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HomeMy WebLinkAboutSKY HARBOR ESTATES #2 LT 2 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: SW930299 PID Number: 015-282-38 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ® New ❑ Upgrade Name JAMES & PAMELA LIBBY ABSORPTION FIELD 17 nppn TrpnrtL7 �Aliria Trinnrh fieri F�1 nA Site Address ' ❑Other Phone Number of Bedrooms Soil Rating Total depth from original grade 5 1.2 GPD/SF 11 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.4 Ft. Gravel depth beneath pipe 6.58 Ft. Subdivision Block Lot SKY HARBOR ESTATES #2 2 Fill added above original grade VARIES 0.8 — 1.63 Ft. Gravel length 52 Ft. Township Range Section Gravel width 3 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 684 Ftz 1 -- Ft. Well 100'+ 100'+ 25'.+. TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCHORAGE TANK Capacity 1500 Gal. Surface Water 100'+ 100'+ Material STEEL Number of compartments 2 Lot Line 5'+ 10'+ NA Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Gal. Remarks SEE ATTACHED LETTER Alarm location Electrical installed by Installer UNKNOWN Tank to PIPE MATERIAL House to tank 3034 d a nfeld 3034 Drainfield 3034 CO/MT 3034 Inspector FWC (2ND POST CONST. —SEE LTTR.) BENCH MARK (Assumed elevation) 100 ft Inspdection 1s CIRCA'93 2�d JUNE 2021 Location and description 3rd 4'" CEMENT SLAB WALKWAY ON-SITE WATER AND WASTEWATER SECTION APPROVAL lln\\ .. Conditional Approval: Date U'-,- l . ' . "" """"' • / Septic System Approved - / 7 Curtis Huffman ����F6,�•,. CE 128991 tom., Date l�7 l 2 sTF�• . 6/4/2021 �,i PROFES001'�- Note: this approval does not include well permit requirements. trcev uo/uzri ts/ PID: 015-282-38 PERMIT: SW930299 ® WELL Iv 50.0' ao cil EXISTING C FCO CL 4BR HOUSE w 's o z n f D 49.5' rr � N2'VA AM 9, 18.5' BW CANT f D r N90 00'00"E 260.00' ^1EIGygORS EXISTING (PAID) D/W 1500—GAL SEPTIC TANK DCO CO }. r--_ CO LOT 2 PAVED D/W DCO RESERVE: REMOVE \ REPLACE Z EXISITNG O FIELD O EXISTING 52' LONG C7 TRENCH D Z 1 m MT O D �o J CO O \ O PAVED D/W A -C=14,8' B -C=9.8' A -D=37.4' `DCO CO /-DCO FCO 5.71 9-- CO NIT CO 93.19 FINAL GRADE 91.64 91.56 B -D=48,6' 91.60 ORIGINAL GRADE 1 1 ORG/OL A -E=42.8' FILTER FABRIC 13 -E=51.9' -E=51.70' 91.02 1,500—GALLON 0•a5 .94 87.14 A - F = 5 2.1' STEEL TANK SEWER ROCK SM t B -F=59.0' A-15=63.3'3' 60'56 B-15=67.8' SPURKLLAAN/D993 TH SEPTIC SECTION 6' A -H=67,5' SCALES NTS 7,3.5]r)/)BOH B -H=67.7' A -I=87.8' SKY HARBOR EST. #2 L2 B -I=78.7' PREPARED FOR: A -J=99.6' JAMES & PAMELA LIBBY B -J=87,1' 11680 CANGE STREET ANCHORAGE, AK 99516 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com SUPPORTjSERVICES: OF A. C. 5 / *� TH c g DATE: 6/4/2021 ` t rtis Huffman SURVEY: JLS 20211 1 r CE 128991 DRAWN: FWCS 'J6/4/21/ SCALE: 1 " = 30' \ssioTs�' i STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD LOCATION OF WELL %3S BOROUGH SUB O LOT BLOCK SECTION QTRS SECTION TO ?IAN LOCATION/SKETCH: WELL OWNER: OCT '~ bI �ihr7j s ALASKA ONR/Ol OF WATER DEPTHS MEASURED FROM:❑casing top ❑ground surface WELL DEPTH: DATE OF COMPLETION Depth of hole: r� ft Depth of casing: -2 6:2 z/ft BOREHOLE DATA: Depth Material Type and Color From To DEPTH TO STATIC WATER LEVEL: rD Z ft below 29 top of casing ❑ ground surface Date: / METHOD OF DRILLING: „ air rotary ❑ cable toot j g ❑ other USE OF WELL: Wdomestic ❑ irrigation ❑ monitor y ❑ public supply ❑ other CASING STICK-UP: ft. Diam: 6 in. tom ft S Casing type: --4L�In. to ;aft s WELL INTAKE OPENING TYPE:/I open end ❑ screened �O ❑ perforated ❑ open hole 111 7 Depths of openings: to ft SCREEN TYPE: Diam: in. Slot/Mesh Size: Length: ft GRAVEL PACK TYPE: _ Volume used: Depth to top: GROUT TYPE: Volume: 16 Depth: from ft to ft DEVELOPMENT METHOD: czt f Duration: ' PUMPING LEVEL AND YIELD: ft after :2-- hrs pumping gpm PUMP INTAKE DEPTH: ft Horsepower: WELL DISINFECTED UPON COMPLETION? 'BYES ❑ NO CONTRACTOR INFORMATION: ` p Reit ed Business Name Signature of Authorized Re resentative Date REMARKS: PLEASE MAIL WHITE COPY OF LOG TO DNR/DIVISION OF WATER PO BOX 772116 EAGLE RIVER AK 99577-2116 I � L L C coW Cd ,00.09Z ll„00,00,06Ncv h ti 0 , g � C0 4 m �0 q �. ;� ??nHas Qo a ¢ ;. J W .• 00 O OQ ULnz � o JV1 Z , �••• G O (n vi •--I �+' �–� O S• O N LLJCl)® N S'8l 1NVO M8 ssX.z EI : -� a �� s Z Q W ee ®® A�� '• 0 O 2 o0 F7 9 ° `�� Vis® ®®® Ete9w W Lo .0.9 Z C/) r ' Z cWn>" o o o F- (n O 0 xa O e d N LLI ] _• Ly J U r s9 x (NO O �i V1 A aOJ tC.. m 8 o v o q � cOc y s e o 0 m 'OS J TSIL •o A •e .0 OlNV31 o x o 11) I W O. b t Q° G o M�asoe�r� N A75 rv 3® L iB -x—X—x._– Z W� �N���❑.� E., a �g , c 2 N—qz ,00'09Z _ ],,00,00.06Na H a o z b N ,X O cna � o � � � � •= �b z� ix ® U -:5 08 Z Lo o O a U N w> o o I �F >- o :a�o I I Z _ V1 Q ] �>. Q S PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930299 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:LIBBY JAMES A & PAMELA J OWNER ADDRESS:10541 JAMESTOWN DRIVE ANCHORAGE, AK 99507 DATE ISSUED: 8/13/93 EXPIRATION DATE: 8/13/94 PARCEL ID:01528238 LEGAL DESCRIPTION: SKY HARBOR ESTATES #2 LT 2 LOT SIZE: 39000 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING.FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS ISSUED BY: DATE: DATE: 203 W 15th. Avenue, Suite 206 ANCHORAGE, ALASKA 99501 (9(;7) 279-5916 SEPTIC SYSTEt4 DESIGN THE PETERSEN GROUP No Ground Water or Impervious L.ayer 'ko lB .Et. Use SEandard Tr'~-~nch Soit Rating. From trust July 16~ 1993 2 rain/in = 1.2 Required Area per Bedroom: i50/].2 =- '"~= sq .F~ TestP, oie Total Depiih I_ess 6 fe~L"' L~,ss 5 fl: Cover Rock Depth < Use t 2 f 't: Num(]~r of Bmdr'ooms - . · o ';-t. L.engtl-~ ol- Trench 125 x 5 ; .L~ = 52 ~' -· ~/","'~ ' )'4'~'/ / STANDARD TREi~CH /' t_ .~' "' FT ..... ' TOTAL WIDTH 2 FT. '~ TO~AL DEPTH ~J--/.._ ~_/. / ~/). ROCK DEPTH 6 FT. · --~ COVER 5 FT. SEPTIC TANK i500 GAL. The £nstatlation of this well and septic system wiil not ~mpact adjaceni: lots. The we}l location conforms t.o the siting o.F the existing wells in the area~ and will not prevent the adjacent lot owners -i:r-om developing these lots or replacing the existing sepi:i;:: systems. The installation OmF this septic system ~i'll not p~.ven_ wells ~rom be installed on the adjacent lot. s. ~=.~ $0 0 LO? 4A 50 i00 150 £00 SCALE: l' = IQ0 FT, £50 3QO VACANT ~ ~/ell LI~T 4 I LOT 5 TDBBEN SPURKLAND P,E, 203 ~/ ]STH, AVENUE ANCH, Al(, 99501 LOT £ SKY HARBOR ESTATE SEC, £1, rl£N RB~I THE PETERSEfl GROUP SEPTIC SYSTEM DESIGN DATE, AUS,, ~, 1993 SHEET, i/3 GRID, 2?34 L~T i I I I I I Well LD? RJPL ACEM~ TOBBEN SPURKLAND P,E. ~03 W 15TH. AVENUE ANCH, AK, 99501 LBT 2 SKY HAR30R ESTATE #2 SEC. 21, rl2N R3W THE PETU~$EN GRDUP SEPTIC SYSTEM DESIGN DATE, AU~. 6, 1993 SHEET, I/3 GRID, 2734 Cleon 2' N/ide 52' L on~ il' ~eep 6' ~e~e~ rock under p~pe 5' Cover 5' Co vet MiroF; 140 --~ 6 Pt of' Septic Rock / UNDEf~ PIPE NO SCALE /~Monltor Ground 4' kiln CO vet ~ver Tonk 1500j~ gal sepi:ic i:onk TDBBEN SPURKLAN]] P.E, ~03 bllSth Ave AnchLrcge Ak 99501 LOT 2 SKY HAR£~7£ ESTATE THE PETERSEN 5B[1UP SEC, 21 TI2N R3~/ SEPTIC SYSTEM DESIGN DATE, AUG ~ 1993 SHEET, 3/3 GRZr, 2734 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) ' PERFORMED FOR: 1 2 3 4 5 6 7 8 9 SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 213 WAS GROUND WATER ENCOUNTERED? Gross Net Depth to Net Reading Date Time Time Water Drop Wi ~,/'~ o '~1 ~ ~ r~ ~ o '/~ ff ~/~ ~/~ I I~ '1~ ~/~ ~ /~ '/~ ,/~ L IF YES, AT WHAT 0 DEPTH? P E 0epth to Waler Aller/) PERCOLATION RATE t TEST RUN BETWEEN ~ FTAND b /Z-F'r COMMENTS PERFORMED BY: % ~ I ~'~'~ CER] ,Fy THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL SYATE AND MUNICIPAL GUIDELINES IN EFFECT ON TNIS DATE' DATE: ~*~ ~// I ~ ~'~ 72-008 (Rev. 4/85) MUNMWAUTY OF � mi tfi✓z Development Services Department On -Site Water & Wastewater Section Parcel I. D. 015-282-38 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description SKY HARBOR ESTATES #2 LOT 2 Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: 7,2-1 1 Location (site address) 11680 CANGE STREET, ANCHORAGE, AK 99516 Current property owner(s) JAMES & PAMELA LIBBY Day phone Mailing address 11680 CANGE STREET, ANCHORAGE, AK 99516 Real estate agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55O Waiver Fee $ Date of Payment S' 2 y "2/ Date of Payment Receipt Number -1 Y2 2 7 Receipt Number COSA # 0 S G a i 1 D,' Waiver # 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. - - Name-of-Fir-m-FI-RSTWATER-CONSUL-T-ING- ---_-- - — - . Phone --.907-350-9566-= .------ Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 5/22/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to r` i these various and dynamic characteristics and are outside the control of the evaluator of the P�ii • ' •�"1��� well and septic system. Therefore, any estimate of how long a system will function satisfactory gam,. • �� ��� for current or future occupants or guarantee that no unseen encroachments, deficiencies or J discrepancies exist can be given by First Water Consulting & FWCS ' *� 9 H•�* r� 6. DSD SIGNATURE �r • Curtis Huffman System #1 Approved for bedrooms ��`��s••. CE 128991 .��,�Awr� F SS NP�"�� System #2 Approved for bedrooms \�TF�F�PROESSO Disapproved Conditional approval for bedrooms, with the following stipu dpi .``���NI I - Original Certificate Date: Q2- 7-Z/ 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other s -e -C. 9 l a"t-L %�r e COSA Checklist Legal Description: SKY HARBOR ESTATES #2 LOT 2 Parcel ID: 015-282-38 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) Water storage tank volume NA gallons Da# drilted®9U�/eA=disinfsated=#©r- of for�aa=tes#?®des--®=I>!fl Total depth 264 ft ® Coliform bacteria is Negative Cased to 264 ft Nitrate 1.84 mg/L ❑ Nitrate less than MRL (ND) ® Sanitary seal is functioning correctly Arsenic ug/L ® Arsenic less than MRL (ND) ® Wires are properly protected ' Casing height (above ground) 24 in. Collected by FWES Date of flow test for COSA 4/27/2021 Static water level at beginning of test 131 ft. Date of Sample 4/27/2021 Well. production at time of test 6.6 gpm Comments B. TANK DATA Age of tank(s) 28 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 48" ® Standpipes/foundation cleanout per record drawing Date of pumping 5/21/21 D. ABSORPTION FIELD DATA Which system tested (date installed) 11/1993 ❑ ALL standpipes present per record drawing Total measured depth from grade 11.1 ft (max) Measured depth to pipe invert from grade 4.5 ft (min) ❑ N/A — pressurized field ® Monitor tubes no to bottom of effective If not state C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: SEE ATTACHED MOA ADVISORY Adequacy test date 4/27/2021 Results M Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 1000 gal New depth 17 in depth into effective Elapsed time 150 min ® Code -required soil cover over field Final fluid depth 0 in ® System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies: FWN 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' if No ft Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft -------Neighb-oring-Abs' rption-ReYds�_ 1'00 Water Main > 10' ® Yes Afiimal-eontair�me in 50 -- el' s if=IVo fif� ® Yes if No ft Water Service Line > 10' ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® 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 ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® 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) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that I 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. I • • ' Curtis Huffman • :. j CE 128991 .• �`�� lliFOPROFESS10NP DEVELOPMENT SERVICES DEPARTMENT o,,5 On -Site Water and Wastewater Section www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 211272 Subdivision: Sky Harbor Estates #2 Lot 2 907-343-7904 Fax: 343-7997 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 28 years old. Typical replacement costs range from $8,000 to $11,000 This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 -year-old steel tank MAY look like. Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org �V '!?�C''! = VIN Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org VIN Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org Fry rsC N Water S U L T I N G @ATEfi/'A'AS1E,WATEF1 SUPPORTS PLAtiff ING 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com June 4, 2021 Municipalities of Anchorage On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC SYSTEM DOCUMENTATION — INSPECTION REPORT LEGAL: SKY HARBOR ESTATES #2 LOT 2 During the COSA process — no inspection report for permit #SW930299 was found in the MOA file or provided by the owner of the referenced property. There was a COSA issued by the MOA in 1994. Attached is the inspection report per recent visual observations and measurements taken. Based on this investigation, it appears the system was constructed as originally permitted. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Fi.r llfIINSU 1111t0 SE0';CES [ F!''1ASIEY1A ER �' 3V?POfiid PI ARHItIG DEPARTMENT O~ HEALTH & HUMAN sERVICES ~ ' "':"~-' ' ~ ' "Division of Environmental services · ' On'~Site Services.Section ' · .. ~ .. ,P.O. Box. 196650 Anchoragel Alaska 99519-6650 ; ';;.~' ?~?.F{ ,; '·',*,; CERTIFICATE OF HEALTH AUTHORITY GENERAL INFORMATION. Complete legal description APPROVAL FOR A SINGLE FAMILY DWELLING site-,adidress or directions) ro~ei'ty )wne'~i:' '"'~.,2,~-¢~"~' /-,¢¢~'~/v/ Day phone enid'ii~ Day phone Agent Day phone Address ~"/~"¢'/ ¢¢"~' ~':~~ ~ ~~ Unless pthe~ise requested, HAA Will:be'held f°'k piokup. NUMBER OF BEDROOMS: :'? :~" "''3" ' Community.well , "~'~'. Public water ' ' · ' '."; ,~. ' NOTE If commumty well system, provtde written.conhrmafton from State, Individual,On-site. · ~ .:.: - ~,~' -~: :' Ho d~ng'tank - ~. ' PubhC'sewe~ .... ' "'" .... '~-": ""~"-' .... '""' ,NOTE:If communtty.wastewater'sYStem;,'p,,ro~ideWrttten;cO~:~firmatton from attestmg to the legahtyand status;of system. 72;025 (Rev. 1/91) Front MOAIt21 5. STATEMENT OF INSPECTION BY ENGINEER. -. : As certified by my seal afl xed hereto and as of.the validat On,date shown' b'e oW veri~that my ' : F~4 L'' ' ' investigatiofl 'Of.this Health AuthoritY Approval a'pPlication shows that thb:0n-site w~ter s~ppl'yt:i and/or wastewater disposal system is safe; functional and'adequate for the 'number of bedrooms :~., and type of structure ndicated herein'. I furthervedf7 that based on the information obtained frOm' '~,. · the Municipality of Anchorage files and from my nvestigation and inspect on, the on-site water iii~ iii :-, '. suPply and/or wastewate~ d'ispOsa i~s~Stem s n ComPi anco with a I Municipal and State codes, ?~':'i~?-'il~ :./ , ordinances, and regui,atiOns in effect on the date of this inspection. ,, ' :. · ~','-¢i:;'-' ' Engineer's signature ' J'~¢""'~' ~ ' 'r~' r"' Date 6. *DHHS SIGNATURE . v.. /'"' Appr ved for Conditional approval for ~-~' bed¢ooms. bedroomS, Wit~ the following StiPulations: Date Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registeredin the State of Alaska. The DHHS does this as a courtesyto purchasers of homes :andtheirlendinginstitut ons nordertosatsfycerta nfedera and state requ foments EmpoyeesofDHHSdonot -cOnduct inspections or analyze data before a certificate s issued, The Municipality of Anchorage is not' .,;~! ','.i responsible for errors or omissions in the professional'englneer's'work : Municipality of Anchorage ~i~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST d'~,~'~//~'~/,c~-~-,¢~, ~'~"~-~?-~.¢ Parcel I.D. Legal Description: A, Well Data Well type ,'"~-,~, ¢~,-¢ ¢"~' If A. B. or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~"~,~-¢ Date completed ,¢~-,.w,,~. ,*,~' /~f Driller Total depth ,~¢~' ¢ Cased to ,,~¢¢ ¢' ¢ Casing height Sanitary seal (Y/N) 2¢~'",¢ Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG / /~ / ~-L~.¢/~~ g.p.m. SEPARATION DISTANCES FROM WELL TO: AT INSPECTION MUNICIPALI'[Y OF ANCI FNVIRONMENTAL SERVICES DIVISION ,, ,~ 2 1994 g.p.m. RECEIVED 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 Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate ~¢~ Other bacteria Collected by: /'¢¢~ Tank size t~-~ ~'z~ Compartments Foundation cleanout (Y/N) ~/4;¢.~-' Depression (Y/N) '4-'/~ Alarm tested (Y/N) ~('~/'~',~?. , , '/t~/~ Pumper ~;~¢ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~r~, To property line /,¢ Surface water/drainage 72-026 (3/93) Front On adjacent lots Absorption field Foundation Water main/service line CONTINUED ON BACK PAGE '~"G,~L. IFT STATION Date in'~ta~led . Sizein gallons_ '-- .. Vent (Y/N) -'"'Rump on" level at Manufacturer _ Manhole/Access (Y/N) "Pump off" Level at High water alarm level _ ~'"' .~ ~,~ Cycles tested Meets MOA electrical codes (Y/N) ~ ' ' ': T .... SEPARATION DISTANCE FROM LIFT STATION TO: '- - Wel!,.gn lot_ D. ABSORPTION FIELD DATA Date installed /¢/'¢ ~' Length ~¢'"'¢-" Total absorption area _ On adjacent lots Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) . Sudace water. / ¢ ¢,,¢ ._Soil rating (GPD/FF) __ Width "~ / Gravel thickness. ~; ¢ ~/~ ~ Cleanout present (Y/N) _ )/ ~.~-,.~ ...~.~;~¢,/ ./ Results (pass/fail) _System type ~'*'¢¢'"~-~'¥' ~'" Total depth // / Depression over field (Y/N) . ~LJ for _ '~Z/ Bedrooms After test If yes, give date Cutbank /L.)/,¢,~ Water main/service line_ Driveway, parking/vehicle storage area SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots ,¢~4 ¢ ¢- Property line ? ¢¢ ¢' To existing or abandoned system on lot _ Well on lot_ / To building foundation On adjacent lots_ Surface water Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HA& inspection. Signature ~~~. ~' Engineer's Name ' CE-8176 HAA Fee $ Date of Payment. Receipt Number c~--~-~¢:~ ~'~ ~/") 72-026 (3/93)* Bsck Waiver Fee $ Date of Payment Receipt Number_