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HomeMy WebLinkAboutMAJESTIC VALLEY ESTATES BLK 2 LT 1 GREA, ER ANCHORAGE AREA BOR~.dGH O Department of Environmental 6~uality 3330 C Street Anchorage, Alaska 99503 INSP/E~TION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ::.'./_ ._ SEPTIC TANK: DISTANCE /Z~ ~/' FROM WELL : MANUFACTURER INSIDE LENGTH ~) INSIDE WIDTH SE:EPAGE ~ _ NUMBER OF PITS / . DIAMETER__ LINING MATERIAL ,/~'¢+~'</ CRIB SIZE: BUILDING FOUNDATION__ ~:(L/j. ,~.~_,~ MATERIAL LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPACITY./] ~''~-~'~z~'~ GALLONS. OR WIDTH '-~ DIAMETER NEAREST LOT LINE__ LENGTH , DEJPTH DEPTH . DISTANCE FROM: WELL TOTAL EFFECTIVE :50~""~ ~ ABSORPTION AREA (WALL AREA) ~ ~'~ SQ. FT. ADDITIONAL ABSORPTION TYPE CONSTRUCTION BUILDING NEAREST FC)UNDATION LOT LINE CFSSPOOL OTHER SOURCES APPROVED DISAPPROVED__ NEAREST SEWER LINE __ REMARKS DEPTH DISTANCE FROM: ? SEPTIC , SEEPAGE TANK /O~-~, SYSTEM //(~')-~ DISTANCES: LOT SLOPE: REMARKS: Form No. LQ-D31 DIAGRAM OF SYSTEM, ,~ //~ f-.~ . DATE_ E:,E'iF:'FtF{:]'MEI``[T ,.:' t.IEFII...TH F:II",IE:' IZN'v' l !;?.l.]l`.!["l~il`,l'['FIL RID]"I:}Xi:T t O1".1 25'J.~1 El. '1'UE:'OR RE;'.., F:IF`[CI-IOF:!FI(7~E., F)i<. tFF I .I LOC:FIT I ['il'-`[ L_ E G R L LOT S]EZE ._ . '"'"-" - rF~EN_.H 'T'¢I::'E OF '_".:;L-):[L RECf~F,'E]'ICI``[ :'r'_'.rE. I1 I~i;: "' .... MI:-t;:-,',IP1UI"I NL,ti',IBER OF E:EE:,E:OOM:~; = -"J: '}:O]EL RR'I-II`,IG (rE;Q F 'I" ,.-" E: R :: ..... 'L;::'Y: 'THE RE6!U I RED c'T,..,.. ZE OF '['tie SO :1: L RE:SORF'T I O1'.,1._.,c~¢c"['EM..., I F(;: ]'FIE L..E~.NGTFI [) I MENS :[ Ol'`[ Z S THE LENGTH ,:: I N FE:ET ) Cfi:' ]"H,E TRENCH OR £:,RF:I ]; i'.`[F' :[ li;i I..D. T'HF£ E:,EF'TH OF i::1 TREi'.,ICH OF.' PIT :(:~; TFIE E:,ISTF:INCE B[ETHEE']",I THE..SLIF.'.r:'F:ICE OF:' THI; GROUN[:, FINE:, THE E~OTTOi'4 OF-THE: E::.,',CFtVFTT]EON ,:::[1:,1 F'EET'). THERE ]:'.:~; NO :C..,E:"F IqZDTFI FOR TRENCHES. THE GRFI'v'EL. E:,EF:'TH ]E :E-J; THE I"1 :[ N ]E MUH [:,EF'TH OF GI;:'.F:IV[:4L E',fETI.,.IEEI`~' Ri'-,ID THE 8OTTOM OF THE EXCRVRT]EON (IN F'EET). I~: ~: n:;F~ If..J ~: [~.". tE if_';:, "~; F~: IF:" "~- ]: ,Z? T' ~c::'~ ~'..Jl ~r:::.". :~: :~: ~L:.". E~': .... :::L E:I-~C:I<F: ]E I.~L. I NG Cfi:' l::lN'-r' GM'E;,TEM H I THOUT D I I'.`[FIL I N'SPECT .1: ON FIND FtF'F'RO'v'F:IL E:,EPF~R'I'MEI',`['F I.,.IZl...l_~. E;E ':ZUE:JEC]' 7'0 F'RO2:,EC'UTZEff.,E MINIMLIM [>If:;TF-iI'.`[CE BETN[::.'EN Ft I.,`[ELI.. [:-lf.`[[) FIN'T' Oi'.,I-SI'f'E :;i;EI.,.IFIG[:". j. EjlEf F:'EET FOR FI PR:[',,,'FIT'E HELL. OR 2C¢Z~ FEE]' FOR Ft F'UE:I_IC I,.I[ELL. HELL LOGS RRE. F:E6!U]EI~'.ED laNE) MtJ_'.::;T D[i.' I:;.:ETURI'.`[ED TO THE [:,F£f:'F'IRTP1Ei'.~T OF THE HELL COMF'EETION. :~;i::'EC I [:' :[ CRT ]E ON.?, FtI'.,I[:, COI'.,ISTRLIO]"]: Obi D I R(]iRRi"IFJ~, FIRE F:I'v'F:I .]E LI::IE~LE :1: iq:E; ]'FII._L fat ]: ON. IF:" ifil.:: ~: f.'ll Z 'If" "..,," [=::1t L. ]iL' lC::.,, F:;' ~]::~ ~:".'". ~Z3f ~..~ EE %.* IE; ~:n'lt I(.:( ~,::' E;Rt ~:']Z, Ii-"'] ]E :~.'; .%!;; tr...~ ~fi!EZ I CERrIF'¢ TFIRT :1..: :[: RM F'F~M]ELIlaF.: 1.4ITH THE REQUIREMEN'T'S FOR FORTH E',V ]"F.IE MLII'.,I:[ CI F'FII..~ I T'T' OF F:INCHORFICiE, 2.: I MILL. INSTFII..L '['PIE SVL:':;TEM ;[l``[ FICCORDI::II`,!C:I:E L, II'f'H THE CODE."~;. 3: :[ LINDER.~;TFII",!D ]'HI::I]' TI"~E ON-'.~;ITE SEI4ER S"r':ii;TEl'"i MRV f;:!EtT.!UII:;.:E ENL.laF:L:JEI"IEi',I]' :IF THE i:;::[:]'J~; ]J DF.:NC:E I ~i; I';::EMOD[£L.EI} TO I F,ICLIJF;,E i'IORE THt::IN ]: BEDROOM::.";. E GEO...CHNICAL 8' DEVEL.,-,)MENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 CO. I?ussell Oyster £~rl Ellis (~94-2774 S0)L LOG 0Bs-2280 ?,oils El' Foundations Land Development PeFformed for: Leg81 Description: Lot 1 '!.. ........ ML - Silt topsoil with roots and orga~CSo Name: CHARLES & POGANY DEVELOPMENT Tel, NO, 694-2334 Mailing Address: Box 363 Eagle..Riv?~{!_~Alas]_~a 9~957~7 Block~ Majestic Valley Estat~.~ ...... sq. fto/BR GP - Sandy Gravel with cobbles to 12 inches. Material very angular and quite loose° 30 inch boulder in side of pit. 125 'sq. ft./BR GM - Silty Sandy Gravel 225 sq. fto/BR SP-SM - Silty Gravelly Sand. Fairly loose. Sand fraction quite fine° Bottom of Pit 200 sq. ft./BR ,~)~;~,) !,later Encountered: Yes No 7J~ )f yes, what .~.< ,~,I D]stallation: Seepage Pit .......... D~-~i~l Fte'~d J]Joi~m~ilts: Pit measured approximately 3' x 10' :Ln plan area. All~ sides of pit logged the sa~eo by: Date: 6 oct. 1975 by A & L DRILLING COMPANY BOX 97, EAGLE FIIVER, ALASKA 99577 * TELEPHONE 694-2588 OWNER OF LAND [' ?7/,/Z:?/~-, ./' ;i'-t:,t;,/i~ DATE-Started Ended PERMIT NUMBER DEPTH OF WELL 'ii', c LEVEl. OF WATER FT. ? DRAW DOWN FT. KIND OF FORMATION: From '; Ft. to -~Ft. :, , , /!i:, Frolll Ft. to ,) '~Ft From '2' Ft. to ~: -' Ft. ~h ,> r/:n(0 "' ~ ' / ,: /lQ.- ~:~" ) . From Ft. to: l: Ft. From ~ Ft. to /'a h Ft From / · Ft. to , :'dJFt. From: :. · ~ Ft. to :',it, Ft. From i Ft. to ,i' ~>' ~Ft. From :;" ;~:~ Ft. to '~ :') OFt. From : :'Ft. to .~ © ~'Ft From .:'"'~;'~ -Ft. to ~.0 Ft. From~Ft. to Ft From Ft. to__Ft. From Ft. to Ft. From Ft. to Ft. & o/.i/) Froln Ft. to.__Ft From_ Ft. to Ft. From Ft. to .... Ft From__Ft. to Ft. From__ Ft. to Ft From Ft. to__ Ft From Ft. to Ft. From Ft. to Ft From Ft. to Ft From Ft. to Ft From Ft. t o.___Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to_ Ft, From Ft. to Ft. From Ft. to Ft. From Ft. to_ Ft. MISCL. INFORMATION: '; / ~' / /:/ i,,:~.,'~ · i!!;"': ' DRILLER'S NAME ': ' b) DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759 OWNER OF LAND ADDRESS , [t;: DATE- Started ~ Ended PERMlT NUMBER DEl'TH OF WELL ST..\TIC LEVEL OF WATER FF. /' [JRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From Ft. to Ft. ~,,,)~ .~ (,'.jv/?l From From Ft. to__Ft. From~ From__.Ft. to__Ft. From__ Ft. to_ Ft. to_ Ft. to_ Fl. to Ft. to.___ Fl. to FI. to Ft. to .Ft. to.___ Ft. to From__Ft. to__FI From FI. to__FI. From Ft. to__Ft From Ft. to Ft From__Ft. to Ft. From Ft. to.__Ft. From Ft. to.__Ft From___Ft. to___ From _Ft. to_ From _Ft. to___ From __Ft. to_ From Fi. to From Ft. to From__FI. to Ft. Ft _Ft. Ft Ft. Ft Ft. Ft Ft Ft Ft Ft ..... Ft Ft, Ft. Ft, MISCL. INFORMATION: DRILLER'S NAME WATI-RWELL - TEST PUMP REPORT Sheet_~of_Z_z Date: 3/9/77 Conducted By M-W Drilling; Tnc_, Owner Jack Rhodes Well Location. Sea Cliff Terrace Address Box 1947, Anchorage, AK 99510 Well Information: Casing Size 6" .Screen Diam. 6" Screen Slot Remarks F. lectric line Pump Information: Intake Depth216 Pump Size 6" Static Water Levee 78 Ay. Discharge 95 Pump On: Time 1407 Date 3/9/77 Pump Off:, Ttl. Depth 469 Depth of Casing458' 35Screen From 469 1'o 459 Air Line Depth GPM, Max. Drawdown 58~ Time 0800 Date , 3/10/77 Computed Spec Capacity = 1.64 gpm/ft D.D. WATER PIEZO- FLOW WATERi PIEZO- FLOW TIME LEVEL TUBE GPM REMARKS TIME LEVEL i TUBE GPM REMARKS Pump on 3/9/77 1407 78 95 Silty 1408: ?, 82 " ,'.. 1409 S i 1 t 1410 100 ,, 1411 120 " 1412 128 " Silty ';'..;..:,:;:.. ;?~ };,~, 1414 129 ,, " ~:~t[~ '~ 1416 129 " 1420 130 " Not as 142~ 1~2 " 1430 1~3 ,, Cle~inq ~up ~,:~ . ~:~: , 1440 ].~4 " 1500 136 " Cle~ 1515 136 " 1545 136 " Cle~ bu~:~me~:s~.~. 1600 136 " 1830 ~ 136 ,, 0800 136 95 Cle~ JVi-W DRILLING, Inc. P.O. B0x4-1224 * 1310C International Airport ~oad (907) 274-461 ] ANCHORAGE, ALASNA 99509 DRILLING LOG Well Owner. Jack Rhodes _Use of Well Location (address of: Township, Range, Section, if known; or distance main road Comm Size of easing 6 Depth of Hole 350 feet Cased to 275 feet Static water level 73 ft. ¢fali~i?. . ::!b¢l°w)~, :: land surface. Finish of well (check one) open end ( ); Screen (X ); Perforated ( [.~i)i.. ~ .. erforat[onJ~ihrig~n SS: .0~0 slot-469'=to 46B[,5~ .040 alo~ 463.5 to ~escrme screen or p . ~ ~lu~ 5.o' of 5 ~i~ w/ K packe~. of drawdown from static i~'~li! :~ ~;',~ ~i~[~ }[ Drillingiig [~2'7~, ~ 76 Date of completion Screen &)~D~Wi~;~l 7g Teslin9 ;~4~ (~D&:C~mber 1976 Depth in feet from '. ji :; ~ ~ ~ ground surface Gi~'~it~il,S pfi.f0rmations penetrated, size of material, color and hardness 2 C'g~ff9~,~ Sg, xckup Si~:~V~ Grave 1: small o ~0 2 TO. 10 TO la4 TO. 15 TO 75 TO 90 TO lO0 TO 191 .TO. 25~ TO. 260 TO 270 TO 350 TO 390 TO 403 ,TO 10 14 15 75 190 191 25S 260 270 350 390 403 B~D~W Skn'd:~'~:" si 1 ty S~lt: 5~mic0nsolidated ~ sft Fine Sand: cle~ water bearing - 50 GPM. 12 heave./ Sil~y Clay Till: sliqhtly sandy Silts%one: sliQhtlv s~dv, fair consolidation 455 Silty Sand: wet9 cavinq ......... · ~ '~f~ · .~//~omall Crav. e'~:,/~s~']-ty/sandy, wa'terbear~n9 10-15 GPM, dirty '. ~ ',',.'.k C:'r¥i~c'd C<mfraclor 1 -- CUSTOMER ' : :::...:. >.,,s..,l', ~<. [)73 M-W DRILLING, INC. DRILLING LOG Well Owner. Jack Rhodes - continued Use of Well Location (address of: Township, Range, Section, if known; or distance main road Comm Size of casing Depth of Hole. feet Cased to feet Static water level ft. (above) (below) land surface. Finish of well (check one) open end ( Screen ( ); .Perforated ( I ). Describe screen or perforation Well pumping test at g~ii~S.p'e~ (l~b.ur) (minute) for. hours with of drawdown from static i~/~11 2 ',: ';.' - Date of completion WELL LOG Depth in feet from .- ground surface Give details Of formations penetra.ted, size of material, color and hardness 455 T0~72 Smady. Wa~er Gravel: one small silty clay lense, good TO. ~', ~",VA Ce~Uff~ Cum'i/cate No~s;'. 814-'~ ~3 .TO .... .TO. .TO TO. _TO. TO TO TO ); ft. 1 --CUSTOMER 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 050-731-05 GENERAL INFORMATION Complete legal description Majestic Valley Estates Lot 1, Block 2 /31 Location (site address or directions) NHN Spruce Lane, Eagle River Address 26nn f')PnRl ~: ~tt-i ~-p 4¢10. Anr-hn~-RrfP A~' Unless otherwise requested, HAA will be held for pickup... Prope~yowner Timothy & Patricia Peden Day phone Mailing address 1705 Eaqle River Road, Eaqle River, AK 99577 Lending agency city Mn~egag~./,3~hn ¥~n~ Day phone Mailing address 121 w Fireweed, Su±te 120, Anchorage, AK 99503 Agent 2001Realt¥/She~-y Boyd Day phone 696-6086 276-2001 2. NUMBER OF BEDROOMS: 3 3. TYPE OFWATER SUPPLY: .. ..... Individual well x Community well % Public water fi NOTE' If community well system, provide written confirmation from State2~DEC attest- in to the legahty and status of system. , ~"E OF WASTEWATE" DISPOSAL: ~ ,;:~'~ ~'~ , ' Individual on-site X ..,2. ,- ~. ~ '~;z~q ....~ Holding tank ' Public sewer '~,,,. NOTE: If communi~ wastewater system, provide wri~en confirmation from State ADEC a~es~ing to the legali~ and status of system. 72-025 (Re~. 1/91) Front MOA i¢21 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 verify that based on the information obtained from the Municipality of Anchorage files and from my invest, i_gation 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 Eagle River Engineering Services Phone 694-5195 P.O. Box 773294, Eagle River, AK 99577 Address Engineer's signature Date ¢P ~,//~ q/'2 S 6. DHHS SIGNATURE Approved for ~ bedrooms, ....... Disapproved.. ~:'Conditional approval for bedrooms, with the following stipulations: Additional Comments ,By:' -/ /C~.~Z. '. ~' ~ ;. The ~ani~ipali~ o'f?~nEhorage Depa~ment of Health and Human Se~ices (DHH8) issues Health Authori~ ',, '~pproval~'0e~ific~t~ .5~sed only upon the representations given in paragraph 5 above by an independent ',, p~ofessional 9nmneer registered ~n the State of Alaska. The DHHS does this as a cou~esy to purchasem of homes and th¢ii' lending institutions in order to ~tis~ ce~ain federal and state requirements. Employes of DHHS do not conduct inspections or analyze data before a ce~ificate is issued. The Municipali~ of Anchorage is not responsible for errom or omissions in the profe~ional engin~fs work. 72~25(Re¥.1/91) Back MOA~I Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /'./H,J'£.57-/¢-- I/HLL,£y ~7' Parcel I.D. ~50 A. Well Data Well type PfLi VA ?'E If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) )/¢-.5 Date completed O(,,/?/ ~)E-~'pC'/vCz~ ~, Driller Total depth ~(~ 0 ' Cased to ? 5 ' ~" Casing height Sanitary seal (Y/N) ~/L¢ '5 Wires properly protected (Y/N) Date of test Static water level FROM WELL LOG ¢,,,l le ~v ov) H Well flow O, {~ g,p.m, Pump level1 ~/-¢0 / SEPARATION DISTANCES FROM WELL TO: Septic/ho~ tank on lot /O0 / Absorption field on lot //(--) ' Public sewer main /,,//,4 Sewer service line SC) ' AT INSPECTION o 3?/ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~/00 ' WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate /~/ /4¢~,/~ Other bacteria ~ Collected by: ~ /,u ¢)1~ E~//2 B. SEPTIC/RiI~EBIRG TANK DATA Date installed /? "]L~ Cleanouts (Y/N) YCS High water alarm (Y/N) Date of pumping ,¢ ~ .4- ~ ¢'.¢ Tank size /~O O Compartments Foundation cleanout (Y/N) ~E;5 Depression (Y/N) /'-1/,-4 Alarm tested (Y/N) Pumper ~.. R. SEPARATION DISTANCES FROM SEPTIC/H~ TANK TO: / Well(s) on lot /0() On adjacent lots To property line ~ 0 / Absorption field Surface water/drainage ¢- I 0(2 i q-- / Foundation Water m~bl/service line -¢'-/O / 72-026 (3,'93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer ~ Manho o~~N) "Pump off" Level at Vent (Y/N) "Pump on" level at High water alarm level ~-~ Cycles tested Meets MOA electrical codes (Y/N~-~ SEPARATION D.~'A'N~FROM LIFT STATION TO: W~etPO~t On lots adjacent D. ABSORPTION FIELD DATA Date installed /~ ?0' Length 3~' ' Width Total absorption area .~ 90 V Date of adequacy test p ~j.//~?/~ 5 Water level in absorption field before test < ~" Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) /25 ,~ ' Gravel thickness Cleanout present (Y/N) Results (pass/fail) Surface water System type ~'",~ f_~/VC/-/ Total depth ~'~ S Depression over field (Y/N) ,,DR ,5' ~S for -~ Bedrooms Aftertest ~,,*~ ~ ~'r--~',-.;~ If yes, give date Al/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //L~ To building foundation On adjacent lots Surface water ,h'/.4 Curtain drain /1/(~W'~ On adjacent lots -/ /(.) O / Property line ~'~' / To existing or abandoned system on lot ' Cutbank ,/.//A, Water maipJservice line Driveway, parking/vehicle storage area /S / E. ENGINEER'S CERTIFICATION I cern'fy that I have checked, verified, or conformed to all MOA and HAA guideline~ Signature ~ Engineer's Name Date ~/'//~/~ L~u~ A. 8utcr~ CE 6736 of this inspection. HAA Fee $ ~g_//~. Date of Payment Race,p, Num r Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back 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.# _~/-~---/_'~\- k'~¢:~ NAA#. 1. GENERAL INFORMATION ~' Complete legal description Majestic Valley;) Lot 1 Block 2 T14N R1W Sec. 23 Location (site address or directions) ~ Spruce La~e Property owner ___Gail Allen Day phone 694-2860 1705 Eagle River Rd., Eagle River, ~K 99577 Mailing address Lending agency N/A Day phone Mailing address Agent Laurel Crouse/ReMax Address 16600 Center Field Dr., Suite 201, Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 %/ Day phone 694-4200 Eagle RiVer, AK 99577 TYPE OF WATER SUPPLY: Individual well x Community well NOTE: Public water 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 NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOA/t21 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 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 Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature Date_ DHHS SIGNATURE ~/~ Approved for .~/~'~/~_~bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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. Em ployees 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: //'~.¢'¢-¢¢¢' ¢./'4,/~¢,~ ~'-~ / ,~-4"..'2Parcel 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._sy_,s, tem number Date completed ~'.~/ ~zs~_~,,e,4'.) Driller. Casedto 75" ? /' Casing height / Wires properly protected (Y/N) /v FROM WELL LOG Date of test ¢,/'? / Static water level ,v~- ,~0~-¢,4 o~ /~ Well flow ~' 4; Pump level g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main PubP, c sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA~.,. Date installed r/~' 2 ~ Cleanouts (Y/N) High water alarm (Y/N) ' Date of pumping ~/'9 t Tank size /¢¢¢' Compartments Foundation cleanout (Y/N) Y~ Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /¢'~ / To property line '~-¢ Surface water/drainage On adjacent lots 7'-/¢~ ~ Foundation 6~z~ Absorption field Water main/service line. 72-026 (Rev. 3/91) Fronl MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallon8 Vent (Y/N) Nigh water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /¢' ?~ Length ~,~' / Width Total absorption area Depression over field (Y/N) Results~fail) Peroxide treatment (past 12 months) Soil rating /.~.r- System type Gravel thickness ~'/' Total depth Cleanouts present (Y/N) )/ Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //¢ / To building foundation On adjacent lots ~'.~,~ / Surface water '~'/"~ Curtain drain On adjacentlots ¢-?~'~ / Propertyline ",~- To existing or abandoned system on lot Cutbank '~'/~ Water main/service line Driveway, parking/vehicle storage area ~-/-~ E, ENGINEER'S CERTIFICATION I certify that Signature Engineer's Name Date ~/'~ have checked, verified, or conformed to all MOA and HAA guidelines in effect On.the date of this inspection. .;.<~- "' :' '? ':,T ',', . %..: :.'/'.'" J.J.~ HAA Fee $ /7¢¢ Date of Payment (/~ Race,pt .umber X '; ? ( ?OU '? ) 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE 0 MUN~CIPALI1Y OF ANCEIORAGE ENVIRONMENTAL SERVICES DIVI~Ft~PI~RTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH NOV 2 5 198'7 CERTIFICATE OF INSPECTION FOR HEALTFI AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 R[CEIVED Application Date I I/~'.~?L~ ~_ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) ~'T I IS.Z- ~: ,Z ~,'t,~-~'r~c Vf~,., Location (address or directions) (b) Applicant Name',I/f;-'~ /(~JJc~.( ~Lo~_ Telephone: Home Business Applicant Address ~_O, ~A' c~~O'-'~ ,~,h.O/tO_b_m..~ ,, /~ ~-~ (C) Applicant is (check one): Lending Institution'l~; Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution A 1¢~_~'~ /~1.O_~-f.,,uc_(. (e) Real Estate Company and Agent _~.,~/ Address _Z~'(70 6".~'-~¢~,,~ S' (fi Telephone _~'~' Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family;~' Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well [] Community,l~" Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, t'~u[~ic 4. SEWAGE DISPOSAL Onsite~/ Public [] Community[] Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Coeservation attesting to the legality and status. Page 1 of 2 72-025 {11,84) ')IJOA~ e,JeeU!DUe leUO!eSeloJd eLJ~ U! 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Xm leq] AI!JaA I 'MOleq UMOqS elep uo!lep!leA aql Io se pus oleJ8q pex!~ie lees A~ ~q pa!J!peo sV NOIZ~BOJNI aN~ fz~a 'Ho~S ]llJ 'SzS]& 'SNOIZO]dSNI 9NlalAOBd ~BIJ 9NIB]]NIeN~ MUNICIPALITY OF ANCHORAGE £NVIRONMENTAL S~P, VICE$ DIVISION NOV 2 5 987 RECEIVED A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: L,,_~ "r' Well Classification ~_.~-,"b¢'~! Well Log Present (Y/N) V D/ate Completed Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ~)O~[,c_ %DC If A, B, C, D.E.C. Approved (Y/N) ~.::/r-'4 $ ~ 2'~ Depth of Grouting Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed '7./6/7 7 -,- Standpipes (Y/N) Y Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /~//'~ Separation Distances from Septic/Holding Tank: To Water-Supply Well ~' '~. ~--.-20't To Property Line / (.~ ] To Water Main/Service Line ,'~ C;' Course ~ I O('.) '~ Size /, /00 q,,~/ No. of Compartments Foundation Cleanout (Y/N) Y Date Last Pumped ////~¢/~' -] ; for -'- Temporary Fielding Tank Permit (Y/N) To Building Foundation /0 ! To Disposal Field ~, I To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026 fRev 8/86/ Fronl ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7/~/7'7 Width of Field t~' ~" Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well :m' 2 CO To Building Foundation ZO) '+ Lot M//.-I To Water Main/Service Line ',"5" O To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ~.p~eptfi'of Field J . Gragel Bed Tgickness .... : .... .. . Standpipes Present (Y/N) ~.~ Date of Last Adequacy Test Type of Syste~m~D_._eS<gn Length of Field To Property Line /.Or To Existing or Abandoned System on ; On Adjoining Lots ~ ~ To Cutbank (if present) Comments LIFT STATION ~ Date Installed % Dimensions Size in Gallons % Manhole/Access (Y/N) "Pump On" Level at % "Pump Off" Level at High Water Alarm Level at % Vent (Y/N) . Tested for ~ Pumping Cycles during Adequacy Test. Meets MOA ~1~ Cmt rimC;~tsCOdes (Y/N) ** Check Permitte~_ati?g Against HA~equest ** I certify that l hav_.,~hec~, ~ifi ~ed>or conformed to aN~MOA and I-~AA gui/delines in effect on the date of this inspection. Si ned ,-"'-\~v,,...~,._.-~ Date \ g ~. - ~ ~ __ - ate , · r Company ~:~V~,..-~*--~ ¢~ ~_.~ MOA No. Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 fRev 8/86~ Back Engineer's Seal " I ' ""i~- MUNICIPALITY OF ANCHORAGE .~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 82BL s,,ee,-A.chor..e. A,esk. 00501 ENVIRONMENTAL ENGINEERING DIVISION ~._~ ~ Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SFWER FAo LITIES DIRECTION$~ Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten {10) days for processing. 1, PROPERTY OWNER PHONE -- PROPERTY RESIDENT (If different from above) ' ' -- 2. BUYER PHONE MA~LING ADDRESS ~. LBNDING INSTITUTION MAI LING ADDRESS / zoo ,4~¢~,~,e r /'~w~'~ '~,~o 4. REALTOR/AGENT 'PHONE MAILING ADDRESS -- 5, LEGAL DESCRIPTION STREET LOCATION 6, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four [] Other ~ SINGLE FAVIILY [] MULTIPLE FAMILY 7. WAT'ER SUPPLY [] INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTI LITY [] Two [] Three ¢~;~CH WELL LOG. A well log is required for all wells drilled since June 1975. For wells dril ~d prior to that date, give well depth {attach log if available.) 8, SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE" [] PUBLIC UTILITY 72-010(3/78) If ndw dual/on-s~te, g~ve installation date ,~.~, '?6 If system is over two (2) years old an adequacy test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY : DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE I NSP ECTOR I NSPECTO R INSPECTOR :)IR ECTIONS: 1. TYPE oF RESIDENCE NUMBER OF BEDROOMS [~ SINGLE FAMILY E~] ONE [] THREE [] FIVE [~ OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER ;2. WATER SUPPLY [] INDIVIDUAL ' DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED F~PUBL C.UT LTY ""7 '~ ?~ Connection Verified INSTALLER []Septic T_ank. or [] Holding Tank Size: /~]~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~*'~ APR ROV ED FOR ~;~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev, 3/78) 4. 5. 6. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received Date of Inspection Approval requested by: Mailing Address: Property Owner: Mailing Address: Legal Description: Location: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Conv. Alaska Mutual Savings Charles & Pogany Development Box 323 Eagle River Phone: Phone: Lane, chalet on the left Type of facility to be inspected Sinqte ~amil¥ No. of bedrooms Lot 1 Block 2 Majestic Valley Subdivision Spruce Lane, 6.5 miles up E.R. Valley Rd off Berry Hill 2 Well Data: Individual A. Type C. Construction Sewage Disposal System: 1976 1. Size 1. Absorption Area Total length of lines B. Depth' D. Bacterial Analysis On-site system B. Installer 2. Manufacturer A. Installed C. Septic Tank: D. Seepage Pit: E. Disposal Field: Distances: , Absorption area , Other contamination A. Well to: Septic tank Nearest lot line B. Foundation to septic tank C. Absorption area to nearest lot line , Absorption area 2. Material Sewer Lines , EQ-034 (1/74) Page 1 of two pages Page 2 of two pages - Re~ st for Approval of Individual .~ .:r & Water Facilities Legal Description Lot 1 Block 2 Majestic Valley Subdivision Comments Approved~a~. ~~,/~7~ Disapproved Date ~-~- 7 ~ /' Approval~Valid for one year from date signed ~.~/Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO , VA FHA CONV ¥ 2. PropertyOwner:_O-_L~rl~e~ ~, ~0¢~c~d. bev4l~rpr~q.WJ~ MailingAddress:_~K ~ ~ ~DayPhone:_ ~ ~G 3. Name of Buyer: '~ Mailing Address: '--' 4. Name of Lending Institution: ' Day Phone: Mailing Address: ~'--' Phone: 5. Name of Realtor or Agent: Mailing Address: Phone: Legal Description: ~ [ , ~)~1(~ ~, . ~'~4t.~Jr, c~ ~dL ~1'~1 .~'~J Type of Facility to be Inspected: ~t ~z.~c- -~-~m, ~, ~ No. Bdrms. ' Water Supply Type of Supply: Public Utility. If Individual, number of dwellings presently served_ Individual If Individual, depth of well Sewage Disposal System Type of System: P~blic Utility If Individual, date of installatio Individual (on-site)_~'~ 72-003(3/76)