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HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 4 LT 7NAME~% 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 [] UPGRADE LOCATION DISTANCE TO: I ~'~.~'~'-- / //~ Abso~.p~areg Manufacturer./-~ ,,..~ /~ Liq, IF HOMEMADE: Well DISTANCE TO: Manufacturer Inside lengtl~ . DISTANCE TO: No. of lines Top of tile to finish grade Well Length of each//~l / Length ~),~O / Type of crib DISTANCE TO: Class/d'O 'T' DISTANCE TO: Width Crib diameter Building foundation Foundation DwelU n q~ ~_¢...~ ,/ Wdt~ Material Nearest lot line NO, OF BEAMS. No. of 'bompar~;~)nts ~- Liquid depth PERMIT NO, Liquid capacity in gallons PERMIT NO. /~..tal length of lines Trench width Distance between lines inches Material beneath tile Total effective absorption area Crib depth B U il d i.~)u hid at i'o n Driller inches Sewer line Nearest lot line//(,,,~ .~. Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER PIPE MATERIALS RATING REMARKS ~,o. !,457-~ 72-013 (Rev. 3/~- k / / / /Z/'. 'N m lama 4 Trr4,(llrf] Ort ling DOC Co. dba L; SULLIVAN WATER WELLS P. 0. BOX 272, CHLIGIAK, ALASKA 99567 ® TELEPHONE 688.3759,•.-,+�• �/ p 0 Q•.... 4•,f. use 'der?.- '"'J'L`C yr DEPTH OF WELL OWNER OF LAND GAS' 1 ADDRESS. %rt. C~ ,T,•.• r•` `;•;•3--'rI STATICIEVELOFWATERFT. LEGAL: DESCRIPT30 j/[��/•�I. Q DRAW DOWN FT; !' f I J . Q DATE.- Started Ended g Y GALS. PER HR . PERMIT NUMBER _ KIND Q CASING NG • �°�:;` �' c�.�/civ �� ��-�,/s c� �.�cy � �: -�`• 3 3, KIND OF FORMATION:11dli From . Ft. to Ft. From Ft. to Ft. ; ••'•m5 i� From �•' Ft. to Ft. L Y' GX4 V5 From Ft. to Ft. From `y Ft. to *a 3 Ft. '�:�p� I 62 d445 From Ft. to Ft, :' f �•, , From Ft. to .53 - Ft. "�'' �� <� VF �. From Ft. to Ft From Ft. to Ft. '� ?C From _Ft. to—Ft "?•.;5;' From Ft. to Ft. From Ft. to From Ft. i ,t. From Ft. to Ft.._._ o.'�� <'• •��t From F 'io Ft.O� From Ft, to Ft; From ' t. to - Ft From Ft. to Ft. •.�...,,;; t From Ft. to—Ft. From Ft. to Ft.::'`;i;�jt a From Ft. to—Ft. From Ft.� t 2 f ) Z' )T,; From Ft. to Ft. From Ft, t Z. Ft: '`''*•'r -} +fir From Ft.'to Ft. From From Ft:`to Ft. From—foo-# z ` rj From Ft. to Ft. From Ft. to t. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft ' '•' �' 4IISCL.INFORMATION: DCIS L`-=—$ ^'^� DRILLER'S NAME xj ~A-FE!: ISSUED~ fl::'F:'l... I., . , ..Z. I,I I: :[) I) R E: S S: :ONTAr]'I" F'HONE: DI3::'ARTMIENT OF~ I'IEALTH AND ENVZRONMIE~NTAL F:'Fi:O'FE:CTION E]2~ I.. S"I'FqZET, ANCH[IRA(~I~:~ AK 9950 2:. 6 -,. ~ .-,.. ,:,,: :: Eilz!.O79E~ E:Nr_~ ]:IqlZI~]:;:ED DES I 09 / :1.9 SOUT'H F'ORK [ [ ~ TTRUCT/E. Al'ID S EI",IG ]: I NG SRE', :1.96 X / I~:AGI..~E RIVIF;R. Al< 99,"J77 6 9 4- 2 9 '7 0 EGAI_ DESCF:~ i F:':. 0 1' S I Z I ..... for'i:.h by {lie I"h..tn:i.'c:i, pal:[ty c)F Arlchc~r'age (MOA) ar'id :t. he SCa'Lc oF ~].a~ka.,, :!: v,~:i.].].:J,n!fs'La].l t'..he sysi:.(.:2m :i. rl a(:c:c)r'(:lancE) I..,,~:i.i'..h all I'I[)A (:':~di,:!Hsi and ar'id :i.r~ (:::(::)mp],ianccs? v,~:i.T.'h i:.l'l(!~, des:i.~:]r'l (:::ritc,.~r,:i.a of 'Ll"iit:~ i:l_~.PmiT.,, I w:i, ll al::lhEu'(e i'..c) all HOA and Sl:.at(.:~ (:){' ('~].a!il;ka ['c)quirc~n'lerlt!i~ l'()r, I:.1'1(~ EH'~.~V~('::'Pa~:.:J(!~' ~.~Py'~.-'~tem (::w~ 'LhJ. s [:,r' any a(:J.j,:t(::(.)i!r'l~,:. (:.ii', nc~arby ICH:.. ; :[ G !'..I E D i.:) A TIE:: F:'I::;'I...]:CANT: ..r.:;OLI]'I..[ F:ORK CCJi'qS'I'F:(LICT ~i~ AND .S EN[::~INli!~EH:IING MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAl. PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] SOILS LOG ~-PERCOLAI'ION TEST PERFORMED FOR: LEGAL DESCRIPTION: L~_~ · ELOPE ~ P--~.At~ ! 1 2 3 4 5 lO 11 12 13 14 15 16 17 18 19~ 20~ COMMEN'rS 72-008 (6/79) Reading Date % _Lo I I ,~ O [.) ,,4 t o PERCOLATION RATE ~O (minutes/inch) TEST RUN BETWEEN '~ ~ FT AND '/~'~"~ FT CERTIFIED BY: DATE: Parcel I.D. 050-661-17 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval 1, GENERAL INFORMATION: Expiration Date 3-z�rzd�/ Complete legal description MOUNTAIN VALLEY ESTATES #1: BLOCK 4, LOT 7 Location (site address) 3751 Birdsong Drive "Anchorage 99577 Current Property owner(s) Coolie Costello Day phone 360-4960 Mailing address Real Estate Agent 2. TYPE OF DWELLING: X Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 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 ❑ WaiverNariance request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 412.50 (COVID-19) Date of Payment D /d_�D Receipt Number sc, COSA T OSC201690 Date: Waiver Fee $ _ Date of Payment Receipt Number Waiver # Distance: d11 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: i z hl I D 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 test 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. DSQ SIGNATURE __?K' — System #1 Approved for _Y_bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the foll #AECC884 ?P,UTY(OF����//i pN, c do St e r ir S77-1/ f /Vo m �m 'Ar�� 1 Original Certificate Date:-), - 23 r Z 0 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 am COSA Checklist Legal Description: MOUNTAIN VALLEY ESTATES 41; BLOCK 4, LOT 7 Parcel 1D: 050-661-17 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA © Well log is filed with Onsite (or attached) Date drilled91-10/84 Total depth 60 ft Cased to 58 ft G Sanitary seal is functioning correctly Al Wires are properly protected Casing height (above ground) 12+ in, Date of flow test for COSA 12/4120 Static water level at beginning of test 22.5 ft. Comments B. TANK DATA Age of tank(s) 13.5 years Tank type/material Measured operating fluid level in septic tank 49° n Standpipes/foundation cleanout per record drawing Date of pumping SEE ARM MAINTENANCE FORM Well production at time of test 6.5+ gpm 'Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes 0 No r� t, Coliform bacteria is Negative Nitrate t,=5.5,q mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 2�senic less than MRL (ND) Collected by GEG, LTD Date of Sample 12/4/20 C. LIFT STATION 0 Required maintenance completed Age of lift station 13.5 years Lift station material STEEL Comments: D. ABSORPTION FIELD DATA BED 0 Which system tested (date installed) 9126184 Adequacy test date 1,214120 ALL standpipes present per record drawing Results F, -/]Pass For 4 bedrooms Total measured depth from grade 4.33 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 4.83 ft (min) Water added 031 gal ❑ N/A — pressurized field New depth 2 in ❑ Monitor tubes go to bottom Of effective. If not, state Elapsed time 95 min depth into effective 'S" Code -required soil cover over field Final fluid depth 0 in F-1 System presoaked Absorption rate 000+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) N/A Gallons introduced gallons If yes, enter date N/A Comments/Deficiencies: 'MIDDLE MT EXTENDS Y BELOW INVERT • THERE APEAR TO BE2 MTS & 1 CtO IN THE BED COSA Checklist yellow sheet NONE 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'Community 5Q �- Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ✓I / Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25'✓1 Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No 50'+ ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' Animal Containment? 50'✓❑ Yes if No ft Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑7 Yes if No ft R Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 1771x5+ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓. Yes if No ft Private Wells > 100' ❑ Yes if No 50'+ ft Water Main > 10'✓Q Yes if No ft Community Wells > 200' ✓0 Yes if No ft Water Service Line > 10' ❑✓ 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) z*:F Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > '10` 1 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' ® Yes if No 50'+ ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water? 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS "MET CODE AT TIME OF INSTALL "NONE OBSERVED WITHIN 50 FEET; HOWEVER, SNOW ON GROUND `SEPARATION TO DECK IS UNKNOWN G. ENGINEER'S CERTIFICATION 1 certify that 1 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 �* Irvl..... ftYvSS..' ...f 79 y✓ E- -1 l.� . #AECC884 "YJ 1111UNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATIN1ENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT X/VNCE ANTP,'RUAIR ;\GREF,7,NJEi7T, horeirl the "ACREENIFNT" f' lel iti l J entered inroasofitil is JQ 'Day of0f— )w Q, by and n herein the "01ATNER," and the Municipality of T aC%cordancc -,,vith (A;,\4C) 15,(--)5.365. In consideration oftlie "'utual covenants contained herein, the parties to this Agreement agree as follows-, I . Advanced Wastewater Treatment Systems. Tile Municipality grants permission ]oil to [lie, Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as..,,. U"t)AJ'T ) C..: ,G located at (legal description) A Maintenance, Repairs and Alterations. ({.)wiper is required to read, understand and initial each section) Throughout tile tem, of diis Agri-cenjerit, tile Owner shad enter into a service agreement with an AWWTS service and maintenance provider approved by the kfunicipal iiv or the 1112 1111facturer's representative. Tile AWWTS shall be maintained in sansfactory condition capable of performing as designed and producing treated septic effluent In accordance with the equipment's approval for operation in the TV-1-unicipality. It shall be the respons' iibi,fiTY Of the Owner during the tel -1-11 of this Agreement to Pay tor all repair(s), maintenance. adjustment(s:), s), replacenleat costs, and inspection costs. This includes alt annual maintemince lee (typically S4001.0 S60 '4`4 ()wncr a!zrccs that only maintenanecand repair personnel approved by the Municipality or the manufacturer's representative will inspect and illake any necessary inaintertance, vepairs or permitted alterations tot), s�,stca. O)A1?l let- acknowledges that regular inaintenatice of an AWWTS reduces the potential Failure of tile system,I w11icli could include Sewage backup and costly repairs or driinfiel(i replacement. (rev, PaQe I ol-3 Owner acknowledges that the Municipality may request records of maintenance, and repairs from the manufactureCs representative or maintenance provider. Owner acknowledges that the fine for filili'18, to maintain and re -pair an AW!VTS may be assessed in, accordance with AMC 14.60,030. 0�vner agreesto grant the JNT 'Ll ip,ality reasonable access to test and inspect. the iii ic AWWTS. The Municipality will give.at least 24-hour notice. h_' , I " Owner agrees that, any sale or transfer of title of the property will riot OCCUr NVithOL11 a new k-'extificate Of 011-SiteSystea-,us Aj)proval. 0111TIler agrees that the AWWTS installation and maintenance -requirements as provided by the AWWTS vendor/installer and approved by theMunicipalityare the grovern ing guidelines for, the conSITUCtiOli, rnainterianceand repair of the Owners AWWTS. Owner agrees to maintain 'remote monitoring of the AWWTS as required by the A'tV)AITS approvat. 3. Terin. The term of this Agreement shall begin on the date of approval by the Municipality to operate- the 1*71SI'alled system, or LiPon transfer of title, and shall colifirlue while the AWWTS is Operational or until title is transterred. 4. Nonwaiver. The failure of the Municipality at any time, to enforce a provision of this Aar eIjj no WaV constitute a Waiver Of the.A PrOVj A -SIOD.ria In airy way affect the validity of the Agreement or any part hereof, or the fight Of the Municipality thereafter to enforce every provision hereof. 1 5. Amendment. This Agrecilient shall only be amended by authorized representatives of the OAvner and Municipality. Any attempt to amend this agreement by either an unaiathorized representative or unauthorized -means shaIl be void. 6. Jurisdiction: Choice ol Utw - Any civil action arising from this this Agreement shall be brought in theSupefi-()T C01,11 -t for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the Tights and obligations of the parties under this Agreement. -7.AAry •, till . orovisiolls of this Agmeernerit decreedhivalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 C, OWNER: (signature) Date: `i�r i;S -fjo. 7 (print name). STATE OF ALASKA. ) 5S. THTRD JUDICIAL<D.TSTRICT ) The foregoing instrument was acknowledged before me this 10 day of (�QCQIYI I7PY 2.01 ZjZ by KVk - ADELINA M MONTOYA NOTARY PUBLIC ROTARY PUTALTUFOR. "" R COIOVA d0 STATEOFCOLORADO M Cormriission expires: Z NOIAR4 11) 20184039668 y MY COMMISSION EXPIRES OCTOBER 18, 2024 By: / (signature) Date: I Z — Z 3 — e rj .(,i -int naive) T'RIc: (rev. 05/1812018) Page 3 of 3 ARM 5e Pt1C Services, LLC 7. Tasks for recirculating/discharge flows: Acceptable ❑ Unacceptable a. If applicable, Jandy valve functioning: 2 Yes ❑ No ❑ N/A b. If applicable, Jandy Valve basin dry: "Yes ❑ No ❑ NIA c. Cleaned collection system in Aerocell unit:Yes T❑ No ❑ Not Necessary d. Design recirculation ratio: 80 : 20 e. Actual recirculation ratio (Estimated): 8. Pump _ System: Acceptable ❑Unacceptable I .a. Control panel in Auto:- i Yes L j No Sludge/Scum levels: 1st: 2nd: 3rd: b. Timer settings IFS Panel (No Override timer): Lj Yes Tank needs to be pumped: ❑ Yes ON: 2.00,--, OFF: d Water softener backwash discharging on system? l Yes Override ON: Override OFF.i e. c. Floats incorrect placement: r=x Yes ❑ No d. Floats working properly: -!E—Yes ❑ No e. High water alarm operational: 5,"Yes ❑ No f ,7 High water alarm count:_ g. Pump run counts: , C i' -i `ifY1 h. Pump run time::"'fes i Effluent Filter serviced: Yes ❑ No I Tank lids secured after inspection: E2 Yes ❑ No k. Weep hole functional: I�;--Yes ❑ No 9. Primary Tank: L'Acceptabie El unacceptable a. Sludge and scum level checked: r Yes ❑ No b. Sludge/Scum levels: 1st: 2nd: 3rd: NIR c. Tank needs to be pumped: ❑ Yes No4�O�` Ve- d Water softener backwash discharging on system? l Yes No e. How many people live on the system?:{ I. Tank lids/caps secured after inspection: -Yes ❑ No g. Last Date Tank pumped: 10. Drainfield: a. Type of Drainfield (circle one): rBed% 5 -wide Deep Trench b. Design Effective depth: inches/feet c. Checked Liquid Levels in Drainfield: 'CIT Yes ❑ No MT#1 Liquid Level: _r A Inches MT#2 Liquid Level:_ Inches MT#3 Liquid Level: Inches MT#4 Liquid Level: Inches d. Is there any surfacing effluent?: ❑ Yes •�5`No Q _ -7 "1 24738 Chugiak Drive "Chugiak, AK 99567 office/ fax:0(907) 588-9433 Email ,ARMServfcesAK@outtook.com (PAGE 2 of 3) ARM Septic Services, LLC 11. Is the remote monitoring system functioning? (if no, describe in comments) - Yes❑ NO a Type of Monitoring system: 6-i NnL 54\,.;.,n L(L1'7 12. Is the system in satisfactory condition/pass inspection? (if no, describe in comments) •;-Yes❑ NO 13. Does this system receive an advisory notice/warning? (if so, describe in comments) ❑ Yes --mo Other Comments. c.G`(�:i`E n� Service Provider. - �" '�J Jo� C A''�'I- Date: 24738 Chugiak Drive `Chugiak, AK 99567 office/fax: (907) 688-9433 Email: ARMServicesAKGouttook.cdm (PAGE 3of3) 3 ( �' ARNP Septic Services, LLC Maintenance Checklist: Advanced Treatment System Operational Checklisk Advanced Treatment System Legal Description: Street Address Senlice provided on: Date: t i - l b _fit.) Time: c� Service provided by: Company: t -'c' Emplotyyeeee.;`Sy---) Date of last service: rt t� f� C) t_; �. By: You Other: 1, Type of Aerocell Treatment System: „ ❑ Cat II -AeroCell Treatment System Cat III - AeroCell Treatment System 2. Conditions at media filter: aAcceptable 'I Unacceptable a. Evaluate presence of odor within 10 It of perimeter of systern: None !� Mild ❑ Strong❑Chemical 71 Sour b. Source of odor, if present: { /Tk 3. Manhole Risers and Pipe Caps: -"Acceptable J Unacceptable a. Coverts intact: ->> es ❑ No 4—, p � b. Method of securing cover: c. Insulation present on all lids? -Yes ❑ No d. Any plumbing leaks or water intrusion: ❑ Yes :el—No e. Surface waterlinfiltration into components: ❑ Yes JWNo ; 4. Venting/Air supply: i�Acceptable F-1 Unacceptable a Air supply unit operating properly Nd'yes ❑ No b. Venting appears operable. 'Yes ❑ No 5. Media surface: --Acceptable ❑ Unacceptable a. Biomat on surface ❑ Yes -�J No b Uniform spray pattern. Yes r `No d. Ponding in/on media. J Yes ' rNo e Plugging/clogging of nozzles. ❑ Yes •�No f Media appears to be settling. ❑ Yes J No g. Appropriate maintenance performed. l -Yes ❑ No ❑ Yes <LJ No h. Pest activity at surface. , 6. Effluent quality a. Effluent odor after passing through media filter: ❑ None ❑ Mild 70i Strong b. Effluent color after passing through media filter: ❑ Clear ❑ Brown ❑ Black,}-,..Y j 24738 Chugiak Drive 'Chugiak, AK 99567 of (907) 688-9433 Email: ARMServicesAK@outtook.com (PAGE 1 of 3) Il MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAL TH AND ENVIRONMENT AL 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) (b) (c) Legal De. ccription (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ~?z~~¢ Telephone: HoJ::qe .f/~ ? .¢/- Applicant Address _¢~¢' ~~~ ¢~~ Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Len ding [nstit ution~'~'~ Address (e) Real Estate Company and Agent Address (f) ne .Ma~the HAA to t.t.t~ following, address: TYPE OF RESIDENCE Single-Family~ Multi-Family ["] Number of Bedrooms 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. 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 72-025 (11/84) 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 investigation of this Health Authority Approval shows that the on-site water supply end/or wasteweter 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 ~ ENi~IN~:I~BiNG Telephone ~/~:~'-~-- ~ ~ Address SJJ B J96X Date EAGLE RIVER, AK 99577 Approved for C/~Z,z~.~.,, bedrooms by ,/~,,/'1///1 /~/~1~-~-~-~,.~_~ ~ff~ff~Date ~,//'~7/4'~' Approved ~ Disapprove~J Conditional~'''~ -- ' Terms of Conditional Approval CAUTION The Muncipality of Anchorage Deparlment 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 is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) WELL DATA Well Clas'sification Well Log Present ~N) Total Depth Static Water Level _ MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: ~ "¢~ , ,%,~Lr'~ If A, B, C, D.E.C. Approved (Y/N) Date Completed ?/[~ Yield C~o~ (~,~,~ Cased to 5' ~ / Depth of Grouting ~-~'~ Pump Set At Casing Height Above Ground Electrical Wiring in Conduit ((~'N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing ~"N) Depression Around Wellhead (Y,~ ;On Adjoining Lots /O~,/'-/" 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 To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~ + ~ ~'~,k~,~l."..)<L.A'~//",~¢..,~ ;Date __ B. SEPTIC/t-I~BiI~!~II~B TANK DATA Date Installed Standpipes ('~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: Size ¢'o~C:r~ No. of Compartments ~-~ Air-tight Caps ((¢~f'4) Foundation Cleanout ~N) Date Last Pumped ~//~/~ ~ ~O/A ;for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course /' ¢'O" To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/ Width of Field Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present ~N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot }"//'? A; To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line /C~C-/'- To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) Comments 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 t hall~ ~t~e j~j~bj~ ~I~P~P r conformed to all MpA and.,HAA, g uidelines in effect Signed r...~,v Date ~//~/~ Company ~ ~VE~, ~K~57~OA No. ~ O~ Receipt No. ~¢ / ~ ~ ~ ~ Date of Payment ~/~,~/~ Amount:$ ~ ~ Page 2 of 2 72-026 (11/84) on the date of this inspection. MUNICIPALITY OF AJ~CHORAGE DIVISION OF ENVIR0~R~ENTAL HEALTH DEPARTMENT 0F ~ALTH AND ENVIRON/~ENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTLFICATE Information Application Date 1. General (a) Legal .Description (include lot, block, subdivision, section~ township, fa.nEe) (b) Applicants Name~./~..~_~../,~ Tele h~ - Home ' Business Applicants Address (c) Applicant is (check one) Lending Institution ~'_.._~ ; ~nerlbuilder C~7~ (e) Real Estate Co. & Agent ,~ M~ ~ Address (f) Telephone ~M~.~.=-the HAA to the following 'address: T__y~ of Residence Single-Family~ Number of Bedrooms Multi-Family Other (describe) 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. Note: If community well system., mas~~ l~i, it nave written confirmation from the State Department of Environmental Conservatfo~ 'attesting to the legality and status, [Page 1 of 2] / ~ ~ File S~arch~ Data and Infot.~nation -" As certified by my seal affixed hereto and as of the validation date shown below, I verify that my inve.~tiga~ion of this Health Authority Approval shows tha~ the on=site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of sgructure indicated herein°. I further verify that~ based on ~he infom=ation obtained from the l~anicipality of Anchorage files and fro,~ my investigation and inspection~ the on-site ~rater supply and/or wastewater disposal ~]ystem is in compliance .with all Municipal and State codes, ordinances, and regula=, ~.ions in effect on ~he date of this inspection° Name of Firm Address -~ ,, ~ '~ ~l~, .~, Terns of Conditional Approval Telephone CAUTION TIlE MI0~I!CIPA.LITY OF ANCHORAGE DEPARTMENiC OF HF~ALTH AND ENVIRONMENTAL PROTECTION (DHEF) ISSUES I~tLTH AUTHORITY APPROVAI~ CERTI~'ICATES BASED SOLELY UPON THE REPRESEN~f~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AM INDEPENDENT PROFESSIONAL ENGINEER REGISTErLED IN THE STATE OF ALASKA° 'IR{E DHEP DOES %q{IS AS A COURTESY TO PIRtC}IASERS OF HOMES AND T~IR LENDING INSTITUTIONS IN ORDER TO SATISFY CERT~A~IN FEDERAI. ~ND STATE REQULRE~- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR A~NALYZE DATA BEFORE A CERTIFICATE IS ISSUED° THE MDNICIP/LLITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OI~ISSIONS IN %~E PROFESSIONAL ENGINEER'S WORK° RR4/eJ/D18 :: "~ [Page 2 of 2] 7-19-84 "-MUNICIPALITY OF ANCHORAGE (MOA) :{.~HEALTH AUTHORITY APPROVAL ( HAA i985 CHECKLIST - FEBRUARY 1984 Well Classification,% Well Log P~esent/.~N) Total Depth ~(~O ~ Cased to Static Water Level. 2-~ '~- Casing Height Above Ground Electrical Wiring in Conduit/(~/~) Sepa=ation Distances from Well~ To Septic/~Tank on Lot ~--- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot./~90 <~ ,' ; On Adjoining Lots /{~O To Nearest Public Sewer Line /~3 /F~ To Nearest Public Se~r Cleanout/Manhole /~J /~ To Nearest Sewer Service Line on Lot ~- Water Sample Collected By J '~J ~/~/_~'/~//~{; Date~'-~--~O~- / Water Sample Test Results ~/7'/ tzf,~-~CT~O~' C~ents ,~3~3/~ ~ Be Standpipes~) Air-tight Caps~/~) Foundation Cleanout~/~) Dep=ession over TaD~k (1~ Date Last P~umped ' Pumping/Maintenance Contract on File !Y~/,~/~ ; for' ~ Holding Tank High-Water Alarm (y~//3)- Temporary Holding Tank Permit Separation Distances from Septic/H~l~ Tank: To Water-Supply Well /6~O ~ To Building Foundation To P=operty Line. ~o '~ To Disposal Field ~'-- To Water Main/Service Line /O '~g To Stream, Pond, Lake, c~ Major D~ainage course ;E Co~u~ nts ReceiPt % Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/~/~ Width of Field ~- ~ ! Square Feet of Absorption A~ea Depression over Field Results of Last Adequacy Test Length of Field Depth of Field Gravel Bed Thick~ess' Stan~i~s ~te of ~st A~a~ Separation Distance frcm A~sc~ption Field: To Water-Supply Well /~o ~-~ ~ To Building Foundation Lot ,4~ ~J To Wate~ Main/Service Line To Stream/Pond/Lake/czr Majo~ Drainage Ccurse To Driveway, Parking Area, c= Vehicle Storage A~ea Comments ~t~ ~ ~ ~ To P~operty Line Z'~ ~ ' 2~o ' ,~ To Existing or' Abandoned System on ; On Adjoining Lots ~ ~ /~9 ;~ ~-' TO Cutbank(if present) /-)o ,J-~-- D. LIFT STATION Date Installed__ Size in Gallons "Pump fkl" Level at High W%ter Alarm Level at Tested for Electz, ical Cod~_~)N ) Comments Manhole/Access ~) ~ .... "Pump Off" Lovel at ~0 /rr ~ t, ~ ' Vent~ ~ing Cycles ~in~~~st. ~ets ~A ** ** Check Permitted Bedroom Rating Against HAA Psquest I certify that I have checked, verified, or ccnfc~ed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company - KB1/dS/s [Page 2 of 2] 2-15-84