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HomeMy WebLinkAboutSUSITNA VIEW ESTATES BLK 2 LT 1 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 // Date Received ~/~Z.S//~j/ Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 2. Property Owner: Mailing Address: 3. Legal Description: 4. Location: 5. Type of facility to be inspected 6. Well Data: A. Type .~----d~ Mailing Address: ~ .~'~..~J~, Phone: ~J Phone: No. of bedrooms B. Depth C. Construction D. Bacterial Analysis Sewage Disposal. System: A. Installed~--/~7~ B. Installer ~'__ /~tur2 C. Septic Tank: 1. Size 2. Manuf ! D. Seepage Pit: 1. Absorption Area ~-d~, 2. Material~/~ E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank , Absorption area , Sewer Lines , Nearest lot line , Other contamination B. Foundation to septic tank , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages P~ge',2 of two pages - Rc~a:e~st for Approval of Individual ~%~r & Water Facilities Legal Description Approved ~ ~/~L- Disapprove~t Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating~tisfactorily. ~ k~ SL~v~ MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section ��_ Fax: 907-343-7997 Parcel I.D. 020-091-39 Certificate of On -Site Systems Approval Expiration Date: 8/29/2025 Legal description SUSITNA VIEW ESTATES BLK 2 LT 1 Site address 4901 VIRGO AVE Anchorage AK Current property owner(s) RANDICH X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: LNOs have been recorded from utility companies for the septic crib in the utility easement, northwest corner of parcel. See DNR recorder's office. M Original Certificate Date: 10/16/2024 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 Development Services Department/ Phone: 907-343-7904 On -Site Water & Wastewater Section " ' Fax: 907-343-7997 3 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 020-091-39 Complete legal description SUSITNA VIEW ESTATES BLOCK 2 LOT 1 Location (site address) 4901 VIRGO AVENUE ANCHORAGE ALASKA 99516 Current property owner(s) SALLY RANDICH 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 50 - 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 $ U Date of Payment �/z zC/ COSA # O >C 2- Waiver Fee $ Date of Payment Waiver # COSA Application.doc COSA Checklist Legal Description: SUSITNA VIEW ESTATES BLOCK 2 LOT 1 Parcel ID: 020-091-39 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test 1.9 gpm Date drilled CIRCA 1970 Total depth *100+ ft Water storage tank volume None gallons Cased to UNKNOWN ft Well disinfected for coliform test? ❑ Yes ® No ® Sanitary seal is functioning correctly ® Coliform bacteria is Negative ® Wires are properly protected Nitrate mg/L ® Nitrate less than MRL (ND) Casing height (above ground) 12+ in. Arsenic I ug/L ® Arsenic less than MRL (ND) Date of flow test for COSA 8129/24 Static water level at beginning of test 60 ft. Collected by 4 Date 8/29124 Comments *DEPTH PER FWCS ACOUSTIC SOUNDER AT WELL FLOW TEST. B. TANK DATA Measured operating fluid level in septic tank 41 in Date of pumping 8/29/24 ❑ Required maintenance completed, if AWWTS Comments: Limited Data — & No FCO. D. ABSORPTION FIELD DATA Which system tested (date installed) *CIRCA 1970 ® ALL standpipes present per record drawing Total measured depth from existing grade 9_8 ft (max) Measured depth to pipe invert from grade 6.4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes (MT) go to bottom of effective. (ED) 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) N If yes, enter date C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 8/29/24 Results JK Pass Fluid depth prior to test 5 in Water added 460 gal New fluid depth 17 in Elapsed time 1440 min Final fluid depth 4 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 40 in (Assumed ED) Effective depth used 4 in (Final Fluid Depth) Effective depth (ED) remaining 36 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED is per measurements, visual observations, review of available records & is unknown, but assumed 3.3' or 40" of ED. *Original crib built approximately in 1970 per well install circa date. Limited data for the 50+ years of these systems. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' ❑ Yes if No *91 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 **103 ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft ® Yes if No ft 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' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' F. ENGINEER'S COMMENTS ® Yes if No ft ❑ Yes if No ***7 ft ® Yes if No ft ® Yes if No ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ® Yes if No ft ® Yes if No ft If tank or field is under driveway comment below Per this investigation with visual observations, review of available record documents along with previous COSAs — the well is approximately *91' to the tank pipe & separation met code at time of installation (50'+) & **103' to the absorption field, ***7' from crib pipe to property line, and it is unknow but assumed the septic tank is 5'+ to the existing crib. 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 FIRST WATER CONSULTING Phone 907-350-9566 Engineer's Printed Name CURTIS HUFFMAN PE Date 09/20/2024 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 these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & fIuGS OF Ak`, TH j • . • . r • .......... J r Curtis Huffman CE 128991 ..•� ��,,,/ `floc • . 99/20/24 . • Cam ,� ��>��°PROFESskox -o COSA Checklist.docx Parcel I.D. 020-091-39 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION:. Expiration Date: C d - 2-2-. 2-7Z— Complete legal description SUSITNA VIEW ESTATES,• BLOCK 2 LOT 1 Location (site address) 4901 Virgo Ave. *Anchorage Current Property owner(s) Danny Cobb Mailing address Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual -Water -Storage Ej Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ 550 Waiver Fee $ - - - Date -of Payment- - - - --- - - Date of -Payment Receipt Number Receipt Number COSA # 0S C. a 2 j 3 0 Waiver # nce: R 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. Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101 -Anchorage, Alaska 99507 I Engineer's Printed Name: Jeffrey A. Garness Date: ! 2/ �Z In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and�o�eOO� industry practices. The reported results describe the condition of the system/s on the date/s of the �� �' { j �l;•, evaluation. Separation distances were measured to readily identifiable features. Hidden defects or..-• ^�l� encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of (. the well or septic system. GEG makes no representation whether an alternative well or septics01(y xstem (�� .Jef can be installed on the property in the event either of the current systems fail to perform a}��i�((( c 5? is (fir the future. The content of this report is for the sole benefit of the person/party that ret perform the evaluation. Reliance upon the information provided in this report by a n or Pa(including subsequent property Y Purchasers)is not authorized, nor will it c Y legal right �. X whatsoever.) N-S/T 6. DVIGNATURE �? o WATER AND m System #1 Approved for J bedrooms c WAST', V,/ System #2 Approved for bedrooms PROGRA700, M R DisapprovedJNT x��\�� #AECC884 _ By: - Original Certificate. Date -_77 -ZZ -2Z 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 Nitrate Advisory ___Septic_ System Advisory ----Arsenic Advisory Well Flow Advisory Other COSA Checklist Legal Description: SUSITNA VIEW ESTATES; BLOCK 2, LOT 1 Parcel ID: 020-091-39 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system _ A. WELL DATA *APPEARS TO BE NORMAL OPERATING LEVEL, PER FIELD B. TANK DATA INSPECTION Q Age of tank50(?) s) years 2 Tank type/material SEPTIC/CONCRETE Measured operating fluid level in septic tank *42 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 6/27/22 - SEE ATTACHED CAMERA INSPECTION -D.-ABSORPTION FIELD DATA - - _CRIB _ Well production at time of test 1.1-}- gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes n No ❑■ Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L ,'Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 6/24/22 C. LIFT STATION ❑ Required maintenance com Age of lift station y Lift station mated **[M ❑ Well log is filed with Onsite (or attached) Adequacy test date 6/24/22 Date drilled 1972(?) 3 Total depth *149.6+ ft Cased to UNKNOWN ft Fluid depth prior to test 6 in Sanitary seal is functioning correctly Q Water added 455 gal m Wires are properly protected 18 Casing height (above ground) 12+ in Date of flow test for COSA 6/24/22 a ❑ Monitor tubes go to bottom of effective. If not, state 125 Static water level at beginning of test 66.3 ft. & Comments *PER GEG WELL FLOW TEST *APPEARS TO BE NORMAL OPERATING LEVEL, PER FIELD B. TANK DATA INSPECTION Q Age of tank50(?) s) years 2 Tank type/material SEPTIC/CONCRETE Measured operating fluid level in septic tank *42 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 6/27/22 - SEE ATTACHED CAMERA INSPECTION -D.-ABSORPTION FIELD DATA - - _CRIB _ Well production at time of test 1.1-}- gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes n No ❑■ Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L ,'Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 6/24/22 C. LIFT STATION ❑ Required maintenance com Age of lift station y Lift station mated **[M Which system tested (date installed) ** Adequacy test date 6/24/22 ALL standpipes present per record drawing Results IDPass For 3 bedrooms Total measured depth from grade 9.66 ft(max) Fluid depth prior to test 6 in Measured depth to pipe invert from grade ***6.33 ft (min) Water added 455 gal ❑ N/A - pressurized field 18 \A New depth in ❑ Monitor tubes go to bottom of effective. If not, state 125 depth into effective 11MQ WN Elapsed time min R Code -required soil cover over field Final fluid depth 12 in ❑ System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) Gallons introduced N/? gallons If yes, enter date N/A Comments/Deficiencies:; PER OWNER STATEMENT, CRIB WAS RE -BUILT IN 2006 "'FROM GRADE TO WHERE PIPE EXTENDS INTO CRIB - L�6F6�51"4-S COSA Checklist yellow sheet Q/f E. SEPARATION DISTANCES F. ENGINEER'S COMMENTS *ABOUT 91' FROM WELL TO SEPTIC PIPE **ABOUT 103' TO CRIB PIPE ***ABOUT T FROM LOT LINE TO CRIB PIPE TANK MAINTAINED SAME OPERATING LEVEL THROUGHOUT TEST. G. ENGINEER'S CERTIFICATION I 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. COSA Checklist yellow sheet #AECC884 f From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' * Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft IQ Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25'2] Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft M Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' El Yes if No ft P1 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' Q Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Field Absorption > 5' p _ Yes if No °"N"° v" ft Private Wells > 100'✓❑ Yes if No ft Water Main > 10' Q 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' E1 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' Q Yes if No ft Private Wells > 100' El Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' Fb11 Yes if No ft Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS *ABOUT 91' FROM WELL TO SEPTIC PIPE **ABOUT 103' TO CRIB PIPE ***ABOUT T FROM LOT LINE TO CRIB PIPE TANK MAINTAINED SAME OPERATING LEVEL THROUGHOUT TEST. G. ENGINEER'S CERTIFICATION I 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. COSA Checklist yellow sheet #AECC884 f Erik Widger From: danton4901 @aol.com Sent: Monday, July 11, 2022 12:34 PM To: Erik Widger Subject: septic crib at 4901 virgo ave To whom it may concern, In August of 2008 the ground above the septic crib at 4901 Virgo Ave developed a 1 foot by 1 foot depression that became visible. This depression in the ground was about 8-12 inches deep. I called an excavation company to look at the issue. I no longer know or remember the name of this company. They excavated the area and found an area of the crib that was damaged by a tree root that had grown above the crib. This excavation company said they needed approval to perform the repair work and recommended Pannone Engineering to facilitate the appropriate approval. I was home the day that someone from Pannone came out and approved the repair. The excavation company did the repair work and I have had no issues since. Danny M. Cobb Arctic Effluent Services, LLC. PO Box 110192 AK 99511 US +1 9076653249 alas ka.aes@gmail. corn INVOICE () t-' �� . EFFLUENT Set -ver anci ctrain 's'e?rvires BILL TO INVOICE A1769 Danny M Cobb DATE 06/29/2022 4901 Virgo Ave. TERNIS Net 30 Anchorage, AK 99516 USA DUE DATE 07/29/2022 DATE DESCRIPTION QTY RATE 06/29/2022 Camera inspection Camera inspection of septic tank to find 1 300.00 large single chamber concrete tank intact with no major signs of cracks, deterioration or root and ground water infiltration. There was no visible baffle for the inlet line of the septic tank. Outlet of septic tank had a pipe stub in with a 90* fitting facing to the bottom of tank. No exterior or foundation cleanout was found. Unable to determine if interior sewer cleanout exists due to no access to home. Visual tank inspection did not provide any red flags concerning loss of structural integrity of septic tank. AMOUNT 300.00 Arctic Effluent Services thanks you for supporting ;our Local Alas'k'a Business. PAYMENT 300.00 '`de look forvaW to seroino your needs for years to come. 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OL (a PQ It ° �= E m m C',n � O C � mZm CO CD m Q _hF��Haw_ O '*+ CL O m I r+ CL W N in m CLD) 3 `n r' - Z O O H � N N w Ln 00 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWEL, LING Parcel I.D.# ~,~[~'} - ~c~\_ ~c~t HA~# GENERAL INFORMATION ~_,_,~ £~ ~,~ Completelegaldescription ~,~- 1 ~l~ ~ ~;~-~ Location (site address or directions) 4901 Verso Street, Anchoraqe, Alaska Property owner S'hev~ Rc~9~ Day phone 27e:--8561 Mailing address 4901 Vergo g~-rRet-: Anc~hc~rage. Al ~ka 9951 Lending agency .qm~-~ ~ M~rg~gP Day phone Mailing address Agent Sale by Owner Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3, TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 4. TYPE OFWASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: X If community well system, provide written confirmation from State ADEC attest- .:lng to the legality and status of system. x 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 further verify that based on the information obtained from the Municipality of Anchorage files and from my inves_tLgation 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 PHI Cc~n.~u]t~ng Engineers 'Phone 344-1385 Address 800 E, Di~ond }~lvd. Su~-~e ~-$~?~2Anchoraqe, Alaska 99515 Engineer's signature ~,_~ ..~_ ~ Date ~- Z~- ~' DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: Additional Comments .. Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS 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% work. 72-025 (Rev. 1/91) B~ck MOA it21 W.O. 96262 Legal Descriptiou:Lot- 1 Rock Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) MA~ 29 1996 Health Authority Approval Checklist Dept. Health gcHur6an SOrVices 2 Susitna View Parcel I.D.: A. WELL DATA Well type RES. Log present (Y/N) NO Total depth N / A Sanita~ seal (Y/N) YES (~ If A, B, or C, attach ADEC letterl ADEC water system number (~) Date completed 1970 ~'~ Cased to 40 ' -v (~ Casing height (above ground) Wires properly protected (Y/N) YES FROM WELL LOG AT INSPECTION Date of test N / A 5 / 8 / 96 Static water level N / A 61 , 9 ' Well production N / A g.p.m. 1 . 2 g.p.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate 0.1 Other bacteria 0 Date of sample: q / R / 06 Collected by: Dustin HiGh B. SEPTIC/HOLDING TANK DATA Date install?:;-'? q. 7Q.? ~: ', Tank size 750~) Number of Compartments 1® Cleanouts(Y/N) YES Foundafio/iicleh'nollt~(Y/N) I~0 :(~) Depression(Y/N) NO(~) High water alarm (Y/N) l',IO(~ DateofPumpmg~.~5/,14~96'?-'PnmperA+ Home Servzcest ]2nc. C. A B SoR PT ION :.1~.. ~!~D. D~T A. Date installed ~ ~ 7 0 · Soil rating (g.p.d./ft2 or ft%drm) - System type Length 10 t ' ' Width 10 Gravel thickness below pipe g~. / Total depth 8 ? 5 Effective absorption area 328 s. fMoifitoring Tube present(Y/N)_ YES~epression over field (Y/N) NO Date ofadequacy test 5/8/96 (~) Results(Pass/Fail)PASSED (~) For 3 (~) bedrooms Fluid depth m absorption field before test (in.); 26" Inunediately after 489gal. water added (in.): 35.5 ' '(~ Fluid depth 26"~"%ins.) Minutes later: 1440 ~ Absorption rate = 489 (~ g.p.d. Septic Pit® Peroxide treatment (past 12 months) (Y/N) NO If yes, give date /,Jo7",5': s~I/e ,o/7" ,~/;.~ ,dr~bed'. -rOI° O~ //~ k~-f 18 0 ~/_ LilrV STATION Date installed Manhole/Access (Y;N) High water alarm level at* Cycles tested /Size in gallons //~Pnmp off' level at* E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tauk on lot 9 'l , '1 ' : On adjaceot lots q ,5 0 ~ + Absorptiou field on lot 'l 0 5.1 ' * ; Oa adjacent lots '1 5 0 ~ + Public sewer main Sewer/septic service line Public sewer manhole/cleanout Lift statioo ix] //x. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 3 2 ' ~ Property liue ~1 0 ~ + (~) Absorption field q Water main/service line 'l 0 + Surface water/drainage ! 0 0 ' +(~)Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Bnilding fonndation. 4 5 ' + (~ Water maia/service line Snrface water ~ 0 0 + ~ Curtain drain HONE® Driveway, parking/vehicle storage area 7 0 ' (~) Wells on adjacent lots q 5 0 ' +(~) Property line +© F. ENGINEER'S CERTIFICATION HAAFee $ Waiver Fee $ Date of Payment Date of Payment Receipt Number Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPAR~/~EHT OF HEALTH AND ENVIEONMENTAL PROTECTION APPLICATION FOR HEALTE AUTHORITY APPROVAL CERTIFICATE I~'afOZ~.tio~ Application Date Legal Descrlptiom (include lot, block, subdivision, section, township, range) /-! 6?- ~ ~I$ ~ T~ q/f~c,~ ~-~?-,,%/~-~ ,~/~,,~., ~f~.~- Location (addregs or directions) Appl/c~-ts Na~e ./~/ZL /~¢~zw~ ~ Telephone - Home Applicants Address ~/ ~/.~o ~/f- Appl~e~t Es (chec~ one) Le~ing Institution Buyer I ! ; Other [----T (explain); . Lending Institution Address Real Estate Co. & Agent Other (describe) Address Telephone (f) Mail Cbe ~ to t,he following address: Business~g/-~2/ Multi-Family~-~ Telephone 2. T~ye of Residence Single-Family~ Number of Bedrooms 3. Water Supply- Individual We!l~ Note: If community well system, must have written confirmation from the State Department of Envlrommental Conservation attesting to the legality and status. Sewage Disposal Onsite~-~ hblie~ Community~-~ Holding Tank~ Note: If cccrmunity -.~il system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status- [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-si~e '-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 ~R~D~ installation. / Address Date ~/~ (ENGINEER SEAL) Telephone DHEP Approval. Approved for'~bedrooms Approved .p~ Disapproved Terms of Conditional Approval Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY ~3PROVAL 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 ~NALYZE DATA BEFORE A 'CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGIHEER'S WORK. RR4/ej/D18 [Page 2 of 2] (DHEP SEAL) 7-19-84 MUNICIPALI%~Z OF ANCHOi~AGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION AUG 2 1 DAT. RECEIVED Well Classification ~/~/~z~ ~. If A, B, c~ C, D.E.Co Approved(Y/N) ~- Well ~ ~esent (Y~) ~ Yield ~ Total ~p~ ~ ~ ~d to, ~r~B~pth of ~outin~ ~ Casing ~i~ht ~ G~nd ~ Sanita~ ~al on ~sing (~ Elec~ical Wi~ing in ~nduit (Y~) ~ ~ession ~ound ~l~ead ~Y~) ~ ~p~ation Distan~s ~ ~11: . ~ To ~ptie~olding Ta~ ~ ~t ~ ~ ; ~ ~joini~g Lots ~ To ~a~st ~ge of ~so~tion Field on ~t /o6~ ; ~ ~joining ~t~ ~/~ ~ To Newest ~blic ~ Line ~ __ To ~est ~blic ~r Clean~t/Ma~ole ~ To ~est ~ ~rvi~ Li~ on ~t Wate~ S~le Colle~ed By ~ ~ ~ ~ ~ ; ~te . ~ Wate~ S~le ~st ~sults ~I~TO~V B. SEPTIC/HOLDING TANK DATA Date Installed /~7~ , Size /~9QO~ NO. of C~'~3a~tn~nts / Standpipes (Y/N) ~ Ain-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Dap~ession over Tank (Y/N) ~/ Date Last Pun~ed ~ Pumping/Maintenance Contract on File (Y/N) /~ ; fop Holding Tank High-Water ~a~ .(.Y/N) ~ Teapota~' Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: To Water-Supply Well .~2~/ i/~ . TO Building Foundation. .~ ~ / To P~operty Line /07~ To Dispc~al Field ?~ / To Water Main/senvice Line 4~./~ _ To St~e~m, Pond, Lake~ c~ Major D~ainage [Page ! of 2] 2~15-84 C. ABSORPTION FIELD DATA Soils P~ting in Absorption Strata Date Installed width of Field Square Feet of Absorption Amea Depression over Field (Y/N) Results of Last Adequacy Test --- Type of System DesiGn Length of Field /~//¢= Depth of Field .~:- W~cHa-~ Gravel Bed Thickness /~/~ .~//~ . Standpipes P~esent (Y/N) Date of Last Adequacy Test ~,//~/~ Separation Distance f~om Absorption Field: To Wate=-Supply Well /~ow- To P~operty Line To Building Foundation ~ ~ ~ To Existing or Abandoned System cn Lot ~/~ ; On Adjoining Lots To Water Main/Service Line //~- To Cutbank(if p~esent) To Stream/Pond/Lake/or Majo= D~ainage Course To D~iveway, Parking A~ea, or Vehicle Storage Area Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Dirge ns ions Manhole/Access (Y/N) "P~ Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA ** Check Permitted Bed~oc~ Rating A~ainst HAA Request I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date of this inspection. Company ~-~5~ ~,~z)f;I' /~CS MOA NO. 2-15-84 Location: BESSE, EPPS & PO~S 2220 EAST 88 AVENUE ANCHORAGE, AK 99507 (907) 349-645~ WATER ~ELL TEST subdivision: Lot: Block: Client's Name: Address: Tester: Initial Reading c~1 Meter: -~-/ ,~ ~ Production Rate: ~-- GPM 24--Hour Capacity ~-- C~llons