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HomeMy WebLinkAboutPETERS CREEK BLK 3 LT 17Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211182 PID Number: 051-115-17 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑✓ Upgrade Name Theresa Cross A ORPTION FIELD ❑ D Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 23334 Glenn Court Other Phone Number of Bedrooms Soil RatingTotal depth from original grade 3Ns-oqo/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original a Gravel depth beneath pipe Ft Subdivision Block Lot Peters Creek 3 17 Fill added above original grade Gr I length Ft. Ft, Township Range Section Gravel width Ft. Beds: Number of Lines DistFINe between lines Ft. SEPARATION DISTANCES To Septic Absorption it Holding Sewer Total absorption area Number of trenches Dist. between t hes From Tank Lift Station Field i Tank I Line Ft2 Well 100+ ( i TANK © Septic ElS.T.E.P. EJ Holding E] Other Manufacturer Greer Capacity 1000 Gal. Surface Water 1009+ Material Plastic Number of compartments 2 Lot Line 5'+ 3 NA Foundation 101+rff5�n%JATION Manufacturer Capacity i Remarks Field verified 5'+ tank to porch foundation. Gal. Field Verified 5'+ tank to absorption field. Alam, location Electric ' coed by Installer PIPE MATERIAL House to tankTank to D3034 drainfield D3034 Dakota Diggers Drainfield CO/MT D3034 Inspector Arcterra Consulting BENCH MARK (Assumed elevation) 100 ft Inspection1� dates: 8/18/21 d 8/18/21 2° Location and description 3i° 8/24/21 4th Roof Corner ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp vws "I, U111414 F Conditional Approval: Datea�A.'"'"""""*®� AV � Y49 IH . Septic System Approved Date �s KENNETH M. bu' S Vitra cE 116' a Note: this approval does not include well permit requirements. 4Rt ItilESS\ (Rev 05/02118) AS—BUILT SYSTEM DETAILS/SITE PLAN Permit ❑SP211182 PETERS CREEK BLOCK 3 LOT 17 PID# 051-115-17 GRAVEL DRIVEWAY. I ' Lot 16 WOODEN FENCE A -C=16.8' B -C=28.1' 1 STORY A -D=18.0' RESIDENCE y B -D=28.3' w o A -E=19.6' 0 B -E=28.6' O NEW "00 ( A -F=23.4' GAL TANK A B -F=29.9' o A-15=24.9' B -G=32.6' A -H=25.3' B -H=34.0' O O 0 to (� SHED En SCALE+ NTS CANT O 1 STORY o RESIDENCE O Lo w Fra DECK evt O 0 O NEW "00 ( b O GAL TANK QF AL Apr 1QS PREPARED FOR: THERESA CROSS {� 23334 GLENN COURT *.-'49 TH yfr CHUGIAK, AK 99567 M: D S. FIELD BOOKS COMPUTE»: CE 7iSG wI BOUNDARY: N A DRAWN: iCSD , X. p 1 sTAaNc N A aieacm: KMD •L.`J. .i' ASBUILT: LANG DATE '' SSIti� DWG. FILE: GRID: Nw13E ACAD PILE FILE " No' 21022 Lot 18 FENCE SCALEI 1' = 30' SCALEI NTS I Lot 3 I a I Lot 2 Lot 1 M GLENN CT. N 90'00'00"E 70.00' GRAVEL DRIVEWAY.,• . 3.6'x6.8' i PORCH 2.0'x23.1' iCANT • ` •:: � 16.6' of o: N 1 STORY r I N RESIDENCE Lot 16 01 12.7' 40.2' C'` SEPTIC DECK C' I PIPES \ 8.3'x8.2' WOODEN FENCE f -MANHOLE SEPTIC PIPES �Lot 17 10,500 S.F. I 8.1'x12.1' SHED N 90'00'001E 70 00' ,n MR. IV) 2.0'x6.8' CANT WOODEN FENCE I hereby certify that I have surveyed the following described property: LOT 17, BLOCK 3, PETERS CREEK SUBDIVISION (PLAT No. P-479) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the 1�_ Day of :fit'"�1���2 at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. �49!H-"*. .d ............................. -.....I�ENNEbFH �.'rLANG/}�. o IIS— 20 5Jd 440R����SSIONAI- �� AECC963 I � I NOTE: THE LOT IS SERVED BY A Lot 3 i Lot 2 i Lot 1 COMMUNITY WATER SYSTEM. PLOT PLAN —_— I AS BUILT _X_ SCALE _ 1 __= 30__ I GRID _ NW 1360Project No. 21-610/ R1 �1 Lang & � S S d C i a t e S inc. Associates, 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 (907) 522-6476 Phone H Professional Land Surveyors (907) 522-4625 Fax ken0langsurvey.com Jonathan®langsurvey.com �4c4g000��4 v OF .A L �� x_11 �S4p0 I hereby certify that I have surveyed the following described property: LOT 17, BLOCK 3, PETERS CREEK SUBDIVISION (PLAT No. P-479) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the 1�_ Day of :fit'"�1���2 at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. �49!H-"*. .d ............................. -.....I�ENNEbFH �.'rLANG/}�. o IIS— 20 5Jd 440R����SSIONAI- �� AECC963 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: OSP211182 Work Type: SepticTank Upgrade Tax Code Number: 05111517000 Site Legal Address: PETERS CREEK BLK 3 LT 17 G:1360 Site Mailing Address: 23334 GLENN CT, Chugiak Owner: CROSS THERESA M Design Engineer: ARC TERRA CONSULTING INC This permit is for the construction of: Effective Date Expiration Date: t�" n t "?.5;. Gk �in fi f Department Lot Size in Sq Ft: Total Bedrooms: 6/2/2021 6/2/2022 10500 ❑ 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 Special Provisions: Locate the beginning of the field to confirmthat the 5' separation between the tank and field will be met. Received By: Issued By: Date: Date: 6—AZ 3 MUMCIPALITY OF ANCHORAGE a ,` ­ Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-115-17 Property owner(s) Theresa Cross Day phone Mailing address 23334 Glenn Court Chugiak, AK 99567 Site address 23334 Glenn Court Chugiak, AK 99567 Legal description (Sub'd., Block & Lot) Peters Creek Block 3 Lot 17 Legal description (Township, Range & Section) Lot Size 10,500 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) (w/wo AD U) Septic Tank 0 Upgrade 0 (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: $-Z Waiver Fees: Date of Payment: Jr- a 8 0�2 1 Date of Payment: Receipt Number: o 8 g 501,G Receipt Number: Permit No. _0SP21 1 )'62— 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 OSP211182, Deb Wockenfuss, 06/02/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211182, Deb Wockenfuss, 06/02/21  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME [PHONE /42 [] U, ,ADE MAILING ADDRESS ~0( ~ ~ ? ~ C ~ J LOCATION NO. OF BEDROOMS ] Well ~ AbsorPtion area DISTANCE T~ /~' i~ ~'~ ~ ~ ~ Manufacturer Mater ~o. of compartmenm O ~ ~ Manufacturer Material kiquid capacit~ in ~allons ~ ~ell ~ ~ Foundation I~ ~earest lot line ~E~MIT ~O. ~ ~ DISTANCE TO:/ 7 /0-- /O I ~~ Z [~ -- No. of lines~_ 0 Length of each line T~.~cnGth ;f ',:,%;;- T~c~ch width ~ Distance be ~ ~ ~ t~l /~ I '/~,~ ~nch~~en lines ~ ~ Top of tile t~inish grade /~ Material beneath tile ~ Total effective absorption area Q ~~ inches Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line m DISTANCE TO: ~ Classy. ~ ~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER ~, PIPE ~ATERIALS SOIL TEST RATING . o AP~~~ DATE LEGAL 72-013 (Rev. ~ ) Permit ~ Applicant: Location: Legal Description: ~?~7 ~ Type of Soil Absorption System Is: Trench: Drainfield: M_UNICIPALITY Of ANCHORAGF ,~; 0~r ~. Departmen ~f Health and Environment '~rotectio~ 825 L Street, ~chorage, A~ 995~k WELL ON-SITE SEWER Phone Nu~er: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: .~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH LENGTH GRAVEL DEPTH · u~a~ WIDTH ~, The length dimension is the length(in feet) of t~e tre~or draznfzeld. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departme will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fe for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER ~1, ! 9 ~ 3' * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I--.u~derstand that the on-site sewer system may require enlargement if /the residence i~ re~~%to include more that 3 be~ooms. S igne~: ~-~/~/~/~ ~. ~< ~~~~/ Is sued by: ~ ~/~ / Appl ~Gant / ~- ,,~ ~ SWP/024 (1/$1) Municipality of Anchorage e On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-115-17 1. GENERAL INFORMATION Expiration Date: �- / ` - 2 bZ - Complete legal description Peters Creek Block 3 Lot 17_____ Location (site address) 23334 Glenn Court, Chugiak,. AK 99567 Current Property owner(s) Theresa Cross Mailing address Real Estate Agent 23334 Glenn Court, Chugiak AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone Day phone 3. NUMBER OF BEDROOMS: 3 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ❑ Holding Tank ❑ Individual Water Storage ❑ Community ❑ Community Class _ Well ❑ Public Sewer ❑ Public Water System M Waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $_ 550 Waiver Fee $ Date of Payment _ o a U A a Date of Payment Receipt Number (0a G Receipt Number COSA # CS Z 1 "A'10 a'10 Waiver # 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 ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN_ BLVD., EAGLE RIVER, AK99577 Engineer's Printed Name KENNETH M. DUFFUS Date LftD 2i 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 Uii' encroachments, deficiencies or discrepancies exist. 6. DS SIGNATURE ` System #1 Approved for KENNET17111610, L rr bedrooms. !�!' �U`• System #2 Approved for bedrooms. \ rp Disapproved. Conditional approval for bedrooms, with the following stipulations: G \ s4cuo,, i tlA, bo,�_ ave -- /�°s - ---- - -- -H3i - i:LSVM o� P o�1. i wl-ee� uJ (INV 2i31dM - 311S -NO �t'c 511 �11)1)))llllll ll� Original Certificate Date: 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory _ Other COSA blue sheet -10-10-12 doc rA- Legal Description: Peters Creek Block 3 Lot 17 Parcel ID: 051-115-17 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA FWall log is filed with Onsite (or attached) Date drille Total depth Cased to ft "\ ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments B. TANK DATA Age of tank(s) 0 years Tank type/material Septic/Plastic Measured operating fluid level in septic tank 49" Standpipes/foundation cleanout per record drawing Date of pumping New Install 8/18/21 D. ABSORPTION FIELD DATA Which system tested (date installed) 5/10/83 ALL standpipes present per record drawing Total measured depth from grade 3.5 ft (max) Measured depth to pipe invert from grade " ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) enic ug/L ❑ Arsenic less than MRL (ND) Collected Date of Sample C. LIFT STATION ired maintenance completed Age of lift sta i years Lift station material Comments: Adequacy test date 4/14/21 Results Q Pass For 3 bedrooms Fluid depth prior to test 3.5 in Water added 450 gal New depth 3.5 in Elapsed time 1 min 11 Code -required soil cover over field Final fluid depth 3.5 in ❑ System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) _ date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: "During 8/18/21 tank installation excavated end of field, verified 6" ED COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Scptis Sink/Lift Station on Lot >100' ® Yes Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No ft Neighboring Tank > 100' if No ft Private Sewer/Septic Line > 25'D Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' ® Yes Animal Con t > 50' ❑ Yes if No ft ❑ Yes if No ft ® Yes if No ft Water Main > 10' ® Yes Manure/Animal Excreta Storage_ 48Q' Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes i 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' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® 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' 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' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 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 | | | . � Lot 2 Lot 1 � | � | _L____________L_____ 7' 16.6' " —2.0'x6.8' CANT LVA WOODEN FENCE .`. | | NOTE THE LOT IS SERVED BY A Lot 3 ' Lot 2 ' Lot 1 COMMUNITY NATER SYSTEM. | | 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone (907) 522-4625 Fax Professional Land Surveyors ken*longsurvey.com OFA� � | hereby certify that I have surveyed the following described property: LOT 17, BLOCK 3, PETERS CREEK SUBDIVISION (PLAT No. P-479) Anchorage Recording=District,Alaska,and that the improvements situated thereon are within the property xnam and do not encroach onto the property adjacent thereto, that no improvements on the property |\4nQ adjacent thany|u encroach on the surveyed premises and that there are no roadways, transmission Unon or other visible eouamnanio on sold property oxoap| as Indicated hereon. ~� Dated this the __61 __ Day of . _I�/��_. at Anchorage, /Wosko U is the responsibility of the owner to determine the existence of any ments, covenants, or restrictions which do not appear on the recorded subdivision plot. 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BLOCK: J QQ9 DOMESTIC ONLY ❑ BOTH FIRE & DOMESTIC CORP. STOP CURB STOP CTO C ❑ FIRE LINE ONLY ElFIRE HYDRANT ONLY FT. COPPER PIPE or 2" KEY BOX DATE OF TAP f Z Z BI A41 tJ C -d j d SIZE MAIN: le ❑ ALLEY ❑ STREET ❑ EASEMENT FT. THAW -WIRE TYPE MAIN:tnI-EXCAVATOR: _Z24W 1:�2AoP_4 iAt4 THAW-PLATE/NUT DISCONNECTS: ❑ YES ❑ NO SIZE OF DISCONNECT KEARNY CONNECTOR COMMENTS: OTHER: KEY BOX LOCATION: caeAf�e' O�m Mp,- E NORTH sT" ' 1� � f I [ S LOT: SIZE CONN ON TAPPING SLEEVE TAPPING VALVE X X MJ TEE M J VALVE FT D I PIPE 5" VALVE BOX COMPLETE TIE RODS EYE BOLTS '/." WASHERS t," NUTS TEST TAP MADE ❑ YES ❑ NO OTHER INSPECTION REPORT ❑ LINE BLOWN OUT I ❑ INSULATED ❑ K B & T.W - OK AFTER BACK -FILL ❑ OPEN BORE FLUSH ❑ 200 LB TEST % ❑ MAIN CHLORINATED ❑ CHLORINE FLUSHED ❑ OK TO TURN -ON ❑ DO NOT TURN -ON COMMENTS INSPECTOR-,ZDATE _ �D MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HI~ALTH & 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 1. GENERAL INFORMATION Complete legal description Lot 17~ Block 3; Peters Creek Subdivision Location (site address or directions) 23334 Glenn Court, Chugiak Property owner Mailing address Lending agency Mailing address Agent Address Michael Aragon & Marvella Snow ... 23334 Glenn Court, Chugiak, AK Day phone 99567 688-1035 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Three (3)~ Individual well Community well Public water ×XX 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 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: \,,,-o'~ \"~ ~.~--~ ~2~ ~,M-.--Parcel I.D. A. Well Data Well type ~'~ ~ ~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date completed Driller Date of test Cased to FROM WELL LOG Static water level Well flo~ Purn-'Fl~vell SEPARATION DISTANCES FROM WELL TO: Casing height Wires properly protected (Y/N) Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Date of s.ampfe~. .g.p.m. ; On adjacent lots "7..~,=, ,=. ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Cleanouts ~/N) ~ Foundation cleanout~N) High water alarm (Y~) ~ Date of pumping .I.~ ""~,\ _ c~ ,~. ~ ~ Compartments ~ Depression Alarm tested (Y/N) Pumper "~'~.¢--~ Well(s) on lot To property line I Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots ~' ~' Absorption field /o ~ Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) LOT 17; Block 3; Peters Creek Subdivision Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address AHFC Telephone'(home) Telephone Business 5~1-1qnfl (d) Real Estate Company and Agent ~v r,,u-r'r,- ¢,~m,~,,/ ,-r-r~,. w+~.: Address 109¢8 Eag£¢. RJu¢_~ Rnad~ Eag2~ R2u¢.~; 42~ 9q~77 Telephone 694-5500 (e) Mail the HAA to the following address: (or check here J~f hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle River Loop Road NO. 204 Eagle River~ Alaska 99577 2. TYPE OF RESIDENCE Number of bedrooms ~' $ Single-Family EX 3. WATER SUPPLY Individual Well [] Community [] Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~ 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. 72-025 (Rev. 7/88) Page 1 of 2 ,', Well Classification P~ ~l'; Well Log Present (Y/N) Total Depth__ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments .~. , 0, ,~, ' MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 :343-4744 Date Completed Depth of Grouting Legal Description: % If A, B, C, D.E.C. Approved (Y/N) __ Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ;Date B. SEPTIC/HOLDING TANK DATA Date Installed ~'-- 83 Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATIONDISTANCES FROM SEPTIC/HOLDING TANK: / O© O No. of Compartments ~ Air-tight Caps (Y/N) "/ Foundation Cleanout (Y/N) ~ /~ Date Last Pumped 3 - ~ © - ~ ;for - Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line I 0 ' To Water Main/Service Line. ! To Stream',. Pond,. Lake or Major Drainage Course Comments c.? To Building Foundation To Disposal Field / O0 ~ 72-026 (Rev, 7/88) Front Page 1 of 2 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING HAA # ~t'~ ~ O..~o~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 17; Block 3; Peters Creek Subd~vision Location (address or directions) (b) Property owner AHFC Mailing Address ,~ .~ ~ (c) Lending Institution Telephone'(home) Telephone Business Mailing Address (d) Real Estate Company and Agent JACK WHITE COMPANY/Kathi 01instead Address 10928 Eagle River Road, Eagle River, Alaska Telephone 694-5500 (e) Mail the HAA to the following address: (or check here,~2¢, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Number of bedrooms Single-Family,~ 3. WATER SUPPLY Individual Well [] Community [] Public,[Z Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-siteJ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev, 7/88) Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'~--"- ~ c~ ~'~ Width of Field ~ l r-h~:', ~L~-~'~ Square Feet of Absortion Area Depression over Field (Y/~ Results of Last Adequacy Test Type of System Design Length of Field ~ ~,~-~ Depth of Field ">-~,~ Gravel Bed Thickness (_.o,~- ~ Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foun~alion Lot "I~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments--"/~/<~ ~ '~ ~'~- To Property Line ~ !._._-F- To Existing or Abandoned System on ; On Adjoining Lots ~b ~ To Cutback (if present) "~ //~' D. LIFT STATION D~,,~ Installed Size~ns "Pump O n"'L"ev.~at High Water Alarm Leve~~~..~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Tested for Meets MOA Electrical Codes (Y/N) Comments Pumping Cycles during Adequacy Test. Signed Company Date MOA No. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the dat inspection. $ & $ ENGINEERING .... A C.gl,~ River Loop Road No. 204 Eagle River, Alaska 99577 Receipt No. Q~'~"-_m"~//~d¢2 Date of Payment Amount: $ Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 APPLIr ,NT FILLS OUT UPPER HA' ONLY Property Owner ~',~ ./~ y'/'~-/z~ C'~ Phone Buyer ~ Address Zip Code Lending Institution Phone Address Zip Code Realty Co, & Agent '~1 ,{,,~)/q ~[ '~' //~ ~.~',/;/,~. ~'~,,5~ ~,.,,/.~ ~..-/~,._~ Phone Address P 0 ~C~ ,.:,~..'/~</:~ ~/-/t_]~/,~:,./.~/ ://~///;~.~'/,~:..~ ZipCode ~:~.~"?.~7 / Type of Residence [~I~M u gle Family Itiple Family No. of Bedrooms [] Other Water Supply ~,,,,l~dividual ATTACH wELL LOG. A well log is required for all wells drilled since June 1975. I'1 Community For wells drilled prior to that date, give well depth (attach log If available). ~;/ [] Public Utility Sewer Disposal [~H11~vidual Year Individual Installed:. [] Public Utility ,~ When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date D ate~ Inspector Inspector Inspector Inspector Field Notes: ~"~ "Municlpality of Anchorage" "Dept. of Health & (~) APPROVED BEDROOMS.~b *CONDITIONS OF APPROVAL ( DISAPPROVED ( ) COND,T,ONAL APPROVAl' Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size ,-023 (3182) ~ MUNICIPALITY OF ANCHORAGE (MOA) (,'~_,1 Health Authority Approval (HAA) \~ _~;_ ~'/ CHECKLIST- FEBRUARY 1984 MUNICIPA~ANCHO RAGE. 343-4744 ENVIRONMENTAL SERVICES DIVISION APR 1 1989 Well Classification Legal Description: If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~'~-O, /~ . Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA ,/ Date Installed ~5'~/g~ Size \ ~:~L.~::~ NO. of Compartments Standpipes~) '"/ Air-tight Caps.) Depression over Tank (Y/d~ ~ Pumping/Maintenance Contact on File (Y/N~ L Holding Tank High-Water Alarm (Y/N) Foundation Cleanou~) ~,/' i~)ate//~, Last Pumped ~-~- ~'~ ; for ~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: "~¢~c> ~ To Building Foundation To Disposal Field To Water-Supply Well To Property Line \:~:) ~"~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page t of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional .and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone Address Date S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle R|ver~ Alaska 99577 6. DHHS APPROVAL Approved for ~,~ Approved /~ bedrooms by Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph $ 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. 72 325 (Rev. 7/88) Back Page 2 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot W/Cf To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ (~1- ~, ~l~eC~ iD~¢' Type of System Design Length of Field _.%cc /~J_.?~::~o~ Depth of Field ~,, ~- Gravel Bed Thickness (~. ~-- Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line [ O To Existing or Abandoned System on ; On Adjoining Lots ~ ' ~- / To Cutback (if present) ~//,c) IOO D. LIFT STATION Date Installed N,N,N' Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date MOA No. 17034 Eagle River Loop Road No..2_.n~.? Eagle River, Alaska 99577. Receipt No. ~:~/~~ Date of Payment Amount: $ ¢'/'.~,~4;~ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 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 investigatior~,ot thi~. Health A'uthority Approval shows that the on-site water supply and/or wastewater disposal system is safe, fUnctional..and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Telephone ~ ,~'"~---'~----~-~/~' $ & 5 b~m~ ....... 17034 Eagle Ri~er Loop Road No. 2.04 Eagle River, Name of Firm Address Date 6. DHHS APPROVAL App roved fo r'~C~f~_3~/~ed roo ms by Approved )(* Disapproved Terms of Conditional Approval Conditional Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTA~OM LIFT STATION TO: W~ On adjacent lots Manufacturer Manhole/Access (Y/N) at Surface water D. ABSORPTION FIELD DATA Date installed 5""~/o - ~ ~ Soil rating (GPD/Ft2) ~ 5' ~/~- System type Length 5f~__ l,,./,¢Y'. ~-¢',~Nidth ,.r¢~ t,J.~,,. ,~.~?~,,.¢- Gravel thickness o, 5- t Total depth ..7. S- ' Total absorption area ~ 7' 5- ~ Cleanout present ~/N) / Depression over field (~ /J' Date of adequacy test ~, ~ / .~ -~-' Results. j~fail) ~'4~'$ for .~ Bedrooms Water level in absorption field before test ~-" After test ~ Peroxide treatment (past 12 months) ('~) /,/~,'/~- ~¢-,Jo,J,J If yes, give date Well on lot To building foundation On adjacent lots Surface water Curtain drain SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ~ ~ c, r '/" On adjacent lots ~/,4- Property line / O / '/' To existing or abandoned system on lot .~ ~ ~ ~ Cutbank ,,,I/,,. Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION certify that I have checked, verified, or con~fl MOA and HAA guidelines in effect on the date of this inspection. I / / / ~' ',.C/~" .,.,:/,. Engineer's ~~R~p ~ad ~, 3a --~'~: .;,: ~: Date of Payment 0 ( {¢ /dC Date of Payment Receipt Number ~ 7 ( ~4 ) Receipt Number 72-026 (3/93)* Back 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 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 data__is inspection. .....,, S & S ENGINEERING "~ / Name of F,,,,, 17034 E. agl-~.;¥~r L;~-~d- "-~; ~J(~/ Phone _~////-,"Z- Address Eagle River, Alas~9~ EngineeCs signature /~~ Date ~ ~ ...... ~ .., .,.~ DHHS SIGNATURE '~ Approved for ,~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: 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 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 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O PERCOLATION TEST IF YES, AT WHAT DEPTH? O P E PERCOLATION RATE (minutes/inch) ~ / L_~ ''// TEST~RJ~N B~"FWEF.~ .t / FT AND FT 72-008 (6~79) Reading Date Gross Net Depth to Net Time Time Water Drop .