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HomeMy WebLinkAboutMOUNTAIN MANOR BLK 2 LT 7B I'-llLIN ! C: ! F',RL I -['"T" I.--_1 ~:'-- Ftt..,llT'_:HCIP..FIC-:iE DEPARTMENT OF HEALTH AND ENVIRONMENTAL F'R. OTECTION 825 -'l_" STREET., ANCHORAGE., AK. 264-4720 L,,..IEL L_ RI'-~ID I:ml'-i--'.~:; I "T"E PERMIT NO. ( ?7067~5 ) DATE OF ISSUE 8;.~1477' L--: 0 F" m..+,,+, HARMING - DIJE TO CHANGING REC-.!UIREMENTS THIS PRINTOUT MAY NOT BE AN E,'.'.',RCT COPY OF THE ORIGIONAL. PERMIT APPLICANT LOCATION LEGAL MARK H ANDREWS STILt. HATER DRIVE ER L7 E~MT MANOR S_BD i060m NEST iVTH AVE LOT SIZE 276:1.209 87128 SQt..IRRE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING "tHE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E:,EP'TH= :t2 LEt-4GTH= 44 m_~ 6~: I-.~ %-' E: L_ E:,EPTH:= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFIEI...D. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SIJRFACE OF: THE GROUND AND THE 80TTOM OF THE EXCAVATION (IN FEET:'.,. THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL E,'ETHEEN THE OLITFRL. L F'IPE FIND THE BOTTOM OF THE EXCAVATION (IN FEET). SEPT I C: TANK .'~.'; I ZE= TI--.IC~ ( 2 ) I I%I~_;F'EC:T I t7_11'-4'_.--;., ARE REQL.I I BRCKFIL. LING OF ANY SYSTEM HITHOUT FINAL INSPECTION AND APPROVAL 8Y THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS i00 FEET FOR R PRIVATE WELL.~ OR 150 TO 200 FEET FOR A PUBLIC WEL. L DEPENDING I. IPON THE TYPE OF PIJBLIC WELL. HELL LOGS ARE REG!UIRED AND MUST BE RETURNED TO THE [:,EPARTMENT WITHIN ]~0 [:,R'T"S; OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY -' SPECIFICATIONS FIND CONSTRUCTION ['.:,IRGF.~AMS FIRE AVAILABLE TO INSURE PROPER INSTALLATION F~ERM I T E:--<,F" I F-:E__%; [:,ECEr,IBEF-: _-~_~: :t., :1_.'_:~- 7';;' I CERTIFY THAT · ~: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELL. S AS SE'T FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN AC:CORDRNCE WITH THE CODES. .S:: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF: THE RESIDENCE IS REMODELED TO INCLLIDE MORE THAN 4 BEDROOMS. SIGNED: ................................................................. APPI...IC:ANT MRRK W RNDREHS '="= · BY .............. [;,RTE I _.-,UED ..................................................... INSPECTION HISTORY - SEWER 2t 0 SEHER L-] 0 WELL INSP 0 NELL LOG DATE 0 DRILL. ER This well is producing ?/~/-)9allo' MOON DRILLING SR BOX 668, BOGARD RD. PALMER, ALASKA 99645 TELEPHONE 745-4071 ~/ater per hour. INVOICE Set pure! /~/2 feet. .NVOICE NO, YOUR P, O. HUMBER TERMS j/ '' /- D~PTH ~. CASIN FORMATION DEPTH DEPTH ~ FT, ~ FT. CAS~ FORMATION IN FT. CASIN FORMATION ~ ~ ~ [~ J~ ' .~m .'~ 102 ~8 ~ f - ' 103 208 ~ 4 1~ 204 ~ 5 105 205 ~ 6 1~ 206 ~ I / ~ ~ lO~ 2o~ ~ ~ / ~ · ~ ~ lOS ~ 208 ~ ~ ~ ~ 109 ,/~ _1o ~ 1~o ~- ~ ~ z~o ~ 11~ ~/, 212 1~ 113 ~~ 113 ~14 114 /~ ~ ~ ~ 214 ~15 115 215 ~16', 116 ~ ~ ~-- 116 ~1~ ~ 117 217 ~1~ ,,// 118 218 ~12 , 119 219 ~0 ~ _ 120 220 ~33[ ~ ~//~ / 12~ 222 ~8 128 ~ ~ ~ '~ 228 ~82 ~ _ / 132 282 ~1 141 241 ~48 A, ./-/~p~ [48 248 ~ { ..... -/-~ ~;, % 150 250 ® A Ar Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 050-671-55 Expiration Date: 1. GENERAL INFORMATION: Complete legal description MOUNTAIN MANOR; BLOCK 2 LOT 7B - 2S" -2 -OZ - Location (site address) 18409 Stillwater Drive *Eagle River Current Property owner(s) Booker Ervin Day phone 831-6777 Mailing address Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $.5 Date of Payment 1'2ep Receipt Number 0775/6 COSA#_OZJ 1 hey Waiver Fee $ Date of Payment Receipt Number Waiver # qly 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, 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. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Garness Engineering Group Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road Suite 101- Anchorage Alaska 99507 Engineer's Printed Name: Jeffrey A Garness Date: t7,t/` In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory lest results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE —�— System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following sti Ir ""HgT_V'ATER Z Jm PROGF,AMulaelol rsE_RVIGE�' B r Original Certificate Date: Y The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations 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. ATTACHMENTS: COSA Checklist_ Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 11 Legal Description: MOUNTAIN MANOR; BLOCK 2, LOT 7B If more than I septic system on lot: COSA Checklist # of A. WELL DATA A Well log is filed with Onsite (or attached) Date drilled 1111/15 Total depth 124 ft Cased to 120 ft FO -1 Sanitary seal is functioning correctly '--] wires are properly protected Casing height (above ground) 18+ in. Date of flow 'test for COSA 9/28/21 Static water level at beginning of test 75.5 ft. Comments B. TANK DATA Age of tank(s) 6 years Tank type/material SEPTIC5TEE Measured operating fluid level in septic 'tank Standpipes/foundation cleanout per record drawing Date of pumping 0CJ )St � O -)-- i D. ABSORPTION FIELD DATA DEEP TRENCH Which system tested (date installed) 1977{') Flz� ALL standpipes present per record drawing Total measured depth from grade 14.25 ft (max) Measured depth to pipe invert from grade 4.66 ft pain) ❑ N/A — pressurized field FW Monitor tubes go to bottorn of effective. If not, state depth into effective 9.5' III] Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced N/A gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 050-671-55 Structure served by this system Well production at time of test 6.8+ Will Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes 0 Ne QKCOliform bacteria is Negative Nitrate S. (Al mg/L �❑1 Nitrate less than MRL (ND) Arsenic ug/L lvl Arsenic less than MRL (ND) Collected by GEG, LTD Dace of Sample 9/28/21 11 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: N/A Adequacy test date 9/28/21 Results ,[DPass For 3 bedrooms Fluid depth prior to test 63 in Water added 515 gal New depth 94 in Elapsed time 120 min Final fluid depth 73 in Absorption rate 450+ gpd Any rejuvenation treatment (past 12 months) NONE If yes, enter date N/A 0T. E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ✓0 Yes Community Sewer Manhole/Cleanout > "100' M Yes if No ft 0 Yes if No Neighboring Tank > 100' 121 Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' R Yes if No Neighboring Absorption Fields 100' Yes if No Animal Containment > 50' 121 Yes if No ,> 0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Seaver Main > 75' MYes if No fit n Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No `5+ ft Surface Water > 100' It ft ft ft ft 0✓ Yes if No ft Property Line > 5' ✓0 Yes if No ft Wells on Adjacent Lots: Absorption Field a 5' n✓ Yes if No ft Private Wells > 100` M Yes if No Water Main > 10' 0 Yes if No ft Community Wells > 200' Q Yes if No — Water Service Line > 10' [D Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 1U✓0 Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' 0✓ Yes if No ft Community Wells > 200' 0 Yes if No Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS *MET CODE AT TIME OF INSTALL G. ENGINEER'S CERTIFICATION I certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet Vol =f ey ice' arness; CE--i 7953 i #AECC884 M ft ft ft AP, L �r y�. v sem.. C ASBUILT Q 4 At • •rH Duane Mark Saward Y Vx . SEWA;RD & I HEREBY CERTIFY THAT l NAVE $U ED THE SCALE f��d© � FOLLOWING - DESCRIBED PROPS = _ AND THAT NO ENCROMMENTS1 IST -Exc AS INDICATED . • IT IS THE RES' Of'U"TY THE OWNER TO • DETERMINE'THE So ANY GRID-' ECAs-EmENITS, COVENANTS„ OR. RE,�TRICTION.S WHICH DO NOT APPEAR. ON THE RECOIM SUBDI- VISION PLAT: UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE U$ED FOR CONSTRUCTION OF FENCE`LIN4 OR FOR ESTABLISHING BOUND - DRAWN; ARY LIMES. - . Q 4 At • •rH Duane Mark Saward Y Vx . UNICIPALI'T'Y OF ANCHORAGE Community Development Department Right of Way Section Dc 1.artment THIS AGREEMENT, made this 25th day of March, 2015, by and between Charles W. Landmesser and Holly M. Ambrose and their heirs, administrators, and assigns, hereinafter called "PERMITTEE'", and the Municipality of Anchorage, a municipal corporation organized and existing under its Charter and the laws of the State of Alaska, hereinafter called the "PERMITTER". WITNESSETH: WHEREAS, PERMITTEE is the owner of the following described real property: MOUNTAIN MANOR, BLOCK 2, LOT 7, according to the official records thereof, on file in the office of the District Recorder, Anchorage Recording District, Alaska, and; WHEREAS, PERMITTER owns and/or maintains the real property more particularly described as follows: The 33 FOOT SECTION LINE EASEMENT and 10 FOOT UTILITY EASEMENT located in the western portion of PERMITTEES property as shown on Plat No. 77- 0023, on file in the office of the District Recorder, Anchorage Recording District, Alaska, and; WHEREAS, PERMITTEE has placed a well upon the referenced easement which encroaches 4 feet upon the PERMITTER'S 10 foot Utility Easement and a septic system upon the referenced easement which encroaches 20 feet into the Section Line Easement. NOW, THEREFORE, it is mutually agreed between the parties hereto that: 1. The PERMITTER, acting through the Director of Community Development Department, hereby grants to the PERMITTEE the privilege of allowing a well and septic system to encroach upon the PERMITTER'S 10 foot Utility Easement and 33 foot Section Line Easement, as shown on "Attachment A," included herewith. 2. The PERMITTEE agrees forever to indemnify, defend, save and hold harmless, the Municipality, its officers and employees, from any and all lawsuits, claims or actions brought to any person for or on account of damage to property or injury, disease, illness or death of persons, including all costs and expenses incident thereto, arising wholly or in part from or in connection with the existence of, alterations, maintenance, repair, renewal, reconstruction, operation, use or removal of the encroaching well and septic system, as placed upon the PERMITTER'S Utility and Section Line Easements. 3. The PERMITTEE shall not assign or transfer any of the rights granted herein to another individual or company without first notifying and securing the approval of the Director of Community Development Department. 4. This Agreement and Permit grants PERMITTEE no interest in PERMITTER'S real property whatsoever, except only the encroachment rights described herein. 5. The PERMITTER reserves the right to revoke this permit upon twenty (20) days written notice to the PERMITTEE. The PERMITTEE agrees upon such notice of revocation, to move said encroachment(s) from the Utility and Section Line Easements in which it is placed. Should the PERMITTEE refuse or fail to comply with said written notice, the PERMITTER may, without further notice to the PERMITTEE, remove or cause to be removed the encroachment(s), and the PERMITTEE hereby agrees to reimburse the PERMITTER for all costs incidental to the removal thereof. In addition to the mutual promises heretofore made, the PERMITTEE has paid the PERMITTER a one-time permit application fee of $115.00. The PERMITTER hereby waives the annual fee of $300.00. IN WITNESS WHEREOF, the parties hereto have hereunto set their hands and seal the day and year first hereinabove written. 7 G E: GRANTOR: MUNICIPALITY OF ANCHORAGE :2 Charles W. dmesser, owner Holly MAmbrose, owner ack L. Frost, Jr. Right of Way Supervisor STATE OF ALASKA ss. THIRD JUDICIAL DISTRICT THIS IS TO CERTIFY that on this day of WUV-V% 2015, before me, the undersigned, a Notary Public in and for the State of Alaska, duly commissioned and sworn as such, personally appeared Jack L. Frost, Jr., known to me to be the Right of Way Supervisor for the Municipality of Anchorage, Alaska, who executed the foregoing instrument, and he acknowledged to me that he executed said instrument as the free and voluntary act and deed of said corporation for the uses and purposes therein mentioned, and that he was authorized to execute said instrument. WITNESS my hand and official seal on the day and year first above written. STATE OF ALASKA THIRD JUDICIAL DISTRICT NOTARY PUBLIC inland for Alaska My Commission Expires: CW111-1 ss. THIS IS TO CERTIFY that on this � 5 day of N4�'2 1 2015, before me, the undersigned, a Notary Public in and for the State of Alaska, duly commissioned and sworn as such, personally appeared Charles W. Landmesser, known to me to be the individual named herein who executed the foregoing instrument, and he acknowledged that he did so freely and voluntarily for the used and purposes therein mentioned, and on oath stated that he was authorized to execute said instrument. WITNESS my hand and official seal on the day and year first above written. f O -JA NOTARY PUBLIC in and for Alaska My Commission Expires: 811"1 11 —7 STATE OF ALASKA ss. THIRD JUDICIAL DISTRICT THIS IS TO CERTIFY that on this t` day of klv_)� 2015, before me, the undersigned, a Notary Public in and for the State of Alaska, duly commissioned and sworn as such, personally appeared Holly M. Ambrose, known to me to be the individual named herein who executed the foregoing instrument, and she acknowledged that she did so freely and voluntarily for the used and purposes therein mentioned, and on oath stated that she was authorized to execute said instrument. WITNESS my hand and official seal on the day and year first above written. NOTARY PUBLIC in an for Alaska —1 My Commission Expires: t OF fJf,1f��))Jits exp I. >c~7~fion (;,ddre~s or d~ _~ctions) (c) Agplicant ~s (;i~q,sk or~o): Londir,g In~Jitution .~dd~',?ss ~T'FE~'-TON: Pave ~Zbe~c,~Z/Ancho~u~ (e) Real '::,'~ - _ Add~oss ~R Boz I~6, Eaq~'~ Riwr, A~aska 99511 Te~epl-one ' 694--(995 ('f) .~,~/{J~he I-IAA to tl~e following addcess: order6d 6y Beverly Bow&rs TYPE OF I~;,_..AD..NCE Single.-Family'~.~ Multi-Family [] Other ....................... Number of Bedrooms .... 3. WATER SUPPLY Individual t/Vell [.~ Community [] Pub;lc [] Note: If community w,fl} system, must have written confirmation from the State Department of Engjr~o)q!32em'!ti]l Conservation attesting to (he legality and status, Page 1 of 2 5;EWAGE DISPOSAL Onsite ~ Public [.~ Community [] Holding Tank [] Note f commun ty well system, must have written confirm~t;on from the State Department of Environmental Conservation attesting to the legality :and status. Ap,)roved ._.~_ .............. Dis~l)toroved Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environment~l Pro~ection (DHEP issues Health Authority Approval certificates b~sed solely ~pon ~he r~prcsenlations given in paragraph 5 above by an ind~peedent professional ~ngH~eer registered in the State of Alaska. The DHEP does this ~s a courtesy to purchasers of homes ~nd their lending institutions in order to satisfy certain f~deral and state requirements. Employees of DHEP do not conduct inspections or analyze dat~ before a cedificate is issued. The Municipality o~ ~nchorage is not responsible for errors or omi~sions in the professional engineer's work. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALiTy OF AN _. DEp~ OF "- CHORAGr: HEALTH AUTHORITY APPROVAL (HAA) tNVI,~ON~E,. ~eALTH & ': CHECKLIST - FEBRUARY 1984 NTAL PROTECTioN 264-4720 If A, B, C, D.E,C. Approved (Y/N) Date Completed ~;;~ ~1~'. "¢7~ Yield Well Classification Well Log Present.N) Total Depth \'?-~ ! Cased to Static Water Level ~ ~P Casing Height Above Ground Electrical Wiring in Conduit(~N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on~ Lot To Nearest Public Sewer Line '. '4,~i Cleanout/Manhole . Water Sample Collected by Water Sample Test Results Comments Depth of Grouting "'-'---- Pump Set At O~ ~, Sanitary Seal on Casing(~)'N) Depression Around Wellhead (Y~) ~,'7...~/'"~ ; On Adjoining Lots \~..~l.~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~...~4A, ~.5 ~:~', i~ ;Date ~::) "- I'g~ ' B, SEPTIC/.~TANK DATA To Water-Supply Well To Property Line To Water Main/Service Line Course Date Installed .~J~7.¢;~. ~?? Size ~."2..¢~ Standpipes (.~N) Air-tight Caps~)'N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) ~/_ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic,q~ank: No. of Compartments (_~.'~---, Foundation Cleanout (Y/~ :te Last Pumped ~ ~ ~q. JZ..-- ; for "-'---- Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/~) Resutts of Last Adequacy Test Separation Distance from Absorption Field: Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (~N) Date of Last Adequacy Test To Water-Supply Well To Building Foundatio~.~ Lot 'i' ./t~ To Water Ma n/Servide Line To S. tream/Pond~Lake/or Major Drainage Course To Property Line t~t"~ To Existing or Abandoned System on · On Adjoining Lots '~c~ I ~ To Cutbapk (if present) TO Driveway, 'Parking Area, or Vehicle Storage Area ~ ''~:: Comments ~ ~ ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed$ & S ENGINEERING Date JUN SRB 196X MOA No. C° m Pa~j~GI-E RIVE.I~.A~( 99577 Receipt No. ~ r~ Date of Payment ~, '- I '? -~'~- Amount: $ Page 2 of 2 72-026 (11/84) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL (DF ON-SITE SEWER AND WATER FACILITY 264-4720 App,ication Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ,~,--/~ ~'/¢.~'c~-¢--- Telephone: Home Business ApplicantAddress _ ~~ ~~ (c) Applicant is (check one): Lending Institution ~;Owner/builder ~'Buyer, ~;Other~(explain);~ Address -~,--- (e) Real Estate Company and Agent '~'~ Address ~ ~~/~- Telgphone (f)~l the btA~ to the following address: TYPE OF RESIDENCE Single-Family ¢ Multi-Family [] Other 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 ~i~ 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. Page 1 of 2 EI~GINEERING FIRM PROVIDIN~ ,NSPECTIONS, TESTS, FILE SEARCH, DA'~,~ AND INFORMATION 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 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 end from my investigation and inspection, the on-si~e water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations the date of th~s inspection. ':~' ,:~. ~..,;,!~E:' q Telephone Address ~7., Date _ _~ ..... .~;--- ' _ DHEP APPROV.'~[. Approved for ~e0.~_ bedrooms by ~¢:~* /-/r/~,¢.~,~,~ Approved ~ Disa~ved Condi~al Terms of Conditional Approval Date _ CAUTION The Muncipality 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 tending 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. 1'he Municipality of Anchorage is not responsible for errors or om~sstons in the professional engineer's work. Page 2 of 2 72 O25 (~ 1/84) WELL DATA Well Classification Well Log Present ~N) Total Depth Static Water Level casing Height Above Ground Electrical Wiring in Conduit~i~N) Separation Distances from Well: To Septic/J:J~ Tank on Lot tW '~IICIPALhTY OF ANcHORAG~ DEPT. OF HEALTH MUNICIPALITY OF ANCHORAGE (MI~IRQNMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Cased to ~-7o~ 1. If A, B, C, D.E.C. Approved (Y/N) Date Completed ~-~'~ "~ '~ Yield Depth of Grouting "---- Pump Set At ~ ~,~--~ Sanitary Seal on Casing([~N) Depression Around Wellhead (Y~) / ~'~:' /'~ -- ; On Adjoining Lots To Nearest Edge of Absorption Field on,Lot //~ ~ '- ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhoie ~ To Nearest Sewer Service Line on Water Sample Collected by ~' ~c;;:~l.~¢,,.~ ; Date I ~,--"Z~t Water Sample Test Results ,.'~-'-'-'-'-'-'-"-~ ~~ Comments ~' \~-~.,- ',4/1~'~--I~ "~,~,'["~ -~-~==(::~ ~ I SEPTIC/J=IO~;HNG TANK DATA Date Installed . .~,~, I°l~?Size'?~ I'7-.~> ' Standpipes(~/N) Air-tight Caps (Y;'N) Depression over Tank (Y,~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course No. of Compartments Foundation Cleanout (Y,~ Date Last Pumped / 0- ~ ; for '"'-- Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field .4,J,/~, To Stream. Pond. Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) ,, ,' , I D TE.ECE,VED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECT~ MUNIClPAUTY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE D~PT. OF HEALTH & (~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~NvI~ONM~NTAL P,~Or~CTION 825 L Str~ - Anchora~, Al~ka 99501 ENVIRONMENTAL SANITATION DIVISION d~ 3 1981 Telephone 264~720 DIRECTIONS: Complete all pa~s o, page 1. Incomplete requ~a will not be pr~d. Please allow ten (10) days for processing. 1. PROPERTY OWNER I PHONE MAILING ADDRESS PROPERTY RESIDENT (If d~fferent from above) PHONH 2. BUYER / PHONE MA ILl NG ADDR ESS 3. LENDING INSTITUTION [ PHONE I MAILING ADDRESS 4. REALTOR/AGENT [ PHONE 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One [] Four ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY I~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY. * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY .YEAR ON-SITE SYSTEM WAS INSTALLED, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. {!):)?),.~, ~' ~i, Jkmc 10, 198] M a r'k /D [ a n n e An d r ew,q % Mark Phillips t314 Birchwood. St~'ceL Anchorage, A ]..a s k ,:'~ 99504 out)3( ..... : I,ot '7 ,Lo..k 2 MounLain Manor Subdivision ,,o ~ - and watel; faci. lities Approval fo~' zh.~, ~ndividual o.~we~ can/lot be grantted trot:il [the fo].lowir~q it. ems have keen comp] eted: (1.) The water' analysis report needa to be submit:.ted to khis office :fr'om the Chem Lab, 56133 B Street~ for our ~*eview. Effective June !, 1981, the lab fee .i.s 820.000. (2) The septic tank pumped with a receipt submi_tted to this off:ice, t .t~:.~ questions, f.].eao: call -this If there are any f ] ''~- '~- } .... e off.ice al:: 264-4720. Sincerely Robert C. t att Associate RC P / 1 j w / MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOI~EPT' ©: ~-_~ T' 825 L Btreet - Anchorage, Alaska 99501 ENVJRONN',[iqTAL ! ,,, ~, ! CTION ENVIRONMENTAL ENGINEERING DIVISION DEC 2 8 1978 Telephone 264-4720 REQUEST FOR APPROVAL OF'INDIVIDUAL WATER AND SI~I/~¥1EIJ~ DIRECTIONS; Complete all parts on page 1. Inaomplata requests will not be processed. Please altow ten (10) days for processing. 1. PROPERTYOWNER/~/g ~ ~ ,, . / f) ~*- PHONE MAILING ADDRESS PROPERTY RESIDENT (If dilferent from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE I MAILING ADDRESS 4. REALTOR/AGENT ~ PHONE h /v L_I , MAILING ADDRESS 5, LEGAL DESCRIPTION 6, TYPE OF RESIDENCE '~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY .~ INDIVIDUAL'* [] COMMUNITY [] PUBLIC UTILITY NUMBER OF BEDROOMS / [] One ~ Four ~l Other ~ Two [] Five [] Three [] Six 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/rON-SlTE** I-- PUBLIC UTILITY ~ ATTACH WELL LOG. A well log is required for all wells drilled since June 1975, For wells drilled prior to that date, give well depth (attach log if available.) **If individual/on-site, give installation date ~:~ If system is over two [2) years old an adequaf:y test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) fi/1~ r~fCIPALiTY OF ANCHO/~AC-;.- ANCHORAGE (MI~JI~ONMEN HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 O'~q ~1985J 264-4720 WELL DATA Well Classification Well Log Present ~i~)N) Total Depth [ "~-¢1 L, Static Water Level Casing Height Above Ground Electrical Wiring in Conduit~i~N) Separation Distances from Well: To Septic/J;~d41m~ Tank on Lot Cased to ~7~ 1. If A, B. C, D.E.C. Approved (Y/N) Date Completed J~¢'~ "'( '7 Yield Depth of Grouting --'--- Pump Set At Sanitary Seal on Casing([~N) Depression Around Wellhead (Y~) / ~'"¢:' /~: ~' ; On Adjoining Lots To Nearest Edge of Absorption Field on,Lot //~' '~''' ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cteanout/Manhole ~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test ResUlts Comments To Water-Supply Well To Property Line To Water Main/Service Line Course SEPTIC/.I:LObl~ TANK DATA Date Installed ~, I'21"J?S ze~ ~4;;' ' Standpipes(~/N) . Air-tight Caps (WN) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: -/~ ~ No. of Compartments L~,~,/---, Foundation Cleanout (Y~l::) Date Last Pumped / 4:2- ~.~- ~ i,.3,~ ; for '--'-- Temporary Holding Tank Permit (Y/N) '~/~ To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage 72-026(11184) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field L~ ~.., Square Feet of Absorption Area Depression over Field (Y~,~J~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ~'~/~I~' To Water Main/Service Line ~r]'~''''~''ll;~h''''' Type of System Design Length of Field ~ ¢'~' Depth of FielS' /~ Gravel Bed Thickness ~,[(. ~ 10~¢~tandpipes Present CN) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area I To Property Line J c;> Jr' To Existing or Abandoned System on ; On Adjoining Lots j ~ I,,,¢ To Cutbank (if present) Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~ ~* ~,,Y ............ Date Compahv .~.~ ~ ,. -~ ....... MOA No. Receipt No. ~ Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ,, ' , DANTE RECEIVED INSPECTION APPOINTMENTS ~ T, ME T,ME T,ME DATE DATE DATE INSPECTOR INSPECTOR I NSPECT~ MUNICIPALI~ OF ANCHORAGE ~U~IClPALITY OF ANCflOBA~E DEPT, OF HEALTH &  DEPArTmENT OF HEALTH & ENVI~ONa[NTAL P~OTECTIJ~VIRONMENTAL P,~OTECTJON 8~5 L Strut - Anebera~, Ala=ka ~gl ENVIRONMENTAL SANITATION DIVISION Telephone 2~720 BEflUEET FOB APPBOVAL OF INDIVIDUAL ~ATEB AND Ol RECTIONS: Complete all pa~s mt page 1. Incomplete requ~ will not be pr~. Please allow ten (10) days for processing. 1. PROPERTYOWNER ~ PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER / PHONE MAILIN~ AOO~E~ 3. LEN~I~ INSTITUTION J PHONE I MAILING ADDRESS 4. ~EALTO~JA~E~T J PHONE MAILIN~ ADDflE~ 5'. LEGAL DESCRIPTION STREET LOCAT, 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One [] Four J~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY ~, Three [] Six 7. WATER SUPPLY ~' INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LtTY depth (attach log if available.) [] Other 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY .YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] 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 []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank 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 IAbsorption Area Sewer Line I Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line 5. COMNIENTS APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate} [] DISAPPROVED !~~/~/~ DATE BY MUNICIPALITY OF ANCHORAGE MUNIciPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOI~EpT. ©-: r~,~,~T,.~ & 825 L Street - Anchorage, Alaska 99501 ENVI~ONMEiq~/'~L ~. ;,, ~ ~ION ENVIRONMENTAL ENGINEERING DIVISION OEO 2 8 1978 Telephone 264-4720 FOR APPROVAL OF INDIVIDUAL WATER AND S~~I~,~ REQUEST DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Pleasa allow ten (10) days for processing. MAILING ADDRESS 2, 'BUYER ' PHONE MAILING ADDRESS 3', LENDING INSTITUTION MAILING ADDRESS ~. REALTOR/AGENT PHONE MAILING ADDRESS 5,' LEGAL DESCRIPTION STR E ET' L~)C~ATI O N 6. TYPE OF RESIDENCE ~ FAM LY SINGLE MULTIPLE FAMILY NUMBER OF BEDROOMS /' [] One ~ Four [] Other~ [] Two [] Five [] Three [] Six 7. WATER SUPPLY ~ INDIVIDUAL* -'1 COMMUNITY [] PUBL C UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give wel depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM __/_ ~ INDIVIDUAL/ON-SITE** I ind~wdua~/on-s~te, g~ve mstallat~ondate ~ . If system is over two (2) years old an adequacy test is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72.010(3/78) [.. THIS SIDE FOR OFFICIAL USE ONLY , , DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FiVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Si~e: 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 I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [] CONDITIONAL APPROVAL (letter must acc, p. Fnpany certificate) [~]'"~ DISAPPROVED ~y~ ~ DATE I '--~'W~ f BY{Title) /~ 72-010 (Rev, 3/78)