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HomeMy WebLinkAboutSTUCKAGAIN MANOR BLK 1 LT 5tuckagain Manor Block 1 Lot 5 #041-023-20 I - MUNICIPALITY OF ANCHORAGE DE,"�9TMENT OF HEALTH AND HUMAN SERIES - Environmental Health Division - 825 " L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name / L DISTANCES SEPTIC TANK ABSORPTION FIELD WELL Address 7�1 9 O j` Tv Joo- A—A A k Q9 S6 � rFTO 11q 14U Phone) Permit No. No. of Bedrooms (y7 /fJ /U LEG AL DESCRIPTION Lot Blackf Subdivision S7u<Karq.tn/ur FOUNDATION (/ Township, Range, Section r n. S 'i +•j- (tJ f ;z iv AS -BUILT DIAGRAM driveway, water bodies, (Show location of well, eta) septic system, property lines, foundation, TANKS Pil�SEPTIC ❑ HOLDING -------- Manufacturerp Capacity in gallons Material No. of Compartments TYPE OF SYSTEM j TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER 6 Y Depth to pipe bottom from original grade - FT Total depth from original grade 8 & FT yr '� _ O Fill added above original grade, FT Gravel depth beneath pipe / FT Gravel length 7-0 FT Gravel width FT S vzl � Total absorption area 0i SQ FTJ Distance between lines VA FT !' icA-. A - Number of hoes ; Soil rating SQ FT Pipe material 2�2% GI 3vs f Installer C -t N �6, :zl Date Installed 7-i S --8s' WELLS PRIVATE ❑ OTHER (Idertitvl Classification (A,B.C) Total Depth FT Cased to FT Installei Date Installed- REMARKS: Scale: - Inspections Performed by. /4EC5 !n< SF6502`i ENGINEER'S SEAL (� Date: -frr- - f certify that this inspection was performed according Ila all Date: Municipal and SI` a guidelines in ellect on this date: (�(J� — Ei $ Health Department Approval: y-� .J72-013 (3/85) __ - l: -T--w' 13 F " 2; II'*.R ED B `` ,,3 F 4 �C=n E= �� DEPARTME:IV"T'r HEALTH AND EhIV:[fiOlyP'IE:I'JIAL`P-ROTECTION ' S25 L STREET, ANCHORAGE, AK 9950:1.a 264-4720 c _ ES EO DO M ham. t4 E _: d...... a_.. Y E: E a;: I'"'d )C PERMIT NO: 850607 DATE ISSUEDs 08/19/85 APP'LICAN'T": S.L.D. CONSTI UCTIOIN ADDRESS: 2440 E. TUDOR RD. ANCHORAGE, AK 99507 CONTACT F'HONQ 563--7848 LEGAL DESCRIP2 SUBDIVISION: STUCK -A --GAIN MANOR LOT; 5 BLOCK: i SECT SON: TOWNSHIPa 12N RANGEd W LOT SIZEo 581100 00FT. OR ACRES) MAX BEDRonr'Sr 4 Listed below arc= the options available to you in designing your septic system. Choose the option that beast fits your site. «# TANK MUST HAVE: AT LEAST TWO COMPARTMENTS I certify that: 1.. I am familiar with the requirements for on-site sewers and weals; as seL forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. 1 will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit.. 3. I will adhere to all. NOA and State of Alaska requirements for the set b<•ack distances from any existing well., wastewater disposal system or public sewerage system on this or any adjar_ent or nearby lot. 4. I understand that this permit- is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. I1= A LIFT STATION IS INSTALLED IN AN .AREA COVERED BY MOA BUILDING CODES, THEN (1.) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) (TS-HUILTS WILL NOT BE As 0§5I) WITHOUT AN EL.ECTRICAL... INSPECTION RE'P'ORT„ AND (;) THE ELECTRICAL W.1" III T LIE ONE" ' A LICENSED ELECTRICIAN. SIGNED C� DATE; _ .. APPLICANT: G.L.D./di STRUCTIOIN ISSUED BY----'DATEeXs _ _, :...... All DEPTH TO PIPE BOTTOM -(FT.) 4.0 4.0. 4.O GRAVEL DEPTH (FT.) 4.5 0.5 3. TOTAL_ DEPTH (FT.) 8.51 4.5 7.5 GRAVEL. WIDTH (FT.) 2.5 20.05". U GRAVEL. LENGTH (FT.) 61.0--- 38,0 65.0 GRAVEL. VOLUME (C:U. YD S.) 29. 32, 28.2 48.2 TANK SIZE (GALS) 1,250.0 1;250.0 1,250.0 .�.� SOIL RATING (SO.FT /BR) 137 125 150 «# TANK MUST HAVE: AT LEAST TWO COMPARTMENTS I certify that: 1.. I am familiar with the requirements for on-site sewers and weals; as seL forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. 1 will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit.. 3. I will adhere to all. NOA and State of Alaska requirements for the set b<•ack distances from any existing well., wastewater disposal system or public sewerage system on this or any adjar_ent or nearby lot. 4. I understand that this permit- is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. I1= A LIFT STATION IS INSTALLED IN AN .AREA COVERED BY MOA BUILDING CODES, THEN (1.) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) (TS-HUILTS WILL NOT BE As 0§5I) WITHOUT AN EL.ECTRICAL... INSPECTION RE'P'ORT„ AND (;) THE ELECTRICAL W.1" III T LIE ONE" ' A LICENSED ELECTRICIAN. SIGNED C� DATE; _ .. APPLICANT: G.L.D./di STRUCTIOIN ISSUED BY----'DATEeXs _ _, :...... All PERFORMED LEGAL DESCRIPTION I :'ET P� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST I 7�'G-�(rUIC !r-i*jT �AUlv�' c�2�1u�G aA VC -c1 Y 5,106 bdawvtr 144 eC(.Weysz RcJed (5-0 5rc'TY mbd DATE PERFORMED: J—/U"-U115 Section: SLOPE WAS GROUND WATER e./a—'- ENCOUNTERED? p / IF YES, AT WHAT -S�y't;wk� d,RH�e DEPTH? De�4U+Ory GClJ�ry / Depth to Water peer Monitoring? Bale: I s L O _ P E PLAN Reading Date Gross Time Net Time Depth to Water Net Drop -Yvvkn a ry vU,- uvav• r ✓vim / PERFORMED BY.. �} .J..' c v "© � I '1°. CERTIFY THAT THIS TEST WAS PERFORMED IN j ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT COMMEENTS w1 -7 uN r v I V NO Frill I ty j -'- rs-N rL/ -Yvvkn a ry vU,- uvav• r ✓vim / PERFORMED BY.. �} .J..' c v "© � I '1°. CERTIFY THAT THIS TEST WAS PERFORMED IN j ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) =r MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & WATER WE ENVILL REE011MppEDNgiAL PgR(]OTTEECTION STATE OF ALA'S'R'At 1♦♦t�®IJ' ARTMENT OF Division of Geological T KWIEQ Drilling Permit No. LOCATION OF WELL (Please complete either la, Its or Is.) A.D.L. No. la. Borough Subdivision Lot Block Ib. 1/4 ors. Section No. TownshipN Range ED Meridian AACH 5YXXA 6A I At M)1 FIQ n. —of—of —of— S❑ I Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: pFX FglzPO1NT 2UAddress: C7,1.'Q 2 44 0 C ruvoR S 1099 Street Address and Area of Well Location Af4cH AK 9rt5P7 2. WELL LOG Feet Below Surface 4. WELL DEPTH: (final) 5. DATE OF COMPLETION I34- fl. — Jrfb7 — Material Type Too Bottom SILAY 5AUDY <IZAVEA, OIMAIN,, I Y _2 6. ❑Cable tool ®,Rotary ❑ Driven Dug 0Auger Jetted Bared Other: fr JAU£IEIli, 5A Al b iff vti/t }d P(i�\IfL �t rr /i. ,Sit, 7. USE: © Domestic Public Supply 0 Industry � Irrigation E3 Recharge 0 Commerical Test Well 0 Other: ) )z zly 4AN1,1615 T 4 LT f ARAVC1LV !S)LNI> RAI WEE 1 'f —0"0V 6RAVEL,t1 `1 6. CASING: E] Threaded ® Welded diom. _1. 1.. to 123 'n ft. Depth weight klbs,/ft. diom. in. to ft. Depth Stickupit. 1i "" f Vf T c . MO 4VATt Q 1-1 It E TA I v P fL Y 6R dr / K1 0015T 6a cim9. FINISH OF WELL: Type: Diameter; ;tLT 612 ` y w IFr Slot/Meeh Size: Length: IF - Set between ft. and ft. Backfilling Gravels pack 1 ) ) t of ✓)) r�-* c�E�r f �t� 2 IO. STATIC WATER LEVEL: j.72 ft. )P/ fvr Above or © Below land surface Date --- Equipment used: ,UUN L>e 3 Ii. PUMPING LEVEL below land surface and YIELD ANCF DEPT. OF RAW �ft. atter 9 hrs. pumping 3y g.p.m. ft, after fire. pumping g. p.m. ONMENTAL PROs 12. GROUTING Well Grouted: 13 Yes ® No C] Neat Cement ❑ Other: MAR 2 S198DMaterial: 13, PUMP: (if available) HP y Length of Drop Pipe ft. capacity a. P.m. H O Subm. E] Jet 0 Centrifical O Other r 14. REMARKS: � a' µ'C4.4 pt, k,jr6VAT"! 0 172- lev o _ g Rew/3. 4S ile, .I?FS/lzcw. P lid ! i FT �vmiviN!7 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature O F C] C _° This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; 1nf, n7: +y}t( _ w rt t l?17P!_1 f tela fi 10,t 7b 01 Reglsiared Business Name Contract License Number f ._Z1.�1_ _ Signed:___; �-�it l Date: Authorized R.,.seat°livo Farm 02-WiVR (11/811 Copy Distribution: WHITE -State OGGS, PINK -Driller, CANARY -Customer Municipality of Anchorage Development Services Department `ILf�I � � Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL I FOR A SINGLE FAMILY DWELLING Parcel I.D. (7` t �' �3 - � l) COSA# D D� Lo5 1. GENERAL INFORMATION Expiration Date: I Q 'Z Iro - Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address STUCKAGAIN MANOR LOT 5 BLOCK 1 6290 FARPOINT DRIVE ' ANCHORAGE AK 99577 CORRINE MOODY Day phone 269-5577 6290 FARPOINT DRIVE ' ANCHORAGE, AK 99577 Day phone PEGGY KELLY w/ DYNAMIC Day phone 261-7625 3111 "C" STREET • ANCHORAGE AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY:' Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 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 On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of Onsite Systems 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 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 riles 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 Finn GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 � Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date •/ Z3%O % Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the porfonnance of the system under the conditions encountered at the time of the lost, and separation distances measured to readily ldentifiablo 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 lost results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. 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 solo 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 Disapproved. Conditional approval for bedrooms. W bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Reort Nitrate Advisory Other ONSITE WATER AND WASTEWATER �• PROGRAM By: de- tel � Original Certificate Date: %' 2, UP (R". IM) Municipality of Anchorage Development Services Department Building Safety Division OrrStte Water 8 Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 995196850 www.muni.orylonsits (907) 3437904 CERTIFICATE OF ON—SITE SYSTEMS APPROVAL CHECKLIST Legal Description: STUCKAGAIN MANOR, LOT 5, BLOCK 1 Parcel ID: 0 V 1 1-6,23-.20 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 9/18/1985 Sanitary seal (YIN) YES Total depth 134 ft. Cased to 129 ft. FROM WELL LOG Date of test 9/18/1985 Static water level 52 ft. Well production 3.5 g.p.m. WATER SAMPLE RESULTS: Coliform Q_ colonies/100 ml. Nitrate!' —5-3 mgJL. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 6/27/2007 47 ft. 3.5 g.p.m. Other bacteria __Laolonies/100 mi. Arsenic: N_ ug./L. Date of sample: 6/27/2007 Collected by: GEG Ltd. e. SEPTICfHOLDING TANK DATA TankType/Material SEPTIC/STEEL Date installed 9/25/1985 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 6/18/2007 Pumper DENALI PUMPING c. ABSORPTION FIELD DATA Date installed 9/25/i9s5 Soil rating (g.p.d./feorqj!� 137 System type TRENCH Length 70 ft. Width 4 ft. Gravel below pipe 4.5 ft. Total depth _S ft. Eff. absorption area 630 ft° Monitoring tube YES Depression over Heid NO Date of adequacy test 6/27/2007 Results (PasslFell) PASS For 4 bedrooms Fluid depth in absorption field before test 10 In. Water added 465 gal. New depth 28 in. Elapsed Tune: 270 rain. Final fluid depth 10 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons "Pump off Manhole/Access water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankiltfi station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole/cieanout N/A Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ 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 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have deterrrrined through held inspm*ons and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date -j I 7-1 I t> COSA Fee S ( 3e) - U O Date of Payment e 71:) Y Jr. 7 r r Receipt Number O 3 3 0 K 9 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number 07/02/2007 13:42 FAX 907 333 8615 AK DMV -FISCAL 0003, vA /C--� 5/9/0} 07/11/2007 18:48 FAX 907 333 8815 AR DXV-FISCAL ARROW PUMP & WER SERVICE/ LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346.9355 • Fax (907) 333.8976 Eagle River: (907) 622-9335 CUSTOMER -1 r J L JO© SITE Q 002/002 N° 07783 J Thank You ' SIGNATURE 0 Hereby Acknowledge the 8a119teCIOry COmpletfon Of the Above Oeaadbed Work and foe M� M alma work b nor po d for In 9O days 1 eg es to allow /Wow Pump & Well Service. LLC. the eght b remove unpaid for equ"Hwd and Marge for Wbor woody pertomod & labor to remove unpaid for equipment) TERMS. ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH MALL Be CHARGED ON OVERDUE ACCOUNTS. �f �1 10 'd ON Xdd Wd 11:50 NOW LOOZ-£Z-lOf �1 sj L ANN �� TOTAL MATERIAL AMOUNTPAY THIS Thank You ' SIGNATURE 0 Hereby Acknowledge the 8a119teCIOry COmpletfon Of the Above Oeaadbed Work and foe M� M alma work b nor po d for In 9O days 1 eg es to allow /Wow Pump & Well Service. LLC. the eght b remove unpaid for equ"Hwd and Marge for Wbor woody pertomod & labor to remove unpaid for equipment) TERMS. ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH MALL Be CHARGED ON OVERDUE ACCOUNTS. �f �1 10 'd ON Xdd Wd 11:50 NOW LOOZ-£Z-lOf �1 -SGwL$Q- SGS ReLN 1072991001 All Dates/TImes are Alaska Standard Time Client Name Garness Engineering Group, Ltd. Printed Datefrime 07/1312007 13:38 Project Name/N Stuckagain Manor L5 DI Collected Datefrime 061272007 12:00 Client Sample ID Stuckagain Manor L5 D1 Received Date/time 0612712007 16:15 %latrix Drinking Water Technical Director Stephen C. Edc P%N SID 0 Sample Remarks: Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Metals by ICP/MS ND 3.00 ug/L EP200.8 C (<10) 07/02/07 07/11/07 MII Arsenic Waters Department Total Nitratc/Nitritc-N 3.63 0.100 mg/L SM204500NO3-r D (<I0) 07/03/07 IDS Microbiology Laboratory TotalColiknrm 0 coVI00mL SM209222D A (<I) 06127/07 DLC MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date J S 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) LOT �LaCK! JTc�Ct'i/hn/ //Ax/E' ���yGv< Sr'C 33 Location (address or directions) (b) Applicant Name ?/{/I- --`` fagef/ Telephone: Home 75 3 Business 51,3- 73'V3 Applicant Address �qqo: (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: Gc "I 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 7/ 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 2 72-025 01/84) G� 8/ 3'TiiGe'ilFiih.�! hilt 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 )n compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Telephone Name of Firm /�'i Tele P AddressfuflL A Date 6. DHEPAPPROVAL v-1ZApproved for �^e bedrooms by -.:!,—of AL egtou8 C.) .` it SACITH 2251•E Approved �><_— Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department 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) nwJNI .IrnL(TY OF ANCHORAol DEPT;OFHEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) MAR Z J7 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 RECEIVED r E C E I V E Legal Description: �✓ ��eX / S7ue4f� A i9s9: 11 T7 -Al 12ya.J SEC 33 A. WELL DATA Well Classification ?R/t✓�s� If A, B, C, D.E.C. Approved (Y/N) Well Log Present Y N) Date Completed %�/�' Yield Total Depth Cased /%g Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing�Y N) Electrical Wiring in Conduit &N) Depression Around Wellhead (Y6 Separation Distances from Well: 1� To Septic/Holding Tank on Lot //? ; On Adjoining Lots iU t1 To Nearest Edge of Absorption Field on ,L'ot / � ; On Adjoining Lots To Nearest Public Sewer Line A/& To Nearest Public Sewer i Cleanout/Manhole 22 AJItf To Nearest Sewer Service Line on Lot to 7 Water Sample Collected by iTcCS �• /iE� Date 3 /O 1, Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed '77Z� g Size %Z6r4 004'1- No. of Compartments 7— Standpipes (Y ) Air -tight Cap Y/ ) Foundation Cleanout(@Y N) Depression over Tank (Y^I Date Last Pumped Pumping/Maintenance Contract on File (Y/N) for Holding Tank High -Water Alarm (Y/N) I Temporary Holding Tank Permit (Y/`N) Alk Separation Distances from Septic/Holding Tank: _ To Water -Supply Well /19 To Building Foundation P To Property Line /0"70- To Disposal Field To Water Main/Service Line � To Stream, Pond, Lake, or Major Drainage Course '4j/h Comments Page 1 of 2 72-026(11/84) 1-5' B/ SF-raai lbi v Ah ox C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 137y_/,3),ey Type of System Design Date Installed9'�� �S Length of Field 'o Width of Field T Depth of Field _ �S Gravel Bed Thickness 1 Square Feet of Absorption Area &.30 Standpipes Presen(Y N) Depression over Field (Y( Date of Last Adequacy Test Results of Last Adequacy Test 4 Separation Distance from Absorption Field: To Water -Supply Well /Ye / To Property Line 2t To Building Foundation / 31 To Existing or Abandoned System on Lot On Adjoining Lots 9 To Water Main/Service Line//% To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course 4_0 To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION / A / f* DateInstalle _ Size in Gallons "Pump On" Level at High Water Alarm Level at _- Tested for Electrical Codes (Y/N) —_— Comments — Dimensions Manhole/Access(Y/N) — "Pump Off' Level at Vent (Y/N) ** Check Permitted Bedroom Rating Against HAA Request ** Pumping-Cyotess during Adequacy Test. Meets MOA Icertify that ld,er ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed � �� Date Company /C.5MOA No. 4� 0 ®��nC�A� a. Receipt No. —I,- 1 "1 Date of Payment " ( 3 —iia c �E= Amount:$ n.� Page 2 of 2 72-026 (11/841 ALASKA ENVIRON'-7NTAL CONTROL SERVIO J, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 SHEET NO. 1 OF p/ CALCULATED BY DATE CHECKED BY DATE g / SCALE ueNr.; OF ENVIRONMENL MAR 1 Nf n1lLvgWG Mm 01111