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HomeMy WebLinkAboutROLLING HILLS VIEW ESTATES BLK 2 LT 1! 2.t2�\ LACtAej SC) b_ 32.a -v1 f i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME r� .. ;1 C4A-XLe� V0GIL) GIS PHONE r I �f0.�/ 2.NEW EJ UPGRADE MAILINg ADDRESS 13+ Z 1� ax LEGAL DESCRIPTION 2�Ifln LOCATIONS G 3 j ' D '�— -, N0. OF BEDROOMS 3 DISTANCE TO: Well t /QQ AbsorptLn rea + Dwelling + S PERMIT NO. 'y 6 Uy F Z Manuf� "toter / � Ma eri q No. of coyartments Uj rn Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth 6 y DISTANCE TO: Well Dwelling PERMIT NO. JV'Z Oz F Manufacturer Material Liquid capacity in gallons O DISTANCE TO: Wel %®O° Foundation Ne rest I ine r! PERMIT NO. !y ® IO w= �� J LL Z No. of lines Length of each line Total length of lines Trench w th Distance between lines Z w / !t& tS,�9 inches Q F Top of tile to finish grade , ` Material beneath tile inches Total effec�.t a abs rption Qrea . �' aj Length Width Depth PERMIT NO. w Qa ~a w Type of crib - Crib diameter Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W 3: DISTANCE TO: Building foundation. Sewer line Septic tank Absorption areals) OTHER At armdc✓ PIPE MATERIALS SOI L TEST RATI NGS-^ / INSTALLER REMARKS j n® S aa' sass O+ossa ggy�a t F / m •� �g r yta a s aqe ess� sa+�aanspaa°o�s4ess asmasees+e.� i June 22, •1968 c oaf a®o %3NAL-9W APPROVED- - DATE LEGAL �` �° 8 j�/CS / pC// g�\ C'fat� s i"• �.s Zf ,D `•/S = 0 / `�-. S/— f i �flc.� IL- 1. �Ne �11�4 C: 11-4110 FZ, Pi, CE'i� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION � �y 825 L STREET., ANCHORAGEr AK 99501 260-472O ~ ... EEI 1 '-F"* ` VJ E -E.: L-. F:�" IEEE IF --e 1111 1: -T- PERMIT NO: 840810 � DATE ISSUED: 09/21/84~ APPLICANT: CHARLES DOWRICK ` ADDRESS: RT. 2 BOX 7327 EAGLE RIVER, AK 99577 CONTACT PHONE: 694�9651 ' ` VIEW EsSubdi�/iaiou LEGAL DESCRIP: SUBDIVISION: ROLLING HILLS 7 -OT. 1 BLOCK: 2 SECTION: 3 TOWNGHIP: 121\1 RANGE: 414 LOT SIZE: 43560 (SQ.FT" OR ACRES) MAX BEDROOMS: 3 Listed below are the options available to you in designing your septic system" Choose the option that best Fits your site. ..... ..... ���� ��_~.~~_~~�~_~~^ 1-: E:E: n F,4"e,! 1:� DEPTH TO PIPE BOTTOM (FT") 4"0 4"0 ^ 4.0 GRAVEL DEPTH (FT") 7"0 0"5 3.5 TOTAL DEPTH (FT.) 11"0 4"5 7"5 GRAVEL WIDTH (FT") 2.5 17"0 5^O GRAVEL LENGTH (FT") 27"0 34.8 41.0 GRAVEL VOLUME (CU.YDS. > 18"8 21.5 30.4 TANK SIZE (GALS) 1r000"0 ** 1,000"0 ** 1,000"O ** SOIL RATING (SQ^FT"/BR) 125 125 125 \ ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS �... ..... .... ..... ..... _�_� ��/ +hat: ` � am familiar with the requirements for on~site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2" I will install the system in �ccordance with all MOA codes and regulations, and in'compliancewith the desigr) criteria of this permit^ 3" I will adhere to all MOA and State of Alaska Tequirements for theset back distances from an"^existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot" 4" I understand th, t this permit is valid for a maximum of 3 bedr�oms and any enlargc..mentwill require an additional permit^ - IF A LIFT GTATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES; THEN (1) AN ELECTRICALPERMIT AND INSPECTION MUST BE OBTAINED; (2) AS--BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REEPORT; AND (3) THE ELECTRICAL WQRK MUST BE DONE BY A LICENSED ELECTRICIAN" GI8NEDATE: D APPi1CANT: CHARL DDWRICK ` ISSUED BY DATE: _���~_��__ SOILS LOG r MUNICIPALITY OF ANCHORAGE ac DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR:ff A - *1 - v - ` LEGAL DESCRIPTION: I5Z ROIL (EW organic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 O 15 �S 16 rn 0 ca 0* ^e Ail 17 J aos 18 4 boo 19- 20 SW - welt grtd*d sands � g*awe't &1� NO. 17 m �� June 22,196E _a'.klll DATE PERFORMED: Sept- Z111.984 US Sulr {' ■O■■ NONE OMEN CA -EN M■EN MMEN ■■N■ NEON NONE ■■■■ WAS GROUND WATER S No ENCOUNTERED? L O P E IF YES, AT WHAT DEPTH? SITE PLAN Sr 1111k vv Reading WON ROEIM Net Time Depth to Water Net Drop ■M■MNx■■1v.�71N ■■N■■EA■nim �EM■ME■EEM■ ■■■E■NN■ME Sr 1111k vv Reading Date Gross Time Net Time Depth to Water Net Drop J •J: PERCOLATION RATE (minutes/inch) TEST R'BETWEEN FT AND FT /� COMMENTS Solis t'a' ,'v\5 a jzs 5g YnY ip2P Gedroom • `Tt+Y@�e beOyvo , 600� = 3%SSQ T7 4reA%6 wa11 4;Ir4la- c p PERFORMED BY: C04&), �Uo CERTIFIED BY: Y'JG Gf� I DATE: p -Z I-84 'ST g -OZ3 E3AJN HORAGC- QTR' • 0DEPB KOTECTION r� WATER WELL RECORD STATE OF ALASKA 4 1 ` DEPARTMENT OF NATURAL RESOURES • Division of Geological d Geophysical Surveys RECEIVED-'-"'. .00ATION OF WELL (Please complete either to, Ip Or lo.) Drilling Permit No. A.D.L. No. lo. Borougr 1 SuDdivisiop=Lot8lock Ib. t/e gtrs. Section No. TorneniSuL�ING PN Rang• E❑ Meridian --—of--of-of _ 5❑ WO _Ic. DISTANCE ANODIRECTON FROM ROAD 1 TERSECTIONS �oLLING ILLS V 16w t1r5t4Tr;S`S �]-17-KS 3. OWNER OF WELL Mr• Chuck DoWrick Address: 'S$ 2 Box 7327 Eagle River, Ake Street Addressand Area of Well Location 2. WELL LOG Feet Below Surface 4. WELL DEPTH: (flaol) 5. DATE OF COMPLETION Material Type Top Bottom 245 ft_R - 20 -a4-- Gravel, soil 0 13 s. OCoblo fact }[Cg�gtgry ODrlven C3 Dug reens one Greestone with grey 210 245 11 Auger O Jelfrd Bored ❑ Other: roc seams, water T.usEX � pmesHe Public Supply 0 Industry 0 Irrigation 0 Recharge 0 Commerical 0 Test Well 0 Other: B. CASING: 0 Threaded X51WOId•d I diam. �.. to 20 11. Depth Weight 17 lbs./ft diam. Into ft. Depth Stickup ft. I I i 9. FINISH OF WELL: i Type' Dlamoterl Slot/Mesh Size: Length: i Set between ft. and IL - Backfilling Gravel pack - 10. STATIC WATER LEVEL: 23 ft, 9 0 0 Above or XIslelow land surface Date IIILLL� 1 Equipment used: IF-- II. PUMPING LEVEL below land surface and YIELD i ft. after hre. pumping g,,, m. t ft. of for Ara. pumping g. D,m. 12.GROUTING Well Grouted: 0 Yes 0 No ( Material: 0 Neat Cement 0 Other: IS. PUMP: (if available) HP i— Length of Drop PIDe ft. capacity m. Cp N m 0 Sabre. Jet 0 Centrifical 0 Other O e 14. REMARKS: r— Production/o. 480 G 1 per ! day 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature _O C] F 0 C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Magnuson Drilling AA 5385 Registered Business Name -- Lite? Number 770504 Eagle River, Ake Address: P.O. Box �' 99577 Signed:_ ep • _ Authorl,,d Repre sentotiv I Date: ' :Form 02-WWR (it/BI) Copy Distribution: WHITE - State DGGS, PINK -Driller, CANARY- Customer Municipality of Anchorage • Development Services Department C ' Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ek.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 7� �/ Parcel I.D. 050-322-01 HAA# o� V Y 1. GENERAL INFORMATION Expiration Date: 11-13-03 Complete legal description ROLLING HILLS VIEW ESTATES SUBDMSION: LOT 1, BLOCK 2 Community Class Well ❑ Public Water System Location (site address or directions) 19211 UPPER SKYLINE ROAD* EAGLE RIVER, AK, 99577 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JUDITH TERPSTRA Day phone 696-1748 19211 UPPER SKYLINE RD * EAGLE RIVER, AK* 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: . 3 3. TYPE OF WATER SUPPLY: Individual Well N Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work. 4. 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 Health Authority 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 riles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(aro) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKW WC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. 337-6179 Date all ?- Conditional approval for bedrooms, with the flowing stipulations: �tltft`rtftnffF!!,!/,!i, g••� ON-SITE ems • (AIATM Anon : M- WASTEWATER )Mn Attachments: J�o . • ..... S\\\�\ HAA Checklist Manitenance Agreements i� rlFnrrcFV�.�� Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other By: Original Certificate Date: 9-13-02 (Rev. 12/01) Municipality of Anchorage .� • Development Services Department y ao Building Safety Division $ . C • . On-site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ROLLING HILLS VIEW ESTATES S/D: LOT 1, BLOCK 2 Parcel ID: 050-322-01 A. WELL DATA *CASED TO BEDROCK (tell type PATE If A, B, or C provide PWSID# N/A Well Log (YM) YES Date completed 20/1984 Sanitary seal (YM) YES Total depth 245 ft. Cased to •20 ft. FROM WELL LOG Date of test 9/20/1984 Static water level 23 ft. Well production 0.33 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 0.614 mg./L. Wires properly protected (YM) YES Casing height (above ground) 12 in. AT INSPECTION 6(6/2003 35 ft. 1.8+ g.p.m. Other bacteria 0 colonies/100 ml. Arsenic: N/A mg./L. Date of sample: 6/6/2003 Collected by: AKWWC, INC. S. SEPTICIHOLDING TANK DATA Tank Type/Material STEEL Date installed 10/15/1984• Tank size 1000 gal Number of Compartments 2 Foundation cleanout (YM) YES Depression over tank (YM) NO Cleanouts (YM) YES High water alarm (Y/N) N/A Date of pumping 9/23/2002 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA PSELOW EXISTING GEAD Date installed 10/15/1984 Soil rating (g.p.d./ft2br drm t 25 System type DEEP TRENCH Length 31 ft. Width 3 ft. Gravel below pipe 7 ft. Total depth 10.33 ft. Eff. absorption area 434 ft' Monitoring tube YES Depression over field NO Date of adequacy test 6/6/2003 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 6 in, Water added 520 gal. New depth 117 in. Elapsed Time: 20 min. Final fluid depth 110 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date F D. LIFT STATION I Date installed Size in gallons Manhole/A i! "Pump on" level at in. "Pump off' in. High water alarm level at in. Datu Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank ' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ i Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage I DP + Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS odder G. ENGINEER'S CERTIFICATION Qat . .ypI I certify that I have determined through field inspections and Q ,� ; - ,t review of Municipal records that the above systems are in 0.. """ •' • ` . ..•' . """ conformance with MOA HAA guidelines in effect on this date. '•.J ff y G e Engineer's Pri to Name JEFFREY A. GARNESS Qn ��J' . CE 7953 Q�f 0 Q44ers P.......•' �r Date 3 Ong_ rofesaio�� HAA Fee $�S Waiver Fee $ Date of Payment g '' �q� ' O3 Date of Payment Receipt Number 4:2l /�L_ Receipt Number (Rev. 12/01) Hpr 28 03 04:35p Judith H.K. Terpstra 9076961748 p.2 I 1 I , IV 1 LD 1 i.. AS-BI41LT I hereby certify that I have surveyed the following described propertv:, L e y / n; c. C M �f if.•.a ,'•�: ii! I/��� ..� =s�yr.:_.� See ._ Anchorage Recording Precinct, Alaski, and that the improve- ments situated thereon are within the property lines and du not overlap or encroach on the property Ivtng adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no road%rays, transmission lines or other visible easement. on said property except ac indicated hereon. Dated at FaRle River, Alaska Ilik. 7 � .-_dav of . ROBERT C. 101 I\SC'\ SC. AI.h.: Registered I.atld "Urvevor leo. MO -1 ti !Ion 7:•-1115•,, Fate I:ic;•r. Alaska �K'577 1+ fill � : �C.. ,1 1 1 7..• R • r V ! ` h flr.r w j� �• n t N •t 1 .�js ..'Y •� W,l. Jim... ;+O � 1 r. � ryl I I 1 I , IV 1 LD 1 i.. AS-BI41LT I hereby certify that I have surveyed the following described propertv:, L e y / n; c. C M �f if.•.a ,'•�: ii! I/��� ..� =s�yr.:_.� See ._ Anchorage Recording Precinct, Alaski, and that the improve- ments situated thereon are within the property lines and du not overlap or encroach on the property Ivtng adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no road%rays, transmission lines or other visible easement. on said property except ac indicated hereon. Dated at FaRle River, Alaska Ilik. 7 � .-_dav of . ROBERT C. 101 I\SC'\ SC. AI.h.: Registered I.atld "Urvevor leo. MO -1 ti !Ion 7:•-1115•,, Fate I:ic;•r. Alaska �K'577 6-11-03: 1:42PM. SGS Ref.# 1033226001 Client Name AK Water & Wastewater Consultants Inc. Project NameM Lt 1. Bk 2. Rollin; Hills View Client Sample ID Outside Faucet Matrix Drinking Water :907 5615301 u 2/ 3 All DatesMmes are Alaska Standard Time Printed Date/Time 06/10/2003 13:17 Collected Date/Time 06/06/2003 10:00 Received DateR'ime 06/06/2003 16:34 Technical Director SV de Released rj� Sample Remarks: L Units Method Limits Prep Analysis Parameter Results P Q Limits Date Date Init Waters Department Nitrate•N 0.614 0.100 mg/L EPA 300.0 (<=10) 06/06/03 IS Microbiology Laboratory Total Coliform 0 cot/100mL SM19 922213 (<=1) 06/06/03 KAP '� ''l 1' (D1(► CESSPOOL` a c 034-5454 P.O..SOa 775511 - EAGLE RIVER, ALASKA 99577 fill. 33� 32-4-G PAGE w DRIVER INVOICE DATE EOOF)�SERVICE EE R VR ICE TIME S t � 1.-.LSC]._�DYdCJJ i 11 1 g U1�St ` �---- E i 5E i Pump Septic Tank w/up to 3 Backwashes i L� Pump Holding Tank ED Extra Time / Backwashes Required ' FZ JR's recommends your next pumping in AUTO Q We will call or send a reminder at that time. j 0 Standpipe(s) needs repair; missing / crimped / broken / no caps 1 �K Only one standpipe on septic tank �3' lank appears to be lX� gallons / crib leach Last Pump # of gallons J Other r Quantity 3 Description Amount Gallons Pumped - Septic System $ iExtra Time / Backwashes 10 ther: q 1 a Total Amount Due: $ Payment Terms: 30 days from invoice date -1.5% per month late fee $25 charge for all returned NSF checks MUNICIPALITY OF ANCHORAGE} • '� Department of Health & Human Services i DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel l.D.# ��6—S —6/ HAA# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township,, range) ,— \ Z � �1�1 �I �� AL -k-_1 Location (address or directions) (b) Property owner 7�C ?��� Telephone ; (home) Business Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Comr Telephone Address 30o0 I 6 f. //IUC14 Telephone (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&SENGIN R G 17034 Eagle River Loop Road No. 204 Eagle River, Aas a 99577 2. TYPE OF RESIDENCE Single -Family 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 -sited Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty 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, 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. n Name of Firm Telephone 5&sENGIN Address 17034 Eagle River Loop Road No. 204 Eagle River, A1a5Kd Date 6. DHHS APPROVAL Approved for -5 by / Date l%l ApprovedDisapprovedConditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88) Back Page 2 of 2 "MUNICIPALITY OF ANCHORAGEMOA \ \ Health Authority Approval (HAA) ) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: 2 A. WELL DATA Well Classification t`'��i�%b't If A, B, C, D.E.C. Approved (Y/N) Well Log Present&N) —Date Completed �'�—g`� Yield Total Depth 2A�5 Cased to 1_0 epth of Grouting Static Water Level Pump Set At NCasing Height Above Ground Sanitary Seal on Casing ON) Electrical Wiring in Conduito/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot t--2>1 Depression Around Wellhead (Y/M ( . ; On Adjoining Lots i k!Vc--> -1- To Nearest Edge of Absorption Field on Lot ��' �� ; On Adjoining Lots To Nearest Public Sewer Line �/78 To Nearest Public Sewer Cleanout/Manhole n To Nearest Sewer Service Line on L t _u IA Water Sample Collected by I*�( ; Date Water Sample Test Results��O``���� Comments B. SEPTIC/HOLDING TANK DATA r Date Installed c6A'� e1' Size ( `PPLO No. of Compartments Standpipes (VN) y Air -tight Caps 01N) —Foundation CleanoutdVN) Y— Depression over Tank (Yo X4 �ate Last Pumped A Pumping/Maintenance Contact on File (Y/N) �' ; for Holding Tank High -Water Alarm (Y/N) N p Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: t To Water -Supply Well ���) To Building Foundation To Property Line 1 To Disposal Field To Water Main/Service Line (p - I To Stream, Pond Lake or Major Drainage Course -l-" Comments fw 72-026 (Rev. 7/88) Front Page 1 of 2 I C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata % e7K` Type of System Design Date Installed Length of Field Width of Field Depth of Field l� i Gravel Bed Thickness Square Feet of Absortion Area 91- Statndpipes Presence N) Depression over Field (Y/&7 _ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD Date of Last Adequacy Test 12,15,-68 To Water -Supply Well \ Jib To Property Line 1 C-_> (� 1 To Building Foundation To Existing or Abandoned System on Lot ; On Adjoining Lots 1� To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course - To Driveway, Parking Area, or Vel}icle Storage Area Comments X 7W i -6m Z D. LIFT STATION q DaInstalled �Y Size in Ga s 'Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments To Cutback (if present) �- Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) I certify that I have checked, verified, or conformed to all MOA and inspection. Signed s 8. S ENGINEERING Company 17034 Eagle River Loop Road No. 204 ag e KIVUr, Alaska 99577 Date 2--2- MOA NoC,� C Receipt No.�� Date of Payment - Amount: $ Z2 l r Receipt No. during Adequacy Test. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID N 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 10927 Date Report Printed: DEC 21 88 @ 12:28 Client Sample ID:L1, B2, ROLLING HILL VIEW EST. Client Name S & S ENGINEERING PWSID :UA Client Acct SNSENGP Collected DEC 15 88 @ 11:45 his. P.O.# NONE REC D Received DEC 15 88 @ 14:00 hrs. Req # Preserved with :4 DEG. C Ordered By : RJS Analysis Completed :DEC 16 88 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGINEERING Released By :2) Special Instruct: Chemlab Ref #: 3738 Lab Smpl ID: 1 Matrix: WATER Parameter Tested Result/Units ----------------------------------------------------------------- NITRATE-N ND(0.10) mg/l Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Performed ND- None Detected NA- Not Analyzed Method EPA 353.2 See Special Instructions Above UA=Unavailable " See Sample Remarks Above LT -Less Than, GT=Greater Than Allowable Limits ------------- 10 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date Sv I�� X3$5 (a) Legal Description (include lot, block, subdivision, section, township, range) L1 7,2- i?oll,rc 5uu'�4 5(o -F140 RIw Location (address or directions) S k I i �7v U (b) Applicants Name Telephone - Home6pb%(61 Business GgiSSoo Applicants Address PCS 1 13zA 73?Z-7 e ✓��'. /���� %9�» (c) Applicant is (check one) Lending Institution ; Owner/builder ; Buyer ; Other [:::I (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone � 1 4 (f) Mail the HAA to the following address: 2. Type of Residence Single -Family rr��Multi-Family Other (describe) J Number of Bedrooms ly'? 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 the legality and status. 4. 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 21 5. V 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 regula- tions in effect on the date of this inspection. Name of Firm C.Or1S--yuCA+^Q Telephone _9A6-ZCIOO . Rum Bid p1 B YtR Address Date �v�y1,1985 6. DHEP Approval Approved for Approved (ENGINEER SEAL) -� (b)rooms Disapproved Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 21 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JUS 17 RECEIVE® A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: _ LI BZ SW'14 S6'fAV RIyJ — Well Classification r?TYvA-rE If A, B. or C. D.E.C. Approved(Y/N) I � Well Log PresentCy-/) CG 2 Date Compl ted q-ZO"$ 4 Yield 4g� Total Depth Z Cased to 210 i3 Depth of Grouting Static Water Level 2 3� Pump Set At Casing Height Above Ground Z4" Sanitary Seal on Casing (Y/N)�l Electrical Wiring in Conduit (Y/N) �/ Depression Around Gb llhead (YIN)N, Separation Distances from 4L- 11: To Septic/Holding Tank on Lot X3,7 On Adjoining Lots Zoe + To Nearest Edge of Absorption Field on Lot i3q ; On Adjoining Lots %So t To Nearest Public Sewer Lire NA To Nearest Public Sewer_ Cleanout/Manhole _ N A To Nearest Sewer Service Line on Lot Iu A Water Sample Collected By Cons A- ucVN`l Circ, nea*S Date T.Ine Z Water Sample Test Results PArss>=D G Comments B. SEPTIC/HOLDING TANK DATA Date Installed Or-+- S+ Size 100o�_ No. of Compartments 2 Standpipes (Y/N) y Air -tight Caps (Y/N) y Foundation Cleanout (YIN) y Depression over Tank (Y/N) iJ Date Last Pumped n e w Pumping/Maintenance Contract on File (Y/N) N A for- Holding orHolding Tank High -Water Alarm (Y/N) 1-41a Temporary Holding Tank Permit (Y/N) N A Separation Distances from Septic/Holding Tank: To Water -Supply Wiell 13-7 " To Building Foundation_-#' To Property Line IS'+ To Disposal Field °.� To Water Main/Service Line N A To Stream, Pond, Lake, or Major Drainage Course r"/ PN Comments Receipt # Date Paid: Amount: [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ©cT 8 Width of Field 36" I Z.S Type of System Design "nZC-NcM Length of Field 3/f Depth of Field Gravel Bed Thickness 7` Square Feet of Absorption Area Standpipes Present (Y/1N) it Depression over Field (Y/N) N Date of Last Adequacy Test N Ew Results of Last Adequacy Test UA Separation Distance from Absorption Field: To Water -Supply X11 138 ✓ To Property Line 1S' + To Building Foundation Zo To Existing or Abandoned System on Lot N A ; On Adjoining Lots 1001+ v/ To Water Main/Service Line n/ A To Cutbank(if present) N A To Stream/Pond/Lake/or Major Drainage Course N A To Driveway, Parking Area, or Vehicle Storage Area ZS Comments D. LIFT STATION N �� Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Dimensions Manhole/Access (YM) "Pump Off" Level at Vent (YM) Pumping Cycles during Adequacy Test. Meets MDA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or, conformed to all MOA HAA Guidelines in effect on the date of this inspection. OF Al "'t "'t Signed C�21 , , Date _%-1- $ s �...r. 1*06 AP It Company CorN34rvc.41;-.!J Cmg1Aeerf , Inc MOA No. ST$S-0a3 `3,• •. �j QAQ �' � M •sglYbi9! KBl/d5/s '° c StV �1'1732.E �� �li►�Q�4 INne 21„1958 .••�Vi �1 v [Page 2 of 2] •�''`••j»...�''•'9``,° 2-15-84