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HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 5 LT 16 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. " MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES A~.~' .... ~ ' ' ' TANK FIELB WELL Phone(s) Per,ut No. ~o. ol BeSoms WELL ~ C) C~ '~ ~+ ~,~.1~, ~ FOUNDATION /1' Township, R~nge, Section [ AS-BUILT DIAGRAM {Show Iocahon ol well. septic syslem, property hnes. ~oundation, TANKS U ~ SEPTIC ~ HOLDING ..................................... 20 z ~ Manulaclurer Capacity,. ~.,,o.. Material ' NO. of Co.padments ~ , ~ l~ Z~' 'Te TYPE OF SYSTEM~ ~ bzl ~ ~ 7c ~dt~: /- ~1i; 5- ~l ~ ' ~)~ )~ TRENCH ~ BED ~ W. DRAIN ~ OTHER Fill added above odginal grade Gravel depth benemh pipe 0 FT '~ FT Gravel tenglh Gravel width ~ ~ ~ FT ~ FT~ 3 ~1~ Total absorption a ~ Distance between lines ~ Number of lines Soil rating Pipe material ~ (J ~ ~ ~ ~ WELLS ~ PRIVATE ~ OTHER Ildenlilv) ~ '' ~ ~-t~ InstallerClassificati°n (A,B,~) /-- T ~l:'X~ ~ Total DepthDale Installed: ET Cased t° FT _-/.--~ ' ~ ~,d,~. l " ' ~' ' ' e ~ ~ '-" " ~ I ch'ffcidl dormed I I~gJ~ ...... Eagle ~Jver Loop Eoa~ No, 204 cedily t)at~/~thisiinspeclion/~ was ped0rmed according to all Health Depadment Approval: _ . . Date: ~ ~ 72-013 (3/85) Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION:.~o?"./~ /~_!~"~,~,.~'~.1. ¢l'~//,E~ ~d'¢¢'-.~, Township, Range, Section: SLOPE SITE PLAN I 2 4 6 10 WAS GROUND WATER ENCOUNTERED? 11 s IF YES, AT WHAT 12 DEPTH? p E 13- 14- 15- 16- 17 18 19 .4\ / Depth lo Water Altert 20 PERCOLATION RATE __ (m~nutes/mch) PERG HOLE DIAMETER __ TEST RUN BETWEEN __ F~AND __._ FT COMMENTS .. ,"~'~ ~ - 17034 Eagle River Loop Road No 20a // '~ /~ PERFORMED BY; ~gJ~ ~]~'C~, ~ ~?~ ~,,ll(~//~'~ ~'"-~ERTIFY THAT~HIS~EST WAS PERFORMED 72-008 (~ev. 4/85) Reading Date Gross Net Depth to Net Time Time Water Drop IMAILINGADDRE,~S ~- 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  .~..~ff~ N E ~EW LOCA,~, * ~ Absorption a DISTANC Manufacturer ~ ~,4~ r' Liq. ca IF HOMEMADE: Inside length NO'OFt..~ROOMS PEPCg, IT NO..-~ ~ No, of compartments Liquid depth Well Dwelling PERMIT NO. DISTANCE TO: Manufacturer Liquid capacity in gallons DISTANCE TO: Material Foundation / N e---~'Ter e s'~o t Tot~l-~ of I~]es ~' I Trench ~idth aterial Length W_e~'~T / Le~gl~l~ o ach 'ne J__.L tc' gra~.~ [Width --- Depth inches Type of crib Crib diameter Crib depth Tara) effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO, DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER J)E:Zi:':'FiF;:Ti'IENT" Hi:::i::!L. TH FiN£:, F2'.!V I F:OI'!H!::]',!T.f:~! '(;rf!i;C'f' 6'?:~5 '" i :i.;.T!?E;ET'., i':I?..K::i!OF:F!(';iE.. FI!(. ?ii;, . ..J:!. I [ ¢'ff":l::ft'Tf'ti'.,! .'l'f]l..ll'.,!i'.J'.d t-:,~' ~::'Fit":ii F: F, 'r vF',:4, I ! ,' ~2 ()[::' '~:;1':) ):1_. F!lB'.5(]f;:F"l"rr'h~ :,~ .:, .:J'! 'l;S C,F;:F!iI',ff:'!EL.I) ' I"'IR;:':; i PIt...!PI HLtidE:EF;'. OF' E:E~:DF;:OOHS :,: X: SO :[ l.... [,;:F:l'i" I l'.b::i ,:'. SQ F'T,."P,F: 'THE ~;:E(;:~I...I ! };~:E;I:::, r~; I ;;EE; OF "f'I'E ';:;F I i. FiErSOF:PT ! O1',1 S'.r':E;T'E:M 'i' ,: . THE; LEi'4G'T'H D:i:I'"IE:N!~]: )1',~ !:5 THE; I_Ei',!GTH ,:: iN F:EET) OF 'THE rF:IZNCH OF'. THE [:,EPTH OF FI TFtEI'.,!E:H O1:;~ PIT !S THE: [:, :[ '.~(;TF!i'.,IE:E E',ET!.,.IEE~:H THE GROIJ!',!C, FIN[:, THtE E:OT"f'OM O1:: TH!Z E;:¢;CFt'v'FI]'!ON ,:: :[[.,f F:'EET). THE GF'.FI'v'EL. DEPTH :I:S THE !"tlNiMLtM [)EF:'TH OF' G~;:FI',,,'EL. DETHEE:N 'TI'IE OUTFF!t...L PIPE f:ff.,lD THE E',OTTOH OF 'THE [~]:*;(:::FI'v'FIT I Ot',1 ( t H F'EET ::,. F'!ZFL', I T F:IF:'Pf. ]: CFII',fT HFr:~; THE: L.,::...:. I ... I ,.:: I !'.~: I I_ ! 'l"¢ "ro ! !'.F :: F:.',i TH I :E; I],!:iiF'FIF:'T'M!EI"~'T D!...IR ! NG THE :1; I'.,i:i:;"!"F:!i...!....¢::!"I~ :f ': .',! I h,!!;Pl~J:Z?T ]: i]1t,-~i OF' l:::lh,!'¢ !.,!E:!...L:L-: F./:, TFiE ~'h,I]' 'i't]1 TH I !i~; F:'F;'.OF:'EF;~'F'.r' I::ff.,!r:' I'.,~ Mf::',Fi? OF _ ~ r,.,.': .:, :'£ I:)ENC!i!::E TH.::.T' 'THE HE ....... I,.! I !_1_ SEF;;:'v'E. ....... t....., !... !,~ T...II'E; Fill::fl":k'F:"t'i ... Ihlf': r"F' I::~N'./ '~'.,.'STE'M I,.II'T'HOUT FTNt:::I :i: !',I:i~;F'ED:?'[' )_' O?.:! Fi!'..![:, :pr.,:,-,,c: "',, . !)EF::'FIF:TMEt",!T' Ht!..L E~E '.SUE',..)'ECT TO F:'ROSEE:UT!EiI",!. MI!',I);MI. JH [:, :i; STI:::Ii"!(]E,..,,~:~::'"r ,F'~:' 4..,. , F! .,r:'l I, ..................... !:::th!I:, I::il".ff," 'i'..!-...';; '[":: :!:;E!41:::!(!iE r, Zll!i;F'OSl::lL. .................'I .':::H::'l i:'i'}:E'T FOR F! h,..[ ', "~ f ~. !,.iE!...L OF: ':! 5El T'O 2 ::: ::: :: c :: I' F'F:OM I:::I F:'!...I(!!',I.. t C HELL t. F:'.'[ I'.,l ']'HE~: T'T'F'E OF pI.JE',L I E: NELl MiHZMI.JM [',"':~'f'[:l'.l:~F' F'I;:OM I:::! F:'i;::I:V!::fT'IZ ~::'_ "FO I:::! F'!:~:I',/FITE '::;F!,.IEF;: !._.INE ?::}; TO F:i ..... Ht'"I. N'~T'"r' :~;EI.,.!ER L. I I",[E ]:S 75 F'EET. IE....L. [J:]GE; FI[~:E PF::'OI. '}[~'l~:~l":, Fd":l[) ."t._'~:T IE',IE F:ETLF;:h. IFC, TO THE I:::,[~:F'l:::l[;:"f'!"l[}:i":!"l' !,.~ITI-:IN (:.$' 'T'HE ,, E.. I. COMPI....ETiOI',I. iD'T'HE:F;: F;;:E(;:¢JZF;:EME:NTS MFI'¢ FIPPL.'¢. SP!EC]:F'iE:!::IT'[]I'¢:E FIN[:, CEff.,!?t"RUCTT")N h , h,. I....h M_E. TO 'r ~.1,:~ I;% i::'~:OF'EF: ;1: NSTFIM_RT :i: 01'.,!. :r( oEr;:T I F"/ 'THFIT J..: i I::I!"I FFIMIL.]:FIF;: I,!I'l"H THE; F;i:EQI..iZREHENT:E; F:'OF: ON-':i'.i;t'T'li~: :E;EI.,.!EF;;::i~; I::!i',![:, !4El..f....:!i; Fl'ii; SET FORTH E!W THE MUN ;2: i t.4 Z L.L I t'.,!:i~;TFiL. I.. TI'lIE ?'r".!:;TEM ): 1",! FICCOFd)Ft!".iE:E H ! TH THE CODES. :;~:: I I...tNDEF:';ST'F!h![::, THR'T 'THE ON-':5!TE :i;i;ENE;F;: S"/S'TEi*'! I"!F1'¢ F~'.EQL!!!~:E; !ENL..FIF~:G!!'.?'!EI",IT :!;F THE RES I C'EHCE :!: S O&E ENGINEERING & DEVELO~.MENT CO, Box 90, Davis St,, Eagle River, Alaska 99577 694-2774 or 688-2280 Fl~m~ell Oyster 694-2774 SOIL LOG Performed for: Name: v.~¢¢ ' ~ __ Tel. ...... / ~Z / /t¢,~ ~'r,~ / ~ Legal Description: ~-¢'H' I~¢ ~.r:z~4 ~ / Depth (feet) Soil Characteristics 11__ PLOT PLAN PERC. TEST Ground Water Encountered: Yes. Proposed Installation: Seepage Pit__ Comments; If yes, what depth 7 ~ ..~ c~ .,~.~ Drain Field ' Performed by: OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER rilli g by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 Ended "' " DEPTH OF WELL STATIC LEVEL OF WATER FT. ; ,','.- DRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to.__Ft From Ft. to / : Ft. From .~ ; Ft. to : Ft. From____ Ft. to r Ft From___Ft. to__ Ft. From__Ft. to__Ft. From__Ft. to__Ft From__Ft. to__Ft From__Ft. to Ft.. From__Ft. to Ft. From Ft. to Ft From__Ft. to Ft From__Ft. to Ft From Ft. to Ft. From Ft. to Ft ~ :" ':' FrotH__ ~ ., ' , ~'~:: . From__ :: ; Frolll ' '~ " '7,' ', From . ~ · : ': " - From___ Frolll From From From From From From From From From From Ft. to Ft. Ft. to____Ft __Ft. to__Ft Ft. to__Ft Ft. to_ _Ft. __Ft. to___Ft Ft. to Ft. Ft. to Ft. Ft. to Ft __Ft. to__Ft Ft. to Ft Ft. to Ft Ft. to _Ft Ft. to Ft Ft. to Ft. Ft. to Ft. Ft. to.__Ft MISCL. INFORMATION: DRILLER'S NAME 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 16; Block 5; Mountain Valley Estates #I Location (site address or directions) NHN Johnny Drive. Eagle, River, AK Property owner Patrie~(a Ma~fta,q Mailing address 1390 Pic~erin¢ Drive. Lending agency Mailing address Agent Eva Loken/ Vista Rez~.['. Estate Address Day phone Fairbanks, AK 99709 Day phone Day phone 689-6464 ~6635 Center~ield Drive, Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 ,' TYPE OF WATER SUPPLY: Individual well ×XX 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: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72*025 (Re','. 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 Address Engineer's signature S & S ENGINEERING 17024. Eae~u River Loop Road ~.Io. 2U~ Eagle River, Alaska 99577 Phone ~'~ ¥ - ~L~'/ 7c] Date 5/~' /¢/6 DHHS SIGNATURE ~' Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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. 72~25 (Re~. 1/91) Back MOA ¢21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SEP, VICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: L~.,-r ~ ~ ~ ~¢- '5"' t,,{.l~ dt~x..~L,V Parcel I.D.: A. WELL DATA Well type ?~xl ~-- If A, B. or C, attach ADEC letter. ADEC water system number Log present {~'q) _ x./ Date completed ~ - b - P ~ Total depth 7 7 ' Cased to 7~1 J Sanitary seal ~(~)N) y FROM WELL LOG Date of test ~ . .t~.- ~ S Static water level z/~ .t S"7 ' Well production ~ t 0 g.p.m. ,.~, ,~ WATER SAMPLE RESULTS: Coliform O Nitrate O, / g-7 Date of sample: ~ .~1 ~ ~ O Collected by: B. ~OLDING TANK DATA Date iostalled '7 - ]c]. it aTank size /OO o Foundation cleanout (Y/,~ ,J Depression (Y/'&sI~ rJ DateofPumping ]~ -B - 7L Pmnper .f']J~ . ffOt.4/~, Casing height (abOve gromid) Wires properly protected AT INSPECTION Other bacteria O $ & S ENGINEERING --170-j~~~ad N~. 2-04 Eagle Rl~er, Alaska 99577 Number of Compartments Z_ Cleanoutsl~) High water alarm (Y/N) C. ABSORPTION FIELD DATA Date installed fl ~9. 7 ~ q 0 Soil rating (g.p.d./ft2 or ft2&drm} /5~//~4System type Leugth ~'3 J Width ~ ~ Gravel thickness below pipe ~ ~ Total depth 7 ' Effective absorption area ~/6'~? ¢ Monitoring Tube present~)~ Depression over field ~Y~ of adequacy test 3 - Iq-~6 Results ~Fail) P~& For ~ bedrooms Date Fhfid depth in absorption field before test (in.); O hmnediately afte~a gal. water added (in.): ~ / o Flaid dcptb ~ (ins.) Minutcs later: / ~b~ Absorption rate = g.p.d. Peroxide treatment (past 12 utonths) (Y~ A)O~ /z~oo~r yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on' level at* E. SEPARATION DISTANCES '~lholding~ tank on lot Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL ON LOT TO: Sewer/septic service line 'Z~ I ~ Lift station ~/~ SEPARATION DISTANCES FRO~S~/HOLDING TANK ON LOT TO: Building foundation /~ / Prope~ line / o t 4 Absorption field Water maitffse~ice line b o t ~ Surface water/drainage IOo ~ ~ Wells on adjacent lots : On adjacent lots ; On adjacent lots Public sewer manbole/cleanout SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 7~ ~ Water mare/service line lo Surface water /o o Driveway, parking/vehicle storage area Curtain drain /,Iot~ ttWO~o,')Wells on adjacent lots [o t5 Property. line /6 ~ ~ F. ENGINEER'S CERTIFICATION in con~Formance with MOA H/L4 guidelines in effect on this date. ~~ ........................................................................................................... ~&~n.2k~;~&~.~( ........... HAA Fee $ Date of Payment Receipt Number Rev. 8~95 OSS: haa.wk.doc 09 Waiver Fee $ Date of Payment Receipt Number CT&E Ref.# Client Sample ID Malrix CT&E Environmental Services Inc, Laboratory Division PWSID o Sample Rem~ks: Laboratory Analysis Report Collected Date 03/12/96 Technical Director 960865.6397 bi6 B5 MT VALLEY #110865-0! Drinking Water ALLowable Prep Analysis N~tra~e-N 0,~57 ~ O.t mg/~'~- ~-'~53.Z 03/1~/96 EMB 200 W, Potter Drive, Anghoroge, AK 99518.1605 -- Tel: (90'/) 562-2343 Fax: (907) 561-5301 '" 3180 Peger Rood, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-968~__ __ ENVIRONMENTAL FACiLiTIeS IN ALASKA. CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURi, NEW JERSEY. OHIO, WEST vIRGINIA MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 16; Block 5; Mountain Valley Estates ~I Location (address or directions) NHN Johnny Drive (b) Property owner Mailing Address (c) Lending Institution Mailing Address Thomas & Marilyn Pierce-Bu¢~!~phone:(home) 257-1593 Business_ P.0.Bo~ 9416 High~and Road Eagle River,Ak.99577 Telephone (d) Real Estate Company and Agent R~,/Max of Eagle. Riu¢_r ATTN: Eua Lnken Address 16600 Ce.n~e.r~i~d Drx'u¢_; Sux'..¢¢. 201 Eagle. Rdu¢.~: Ab. 99577 Telephone 694-4200 - (e) Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING ~.7034 E-=g!e Ri*ce_,' Ln~p Eagle River, Alaska ~2577 2. TYPE OF RESIDENCE Single-Family E~¢ Number of bedrooms 3 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must.have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site,~ 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. 72-025 (Rev 7/88) Page 1 of 2 5. 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, Iverifythat my investigation of, Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is sah. 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 Telephone .5 & $ F. NGINEERING Address ..... ,. R:;,~. i Date Eagle River, Alaska 6. DHHS APPROVAL Approved for 3 bedrooms by Approved ,/~ Disapproved Terms of Conditional Approval Conditional Date The MunicipalityofAnchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S 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 DHHSdonot conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 '¢'°~~ MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) .~C c,\',l\~lCiPA~l[~ ~[,~. FEBRUARY 1984 .,G:''r~5~ ~. ._ Legal Description: Well Clas~tion ~;Mq {¢. ~i/W Well Log Present (Y/N) ~ _Date Completed Total Depth ~ 8' Static Water Level Cased to ~ ~ Casing Height Above Ground Z_o-Y It.; ,51o,'.1<' Depth of Grouting -- Pump Set At Sanitary Seal on Casing (Y/N) If A, B, (3, D.E.C. Approved (Y/N) tO/¢~ Yield .~.~ q,a/w Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot { OO '/- To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results foo IoO '¢ /oo '.,L To Nearest Public Sewer Cleanout/Manhole Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~- 1~-~2*Size Standpipes (Y/N) cl Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ,/oOo~,/ No. of Compartments Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) 4¢ Date Last Pumped ~' -- 2. - ~ 0 ; for Temporary Holding Tank Permit (Y/N) ¢/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well [Oo '/- To Property Line I o To Water Main/Service Line / O t To Stream, Pond, Lake or Major Drainage Course Comments ~ C_[~ldoo~ To Building Foundation _ To Disposal Field I O0 "q- 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ! ~--© ~/'~Z~ Type of System Design Date Installed ~ - ,2 ~ - ~' O Width of Field Square Feet of Absortion Ar~ea~ Depression over Field (Y/N) Results of Last Adequacy Test Length of Field '~'.'.'~-- Depth of Field ~..~-~%avel Bed Thickness ~_ Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation "~ Lot [ © ~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) fd / Comments D. LIFT STATION Date Installed ~ Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff( inspection. Signed Company Date MOA No. S & S ENGINEERING Ea,cjle River, Alaska 99577 Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7188) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Older t 26024 Date Report Printed: AUG 6 90 @ 12:3~ Client Sample ID:Li6 B5 MTN VALLEY ADD l PWSID :UA Collected JUL 31 90 ~ 15:00 hrs. RecelYed AUG I 90 @ 14:00 h~s. Preserved with :AS REQUIRED Client Name : S ~ $ EN6INEERING Client Acct: SNSENGP P.O.~ NONE RECEIVED Req ~ Ordered By : R. SHAFER Analysis Completed :AUG 3 90 Laboratory Superv~s,o~3~HEN C. Released Ey: Special Instruct: Send Repoxts to: I)S ~ S ENGINEERING 2) CheM_ab gel ~: 902772 Lab Smpl ID: I ~atrlx: WATER Allowable Parameter ~ested Result Units Method Limits NITRATE-N 0.15 r~/1 EPA 353,2 lO Sample ROUTINE SAMPLE. SAMPLE COLLECTED BY RDJ. Remarks: Tests Performed ' See Special Instructions Above UA-Unavailable None Detected .· See Sample Ramaxks Above Not Analyzed LT-Les8 Than, GT-Gxeater Then MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL GENERAL INFORMATION (a) OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date Legal Description (incl~e lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name/O~vl ./'~¢-~',Z - Z~.~,c"/'~ Telephone: Home L~'~',¢- ~,o~¢ Business Applicant Address .~-'~ Y~ ~/'~'[(' t'Jl~l~l~J'vJ /~-, ~[.yS. (c) Applicant is (check one): Lending Institution [~; Ow~,/builder,J~; Buyer []; Other [] (explain); (d) Lendinglnstitution 4~/~/~ Telephone Address ¢o ¢. ~¢".' /~" ¢ ¢~ "7? (e) Real Estate Company and Agent Address Telephone (f) I~he HAA to the following address: 5RB 196Z EAGLE EIVlll~t AK 99577 TYPE OF RESIDENCE Single-Family B'~Multi-Family Number of Bedrooms. Other WATER S UPP~.~// Individual Well ~1 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 ~ublic [] 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) FNGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown betow, I verify that my investigation of thi~' 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. S & S ENGINEERING Name of Firm SR B 196X Address Date Telephone Approval Date CAUTION The Muncipality of Anchorage Department of I-lealth 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 o~ 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 MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: NOV 3 RECEIVED Well Classification Well Log Present (~/N) Total Depth .-.-¢~ Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit t~N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved (Y/N) Date Completed _ ~'-~ ' ~ Yield Depth of Grouting Pump Set At ~t'/t Sanitary Seal on Casing ~,N) Depression Around Wellhead (Y/~ /c:,~ / '¢' ; On Adjoining Lots /om to'Q/' t' On Adjoining Lots /mO/'+ To Nearest Public Sewer To Nearest Sewer Service Line on Lot B. /~HOLDING TANK DATA Date Installed )'lq' -¢ ~ 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: To Water-Supply Well /Om To Property Line /Or.c, To Water Main/Service Line Course [00 Size /o~0 No. of Compartments Air-tight Caps ~N) Foundation Cleanout (Y~ Date Last pumped . /.¢P ' .~," /~/,"~ ;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¢1/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Type of System Design Length of Field ~ .~'~' Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot Depth of Field ~,5' ' Gravel Bed Thickness ~', &?/ Standpipes Present ~N) Date of Last Adequacy Test /¢2 -~/- ~'~, To Property Line /O To Existing or Abandoned System on ; On Adjoining Lots To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) /'¢¢/-f- 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 MOA and HAA guidelines in effect on the date of this inspection. Signed,~ & S ENGINEERING Compal~[ I~ 196X EAGLE RIVER, AK 99577_.. Receipt No. ate of Payme, nt mount: $ Date MOA No. Page 2 of 2 72-026 {11/84} APPLI¢ NT FILLS OUT UPPER HAl '" ONLY Buyer Address Zip Code Phone Lending Institution Realty Co, & Agent Address Zip Code Phone Phone Legal Description Street Location Type of Residence "~J~ Single Family [~ Multiple Family No, of Bedrooms [] Other Water Supply Individual F~I ~ ~,~ ~¢L'/~'/'b ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. '~]'~ Community For wells drilled prior to that date, give well depth (attach Icg if available). [] Public Utility ~C~, Sewer Disposal ~ Individual Year Individual Installed: [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING (;AN BE! INITIATED. Time Date Inspector Time Date Inspector Time Date Inspector Time Date Inspector Field Notes: O ~c ~ o:~s.+-' (I) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE MUNICIPALFrY OF ANCHORAGE F'EPT. OF t!:/.L'~'tl & [iNVt RON;,/C~ I'AL pR.O FECFION RECEIVED *CONDITIONS OF APPROVAL Soils Rating -- ]-Date Sewer Installed /- Well To Absorption Area ¢! ~ (23 ~--~"~' Well Log Received Well to Tank /O~'"~ I Septic T~k Size