAGE 1 OF 1 DATE ISSUED: 8/26/91 EXPIRATION DATE: 8/26/92 PARCEL ID:01737204 LEGAL DESCRIPTION: KNIK HEIGHTS BLK H 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 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). 3o THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ISSUED BY: ~~'~[~.-/,.~f~'~Y~LK,~,~-~ ..... t .... lx / ,' DATE: DATE: ~//~z/ HAAS & ASSOCIATES Construction Services (907) 563-4921 SHEET NO, OF SCALE / ~- YO / HAAS & ASSOCIATES Construction Services (907) 563-4921 SHEET NO CALCULATED BY CHECKED BY SCALE OF ~'~ ~'~ DATE DATE ooo(; LOT 4, BLOCK H, KNIK HEIGHTS NEW SYSTEM DESIGN This design is for a trench system with 10' of rock depth. System Design = 4 Bedrooms x 250 st/bed = 1,000 st. (Due to the variation in the sand lenses, the 188 sf/ bed· soil classification was increased to 250 sf/ bed.) Trench = 50 'feet x 2 x 10' depth = lO00 st, ek. All materials, construction methods and required inspections to follow MOA rules and re.gulations, The contractor is responsible for notifying the Engineer and the MOA at least four hours in advance of ail inspection needs~ Contractor will insure no additions or changes have been rnade to the location of wells and 8ept±c .systems on the adjacent lots prior to the time of constrtiction of this system. If any changes to those systems have occurred, the eflginee~ should be immediately notified for review and possLble changes ~ll be made as necessary. The OL material will be removed to the underlying ~ravelly sand material under any portion of the trench area. The lot slopes down to the west and from the N and S lines to the center. The installation of the trench ~ill have little or no effect on the surface drainage, grou'nd water~ for the adjacent systems in the area. The septic system should be properly maintained to include septic tank inspection and pumping on an annual basis. If a garbage disposal is used the tank size should be increased to 1,500 gallon tank and the tank pumped on an annual basis,, MOA CE 90~030 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGALDESCRIPTION:~'Y~~-, ~1~C5 //~' ~/,/¢-- /~ Township, Range, Section: 1 2 3 4 5 6 7 . 8 9 10 11 12 13 14 15 16 17 18 19, 20 O L -l-~ ~ ~ 6//t7 SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Deplh to Waler Alter /~///,~ Monitoring? . SITE PLAN Reading Date 7,¢' 7,~~ 7,~ ,, Gross I Net Time I Time Depth to Water 5', 7.~- Net Drop PERCOLATION RATE _. ~ (minutes/inch) PERC HOLE DIAMETER __~ ' / / · [~ /' / UERTIFY THAT THIS TEST WAS PERFORMED IN ACDORDANCE WiTH ALL STATE AND MUNiCiPAL GUiDELiNES iN EFFECT ON THiS DATE, DATE: _~--/3--¢/ 72-00~ (Rev. 4/05} Municipality of Anchorage HUMAN 825 %" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGALDESORiPTiON:~m'~Y~ ik ~J¢.5 ~'/¢ 3/,~_- /LT/ Township, Range, Section: 1 2 -- 3 4 5 6 7 8 9 lO 11 12 13- 14 15 16 17 18 19 20. '7-F/¢- ¢--- OL 5>,'/ 5//// :¢~¥ SLOPE SITE PLAN ENCOUNTERED? 8 IFYES, ATWHAT ~,~/> ~ DEPTH? p E Menllorlng? Dale.. Resding Date Gross Net Depth to Net Time , Time Water Drop ~/ Ii ~ z,r_ , ~, 7~ 2, z~~ PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER ~ II ~ , . , TEST RUN BETWEEN ~;~ FT AND '~ FT ' I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON TNIS DATE. DATE: ~/~ ¢ ¢/ 72-008 (Rev, 4~85) (907) 243-2282 FAX: (907) 243-4852 OCTOBER 11, 1991 KEN JOHNSON DRILLING CO. WATER WELL DRILLING PUMP SALES AND SERVICE 38 Years Alaska Drilling KEN JOHNSON 3163 LINDEN DRIVE ANCHORAGE, ALASKA 99502 JIM EMMEL 12741 SHELBURNE RD. ANCHORAGEJ ALASKA 99516 345-5709 RE. KNIK HEIGHTS BLK H LT FOUR ~ATER ~ELL LOG 0 FT TO 7 FT 7 FT TO 13 FT 13 FT TO 58 FT 58 FT TO 60 FT 60 FT TO 70 FT 70 FT TO 90 FT 90 FT TO 95 FT 95 FT TO 98 FT 98 FT TO 130 FT 130 FT TO 171 FT 171 FT TO 176 FT 176 FT TO 178-6 BROWN SILT AND ORGANICS MED. GRAV WITH GRAY SILT BINDER BROWN SAND WITH SOME FINE GRAV SAME WITH SOME CLAY TEXTURE GRAY CLAY WITH SOME GRAY SAME WITH MORE GRAV MED GRAV WITH BROWN BINDER COBgLES GRAY SILT WITH COURSE GRAV SAME WITH COURSER GRAV..SOME COBBLES WATER BEARING..DIRTY GRITTY GRAY SILT AND GRAV..BAILS DOWN WITH POOR RECOVERY..10 FT HEAD WATER BEARING MED. SAND AND GRAVEL.. TEST BAILED 1 HR. AT 5 GPM TOTAL CASING 180FT 5 IN. STATIC WATER LEVEL 148 FT. DRAWDOWN TO 171 AT 5 GPM AND STABLE 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 SYSTEM PERMIT PERMIT NUMBER:SW910325 DESIGN ENGINEER:ROBERT KNIEFEL, P.E. OWNER NAME:EMMEL JAMES N & OWNER ADDRESS:12920 BAINBRIDGE RD ANCHORAGE, ALASKA 99516 DATE ISSUED:10/08/91 EXPIRATION DATE:10/08/92 PARCEL ID:01737204 LEGAL DESCRIPTION: KNIK HEIGHTS BLK H LT 4 LOT SIZE: 43000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ISSU HAAS & ASSOCIATES Construction Services SHEET NO OF (907) 563-492]. CALCULATED BY "~'~ DATE C,ECKEO ~ ~ 5,.~c.~ ~.~, ,'t ~ Z~VIo;JV ~/~/~ ~c~E_ /'~- James N. Emmel i .... 12741 Shelbnrne Road ---"; MUNICIPALITY ©F ANCHORAGE Anchorage, AK 99516 ~ - E~IRONM~NTAL SERVICES DIVtSIO~ ..... ~.F~,. ~v~--~?~/' ,'""' · .......... /~ ~ .... OCT ~ ~ ........ ~ ~.,, . . .~. / ~ · .... ~ .......... ~ ..... : .......... / ' ~ ~...~' ....... ~ ............ : ......... :~ ~ ~-....¢. -~ . ~ · ~ . ......................................... ............... , ............... ...-"" ..-:,..,, ......... ex. . . ~ '~t ~ ......... ~ · . --~ ~:~:-.- .a~L' ~ / x/¢ ~-' __...' =..~ ,,~. ~ _~ ~----- ................... : .... .. ~,~ ~,,~ -~,,- . ...................... :. - 6`0 .................... ~ ,,'Ti'T'~'? :'. ~ , . , 0 I ........ , ~ ~ ......... ,~, ;~,,~, - ~- ~- ........ : ....... "~3~ , .~ ........... ~o' ~ % ~ .... ~~ ~. '-. .... ... . ~ Ot 4[~tI · -;" "'- .......... ~.,~ ......... ~.~ ~,r .~ t ........ ..... ~ ~ ~ ~ .... ~ ~1~,. '~,~'... ........ ,:&~ . . 57~, Io7 Municipality of Anchorage Development Services Department Building Safety Division On-Sit~'~Water and Wastewater Program 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. GENERAL INFORMATION Complete legal description Location (site address or directions) Current Property owrJ;r(s)' Mailing address Lending agency - Mailing address Real Estate Agent Mailing Address Expiration Date: 030097 Day phone Day phone Day phone ~ssothe~emqueste~ HAAwillbeheld~DSD~rp~k~. NUMBER OFBEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank [] ~ommunity 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) 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 less than 30 days old. (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. 4. 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 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 fram 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 M~<-[~r[l~J~N~¢t~,~ [~,,~, Phone Address Mt,,~O 6/?~,,,~r~,' ~¢*~, · ,. ;",~' ..'--,- .... ... Englneers'Pnnted Name ~ r~l't ,.k~.,./.A~./~.~ ~- '~'~"~,'1' Date '~/{~/,., DSD SIGNATURE Approved for LJF' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments ';..' '. WATER AND WASTEWATER ~ : Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ,.~ -,:~--/'~ - ~ 3 (Rev. 12/C0) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage, ak.us (9O7) 343-79O4 Legal Description: A. WELL DATA ' Well type ~*~.~'~-'~ Date completed K~'ff/q ¢ Total depth /fro fL HEALTH AUTHORITY APPROVAL CHECKLIST If A, B. or C provide PWSID # /'/,q. .. Sanitary seal (Y/N) y Casedto t ¥ o ft. FROM WELL LOG Date of test Static water level Well production ~. o WATER SAMPLE RESULTS: coliform . .~ colonies/100 mL Date of sample: Well Log (Y/N) ~/ Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION SEPTIC/HOLDING TANK DATA Tank Type/Material ~ £ c.~- t Tank size 1% w.!.. gal. in. ft. g.p.m. /, ~"- g.p.m. ,)1, mi, Collected by: Number of Compartments t_. Foundation cleanout (Y/N) ~' Date of' Pumping '"~/b/'O' ~ .................... G;-AB$ORFTiON FIEI.~D~D"A1 A' .................... :'**" ' Oateinsta,,ed f/~./~'. SoliraUng (g.p.d~ft~o~ Length 5"0 ~ It. Width "~.. ~:~ ff. Total depth/'~f ft. Eft. absorption ama I~e~ Monitoring tube Date of adequacy test .~ Results (Pass/Fall) Fluid depth in absorption field before test 2. ~ in. Water added (~ ~°tal. Elapsed Time:/H~min. Final fluid depth '~' (~ in. Absorption rate >-- Date installed Cleanouts (Y/N) Depression over lank (Y/N) ~. High water alarm (Y/N) f~,/~' Any rejuvenation treatment (past 12 mo.) (Y/N & type) System type I0~' e.o-kr-ev,~-~, Gravel below pipe lO fl. Depression over field ~' For ~ bedrooms New depth ~' in. G ~'o ~ g.p.d. If yes, give date LIFT STATION Date installed Size in gallons . "Pump on" level ~ in. Da~,~j3;t~-'""--- Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tenon lot 1 ~,u ! ~" Absorption field on lot ( Public sewer main /,///4- Sawer/septic service line High water alarm level at in. Meets alarm & circuit requirements?. On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC:~CLC:;~C TANK ON LOT TO: Building foundation Water main Wells on adjacent lots Pmperbj line /¥ Water service line Absorption field Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line f O ~/c. ' "B-ullding fobndation (~ ~J- Water main Water Service line Curtain drain COMMENTS Surface water './c~ · ~ ,/-- Driveway, paddng/vehide storage Wells on adjacent lots G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance wfth MOA HAA guidelines in effect on this date. Engineer's Printed Name HAA Fee $ ~ ~-~', Date of Payment Receipt Number (R~. 1~) Waiver Fee $ Date of Payment Receipt Number Y IL ME Laboa,G, 200 W. potter Drive DrinkingWater Analysis Report for Total Coliform Bacteria Anchorage. AK 99619.1605 }!p Tel: 19071662-2343 READ IYSTRUCTIOISO.NREYERSESIDEBEFORE COLLECTING SAMPLE Fax (907) 561.5301 nrusT aE CDMPLEnD BY WATER SUPPLIER I TO BE COhIPLETED BY LABORATORY C PUBLIC WATER SYSTEM I.D., p PRIVATE WATER SYSTEM Q teditrams ffn.e lx-irr e -^ A/ tfSo. u ea a 99V6 w. C Srrd lteseler p Send Invoice SAMPLE DATE: If':1'f1��j 913 rF:q Month Day Year SAMPLE TYPE: C Routine C Repeat Sam -pit (for routine Sam pIt with lab ref. an. p Special Purpose SAMPLE LOCATION' D Trcated Water 0 Untreated Water Tin" collected ct .l T..l..J Collected By Analysis shows this Water SAMPLE to be: X Satisfactory C Unsatisfactory p Sample over 30 hours old. results may be imrchable 13 Sample too long in transit: samp:e should not be over3l Rou-s old at examination to indicate rchable resulti. Please send new sample via special delivery mail Data Received �• 24'y3 Time Received 5 Z� Analysis Began Anslydcal Method: Membrane Filter p MM0.MUG 1031500 -AA- I O3150^�I0 2A- �� IIiU� 1 Scotto A.D.LC. "00 ml. Analyst �Result* Anch Fbks Jun 0 Fated Dow. Tim; Client notified of ansatisfactory results: 11 tbootd Spoke ahh Date: Time: BACTERIOLOGICAL WATER A11A.LYSIS RECORD %tMO..MUG Result: Tout Coliform L can ►Membrane Palter. Direct Count Colonin/100 ml Vertfcatloa: LTB BG9 COLIFIRN Fecat Conform Confirmation Final Reported By `:/ Coliformlloo ml Date I -Z)'3 Time 16ZO hn ❑• Fated rvrc-TN.N.. r. C.... i i %1E;GS Membor of the SGS Grouo t3oci ti G"rele de Surve- Vons! 1+ " - i SGS- SRef.a 10314.1001 Chcnt Name Mike N. Andaaan, LE Project Hamel# Lot4 Blk 11 Knick Heichts Cl-ent Sa.Tplc ID Lot 4 Blk 111Cnick Hoightc MaMc Drinking Nater Simpic kanarks: ,t , All DatesfTimea are Aluka Standard Time Printed DaWrIme 03!17:2003 16.07 Colleeted Datetlime 03.'14,!20C3 5.30 Re.:Bed Daterilme 03'1420039^Y 0 Techalcal Director p ,.$tephea CRe!eaud By yv r1w. 7 'lits Allowable Prep Analyi4 anrreur k.cu KL Cnila hlethxd Limits Date Die Init Waters Departacent Nitrate 0.351 0.200 ng,L EI'A300.0 ( 191 03!14103 15 Nia:obiology Laboratory Totai Cclifcnr. 19 CD. No Coli. ecl/Mml. SMIS 9222B Y id3 B6 rMEAS� �� - { - S.O.Od'E issiP�pq o- I aN i4.1 04 ~•• _�31 a 1 , w i.OJ c0��j III ENT SOT 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORIVIAT1ON Complete ega descript on Location (site address or directions)1CS/'-c(a(5 ~"~P,, ~ g,t, Oo~ Property owner Mailing address Day phone Lending agency Mailing address Agent Address Day phone Day phone 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 WASTEWATFR 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 MOACf21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by myseal affixed hereto and as olthevalidadon date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverifythatbasedontheinformationobtained 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 Address Engineer's signature Alaska Water & Waate-~.'at 7320 East. Chester Hts..~ir~ Andhorfi g6,/Alasl(d 99504 ! / / ,'!f' , Phone [e _. -. _ Date DHHS SIGNATURE ~/" Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments "1: ,; /. : 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 (Re',,. 1/91 ) Back MOA #21 Municipality of Anchorage ...... /~,\ DEPARTMENT OF HEALTH & HUMAN SERVtGE$ Environmental Servioes Division MUNIQP^LIT¥ OF 825 L Street, Room 502 · Anchorage, Alaska 99501 · Health Authority Approval Checklist Legal Description: K~J~IC I"~-~ bo~-L( [ ~-/~- /'~ Parcel I.D,: A, WELL DATA Well type Log present ~(.~N) Y~-~' Total depth Sanitary seal (Y/N) If A, B. or C, attach ADEC letter. ADEC water system number Date completed /0////~ / Lo~- Casing height (above ground)_ Wires properly protected ~/N) FROM WELL LOG Date of test Static water level Well production g,p.m. AT INSPECTION g.p.m. WATER SAMPLE RES~S:~ Coliform Nitrate Date of sample: ~"~ I l ~ / ~' ~ Collected by: ¢J1¢ Other bacteria __(~ B. SEPTIC/HOLDING TANK DATA Date installed cl[\°t-- 5/2otq~_Tank size /~,~:-~ Number of Compartments ~ Clea'nouts(~N)___ Foundation cleanout~N) __/k/~. Depression (Y/~)~ High water alarm (Y/N) _ t'-~/~q Date of Pumping S/[~/q8 .Pumper //~ e/--'~O/v4f-O5 /c,,,m p/,~E,- C. ABSORPTION FIELD DATA Date installed ~'/[~,/°~\ Soilrating (g.p.d./fFor~ lt¢~, :~0%~¢'~Systemtype~ /~a~O ' Length _ ~0' Width ~,S ~ Gravel thickness below pipe /0 Total depth Effective absorption area ll0os~ -~"~..¢~¢:, Monitoring Tube present¢/N) F Depression over field (Y~_ Date of adequacy test %tt~(*9 %% For ~3~L bedrooms Fluid depth in absorption field before test ~.); ~" Immediately after~ gal. water added (in.)~ Fluid depth ~~,5~1 (ins) Minutes later: ~¢¢ Absorption rate = ~ g.p.d. ; Peroxide treatment (past 12 months) (Y~ ~O If yes, give date Manhole/Access (Y/N) ~n" level at* "Pump off" level at* · ~ycles tested ~~. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /6)0 '¢ On adjacent lots / Absorption field on lot /0 0 L/_ On adjacent lots /do '/- Public sewer main /'J//~ Public sewer manhole/cleanout Sewer/septic service line ~ ~ Lift station /"J,"//f SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation / 0 ~+ ' Property line / 0 Water main/service line !0 '4- Surface wateddrainage /0~ SEPARATION "DIsTANcE FROM ABSORPTION~FIELD ON LOT TO: Property line Surface water Curtain drain )~J0~6 /0 '+ Building foundation /dO Absorption field Wells on adjacent lots /C~ / 0 ~ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipa~ it the above systems are /n conformance with MOA HAA guidelines in effect on this date. Signature ~% Engineer's HAAFee $ j~ ~'~ Waiver FeeS Date of Payment ~-/~-~* /~"~ Date of Payment Receipt Number {~ ~ / ~ '~/~-~¢ ~ ~ecaipt ~um~ar 72-026 (Rev. 3/96)* I IHI--r-~cJ--i~J'-~: U~I: 42 CTS~E ESI ANCHORF~GE ~l~i~ CT&E Ellv,ronm,,~, Services Inc. C[len! Nmue .ProJ~c~ N~neJ# Client Sample Matdg Ordered By 982348001 AK Water & 'Wzstewatcr Servi¢os Lt 4, Bk I-I Knik Pits $/D L~ 4, Bk H KnJk Ht,q S/D Drialdnl~ Water Client i'*rlntetl Date/Thne 05/21/98 14:09 Collecled Da*e/I'~o 05/18/98 15:55 R~eivnd Date~me 05/19/98 09:2J T~/~I DIr~tor: ~ephe~ C. E{le ~L U~its Ne~hod ¢oW~0DnL ~M~ 92~0 0,100 Io~/L ~PA ~00,0