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Home My WebLink AboutMOUNTAIN VALLEY ESTATES BLK 2 LT 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ~EW MAILING ADDRESS LEGAL DESCRIPTION ~ ' ' " ' LOCATION i-/iz_/-¢~//.~ ~, Well ~ I Absor ~t on area o D,STANCETO: I % I ,' ~ ~ I Manufacturer , ~ ILiq' ~apacity in gall°nsl IF HOMEMADE I Inside length ~ / Well ) Foundation ~ / DISTANCE TO: I /No. o, Length of each ,fn~/~ Total length of ,]nes ~ ITop of tile to finish grade / I I Material beneath tile / /Length ~ / Width ~ / Depth / ~ ~/~ Type ol crib Crib diameter Crib depth ~ ~ Well -- ( Bu ding found~tio~ . IClass Depth . z Driller Material Width NO, OF BEDROOMS~ PERMIT NO. ~: , PERMIT NO. Material Liquid capacity in gallons Nearest lot line PERMIT NO. Trench width Distance between lines inches Total effective absorption area Total effective absorption Nearest lot line Distance to lot line IPERMIT NO. IAbsorption area(s) Septic tank OTHER PIPE MATERIALS 8OIL TEST RATING INSTALLER REMARKS LEGAL Permit ~ Applicant: Location: MUNICIPALITY OF ANCHORAGE Department ( Health and Environmental :otection 825 L Street, Anchorage, AK. 99501 264-4720 * * * HANDWRITTEN PERMIT * * * WELL AND/OR ON-SITE SEWER PERMIT ~j~ ~ Mailing Address: Legal Description: ~_ /~ Type of Soil Absorption System Is: Trench: Drainfield: Maximum Number of Bedrooms: Phone Number: _ size: Seepage Bed: ~ Holding Tank: Soil Rating(sq.ft/br) ,,~ k The Required Size of the Soil Absorption System Is: DEPTH 3 LENGTH ~'~-~P'. GRAVEL DEPTH Co WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall Pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~-~ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if thez~esidence~r~mOdeled~//I///~' to inslude more that 3~ ~.'~b~r°°ms' Signe~:Apll~ica~t~-~,- %/~'~-"~------/ Issued by: "~'~4/[~O~× Date: ?/~-/~ SWP/024 (1/81) [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS SLOPE SI PLAN WAS GROUND WATER S ENCOUNTERED? V¢,~ O~ / P IF YES, ATWHAT i E / DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~"/ (minutes/inch) TEST RUN BETWEEN Z FT AND ~ FT Z/ C E R T i , i E D J~.~-'~/¢~..- 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. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ' , .;' ~' .' .' ! .... ~i ~.: ' .'. Lot I0; Block 2; Mountain Valley Location (site address or directions) Property owner Mailing address Lending agency Mailing address Mile 5.7 HiEand Road Eagle River, AK Dave a~.d Joanne Putn~, Day phone P.O. Box 4050 Tresque Isle, Maine, 04769 Day phone Agent Eva LoAch/ REMAX OF EAGLE RIVER Day phone Address ~6600 Centerfi~ld Drive Ea.ql~ Riv~% AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 694-4200 3. TYPE OF WATER SUPPLY: NOTE: 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Co mmunity on-site Public sewer .- - . Individual well X×X Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. .'" ,., ~, ,,, :--, ~ :~ ,-'2 -- ,:,;, :, .?~ 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 .. 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 ~hat 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 $ & $ ENGINEERING 17034 Eagle River Loop Road Ne, 204 Address Eagle Rive~', E nginee~s signature Phone ~' ~/~f - ~-~) '7 ~ DHHS SIGNATURE Approvc~t for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date//-Z ~>- '" -" [;i · ~,~he ~umq[pahty of A0chorsge Department of Health and Human Servmes (DHHS) ~ues Health Authority V~Approva ~ert ficates based on y upon the representations given in paragraph 5 above by an independent pr~fe~,ional en¢ih~r registered in the State of Alaska The DHHS does th s as a courtesyto purchasem of homes and their; lending institut ons n order to satisfy certain federal and state requ rements. Employees of DHHS do not conduct inspections or anal~e data before a certificate is i~ued. The Municipality of Anchorage is not responsible for errors or omiss~ons ~n the professional engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~-,:-r \o ~,.-v..- '2-- t'-~ok¢~, \l~:)arcel I.D. A. Well Data Well type ~2~.~ k-~ Log present (Y~. ~ If A, B, or C, attach ADEC letter. ADEC water system number ~ l/, Date completed ~, )Y---- Driller t..3 i~-_ Total depth Sanitary seal Cased to ~7.--t'v Casing height Wires properly protected (~j~N) ,~ FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I c, o Absorption field on lot \ ~o Public sewer main ~ It,- Sewer service line '7,,,~' g.p.m. AT INSPECTION ; 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 '7 ¢ ~. 7.- .- ~, '5 Cleanouts ~N) High water alarm (Y~ Date of pumping Tank size \ -L.¢o Compadments Foundation cleanout ~N) 5 ',/ Depression Alarm tested (Y/N) \~, ---z- - ct4 Pumper -~'~-. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ c~ ~ To property line ~ c> Surface water/drainage 72-026 (3/93)' Fret On adjacent lots I co ~ ¢¢ Foundation Absorption field & 7_- ' 2 Water main/service line I~o lY CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTA_.blGEm-R~M LIFT STATION TO: On adjacent lots Manufacturer Manhole/Access (Y/N) "Pu~ Surface water D, ABSORPTION FIELD DATA Date installed "/~ 7~ ~ - 6 '7 Length 5~O ' Total absorption area Date of adequacy test Soil rating (GPD/FF) Width ~5'- ~ Gravel thickness /,2 5-c, ¢' Cleanout present ~N) / / ' '/~ 9 ~ Results~ail) ,/,'~-~ Water level in absorption field before test O *' After test ..~.PeroXide treatment (past 12 months) (Y/~ /-/o,,-/~- _/mz ~,~ ~//,.( If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Sudace water / Curtain drain System type /~ £ ~ Total depth /9 / Depression over field (Y~I~P ,,-/ for ~ x'// Bedrooms On adjacent lots / oo / ¢ Property line 70 / + To existing or abandoned system on lot Cutbank "'-¢ ~ Water main/service line Driveway, parking/vehicle storage area / o E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff_e,.c(~..~,,~.LJate of this inspection. Signature , Engineer"s Name H~ Fee $ ~0~, ~0 Waiver Fee $. Date of Payme. d -/0 - ¢¢ / ., Date of Payme~ Receipt Numar 'er ~ { 7 ~ ~. ? Receipt Numar 72-026 (3/93)' Back 11×09×9~ 1~:56 CT&E ENUIRONMENTAL LAB SERUICES CT~ R~f, ~ client Sal.ple ID Matrix Commercial Testing & Engineering Co. Environmental Laborato~ Services ~~'~'~'~'~'~a~'~'j~''a~'~'~''~;~ lABORATORY ANALYSIS REPORT 9~.5672-1 510 BLK2 MOUNTAIN VAI,LEY EST WATER Client Name S & S ENG]iNEERING OrdeDed By RAY Project Name Froje~ PWSID QA 8ample Remark~ ROUTINE Rnf4PLE COI,I,ECTED BY; RAY. WOEK Order 10658 Pripted Date 11/09/94 Received Da~e ll/04/~ ~ 17:00 hrs. Te(~h])[cal Director ~T~PHEN C. ~C Allowsble ~t. Anal Parameter Resul%f~ Qu~l U~l~.t e Method bit1%iCe Date Date Nitratc-N 0,2.9 m~/l., ~PA 353.2/300,0 10 11/07/94 CHR See Special Instructions P. buve UA - Unavailable S~¢ Sample Remarks A~ove NA = ~oC Analyzed UDdeteutcd, Repor~=d value i~ the practical ¢~an~iflcatlon limit, LT = bees Than GT - Grea~sr Than Second~z'y 5633 8 Street, Anchorage, AK 99518-1600 --Tel: {907) 562-2343 Fex: (907) 561-5301 ENVIRONMENTA~ FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW J~RSEY, OHIO, UTAH. WEST vIRGINIA 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 Lot 10; Block 2; Mountain Valley Estates Location (site address or directions) MZZe .5, 7 HZZand Road Property owner Mailing address Lending agency Mailing address Agent Eva Loken Ted & Joy Johnson Day phone 337-0627 P. 0.Box 210948 Anchoraq¢, Alaska 99521-0948 Day phone RE/MAX OF EAGLE RIVER Day phone 694-4200 Address 16600 Centerfi~ld Drive #201 Eagle River, Ak. Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS'. $ ~ TYPE OF WATER SUPPLY: Individual well XX Community well Public water NOTE: 99577 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: XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1191) Fronl MOA #21 '~JOM s,JaaU!l~ua leuo!ssejoJd eq~ u! suo!ss!Luo Jo sJOJJa .Iai elq!suodsaJ lou s! @6eJoqouV jo /q!led!o!unl, N eq/ 'pangs] s! e~eo!J!]Jeo e eJojeq e~ep ezXleUe JO suoRoedsu! ~onpuoa 1au ap SHHQ Jo seaXoIdLu:E] 'slueuuaqnbaJ e~els pue leJepa~ u!e]Jao Xjs!~es o~ Jap Jo u! suo!~nl!~su! bu!puel J!eq~ pue sauJoq jo sJeseqomd oh Xse]Jnoo e se s!q~ seop SHHO eql 'eNSelV jo e~e~$ eq~ u! peJels!aeJ Jeeu!6ue leUO!SSejo~d ~uepuadepu! ue Xq e^oqe 9 qdeJ6eJed u! ua^!8 suop, eluasaJdeJ aql uodn ~lUO peseq .se~eoi]!]JeO le^oJddv X~poqlnv q),leaH sense! (9HHC]) sea!Mas ue~unH pue qlleaH jo ~ue~u]dedeQ e6e]oqouV jo Xl!led!o!unlAl aqJ. S]UeLUWOO leUO!]!PPV :suo!~elndp, s 8U!MOIIOJ eq~, 4]!M 'sLuooJpeq JOb le^oJdde leUO!~!puoo 'pe^oJddes!C] 'suJooJpeq ~- Job pe^oJddv ---~ ~l~nJ. IfNOlS SHHO eUOqd ~0-~ ~ON 1oeo~l dool ,~e^!~ elEi-3 'k~:O/L ~Nl~l;99Nl~l~=l ~ ~' $ eJn],eua!s s,Jeeu!au=l sseJppv wJ!-I Jo euJeN · uo!]oedsu! s!q] jo e]ep eH] ua ]oejje u! suol]elnaeJ pue 'seoueu!pJo 'sepoo e]e]S pue led!olunlAI lie q]!~ eoue!ldtUoo u! s! u~e]sXs leSOds!p Je]e~e]seM ~o/pue Xlddns Je]~ e~!s-uo eq] 'uo!~oedsu! pue ua!leap, se^u! 4LU LUO~J pue sel!J eaeJoqou¥ bo X]!led!o!unlAI eq~ uJo]j peu!e],qo UO!]eLUJOJU! eq] ua peseq ~eq] XjHe^~equnj I 'u!eJeq pe]eo!pu! eJn~on~]s bo edX] pue SLUooJpeq bO ~eqLunu eq] ~oj e~enbepe pue leUOp, ounj 'ejes s! Lue]sXS lesods!p Je],eMe],se~ Jo/pue ~lddns ~e]e~ e],!s-uo eq], ),eq] s~oqs uoReo!ldde le^oJdd¥/qpoq]nv q]leeH s!q] jo uo!]eaRse^u! XLU ],eq], Xjpe^ I '~oleq uMoqs e]ep ua!lap!la^ eq] jo se pue o~eJeq pex!j,~e lees XLU Xq pe!j!]Jeo s¥ '9 I:I~t~INIgN=1 AG NOIJ. O~IdSNI -I0 .I.N~IIN~.IV.1S Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. ADEC water system number _ O ~ Driller Date co. mpleted / Cased to ~ "dC%-t · ,,. Casing height Wires properly protected ,~--9/N) Legal Description: ~..-.c:,"( A. WELL DATA Well type ~¢"~'~¢'~-- If A, B, or C, attach ADEC letter. Log present t~b Total depth Sanitary seal ~N) FROM WELL LOG AT INSPECTION Date of test Static water level ~ "~'..~\ Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform O °° t"/~o ¢,.¢.., Nitrate Date of sample: ~ ~/(-~ Collected by: Date of pumping Other bacteria /,../o ~.1~. S & S ENGINEERING B. SEPTIC/HOLDING TANK DATA Date installed -7 -' 7.-'~-- - ~:> ~ Tank size [7- .~Fc:> Compartments %" Cleanouts ~/N) ~/ Foundation cleanout ~0N) ~ "~ Depression (Y/~) High water alarm (Y~ ~ Alarm tested (Y/N) /-'[IA ~, "¢'4'"'~2~-- Pumper ¢T:'_,-,~. ~.-~,,*~,~ ~ 17034 Eagle River I.oop Rea~l No. 204 Eagle River, Alaska ¢9577 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /oo ~ ~ On adjacent lots /~ Topropertyline lo ~4. _Absorption field ~'z. ~ Surface water/drainage /~'~ /~ 72-026 (Rev. 7/91) Front Foundation Water main/service line /¢- CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA ele~ SEPARATI~.ON'~ISTANCE FROM LIFT sT/~TION TO: VCEII on lot ~ On adjacent lots Manufacturer Manhole/Access (Y/N) ~ "Pump on" level at --~ "Pump off" level at ~ Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length ~'-c~ Total absorption area / Depression over field (Y~ Results4:~feil) Date of adequacy test for ~ ~ L~"¢-- ,eroxide treatment (past 12 months) (Y(~) ~U¢~-J'~-- ~/~f'~,J ~-/ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /oo /~ On adjacent lots /"~ / ~' To building foundation On adjacent lots Surface water /~'z2 /~' Curtain drain /"/ Cutbank Soil rating '~' 1-" ~ / ¢:;¢'" System type Gravel thickness ~ '~ Total depth Cleanouts present~/N) If yes, give date Property line /~2 ¢'~ To existing or abandoned system on Water main/service line Driveway, parking/vehicle storage area bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature S & $ ENGINEERING 17034 Eagle River Loop Road No. 204 ,::~,,!.: ph,.: ,, ,~,~a~l,;~ 99577 Engineer's Name Date HAA Fee $ /7 Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number FOLD Subject: To: & EAGLE RIVER, ALASKA 99577 ROBERT A. SHAFER, P.E. 694-2979 FAX: 694-1211 Lot I0; Block 2; Mountain Valley Estates Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage., Alaska 99519-6650 HEALTH AUTHORITY APPROVALS EXCAVATING I CIVIL ENGINEERING WORK ARRANG ED I ADEQUACY TESTS I SOIL TESTS WATER & SEWER LIN ES & MAIN EXT. ON SITE INSPECTIONS DATE OF MESSAGE I ROUTING SYMBOL I October 6, 1992 SIGNATURE OF ORIGINATOR TIT~~ ~'~ i FOLD MESSAGE On September 11, 1992 a we~l flow teat was performe, d on the we~l located on the referenced property. The w~l was found to produce a minimum of 6 gallons per minute (GPM), with the pump cycling between 18 ft. and 24 ft. Afte& the test was completed, several fauce~ were. turned on with full flow. The wat~ lever was drawn down to the pump at 32 ft. b¢1ow the ground surface. The Rea~tor then proceded to have the. pump set lower to determine, at what leve~ the water was cascading into the we~l. From the ground surface to 42 ft. below no wate~ was found to be cascading into the well. REPLY From: DATEOFREPLY IROUTING SYMBOL SIGNATURE OF REPLIER TITLE OF REPLIER RETAINED BY ADDRESSEE CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99519 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS RESULTS for INVOICE # 58227 Chemlab Ref.~ 92.4915 Sample ~ 7 Matrix: WATER Client Sample ID PWSID Collected Received Preserved with LIO B2 MOUNTAIN VALLEY EST. SEP 11 92 @ 10:30 hrs. SEP II 92 ~ 15:00 hrs. AS REQUIRED Client Name :S & S ENGINEERING Client Aect :SNSENGP BPO# : Ordered By :R. SHAFER POW :NONE RECEIVED Analysis Completed : SEP 14 92 Laboratory Supervisor : STEPHEN C. EDE Released By :~ ~.~ ~ Send Reports to: i)S & S ENGINEERING Parameter Results Units Method Allowable Limits NITRATE-N 0.39 ms/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: BAY. Remarks: I Tests Performed ' See Special Instructions Above UA~Unavailable ND~ None Detected *' See Sample Remarks Above NA- Not Analyzed LT-Less Than, GT~Greater Than ~'~,~ SG-~ Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date , '¢:~- ~.~'7..~ ~'7 GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, r,~ge) Locatior~(address or directions) (b) ProPe-dy O~wner ~4¢2~/-~ Telephone ~¢~'~ '- ' ' ' -/ ~ ' ' (e) Mail the HAA to the followinq address: or; Check here ~. if hold for pick up. List contact person and day_phone number below, TYPE OF RESIDENCE Single-Family I~ Number of Bedrooms WATER SUPPLY Individual Well E~ 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 A'l 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 72 025 IRev 8/861 Front 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 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 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 $ & S ENGINEEEING Address Date 17034 Eagle Rl~er Loop Road No. Telephone DHHS APPROVAL Approved (~ Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/86} Back WELL DAT4 F C ti'IV E [) MUNICIPALITY OF ANCHORAGE (MOL,, HEALTH AUTHORITY APPROVAL (HAA) MUNICIPALI'IY OF ANCHORAGE CHECKLIST - FEBRUARY 1984 ENVIRONMENTAL SER\qCLS DIVISION 264-4720 Legal Description: Well Classification Well Log Present (Y/~ Total Depth ,¢~ CH Cased to Static Water Level ~ / Casing Height Above Ground Electrical Wiring in ConduitS/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D,E.C. Approved (Y/N) Date Completed ~ - ('~'¢:~-- Yield Depth of Grouting Pump Set At Sanitary Seal on Casingd~)N) Depression Around Wellhead / O¢/?~ ; On Adjoining I. ots / CO ~ / ~c~ /"f ; On Adjoining Lots / To Nearest Public Sewer To Nearest Sewer Service Line on Lot To Nearest Edge of Absorption Field on ~.ot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by ~'-)"~ ~----~ Water Sample Test Results ~..~/~'"~['~~ Comments ¢ B. SEPTIC/.H~EDtNG TANK DATA Date Installed "~¢'~-'¢-"~:~'"~ Standpipes ~/N) Air-tight Capsd~'N) Depression over Tank Pumping/Maintenance Contract on File (Y/N) lA Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/~ Tank: To Water~Supply Well To Property Line To Water Main/Service Line Course Size /'~'¢~'-'¢ No. of Compartments Foundation Cleanoutd~/N) _, Date Last Pumped _ ,d/~ ; 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 72-026(11t84) Soils Rating in Absorption Strata Date Installed '~ ¢-~'"~'~'7 Length of Field Width of Field "~ '~'~'~ / ~ Depth of Field /O ! Gravel Bed Thickness (,~ Square Feet of Absorption Area ,/~"~'~'~ ~ Standpipes Present ~YN) Depression over Field (Y~;~. Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: 1 ~o /.-4-- To Property Line To Water-Supply Well To Building Foundation Lot /'J/~' To Water Main/Service Line / ~2 / .& To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ;~ ,~ /¢'~:~f¢-.- To Existing or Abandoned System on ; On Adjoining Lots ~"~ c~ To Cutbank (if present) D. 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 ~OA and~ HAA guidelines in effect on the date of this inspection. Sigrife~. ~ [~NGINEERING Date ~'/~,'¢'/~'7 ~ 17~.~ ~ :': ~ River L~p, Road No. 2u~ / ~ ~ ~ ~ ¢~,.,',~:~.. ~ Co~E[w,, /,,~c::k= 995~ MOA No. ~ ~ -":')'. :; ,'~ ..... Receipt No. /'~ ~ / O O0 ~ Date of Payment ~/~O/~ , ~ Amount: $ /~~ Page 2 of 2 72-026 (11184)