HomeMy WebLinkAboutPENNINGTON PARK BLK 1 LT 6A Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Name: ~pgrade ~ ~. ~~ ~~ Wastewater System: ~ New Address: t~~ ~~~~ ~ ABSORPTION FIELD P ~__~ ~ No. of Bedrooms:  ~eep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from original grade:  Subdivision: ~ Depth to pipe bottom from original grade: / Gravel depth beneath pipe Township: ~ Range: Section: Fill added above original grade:~l Gravel length: WELL; ~ New ~ Upgrade Gravel~ ~~~( Numb~r°f lines: Ft. Ft. ion (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:~ ~ t/~~ Ft. Ft. I ~ SQ, Ft. Driller: Date Drilled: Static Water Level:Ft..~~lnstaller: ~~~ Date installedL Yield: ~ Pump Set at: Casing Height Above Ground: GPM Ft. Ft. TANK SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ublic/Private Manufacturer: _ Capacity i~~ From Tank Field Station Tank Sewer Lines ~~¢ Weld ~1 ~j~l ~ ~ ~ Material~~ Number of~rtments: Surface Water I~O'+ i~ ~ -- ~ LIFT STATION Line ~/ I ~ / ~ ~ ~ Size in gallons: Manufacturer: Foundation ~ I ~/ -- __ ~ "Pump on" level at: I "Pum~el at: High water alarm at: CurtainDrain ~ ~,~ ~ ~ ~ Pump Make & Model } Electri~lnspections performed by: Remarks: ~t~l~ ~t~~~ BENCH MARK Location and Description: Department of He~ and Human Services approval 72-013 (1/91)MOA 25 Permit No. ,~V~ ~) ~- O0 ~ ~ Page "~ of ~' Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report --__. J ,EAL 72-013 A (2/91) MOA 25 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920022 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:PISA STEPHEN G & THERESA OWNER ADDRESS:17300 MARIJANE ST ANCHORAGE, ALASKA 99516 DATE ISSUED: 3/02/92 EXPIRATION DATE: 3/02/93 PARCEL ID:02018157 LEGAL DESCRIPTION: PENNINGTON PARK BLK A 1 LT 6 LOT SIZE: 46075 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: -,--,~, ISSUED BY: ~ / HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ROBERT SHAFER, P.E. ROGER SHAFER, P.E. February 25, 1992 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, Alaska 99501 REFERENCE: Pennington Park Subdivision, Block 1, Lot 6A Request you issue a permit to upgrade the septic system serving the referenced property. An adequacy test was performed on the existing system and the absorption capacity of the existing trench was found to be inadequate. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The ground water monitoring tube within the hole has been checked and found to be dry. Attached is an upgrade design which shows the location of the proposed trench. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic upgrade. If you have any questions or require additional information for your review, please contact us. Sincerely, ROGER J. RJS/lsu 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE UPGRADE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST SLOPE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p Deplh to Wa.~tar. TA~., / Monilorino? _C,,"'.,~---7 SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop I ~l~,~/e~- +.~ ----~>" --- ~/ ~' ~.- ~ ~ ~/~' ~/~ ,, ~ ~ ~ ,, U '/~' ~1~" ~agie River, Alaska 995~ ¥ ~ v ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON HIS DATE. 72-008 (Rev. 4/85) PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER ~-~ # -CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: GRE,~,ER ANCHORAGE AREA BOk Department of Environment81 Quelity 3330 C Street Anchorage, Alaska ggs03 JGH ~SPECTI_ON REPORT ON-SITE SEWAGE DISI~SAIj SYSTEM · SEPTIC TANK: DISTANCE /~'-'~ ~' FRO~ WEU~ ~^NUF^CTURER INSIDE LENGTH ~ INSIDE WIDTH '--- -. LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPAC ITY/~) GALLONS. TILE DRAIN FIELD: ,,_, /~ TOTAL LENGTt4..~ ~-.-_ [ ~ W,OT~/~ ABSORPTION ARE* DEPTH: TOP OF TILE TO FINISH GRADE FT. LENGTH OF EACH LINE DEPTH OF FILTER ' TYPE'S_ eil t~ CONSTRUCTION IN. DEPTH DISTANCE FROM: BUILDING NEAREST N~AREST SEPTIC SEEPAGE FOUNDATION__ LOT LINE__,, SEWER LINE TANK SYSTEM CESSPOOL OTHER SOURCES APPROVED__ DISAPPROVED REMARKS DISTANCES: _,',qF INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: ~ t ~..~)~ ,, . Form EQ-032 PERM I l' WI]. i',"! El I'-.I I [: I F' FI L_ I l" '~.' CI F- fsi I'-.I C: Fi El F..'.'. ~ ~]]~ FZ [:,EF'~RTMEN'T OF HEALTH ~N[:, EN',,,'IRONMENT~L F'ROTECTION 251Et E. TIJ[:,OR RI:,.., ~NCHOR~GE., ~K. 9~5Ei7 27'6-222t ('763:~8) AF'PL I CANT L O C A T I O N LEGAL =, TE,., E PISA MARI,IHNE ST L6 Bi PENN INGTON F'K 8]~20 EL[.EFi..E, EF..RY ST LOT :., I ,.'E 4~'~.'.1,".:, -':,U JHEE FEET 'I'YPE OF '=;OIL ABSORBTION SYSTEM IS' TRENCH MR::.::IMLIM NUI',IE:ER OF BEDROOMS SOIL RHTIN_~ ,'qQ FT,--'BR)= :1..,=: .... 't"HE REL:.!LiIRE[:, SIZE OF THE SOIL ABSORPTION SYSTEM IS' [:, lEE F' T H = ~'; L E I%! mZi 'T' H = 4 ":-', ~3 !:;: !~ ",,-" E L [:, IrE F' T' H == -:~ THE LENGTH DIMENSION IS THE LENGTH ,:i IN FEET) OF THE TRENCH OR [)RRINF'IELD. THE DEPTH OF R 'TRENCH OF.: PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE GROUND AND THE BOTTOM OF THE E:-qCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL [:,EF"TH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OI..ITFRL. L PIPE AN[) THE 80TTOM OF THE EXCAVATION (IN FEET). Ill E ~]:! LI I Fi: E [:, SEC F' T I C: 'r R I'-,! I-::: S I Z E: = :1_ ~:Z~ i:_'E1 ~.:.'i Ci R L... k,. C, f'-,~ D~; BACKFILLING OF ANY =,~:=.TEfl WITHOUT FINRL INSPECT ION RND RFFR_., HL BY TH tS '-- ' -' "'1'~"- F,' I . [:,EF'RR1-MENT WILL E:E =,UE, JEL. T TO FF.'.CL-,ECLTION. MINIMUM DISTt~NCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS; &E~O FEET FOR R PR I',/ATE WELL OR 200 FEET FOR R PUBLIC WELL.. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT HITHIN 3:0 DAYS OF' THE WELL. COMPLETION. SPECIFICR'TIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE ~0 INSURE PROPER I NSTALLA'T I ON. I CERTIF'Y' THAT ±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS F4S SE'l" FORTH B'¢ THE MUNICIPALIT'¢ OF ANCHORAGE. 2: I WILL. INSTALL THE SYSTEM IN ACCORDANCE WITH THE CO[:,E'.'-3. 3:: I UNDERSTRN[:, THAT THE ON--SITE S~ER SYSTEM MAY REQUIRE RES i[:,ENE:E IS; REMODEI..E[:, T~~]D.~f~:E THAN ~: E:EDROOMS. S I GNED: RPPL I CANT STEVE P ISR ...... ...... ENLAR[~EME. N] IF THE GREATER ANCHORAGE AREA BOROUC" Department of Environmental Qu, ,ty 3330 "C" Street Anchorage, Alaska 99503 _ , :) SOILS LO(, t EROLA1 ION FES 1 Performed for' ..>~L<., ~, ~ \ (' ,~ Legal Description: [ ..r (~ P3~('l ~ ,x~,~,~.,. F ~ '-- ~ ~, ' ---r , /n~s form reports: Soils' log_~ .... '~. ' Percolation test Depth Feet 1 -<.;._1,5- 10- 11 - 12 13- 14- Was ground water encountered? If yes, at what depth? Reading Date Gross Time Net Time Percolation rate mi nute. Depth to Water Net Drop 'Proposed installat~=-*-6'n¥'-~if]a.--qe Pit Drain Field ',.)epth of Inlet . Dept}~--t¥-~b~-'-O¥-i)it or t~ench COHHEIITS' L ~]:: ...... : ]~ ...... . L~ ~ ~-x ~,:~ ,'~ ~o ,~.v~~4 ~¥'--¥¥"~ Performed gy:(~ c;",:~-~x ~ ~(----x.,.. Certified By~i --~k~x, ,'D r-x.~.-. DaLe: ]]OX ~!}~(~9, ~?AR ]~OU?E A ANCltORAGE~ ALASI~A SIX INCH WATER WELL DRILLED aND CASED OUT TO THE DEPTH OF DRILLED at THE RATE Of $17.00 Per FOOT. PROPErtY OWNEr ~. ~lt®~ LOCATION OF WELL SITE Lt. ~ ]~lk~ ~ ~d~l ~6~II~iN~FO~/ DRILLER ~Le Claus of WELL LOG: O----ZS' Sand7 ela~ with 15~ gravel. 25---49' Gravel with 20% ela~ binds. Several swmll boulders. 180 fea~; ~---51 ' Sa~ly gravel shewing sm aiga~ ef water. Very small amount. 80--1.~' Sedime~tar~ bed~eck,· Very weak signs ef water en top of bedr~k at 80 feet, XS~-XSO' Sedimeata~ reek with seae signs of wet ~rou~ reck frea X?O te 1.73. This well should pttup 2,5 GPM and lmp~ovo to at least 305 GPH ~000 gallons in a 2~ hour time frame, Water standing within ~0 feet of su~faee. FUroR should be installed 1.0 feet off bettea. COST INCLUDES' ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLINg. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF DATE $30~0.00 THANK YOU VERY MUCH. SERVICE CHARGEOF ~% PER M 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 DWELLING Parcel I.D. # O -- I - 5 1. GENERAL INFORMATION Complete legal description Location (site address or directions) ' Pro~Perty owner Mailing address Day phone '~ ¥~-- of 2_. ~' Lending agency Day phone Mailing address Agent '~,q~l~,c~.~ I- rt Address 02 Itl t', ~ ,, ~ Unless otherwise requested, HAA will be held for pickup. ¢._ 2. NUMBER OF BEDROOMS: :~'-- '~ rtl c- 3. TYPE OF WATER SUPPLY: rtl,..., ~ Individual well rm ,..,-, : -'- Community well ~ Public water -Day phone NOTE: 4. TYPE OF WASTEWATER DISPOSAL: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. · . Individual on-site Holding tank Community on-site ',, Public sewer If community wastewater system, provide wri~en confirmation from State ADEC a~esting to the legality and status of system. NOTE: 72-025 (Rev. 1/91) Front MOA~21 Se 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 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. DHHS SIGNATURE · , ~ Approved for 3 DisapprOved. Conditional approval for bedrooms. bedrooms, with the following stipulatiOns: 'Additional Comments ~ .:, be Man~c~.,ahty of ?.~R'ch?age Department of Health and Human Services (DHHS) issues Health Author' 'A' ..... '- ,ty · pproval Cerbflca,te~.§a~ed only upon the representations given in paragraph 5 above b an ~nd '. , ,' ,~" ,,. Y ' ependent profess~o,nal engmee¢ registered in the State of Alaska. The DHHS does this as a courtes t a ..... ,.'~,n _. ~,.~,, ..., ....... Y o purchasers of homes nd ~e~rlenamg restItutions m oroer 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 p.rofessional engineer's work. 72-025(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: j, OT ~/~: .'~,,.~ Parcel I.D. A. Well Data -~--bi,~'[-o[,,t 'P,~ Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) '"'l Date completed 7/0/'7 ¢o Driller ~ A ~/PA ~ '¥- Total depth I ~.~ Cased to ~ Casing height j c~'l Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y' FROM WELL LOG AT INSPECTION Date of test ~7/0/ ? ~ ~//~'~/~ ~ ;;~ Static water level ~,~ ~ ~ ~7 I'1'1 Well flow c~, ~'' g.p.m. /o > g.p.m.l-rl~ Pump level1 ~o /~ ~ ~o '~d "~ SEPARATION DISTANCES FROM WELL TO: I;~ Septic/holding tank on lot i(9 ~ Absorption field on lot ( I ~ Public sewer main ; On adjacent lots ; On adjacent lots 125 Sewer service line Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESETS: Coliform Date of sample: ~/iq / ~'" B. SEPTIC/HOLDING TANK DATA Date installed ~, '(~ , ~,~.- Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate ~_~ ,~ V~. 1//~' Other bacteria Collected by: Tank size //~ ~cO Compartments Foundation cleanout (Y/N) / Depression (Y/N) H/~r Alarm tested (Y/N) /'{///--~- 7/7./~] ~' Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots ~ 051 Foundation '3~) Absorption field ~.4 Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~-~ · ~ ~ Length 7.~ Width Soil rating (GPD/FF) ~)./'/ Gravel thickness System type Total depth //, ~- Total absorption area !/b ~ Cleanout present (Y/N) Date of adequacy test ~ ~/~ ~" Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Depression over field (Y/N) /"'/ for ~'~ Bedrooms After test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot II -7¢ ' To building foundation ~,~ I On adjacent lots ~ '5,1D Surface water N[IO Curtain drain 1~ (~) i On adjacent lots IO,..~ Property line To existing or abandoned system on lot Cutbank N 0 ~ ~- Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec, t on the date of this inspection. Engineer's Name Date HAA Fee $ ~-dJ~. ~ Date of Payment ~-,~/,,/~ ~< '"-'- Receipt Number / D.~.~,.//".,~,~-') Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back zTL CT&E Ref.~ Matrix Client Sample ID CT&E Environmental Services Inc. Laboratory Division ~"~'~'~J'~'~l~r~-~r~'f~'~'~'~'~'~r~'~-~-N~jfjffj~ff~jfff~~ 95.2 0-1 Laboratory Analysis Report WATER L6 BLK1 PENI~INGTON PARK Client Name TOBBEN SPURICLAlqD, P.E. WORK Order 15606 Ordered By Printed Date 06/22/95 @ 15:52 hrs. Project Name Collected Date 06/19/95 @ 13:20 hrs. Project# Received Date 06/19/95 · 15:10 hrs. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: SAMPLE COLLECTED BY: LANS SPuRKLAND. Qc Allowable Ext, Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 2.53 D m~/L EPA 353.2 10. 06/21/95 * See Specxal Instructions Above =UA Unavallable %~ See Sample Remarks Above NA = Not Analyzed ~i = Undetected, Reported value is the practical quantification limit. LT = Less Than ~= Secondary dilution. GT = Greater Than 200 W. Potter Drive, Anchorage, AK 99518-1605 -- Teh (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS. MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA 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 DWELLING Parcel I.D. # 02018157 1. GENERAL INFORMATION Complete legal description Lot 6A; Block I; Pennin.qton Park Subdivision Location (site address or directions)/7500 Marija~e_Str6et Property owner Mailing address Teri Pisa 17300 Marijane St., Anchorage, Day phone Alaska 99516 279-7611 Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well X× Community well Public water NOTE: 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 Public sewer NOTE: XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status ¢f system. 72-025 (Rev, 1/91) Front MOA #21 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 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 Address S & $ ENGINEERING 17034 Eagle River Loop Road No. Phone Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE .~ Approved for ..~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional comments 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:'~_~k-[~."l I~L4"["~::~I,,./'-~::~"~.~.~'" - Parcel I.D. A. WELL DATA ~ Well ty~~~ If A, B, or C, attach ADEC letter. ADEC water system number Log present(~4) Total depth Sanitary seal (Y/N) Date completed ~ - I ~ - ~ ~ Driller"~,C-t~-~ Cased to-'~'~::) "~~asing height ! ~-' '+' Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot J ~::) / Absorption field on lot Public sewer main AT INSPECTION MUNICIPALITY OF ANCHORAGE ~ I ENVIRONMENTAL SERVICES DIVISION Sewer service line ; On adjacent lots RECEIVED ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform d Nitrate ! Date of sample: ~' "~- ~ ~- Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed '~ '(-~ -~J' '~-- Tank size Cleanout~l~) '~ High water alarm (Y/N) Date of pumping I,J~ Foundation cleanou (~N) "(/' ,~ Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot lz~ / To property line ¢DO Surface water/drainage On adjacent lots Absorption field Compartments Depression Foundation 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 electrical ~N) SEPARATION DI~CE FROM LIFT STATION TO: Well on ~ On adjacent lots ~°le/Access (,,Y/N) "Pump on" level..a.t/ ' Pump off" level at J Cycles tested Surface water D. ABSORPTION FIELD DATA Soil rating Date installed Length ~ ::::~' Width Total absorption area J l (~::~ Depression over field (Y~ ,~ Results (pass/fail) Peroxide treatment (past 12 months) (/~ Gravel thickness Cleanouts prese~N) Date of adequacy test, for "~ If yes, give date bedrooms Curtain drain Property line To existing or abandoned system on lot J('J ~ ~J ~'~ Water main/service line SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots I ~'~' / To building foundation '~--~ / On adjacent lots ,,~.~ t..~ Cutbank Surface water !~j ~--Jc- Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this insP~tion. S & S ENGINEERING Signature 17034 Eagle River Loop Road No. 2C1~4 Iblslle River, Alaska 99577 Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment ///~ 75~') Receipt Number 72-026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS RESULTS for INVOICE # 50935 Chemlab Ref.# 92.0474 Sample % 1 Matrix: WATER Client Sample ID : L6A BLI PENNINGTON PARK SD. PWSID : UA Collected : FEB $ 92 @ 17:00 hrs. Received : FEB 6 92 ~ 15:15 hrs. Preeerved with : AS REQUIRED Client Name :S & S ENGINEERING Client Acer :SNSENGP BPO! : Req{ : Ordered By :R. SNAFER POW :NONE RECEIVED Analysis Completed : FEB 7 92 Laboratory Sup~vl~or : STEPHEN C. EDE Released By :~-~ ~_~ ~ Send Reports to: i)S & S ENGINEERING Parameter Results Units Method Allowable Limits NITRATE-N 3.0 .~/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: J.W. Remarke: 1 Tests Performed ' See Special Instructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above NA- Not Analyzed LT-Less Than, GT-Greater Than ~-~SGS Member of the SGS Group (Soc,¢t(~ GOn(~rale de Surveillance) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONmeNTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date_January 3l, 1985 (a) Legal Description (include lot, block, subdivision, section, township, range) _Lot ~, Block 1~ Pennin~ton Park Location (address or directions) 17003 Marijane Street (b) Applicants Name Steve Pisa Applicants Address 17003 Marijane Street 345-1901 Telephone - Home Business N/A (c) Applicant is (check one) Lending Institution .~ ; Owner/builder [~ ; Buyer ~ ; Other ~-~ (explain); (d) Lending'Institution Address ~:~.~/4 ~ (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the following address: 2. Type of Residence Single-Famiiy~ NUmber of Bedrooms 3. Water Supply Individual Well~[ Multi-Family~-~ Two Other (describe) 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] Engineering Firm Providin~ 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 A. W. i4urfitt Company Telephone 349- 7531 Address 17003 Mari~ane Street Date January 31, 1985 DHEP Approval Approved for bedrooms Approved ~_~ Disapproved -- Conditional ~ Terms~. of. Con,d~it ion,al_ Approval., ~O/b'/'~L~. ~ ~O~z'~ '~ ~ ~+~~ ,, ~~ .~/~'~ 1'~ CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF EEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSb~S 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 COL~TESY 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 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUI~O~TY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: Pennin§t0n Park MUNICiPALiTY OF AN(~HORAGE DEPT. OF HEALTH & Ej'.IV~RONMi~NTAL I'¥.C, i'LCFION 1985 RECEIVED Lot 6, Block I, Well Classification Single Famil.y Well Log P~esent .!Y/N) Yes Total Depth ] 80 ft.. Cased to Static Water Level 50 ft. Casing Height Above Ground Electrical Wiring in Conduit (Y/N)Yes Separation Distan~s f~ Well: To Septic/Holding Tank on Lot ] 05 feet To Nearest Edge of Absorption Field on Lot 2 ft. (pum~house) If A, B, c~ C, D.E.C. App~oved.(.Y/N) N/A Date Cc~le~d ..J. uly 10, 1976 Yield 3.5 .qal/mi ]80 feet ~ Depth of G~outing unknown Pump Set At ] 70 feet Sanitary Seal on Casing (Y/N)Yes Depression A~ound Wellhead (Y/N)No ; On Adjoining Lots 183~e~ ] ]0 feet; On Adjoining Lots~%q 50 feet To Nea~estPublicSe~= Line N/A To Nea~estPublic Se~r Cleanout/Manhole N/A To Nea~est Se~r Service Line on Lot Wate~ Sample Collected By Allan W. Mu~f~tt ; Date 01/27/85 Water Sample Test Rssults Satisfactoqy Cc~nts varJance ~ranted for adjoJnin§ well/septic distance. N/A B..SEPTIC/HOLDING TANK DATA Date Installed 6/76 Size 1000 ~al. No. of Cc~pa~nts 2 Standpipes (y/N) Yes Air-tight Caps (Y/N) Yes Foundation Cleanout !Y/N)Yes Depression ove~ Tank (Y/N) NO Date Last Pumped 1-24-85 Pumping/Maintenanc~ Contract on File (Y/N) No ; fo~ N/A Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N)N/A Separation Distances f~cm Septic/Holding Tank: To Water-Supply Well IQ5 fee~ To Building Foundation 45 feet To P~oper~y Line 20 feet To Disposal Field l0 feet To Water Main/Se~vic~ Line N/A To St~e~, Pond, Lake, c~ Major D~ainage Course Comments [Page 1 of 2] 2-15-84 Co ABSO~ICXN FIELD DATA Attached as per Permit No 76338 Soils Rating in Absorption Strata ___~~Type of System Design Trench Length of Field 50 feet Date Installed Width of Field 6/76 3 feet Depth of Field 6.5 feet Gravel Bed Thick~ess 4 feet Square Feet of Absorption A~ea 375 feet Standpipes P~esent (y/N)Yes Depression ove~ Field (Y/N) No Date of Last Adequacy Test 0]/27/.85 Results of Last ~equac~ Test Satisfactory Separation Distanc~ f~cm Absc~ption Field: To Water-Supply W~ll 100+ feet To P~operty Line ~O+ f.~et ... To Building Foundation 60+ feet To Existing or Abandoned System cn Lot N/A ; On Adjoining Lots 83 feet To Water Main/Service Line N/A To Cutbank(i~ P~esent) To St~eam/Pond/Lake/c~ Major D~ain~ge Course N/A To D~iveway, Pa~king. A~ea, c~ Vehicle Sto~age A~eal0 ft. drive across (insulated) Ccmmments 300 gals water introduced to system, no water level change at time of test. D. LIFT STATION N/A Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Date Installed Size in Gallons "Pump On" Level at High Water Alarm LeveI at Tested for Electrical Codes(Y/N) ' - Ccm~rents .... ** Check Pe~itted Bed~oc~ Rating Against HAA Request I certify that I have checked, %~rified, c~ conformed to all MOA HAA Guidelines in effect , Company A. W. Murfitt Compan7 MOA No. ST84-015 ":' , ' [Page 2 of 2] 2-15-84 LE FAMILY-' E FOUR