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Home My WebLink AboutMOUNTAIN MANOR BLK 4 LT 1 "UNICIPALITY OF ANCHORAGE Heal and Environmental Protec n Fourth Floor West ~ 825 L Street Anchorage, Alaska 99501 264-4720 SEPTIC "I'A I ,~ K: ~4..~ NUMBER OF DIS1/~,NC [£ ......... CO1',4 PA fCFM ENT$ F ROr'd wi:~_L__ [~L_~ MAr:U/ A(_ tLJi~ER ~ F. 1,:\ t'!: RIAL fN!i'.JE L_ENC;I[I .... II'qSi[)E WI[)I H _. . LIQUII) [)EPI'H ...... LIQUI[) CAPACITY ~GALLONS. TIrE DP, AtN FIEI._[3: .. I ~.3t TOTAL LEN,aTI (,~; DI%'[/C~iC! FROM ~','~Lt_~ ._[OUff QATI(.)N ....... NEARI.ST tQI LINE ....... OF' LINE ~ of Lines ..... i:)!s I,:~N(:E [3E1 WEi:N LINES · ..... [ [~i~hlCtl TO1-AL_ EFFECTIVE _ SQ. lT. t ENGFIt OF EACI~ t INE Dt-Pqlt: IOF Ol IlL[ 10 t if,JlSIt GRA[)E. ~ vIA-IE]Rlzk!, t EfiEA1 ff ~ N. ABOVE TILE SEEPAGE PI'f: k)I~.M[:rER ....... OR WIDTH ..... LENGi'I~ ...... DEPTH Log Crib Rings Crib Size: Dh'\METt 'lO 'I' ,,'~ t. L t- I ITC TI V E BUlL ) fti F(jUNI)A!ION , NFAR[ST t_o'r t INE ....... A[:SOR["] ION /~][-A (WALl_ AREA) SQ, FT. Well Depth: ' ' Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: ~I of Bedrooms: Installer: Remarks: PERMIT NO. AF'F:'L.. I CANT' LOC:FTT I ON LEGFIL 'T'YPE OF SGIL RBSORBTION SYSTE:M IS: TRENC:H t',IRXIMIJM NUMBER OF BEDROOMS TM 4 SOIL. RATING (SQ FT/8R)= '],.20 'THE REQUIRED SIZE: OF THE SOIL ABSORPTION SYSTEM IS: E:;, E.] F:' -r H == :S2: L. Et I'-,I I::i ]- H = 4 ::I.. ~'3 R R %-" .IF..: L.. [) E] F' 'T H = E; THE I_ENG]"H DIMENSION IS THE LENGTH (IN FEET) OF 'THE TRENCH OR DRRINFIEL[:,. THE I}EF'TH OF R TRENCH OR PI]" IS THE [:,IS]"ANCE BETWEEN THE StJRFRCE OF THE GR[)UN[:, RN[) ]"HE BOTTOM r)F THE E',.,(CAVRTION (IN FEE]'). ]"HERE IS NE) SE]" WI[:,TH FOR TRENCHES. THE GRF~',,,'E[... [:,EPI'H IS THE MINIMUM [:,EPTH OF GRAVEL.. BETWEEN THE OUTFRI_I... PIPE AND THE BOTTOM OF THE EXC:RVRTION (IN FEET). ~-!.;E:F'T' I C: ]-Rr-JK: S I DZE:= ::LZ.;.:5 0 F' R (L": I-::: R ,]:~ EE F' L. R r-,l 3f' 121F' 'T' I A F'RCKRGE PLANT blRY BE IN.=,'fHL.LE[ RT THE FERMI]lEE _ r~P'TION =,UP.',JEI_.] TO THE FOL. LOW I NG CONDITIONS: :l.. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALL. El:,. ;.-]'.. R CONTINUOIJS MAINTENANCE RGR. EEMENT IS REG]IJIRE[:,. IF R MAINTENANCE RGREEME. NT' IS NOT KEPI' CURRENT YOU MAY BE REQUIRE[:, TO ENL. RR. GE THE SOIL.. ABSORPTION SYSTEM RN[),.."OR '¢OU MAY BE SI. JBJECT TO PROSECUTION. ......... '"f'l.,.i(21 ( ~.:.". ) ][ I"-J".'.&_- F"E: C: -r I Cll"-,I L=;.- RE:E; BRCKFIL...LING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND RPpRI]VRL. B"r' THIS [.',EPRRTMENT WIL. L BE: SUBJECT 'T'[) PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL.. AND ANY ON-SITE SEWAGE DI'..-.-;POSAL SYS]"EM IS d..00 FEET FOR A PRIVATE WEL. L. OR 200 FEET FOR R PUBLIC WELt .... WELL L. OGS ARE RE(;,'tJIRE[:' RNI.') MUST BE RETURNED "ri.") 'r'HE [)EPRRTMENT WITHIN ~:0 DAYS OF THE WELL. COMPLETION. O'T'HER REf.;¢..JIREMENTS MAY APF'L'-r'. SPEC:IFI[.':RTIONS AND CONSTRI.JCTION [)IRGRRMS ARE A',,,'RILRBLE TO INSURE PROPER INS-rALI...ATION F' E: ~.'. r"# :[ T' E: :=-:: F' I F-: E: :~; [3', E.'] C: F_: I"1 B E; F-: :~: :J, .... :.t .".7) ]':'" ]:" :1: CERTIFY 'THR]" :1.: I AM FRMILI'AR WITH THE REQI..JIREMEN'FS FOR ON-SITE SEWERS AN[) WEL..L.S AS SEq" FORTH BY THE MUNICIPAI...ITY (:iF ANCHORAGE. 2: I WILL INSTALL. THE SYSTEM IN ACCORDANCE W~TH THE CODES. 3:: I UNE:,ERS'T'ANI::, THAT 'r'HE ON-SITE SEWER SYSTEM MAY REf..]L.IIRE ENLFtRI.'.3EMENT IF:' THE RE'"";I[:,ENCE IS R. EMO[:,EL. EE:, T~ INC:LI.J[:,E MORE THAN 4 8EE:,ROCtMS. S I GNED: ~ ....... ~ ................................. ~~RPF'L I CFC.d]' MC: I...EOE:, CONST I SSL.IIE[:, 13'?'. _ ...... E:,ATE ........................................... f 0 Et E GE( Russell Oyster 6942774 SoUs Et Foundations Performed for: 'ECHNICAL ~ DEVE Box 90, Davis St, Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG < . ,3 ~,./:'~"/:,'.,::' ', !)./,: Mai 1 ing Address: Legal Description: :'~:~'~.', /',/,,'~ -~ ~Jfeet} 3PMENT CO. Land Development , d/,'/'./ .. .......... S__oll Ch~Kacterlstlc) 15 16 Gr'ounU Water Encountered: Yes Proposed installation: Seepage Pit__ Cor~nents: No '~' If yes, what depth Drain Field~ Performed by: This well is producing MOON DRILLING SR BOX 668, BOGARD RD. PALMER, ALASKA 99645 TELEPHONE 745-4071 ~ BIk, Sub, gallons ~ water per hour. INVOIC~ WELL LOG INVOICE NO.. DATE ~ YOUR P, O. NUMBER TERMS SALESMAN CA$1N FORMATION CA$1N FORMATION CASIN FORMATION 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 INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Fob 6. F ~/ ~ ~-~- /~¢_ 5¢-~.--- Day phone Lending agency Mailin. g address Day phone Agent Address ~C~3/~' ~/~/Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: /'-/ '~ TYPE OF WATER SUPPLY: Individual welt 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 WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOAi¢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 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 KND Engineering 20441 Ptarmigan Blvd. Address Ea.qle River, AK Engineer's signature Phone DHHS SIGNATURE // Approved for P'0 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additiona~ 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. Employees of DHHS do not conduct inspections or analyze data before a cerUficate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-O~(Rev. 3/91) ~ack MOAiCZ1 Municipality of Anchorage 0C'i DEPARTMENT OF HEALTH & HUMAN SEI:~IGES-'~ ~' Environmental Services Division ..... ~' ~ s~v~c~s D~V~S,~' 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~7~ '/ 8/~"/-/ ,,~~/~,4,~/' Parcel I.D.: ~-.,~-~-~ - ~' 7/ ~ ~-~F~ A. WELL DATA We, type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed / ~ 7 7 Cased to 2///~ ~4~--Casing height (aboVe ground) //" Wires prOperly protected (Y/N) ~ Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform FROM WELL LOG 1 77 Nitrate AT INSPECTION 1,1 g.p.m. Other bacteria Date of sample: /D - 7- B. SEPTIC/HOLDING TANK DATA Date installed /D-/2-.~7 Tank size Foundation cleanout (Y/N) ~/. Depression (Y/N) Collected: /~//I///'~ ~_~c~," Number of Compartments . ~- . Cleanouts (Y/N) . High water alarm (Y/N) /~/ Date of Pumping /~./z/..~ Pumper C. ABSORPTION FIELD DATA Date inStalled /0-1~' ~ Soilrating (g.p.d./~or~/bdrm) l~-g) Length Width Effective absorption area ~:~ /Monitoring Tube present (y/N) . Date of adequacy test 7-Z~ '~ ~ 7' Results (Pass/Fall) Fluid depth in absorption field before test (in.); Fluid depth / (ins) Minutes later: ~ Peroxide treatment (past 12 months) (Y/N) /~/ Gravel thickness below pipe ~_~ / System type Total depth Depression over field (Y/N) ~ For . Y Immediately after~/~ gal. water added (in.): Absorption rate = ~, O~ ~ q.p.d. If yes, give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (WN) High water alarm level at* Cycles tested E. SEPARATION DISTANCES / Size in gallons / ~ump on" level at* ~"Pump off" level at* ////'Datum . SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line /~ / -F On adjacent lots / C)~ /-~ On adjacent lots J ~)(,.~ ~ ~ Public sewer manhole/cleanout ~-~- ' ~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /~ / '/' Property line ! O ~ ~ Absorption field -~ Water main/service line ~- ~' /~ Surface water/drainage ~ O O t.+ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~4--~ ~-('~ ~ Building foundation ,~ ~ -{- Water main/service line Surface water / ~:)~ ~ ~+ Driveway, parking/vehicle storage area Curtain drain ~O '-+ Wells on adjacentlots /~ ~:) ~ '~ F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal recordsa in conformance with MOA HAA guidelines in effect on this date. Signature ~-~, ~ Engineer's Name ~ ~ ~/ ~c~S HAA Fee $ Date of Payment //,~ Receipt Number ~ ,~,~-~z~' z~ ' ' ~//~/,~/,Z' ? J 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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 GENERAL INFORMATION Complete legal description Location (site address or directions) /,~ ~' Property owner Mailing address Day phone Lending agency Mailing address Day phone Agent Address 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 WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I 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 KND Engineering 20441 Pt~migan Blvd. Address Eagle River, AK Engineer's signature Phone DHHS SIGNATURE v Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~-- /'./~/4¢~¢ ./~--~ Date ¢7__.~/~? 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 pu mhasers 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 fRev. 1/911 Back MOA ~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVIC~ DIVI$1O~ A. WELL DATA Well type Log present (Y/N) Total depth ~'~ 7~) ' Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed /¢.~/ Cased to .~J' ¢¢ /¢~'z~P(.~ Casing height (above ground) Wires properly protected (Y/N) REEEI [D Date of test Static water level Well production FROM WELL LOG 1977 g.p.m. AT INSPECTION /,/ g.p.m. WATER SAMPLE RESULTS: Coliform ¢¢' Nitrate Date of sample: ~ B. SEPTIC/HOLDING TANK DATA Date installed Io-1, -77 Tanksize Foundation cleanout (Y/N) / Depression (Y/N) /4/// Date of Pumping '~-%~;- ¢? Pumper Other bacteria Number of Compartments ~ Cleanouts (Y/N) Y High water alarm (Y/N) ~¢//¢ C. ABSORPTION FIELD DATA Date installed Length Ye / ' Width .~ I '~ ~ ~,m~-~ Gravel thickness below pipe Effective absorption area ~ Monitoring Tube present (Y/N) Date of adequacy test ~ %~.,~ ~ ~ ? Results (Pass/Fail) Fluid depth in absorption field before test (in.); .~____ Fluid depth ~' (ins) Minutes later: .:~ Peroxide treatment (past 12 months) (Y/N) . Soil rating (~.,. ...... or ft/bd m) vza~ System type ~..,/ Total depth ? / . Depression over field (Y/N) /{// . For ~/ Immediately affer~,/~ gal. water added (in.): Absorption rate = ~z:~4~) 7L g.p.d. If yes, giVe date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION / / Date installed / Size in gallons ~ Manhole/Access (Y/N) / "Pump on" level at* / "Pump off" level at* CyclesHigh watertestedalarm level at*/ *Datum ~ E, SEPARATION DISTANC£S SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot z/~~) /~' Absorption field on lot .,/'~)('~ On adjacent lots On adjacent lots Public sewer main Sewer/septic service line Public sewer manhole/cleanout Lift station SE:PARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: ! Foundation //~/~ w~ Property line //'~:;~ ~ Absorption field ~ ! Water main/service line ~-~' ~/ Surface water/drainage .,/~ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ,~ t~- Building foundation ,~ ~: Water main/service line Surface water /'~9'~ /''~ Driveway, parking/vehicle storage area Curtain drain j~) /~ Wells on adjacent lots ~)49 ! Y' F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MOA HAA guidefines in effect on this date. Signature ,~, Engineer's Name Date ~/,//~/~7 HAAFee $ c~ ,~ Date of Payment <~/~-//~,/~' ~ Receipt Number .~>.~,Z'~~ &O/~'×> Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHOI:tAGE DEPARTMENT OF HEALYN A~,D ENVIRONtVI';£kFi'AL PROTECTION tJtVISION OF ENVtRONI/,]tE;N'i'AL I. IEALy[~ CER'ilFICATE OFIN'ciPECFION FOR ltEA! 1'1.4 AUFIIORFiYAppIIOVAL OF ON--SrTE SEWER AND WA1 Erl FACILI'rY 264-4720 GENI?:i~AL (a) Application Date. /!.Lt2-{.U ~[2 J..? ~_ _Z~.~(~ t~ Legal De-x;' ption (include tot, block, subdivision, section, township, range) Iocation (~(R_h'ess or .......... e ephone Homo . ~ : .... [~usJncss ...... {{- ,~ ]~a~jc 1~ v(~'~ A( 995' ' . .... (c) AL~p can: is (chock one): I_ending Institubon B ' Ownor/builder [3 Buyer []; Other ~1 (explain); Rea] i o'" (d) Len(ing Instiiution I~/A ~ ............. Telephone (e) Real ' -~' ' Address; 'l e!ephone (f) Mail the I. IAA to the iollowing address; 'r~'Y PE (')l'? ',(;ingle Family ~.] Mulli.-Family L] Other NLliiiber Oi Ii~odroorns :3. WATER SUPPLY Individual Welt [~'] Community E'J Public ['] Note: If community well system, ITILISt have written confirmation ro~ ] ll]~ et. t l)epa~ ~ment of l:nwronment~tl Conservation attestiog to/he !eg;dity end status SEYFAGE Onsite I~l Public ~] Community I]-I Holding Tank E.] Note: if (1ommui fity well systocn, must have written confirmation from the State F)eparlment of Environ mental Conservation attesting ti) the legality and status. Page I el 2 ENGiNEeRiNG FIF~M P~OV~i3h..; IF,!SPECTIONG, '- ~ ',' ~-,~ :, · Eot ,~, FILE ~:Af,Cl;, D,., A AND INFO[~qA-i'ION AS certified by ~ny seal affixed h(~Feto ii,]c] as of the vatidatiol~ date shown bob)w, t verify that my invcs(igatio- of thin I lealth A tho ' ty Approval sho~ s thai tho on-site water suppiy alld/of wastow{iter disposal syste n } safe functional and adequate for the numt)er of bedrooms and iypo of str uctnre indicated he~ em. I fu~ ti lc* verify that based on the information obtained flora the Municipality o[ Alichorage files and from nly r vestigation and insl)ection, tho on site wate~ sul)ply and/oF wastewater disposal system m m compliance with all Munieil)al and Slate codes, ordinances, and regulatio s m effect on the date of ti-tis inspection. ' ' EAGL~ IIlVER ~NGINEEI~IN6 SCRVICES Name of F*rm LA[~LL It~Vifl,, AI(99~Z-Z - I~,ephone Address .... ?,, ~L BOX '/7~294 ~ c:--~,- ~ - 6944)i95 CAUTION The Muncipatity of Anchorage Oeparlrnent of Health and Environmental .rh-otec[ion (DI-tEP) issi]os Flealth Authority Approval certificates ba,,~,d ,,,,1~1~ upon the representations [liven in p,~Fa.qrap 1 5 a love by ail independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of holsqes and their lending institutions in order to satisfy certain federal arid state req ] 'ements E:Fnployees o[ [)HEP do not conduct inspeetio~ls or analyze data before a certificate is issued. The Municipality l o Anchorage u-~ not responsible for errors or omissions in tile professiomd engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MO~-,~ MUNICIPALITY OF AN£HO~LTH AUTHORITY APPROVAL (HAA) DEPT. OF HEALTH & CHECKLIST- FEBRUARY 1984 WELL DATA Well Classification EN¥1RONMENTAL PROTEC'[ION 1 2 986 RECEIVED 264-4720 Legal Description: ~ 7~ / a~J:~/'MF ~ /~,uDr T lZl ~ tC lc,: ...~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Total Depth r;~ ?~ Static Water Levet 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 /v'~,.~. /Y Date Comple, ted ?~_2~ Yield Cased to ~ / ,~-~,-,~Depth of Grouting ~-Y~P-- ' /'~/'~,,-," /~".,,~ ~-~ ~--',~.t Pump Set At Sanitary Seal on Casing (Y/N) ,? Depression Around Wellhead (Y/N) ; On Adjoining Lots ~"~ ' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments To Nearest Sewer Service Line on Lot ~4' ' B. SEPTIC/HOLDING TANK DATA Date Installed t ~ -J '~ 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) Size I ¢~,.~-O No. of Compartments 7 Foundation Cleanout (Y/N) Date Last Pumped /]n~v D.~j ; for Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line J O To Water Main/Service Line Course /~ lO0 ~- ID+ To Building Foundation ~ ' To Disposal Field ~ ' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed I c~ "7 ~ Width of Field ~ ~" Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot !U I A To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field . ~"7~' / Depth of Field c~ i Gravel Bed Thickness ~ / Standpipes Present (Y/N) Date of Last Adequacy Test be~cc~wl_~ Tre ~ c.L. To Property Line I To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) M 10t LIFT STATION ~,//~; 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 J~' Date Company /..~R ~.~-J' MOA No. Receipt NO. ) C:::~ t, ~ ~ Date of Payment ~""~-2 ~ ~; ~ Engineer's Seal Amount: $ Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 1 Blk 4 Mount~a_i_n Man_o.r_~.T_~lq__N, R1W, S_q_c.'. Location (address or directions) Stillwater Road (b) Applicant Nam~f'or~_ine Schultz Telephone: Home 694-~2479 Business N/A AppticantAddress 85.~_2 E. Turf Court Anchorage, AK. _99504 (c) Applicant is (check one): Lending Institution []; Owner/builder~;]; Buyer []; Other [] (explain); (d) Lending Institution _N'.~_ ........... Address (e) (f) Telephone Reap Estate Company and Agent ~/A Address Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms .... _4 Other WATER SUPPLY Individual Wel~j;J Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [~ 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 72~);~n~84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my i nvestigat on of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm _ F_&P.I~I: ~!.vJ:_~ .... ". ;=RV!CES--- Telephone Address EAGLE RIVE~ /,~' ,,~ Date __ ,~ ./~-r'~ _6e~5 ~GLE RIVER ENGINEERING SERVICES ~GLE RIVER, ~ 99577 P. e. BOX 773294 694-5195 Engineer's Seal DHEP APPROVAL Approved for '~- bedrooms by _/_~L~/~ ...... ~. Approved ~'"'"-'~ Disa~v"ed Terms of Conditional Approval Conditional __ 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 lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage ~s not responsible for errors or omissions irt the professional engineer's work. ' Page 2 of 2 HEALTH AUTHORITY APPROVAL ("AA) CHECKLIST- FEBRUARY '1964 264-4720 Legal Description: WELL DATA Well Classification /¢~,~, c,-.e ~ Well Log PreSent (Y/N) Total Depth ~ 7 ~ Cased to .2/' ~,,,~,,~ Depth of Grouting Static Water Level ~M; / Pump Set At CaSing Height Above Ground /,2 /' Sanitary Seal on Casing (Y/N) /v .~/ Depression AroUnd Wellhead (Y/N) Electrical Wiring in Conduit (Y/N) Separation Distances from Well: If A, B. C. D.E.c. App[oved (Y/N) Date Completed / ¢ ~ 2 Yield 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 ; 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 Standpipes (Y/N) ~' 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 /~ ~' To Property Line /~ To Water Main/Service Line /c> ~ Course ,,A,,'~, ,.~ Size //2 5--~ No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ,~'~' ,P-.z,/ / ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ~ / To DiSposal Field To Stream, Pond. Lake, or Major Drainage Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed //~ 2 "~ Width of Field ~' ¢' Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot Type of System Design Length of Field z./~ / Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ?¢ ~ To Existing or Abandoned System on ; On Adjoining Lots To Water Main/Service Line ,'"¢ ¢- To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area / '~ ~ Comments ~'-,,,~ ,,~,~s'~- ~,,~¢.f .¢¢,,~.~-~ ..r?-.r.~ ./---,,¢¢ LIFT STATION ~ 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. Date .~-?,~ ~-./-~¢' 5"'- SignedY~ Company ,,~,4'~,._,,~_. j", '. MOA NO. Receipt No. ~ .~-j'~)-7 ~ Date of Payment ~ ~' '~'~ ''~¢'~' Amount: $ Z/5' O-~-~ Page 2 of 2 72-026 (11/84) Engineer's Seal DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSPEC'FQR ~ DEPT OF H~ALTFI & MUNICIPALITY OF ANCHORAG~ - ' ", DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTiF~IRONMENTAL PKOTECT O[~ 825 L Street - Anchorage, Alaska 99501 ~'~' I'~0V ~,L~ 1980, ENVIRONMENTAL SANITATION DIVISION Te'g"h°"e RECEiVE REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten {10) days for processing. MAI LI N~i'~,DDR ESS PROPERT~Y~ RESIDENT (if different fron~bove) PHONE 2. BUY~ ,-~ h, ', Y/) PHONE 6. TYPE OF RESIDENCE ,~-~'SI NG LE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [~-.~ Four [] Two [] Five [] 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. - ~--~ '--~.L~..'~-~ ---: ,, -~---~-,'~----,.'x'~ -'~-~ 72-010 (Rev. 6/79) 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: ~.~-S-~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sb~e~' Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS F"OVED FOR/ BEDROOMS [] CONDITIONAL APPROVAL {letter must accompany certificate} [] DISAPPROVED DATE BY - - MUNICIPALITY OF ANCHORAGE~ ~ DEPARTMENT REQUEST FOR APPROVAL OF INDIVIDUAL WATER'AND SEWER ~c~Li~i'E~ DI RECTION8: Complete alt parts on page 1. Incomplete reque~ will not be pr~ed. Please a Iow ten ! 0) days for process ng. ~'~PRQPERTYOWNER '~ ' E ' ~INGrADDRESS - ' ~ ' ROPER~ RE~JDENT,(If different from above) v - ' ' ' - ' ' , ~ ~ PHONE MAILING~ADDRESS~ 3; LE% Ne~NST~TUT~ON .~ - ' ~ - · I PHONE MAILING ADDRESS ' ', REALTOR/A~ENT lB. LEGAL DERCRIPTION : CATION ._ , , NUMBER OFBEDROOM~ ' ~INGLE FAMILY . ~ One ~ur ~ Other ~ Two ~ FVe ~ ~ MULT PLE FAM LY ~ ~ Three ~ Six 7. WATER~ SUPPLY ~DIVIDUAL~ ' ~ ATTACH WELL L ~ 'ncc June lg75 Forwe sdriled pr or to that date, gvewe ~ PUBLIC UTILITY ' depth (attach og f ava ab e ) ~DIVIDUAL/ON-SITE** **If individual/on.site, give installation date ~ 7 ~. ~ PUBLIC UTI LI TY If system is over two (2) years old an adequac~test is required ~OTE: THE INSPECTION FEE MU 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 F~I INDIVIDUAL DEPTH OF WELL /'[] COMMUNITY f DATE DRILLED / [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED Connection Verified INSTALLER El~eeptic Tank or []Holding Tank Size: I .~,~"~ If Tank is homemade SOILS RATING give dimensions: | ~ TYPE OF TANK MANUFAC~ TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~ :- - ~ CONDITIONAL APPROVAL (letter must accompany certificate) LEGAL DESCRIPTION 72-010 (Rev, 3/78)