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HomeMy WebLinkAboutSKYLINE VIEW LT 3 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231248 PID Number: 051-192-04 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Theadrata Williams A ORPTION FIELD Existing ❑ D Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19333 Wildwood Dr. Chugiak AK Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 ISF Ft. LEGAL DESCRIPTION Depth to pipe invert from originalde Gravel depth beneath pipe Ft. Subdivision Block Lot Skyline View 3 Fill added above original grade Gr I length Ft. Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dis a between lines Ft. SEPARATION DISTANCES ToTotaf Septic Absorption Holding Sewer absorption area Number of trenches Dist. between t ches From Tank Field Lift Station Tank Line Ft= Well 100+ 25+ TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100+ I I Greer 1000Gal. Material Plastic Number of compartments 2 Lot Line 5+ NA Foundation 10+ I TATION Manufacturer Capacity Gal. Remarks Alarm location Elects i ailed by PIPE MATERIAL House to tankTank to D3034 drainfield D3034 Installer JR's Drainfield CO/MT D3034 Inspector Arcterra Consulting BENCH MARK (Assumed elevation) 100 ft Inspection n 1 Location and description dates: 8/31/23 20 8/31/23 3b 9/1/23 4th Garage Slab ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date :���A ��♦. * 49I11 * �` I Septic System )/?_7_ KENNETH M. D S � CE 11'; Approved Date /_7_0 L3 ♦jr�,p �� ♦��� Note: this approval does not include well permit requirements. ������ (Rev 05/02/18) AS—BUILT SYSTEM DETAILS/SITE PLAN Permit ❑SP231248 SKYLINE VIEW LOT 3 PID# 051-192-04 N A -C=31.2' B -C=54 6' o A -D=32.8' B -D=55.2' A A -E=34.3' B -E=56.6' A -F=38.8' B -F=61.0' A-6=39.9' A N B-6=62.0' A -H=40.8' o r_� B -H=63.0' M j 100,8Enn 1000 GALSEPTICTANK SCALES NTS OF ALS ■ W fi �1 m . TH 0 N1 � D I fCE -7116 ' iv N ! m 55I0�� � i s d� ``� D PREPARED FOR: THEADRATA WILLIAMS P❑ BOX 672292 CHUGIAK, AK RELD BOOKS BOUNDARY. N /A S'rMNG N/AA ASBuiu: SLS DWG. FILE: AGAD FILE FILE COMPUTED: DRAWN. KS❑ CHECKED: KM❑ DATE: 9 /1/23 GRID: NW1159 JOB N' 23112 WELL SCALES 1' = 30' SCALE: NTS .1110 con N ° PD Q O CD c ci.iCp CD � �•� �.�°cpm w � '�." r co 0 t4 � O °� CD (D CD N O 0 00 p. � `� CDCI1 ' (D O� O rvi CRcr �•••j ^^ U) (D p'' O CD � �' � � hal I�•.�-] � ►� � O /r+ cr o ,N 89 59� 00» W 330.00 cn d o 134.3 rn boc q 00 .r. O ►-. =r Wr _ .`P � � WCD CD �¢�71, CD v o pI z �ti '00z r p co CD AW n 60 0,�r, ; y I CSI O m RA VA C, U) 0 IT- •.O 0 ' . •� v 00 • s �� •Yo r• : MW \, .�� 00 •r , _ N 89'59'00 W 330.00' � SCS a PROF CDODcoS'l o 'o 30' 30 ataOl 9 I Cli- N � C-7,9 >4 0' cD (D (D Ul C-t- 3 �� coo i MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231248 Work Type: SepticTank Upgrade Tax Code Number: 05119204000 Site Legal Address: SKYLINE VIEW LT 3 G:1159 Site Mailing Address: 19333 WILDWOOD DR, Chugiak Owner: WILLIAMS THEADRATA & CELESTE N Design Engineer: ARC TERRA CONSULTING INC This permit is for the construction of: Effective Date: Expiration Date »Zcnt � . f Department Lot Size in Sq Ft: Total Bedrooms: 8/17/2023 8/16/2024 43560 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: 7Q A_(L Z Date: Issued By: �� �� Date: 3 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICAMELL PERMIT APPLICATION Parcel I.D. 051-192-04 Property owner(s) Theadrata & Celeste Williams Day phone Mailing address PO Box 672292 Chugiak, AK 99567 Site address 19333 Wildwood Dr. Legal description (Sub'd., Block & Lot) Skyline View Lot 3 Legal description (Township, Range & Section) Lot Size 43,560 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) X❑ (w/wo ADU) Septic Tank ❑X Upgrade X❑ (D) El Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Dea Duffus (Signature of property owner or authorized agent) Permit/Rush Fees: h Z2_5- Date Z5- Date of Payment:3 T' Receipt Number: Permit No. 0'q923 I Z`A13 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231248, Curtis Townsend, 08/17/23 A TRCERR A C O NSULTI N G ,I N C . A TRCERR A Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231248, Curtis Townsend, 08/17/23 MUNICIPALITY OF /\NCH()RAGE DEPARTMENT OF HEAl. TH ~ ENVIRONMENTAl,. PROTECTION ENVIRONMENTAL ENGINEc,~ING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WEI. L INSPECTION REPORT MAILING ADDRESS LEGAL DESCRIPTION LOCATION ] Absorption area kDwelting ~.'~ / Z/ ~I Materi~. ¢~...~. Inside length ,~-- IWidth Dwelling lMaterial NO, OF BEDROOMS _ PERMIT NO. ~"¢¢~';{0~J(¢(/ Liqu icl depth PERMIT NO. ~q~quid capacity in gallons Foundation ~.d~.? ! PERMIT NO.o¢,~ CO (,¢ 4./ Distance between lines Total length of lines Material beneath tile .~. Del)th iNealest lot line / ~ /o Length Width Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: DISTANCE TO: ~[~epth Building foundation OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS Total effective absorption area PERMIT NO. Nearest Io~ line Septic tank ~. / F~'-R MIT NO..-, [Absorption area(s) Driller Sewer line APPROVED DATE LEGAL 72-013 (Rev. 3/78) · THE LENGTH D I HEh,IE; '( OH :~: S THE: L.EN~3'FH ,:: ~t:1'.,I F'~!:E.:!' ::, 0!::' THEE 'TFi:E:i'..!CH E!Fi: D?.!::! :1: B!I::: !: ELD. THE U,E:PTH OF' FI 'I~IR~:2,1CH 0!:~: t:::':[T i[~; '.FF!I~: I;::,:~:ST!:::!NC:~i: I!i?E":f'F!E:I::~:N 'THE: GF4:C!t..IND F:fi'.,!D THE-: BOTTOH OF' THE ~i::'-.::C:Fi'v'FFf' :i: ON ':: ~: N F'EET TF!EFitE: :l:t~:~; NO SET I.,.I:[DTH t::(:)!~: 'T!..ItE ~:~il:;~:l:::!~,,,'!~:!... i)!!'{F'TH :['_:.'i; THE: i'I:[I'..!:(HLIH I::,E:F"T'H (:~F' GF::FF,,'E!:L. E!~Ei:T!.,.II~i:Eb! 7'HliE: OUTF:F!L.L.. t::IND THr::~ E~O'F'i"OH (::Il:: THE: E',:.::CF!'v'F!T :[ ON ,:: ]: h! i:::'tE~:"[' ::,. i::fq'~l.:'l=:i:L,L.'rhl":i ............... f"~l:: FN"r' ii~;~'~'~ii.:.;"l"~ii:l"'l H!:THOI...IT F"[I"!FI_ :l t"~::~i;F'EC:T :[ :E N FIND ::I::'r::?OVF![. l"l': TH .... 'r,::: E:,E:F:'FIF:TH!i~.:NT ,d):L.L. E',F~: 'i~;UEi].)'.~.~)E:T "FO i'"!]:N];t"'!L!H [::, :!: :5'i'FINCI~: fiq:i:'I'HE:E:H I:::! HEL. L.. :!.f.:'iu3 F'!L::~:T I::TIF.: F:! I:::'!;~:~",,'!:!"i'~E HEi:L.L UF:'(.')N "FHIE Th"F'E: OF:' !:::'i._IE',!~. :[ !::: I,!E:L.I H :!: h,! :I: HUH 13, J: 'i~;TF!N(::E: F'F:OI"'! FI ,F'F4: :[ TO F! COi'"IhiLIN ): Th" !S E !.,.! E Fi: L. :!7 NE 7!: S 75 !::"E:~Z:T. !,.!EELL L.O~}i;E; FIFi:ii~: F:E(i:!I..I:[f~:E:I_::, FIND HLI'.i'~;T O1::: 'T'HE~: N~.i:L.L. COHF'L.!::i:'I']: O"FH!!~:?. Fi:E(i:!U :[ !R~i:'hl.r. ENTS ?IFF? F:fi::'F:q..."d. !:::P,?!::I Lt. L. FtI!3L.E:: 7'0 :1: i'.,!SLIB:Ii!~ F::'i-;:OF'I:E!:;? :[ Ci!Ef;?.'T :( l::'"r' TI'dF!T :1.: ]: f::fi'"l F::'Fhnl:i:L:t:I::!I:;~: I.,t:("FH 7'H~E Fi:E:(::!I...I):t:~:i!~.ZH~ENT'.:ii; F'OF?. ~:L'lht.....:ii:;:!:"l'F7 SIi!i:FIE,r-~:% FIND !.,!I~.:L.i..~'~i; !::l:iE: :!~;liii: F !:g31qi'T'H EP'? THE h'lUl'q :( C ): ?FIE ;~ "l".d ;~:?: ]: b.!:[ L.L. i: N':'-:TFf::IL.!... THE: Sh.':ii;TE:h! :}:.:: J: UHDEF:STF!HD '!'HFIT THE: ~31',F.-.:i:;:!:TE: :i..:E:b.!~::Fi: Sh.'::?i"!::JH I"iF!? l:;i:f!i:~7.!t...t]:~'~:E: iENL. FiF:'.G~!::I"!!Eh,Fi" ;t:I':' 'T'H!E I:RI'?ii;]:I3,1!i~:NCE: ]:'E; IqrE:HO[)!!~:L.E[::, O & E ENG,NEERING & DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name:. ~ Mailing Address: Legal Description: ,-~ Earl Ellis SOIL LOG 688-2280 Depth (feet) 0 $oll Characteristics 7 8__ 9__ 10__ 11__ 12__ 13__ 14__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit__ Comments: No ~ If yes, what depth Drain Field Performed by: PLOT PLAN PERC. TEST _1 t' q L~dFI This 1;- ,,'ii, feet by DOC CO. dba P.O, BOX972, CHUGtAK, ALASKA 99567 ~, TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL PE~IT NUMBER DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR __,~? ,~ O KIND OF CASING ~ GO '~2_ KIND OF FORMATIO, N: From tS~ Ft, to '-?.-Ft From From_. From. 7 From Ft. to_. Ft .... '-~'/ (.,Yff,,"q g/ Fro,n~Ft. to ~7 Ft.. ~a~ a~ ~ ~ From Ft. to. Ft, ~O d~ ~.~_ Fromm. Ft, to~_~Ft. ~0 d~ ~ From_~Ft. to~ Ft. ~ ~ :rom_ Ft. to Ft ~ ~7~ . ;rom ... Ft. to_ Ft.. 41SCL. INFORMATION: From___Et. to___ .Ft __ From__.Ft, to__~Ft. From__ Ft. to i Ft. From_ Ft. to__ . _Fi. From__Ft. to ~Ft From. fit. to ___Ft. MUNICIPALITY OF ANCHORAGE-- From ..Ft. to From Ft. to_ Ft. ' From Et. to .~IL ,'; 0 ~n~ 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 / DRILLER'S NAME MUNICIPALITY OF ANCHORAGE o_ Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-192-04 Legal description SKYLINE VIEW LT 3 Site address 19333 WILDWOOD DR Chugiak AK Expiration Date: L 2 Z '{j 2--3 Current property owner(s) THEADRATA & CELESTE WILLIAMS X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: bedrooms, with the following stipulations: f By Original Certificate Date: 9/22/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE RUSH Development Services DepartmentPhone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-192-04 Complete legal description Skyline View Lot 3 Location (site address) 19333 Wildwood Dr. Chugiak, AK Current property owner(s) Theadrata Williams Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: © Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass Age 0 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $330 Waiver Fee $ Date of Payment -9S / 2D1- 3 913�Z3 Date of Payment COSA # SSL 3 3 Waiver # COSA Application—June 2022 COSA Checklist Legal Description: Skyline View Lot 3 Parcel ID: 051-192-04 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA J❑ Well log is filed with Onsite (or attached) Date drilled 3/16/82 Total depth 154 ft Cased to 150'9" ft ✓Q Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 3/17/23 Static water level at beginning of test 137 ft. Comments B. TANK DATA Measured operating fluid level in septic tank New Date of pumping New install 8/31/23 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 6/18/82 ✓❑ ALL standpipes present per record drawing Total measured depth from grade 11.8 ft (max) Measured depth to pipe invert from grade 3.8 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. 0 Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficienci COSA Checklist June 2022 Well production at time of test 5.7+ gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑J No Q Coliform bacteria is Negative Nitrate 3.44 mg/L ❑ Nitrate less than MRL (ND) Arsenic ND ug/L ® Arsenic less than MRL (ND) Collected by Areterra Consulting Date 8/24/23 STATION ❑ Require- ' tenance completed Age of lift station rs Lift station material Comments: Adequacy test date _ Results J❑ Pass Fluid depth prior to test 3/17/23 56 in Water added 450 gal New fluid depth 70 in Elapsed time 10 min Final fluid depth 56 in Absorption rate 450+ gpd FIELD STATUS —POST RECOVERY Effective depth (per record drawings) 96 in Effective depth used 56 in Effective depth remaining 40 in l E. SEPARATION DISTANCES From Private Weil on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ./❑ Yes if No 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' 0 Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' Z Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50'✓❑ Yes if No ft Yes if No ft ft If tank or field is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' © Yes if No ft © Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ./❑ Yes if No ft Surface Water > 100'✓❑ Yes if No ft Tank to Property Line > 5' F Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ❑✓ Yes if No ft Private Wells > 100' © Yes if No ft Water Main > 10' ✓❑ Yes if No ft Community Wells > 200' Q Yes if No ft Water Service Line > 10' 2 Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Areterra Consulting Phone (907)-696-6111 Engineer's Printed Name Kenneth Duffus Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. COSA Checklist June 2022 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 ~-'~/ - / °\.E).- ~-~ HAA# ~"~q \ 1. GENERAL INFORMATION Complete legal description Ac~'e Lot 3; Skyline View Subdivision Location (site address or directions) 19333 Wildwood Drive, Eaqle River, Alaska Property owner AHFC ~108517 Mailing address WA ~94291 Day phone Lending agency CITY MORTGAGE Day phone Mailing address Baqle Rive~ Alaska/ ATTENTION: Mask Tuuskett Agent r,ori ~rowder/,lA~K WHTgR CQMPANY' Day phone Address 10928 Eagle Rive~ Roa~, gagle R±ve~, Alaska 995?? 694-5500 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well NOTE: XXX Public water 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 NOTE: XXX Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 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 furtherverifythatbased 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 S & S ENGINEERING Address 17034 Eafile River Loop Road Eagle River, Alaska 99577 EngineeCs signature DHHS SIGNATURE --~ Approved for ~ Disapproved. Conditional approval for Phone bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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. 72-025 (Rev, 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA ~'~ ~.~,,5¢ Parcel I.D. Well type Log present Total depth Sanitary seal If A, El, or C, attach ADEC letter. ADEC water system number \/ Date completed ~2~~L-¢- ~'7~- Driller Casedto ~.~C~' ~" Casing height Wires properly protected ~N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~) Date of sample: (1-'~-~1 / B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (~N) High water alarm (Y/~ Date of pumping Nitrate "-Z., 1 ~r/~, ~:~ ~ ?_~ ~ c[ ~ Co Ilected by: Other bacteria /,~ S & S ENGINEERING 17034 Eagle River Loop Road No, 204 Eagle River, Alaska 99577 Tank size ~, Oc:~O Compartments Foundation cleanout (Y~ /tJ/ Depression (Y~j~ Alarm tested (Y/N) ~'~ %' ~ ~ cl ~ Pumper ..L_-_-_-_-_-_-_-_-~, ¢--. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line \ ~ Surface water/drainage On adjacent lots /oo ~'~ Foundation Absorption field ~ + Water main/service line ~- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C, LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level ~ Meets MOA el~  DISTANCE FROM LIFT STATION TO: We-Il on lot On adjacent lots D. ABSORPTION FIELD DATA Manufacturer Manhole/Access (Y/N) "Pump on" level at -----'-'--~"Pump off" level at Cycles tested Surface water Date installed Length "~ Total absorption area Width Gravel thickness ~ ~ Cleanouts present 4~j;~N) Date of adequacy test If yes, give date Depression over field (Y~) /~ Results .~'~fail) _. ~ ' for Peroxide treatment (past 12 months) (Y,~ _/~A~_ ~:~AJt~ ~,,(~' Soil rating. [oc~ ~/l~r~ System type· Total depth _. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot_ I~oo~''' To building foundation On adjacent lots_ Surface water l<~c~ ~'~ Curtain drain ~l~ E. £NGINEER'S CERTIFICATION On adjacent lots. Property line_ To existing or abandoned system on lot__ f"[ (/~ Water mai n/service line Cutbank bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect o~ the date of this inspection Signature ....... _ Date Date of Payment (.- ~ Date of Payment Receipt Number ~ ~ O ~ ~ ~ Receipt Number ~2-026 (Rev. 3/91) B~ck MOA 21 Driveway, parking/vehicle storage area _ NT FILLS OUT UPPER HA ONLY APPLr ~ ~ //z ~ Phone Pr0PertyOwner -7-~g)/?? /'7//(¢(~(...-~.'1¢~'-~ ~.~:./~ ~f~ ~ Buyer ~ - Zip Code /~g//, ~' Address Phone Address .... ,, , Zip Code Street Locati~ [.// /' t: /:) (.¢J ¢O 1) ,~ / I ~ (~ Type of Resi~nce , ,_~.. ~ SingleFaml,y D Mulliple Family No. of Bedrooms , ~ Other Water Supply ~ Individual A~ACH WELL LOG, A w¢l 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 Sewer Disposal ~ Individual Year IndivBual installed: / ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OOESSING CAN BE INITIATED. Time Time Time Time Date Date Date Inspector Inspector Inspector Inspector (..~) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* BY: .... Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received ~ __ (~, 72-023 (3/82)