Loading...
HomeMy WebLinkAboutPETERSON LT 64AOnsite File Lot 6441��, As -built survey submitted with OSPI81348 is missinr drainfield survey will be required. �� �� ,� �., .� �x � ,t � ? x � ,�' � '.� ,.,k 2 ,,, ?. fie+ r� 3 � a i'�l :�,`"� � � �� � �:� ��� � ���= •gib _ ���, Municipality of Anchorage FEB O �Z Community Development Department2019 Page 1 of 2 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181348 PID Number: 051-171-37 ❑ New Upgrade Name: SHELLI LENHART ABSORPTION FIELD El Deep Trench F1 Shallow Trench F-1BedBed ❑ Address 19178 S. BIRCHWOOD LOOP ROAD ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot PETERSON 64A Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft. Well 100+ N/A N/A N/A (E) TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCHORAGE TANK Capacity 1 1250 Gal. Surface Water 100+ N/A N/A N/A Material Number of compartments Lot Line 5+ N/A N/A N/A STEEL 2 NA Foundation 10+ N/A N/A N/A LIFT STATION Manufacturer Capacity Curtain Drain 50+ N/A N/A N/A Gal. Remarks L� ©N, Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank 3034 Tank to drainfield 3034 JR'S SEPTIC SERVICES Drainfield CO/MT 3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 235.0 ft Inspection 5, dates: 1 10/11/18 2"d 1/31/19 Location and description 3'° 41h BOTTOM TRIM AT HOUSE POINT A COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Conditional Approval: Date �G.. . ;Q Steven f . •II_'anriorie*� Approved - CA� Date a/(0/19 �.•, CEp 8149 Ar �1� FD�n ' . p�� - 1 i / WELL E ---- ! WELL E 64A 3BR 107.7^ 5FD A / INSTALLED 1250 SEPTIC TANK W T2 W/DCO AFTER 235 77.9 DCO I / DECOMMISSIONED 1250a SEPTIC 64B / SEPTIC TANK PER MOA CODE I �AREA� / I I I DRIVEWAY I _ I _ _ _ — _ M' Util Esmt ALL MEASRUEMETN ARE ± 1.0' A B T1 34.7 61.2 T2 39.5 67.4 DCO 40.5 68.9 BIRCHWOOD LOOP RD230 W o� > — w — w — WATER LINE / ao O O o Z z z D w o WELL RADIUSZD w w w m w — 5S — SS NEW SEPTIC v v o ABBREVIATIONS EL.234.5 TH TEST HOLE _ (P) PROPOSED (E) EXISTING CO CLEAN OUT NO. FC FOUNDATION CLEANOUT _CONNECTED FS FLOW SPLITTER 1250 g SEPTIC MT MONITOR TUBE NO. 229.9 TANK 229,7 TO EXISTING TYP TYPICAL DISCHARGE PIPE PROFILE SCALE: NTS NOTES: �7� PAMONE ENG C, LLC SVC, T Date RECORD DRAWING P.O. BOX 102954 ANCHORAGE, AK 99510 '••.. 2/5/19 PHONE (907) 272-8218 FAX (907) 272-8211• �' Scale � 1 " = 50' PETERSON L64A D. NO SHELLI LENHART "�'i�.'t�anrio�e• 051-171-37 DRAWN ACP SITE: 19178 S BIRCHWOOD LOOP RD PO BOX 671442•. CE 8149 ••y PERMIT NO. OSP181348 Sheet CHUGIAK, AK. 99567 2OF2 I W ANI I zz, • MUNICIPALITY OF ANCHORAGE t,,,,,, On-Site Water&Wastewater Program off �„� PO Box 196650 4700 Elmore Roadt:!;::)' V �% Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 http://www.muni.org/onsite C• HORIV On-Site Wastewater Disposal System Permit Permit Number: OSP181348 Effective Date: 10/1/2018 Work Type: SepticTank Upgrade Expiration Date: 10/1/2019 Tax Code Number: 05117137000 Site Legal Address: PETERSON LT 64A G:1155 Site Mailing Address: 19178 S BIRCHWOOD LOOP RD, Chugiak Owner: LENHART SHELL! P Lot Size in Sq Ft: 46248 Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 2 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Date: �d Issued By: K.Q ' .1 I ♦ Ca)TJtt(?J? Date: Oe 18 PLrft•IS MUNICIPALITY OF ANCHORAGE Community Development Department t Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water& Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-171-37 Property owner(s) SHELLI LENHART Day phone Mailing address PO BOX 671442, CHUGIAK, AK 99567 Site address 19178 S BIRCHWOOD LOOP RD Legal description (Sub'd., Block & Lot) PETERSON L6 A' Legal description (Township, Range & Section) Lot Size 46,248 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank Q Upgrade Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 215. Waiver Fees: Date of Payment: lb (t.([g Date of Payment: Receipt Number: i0OggiC3 Receipt Number: Permit No. O S PI j1! 3'�"rr Waiver No. Permit App_:•: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181348, Rebecca Carroll, 10/01/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181348, Rebecca Carroll, 10/01/18 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 l~HONE ~ '~EW NAME LEGAL DESCRIPTION LOCATION .... /'~ ~ ,] NO. OF BEDROOMS Wal ~/ Absorpt o~are~ t D~n~/k~/ , PERMIT NO. ~/ . , ,.. , - /, ~Z IManuTacturer ~' ~ /~g Mater~al ~ No. of compartments ~ Liq.~a~ci~]~a OhS Insidelength Wdt~ L udde th ~,~ , IF HOME.DE: / ...... q ~ ~ ~ I ........... IWell J~eling PERMITNO ~--~ IManufacturer ~ I ,/~ lMaterial Liquid capacity in gallons ~ O. Of hnes ~ Length ~;h lice. Total lengt~ of ~n~, ~ r Tr..oh wi~,_. D stance betwee~ lines ~ ~ I Top ct ti~e to dnisn grade ,~ / _ Material beneath tile . ¢ ~ / ~ Total effectiv~so~(io¢¢~rea ~ I Length Width / ~ ~epth PERMIT NO. ~ Typeof crib Crib diameter ~ Crib depth Total effective absorption area ~ We]l ///~ I Building foundation Nearest lot line DISTANCE TO: ¢ , ~ Class ~/. ~epth .... D~iUer D stance to lot line PERMIT NO. ~ I DISTANCE TO Building foundation 8ewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS DATE 72-013 (Rev. 3/78) Permit ~ Applicant: Location: Phone Number: Legal Description: .~ ~//'/¢ //~7~._/f~,/~_~/ Lot Size: Type of Soil Absorption System .Is: Trench: L~/ Drainfield: ~ Seepage Bed: Holding Tank: Maxlmum Number of Bedrooms. The Required Size of~%~e Soil Absorption System Is: DEPTH ¢-~ LENGTH ~/~-~/_/G RcAVE L DEPTH ~% WIDTH MUNICIPALITY OF ANCHORAGE Departmen~ ~f Health and Environment~ Protection 825 L Street, Anchorage, AK. ~9501 264-4720 ~C]~2~.ANDWRITTEN PERMIT * * * ~ ON-SITE SEWER PERMIT The length dimension is the length(in feet) of the trench or drainfield. 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 = /r-~-O GALLONS * * Permit applicant has ~he 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 departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee for a private well or 150 to 200 feet from a public well depending upcn 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 31, 1 9 * * 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 understand that the on-site sewer system may require enlargement if the residence is ~emodeled to include more that~bedrooms. / SWP/024(1/81) [] SOILS LOG /t~._~T~_, MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION !,,~4~/:! 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: DAT~E PERFORMED: LEGAL DESCRIPTION: . 4 ,-- ~- ~, ,_ t'~ ~ ~e~,/~ SLOPE SITE 1 6 7 8 9 10 I1 WAS GROUND WATER /L/C:~ S ENCOUNTERED? L 0 P E IF YES, AT WHAT DEPTH? 12 13 14 15 16 17 19 PERCOLATION TEST Gross Net Depth to Net Reading Date Time Time Water Drop / /qa.,c " ' /7-" ' - 20 PERCOLATION RATE TEST RUN BETWEEN ~ FT AND >~...,?~...-...,.~. FT COMMENTS / 72-008 (6/79) DOC Co, dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGiAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS : LEGAL DESCRIPTION DATE - Started DEPTH OF WELL Ended PERMIT NUMBER STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR .:, ~,., c KIND OF CASING ~" '" ' ~'- KIND OF FORMATION: From Ft. to , Ft. From Ft. to ~ /, ,, Ft. From __ Ft. to.__ Ft From ' Ft. to ~ ' Ft. From Ft. to ' :. Ft. From __ Ft. to.~Ft. From __ Ft. to___Ft. From__ Ft. to.__Ft. From Ft. to ~ . Ft. From' Ft. to ~ : Ft. From Ft. to ::~ Ft, From__Ft. to Ft, From__Ft. to Ft, From__Ft. to Ft. From Ft. to_ Ft. From__Ft. to.__.Ft. From Ft. to Ft. From_ Ft. to Ft. From Ft. to_ Ft. From Ft. to__Ft, From Ft. to .... Ft. From___ Ft. to Ft, From Ft. to Ft, From Ft. to .Ft, From Ft. to Ft. From Ft. to Ft. From__.Ft. to__ _Ft.__ From Ft. to__Ft. From Ft. to__Ft From Ft. to Ft. From Ft. to__Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to__Ft M1SCL INFORMATION: DRILLER'S NAME_ 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) / Location (address or directions) (b) P re pe rty own er,~/¢7"/~,y~c"~ Y~/'.S'o ~-~ Telephone: (home) Business Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Telephone ~ ¢¢- ~ ~<D Mail the HAA to the following address'. (or ct~eck here ,Ef~fif hold for pick up.) List contact person and day phone number below: 17034 Eagle Ri.Yet Loop RoaU TYPE OF RESIDENCE Single-Family/~:(' Number of bedrooms ,3 WATER SUPPL~, Individual Well/E:k Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 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 Name of Firm 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, Iverifythat my investigation oft. hi~ Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional end 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 17034 Eagle River Loop Road No. 204 Date / - / 6. DHHS APPROVAL Approved for ,7 bedrooms by Approved ¢/~ Disapproved Terms of Conditional Approval Conditional 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 A. WELL DATA Well Log PresentO¢/N) ~/ Date Completed Total Depth'¢/'~/¢// Cased to ~. ~//~ ¢/ Depth of Grouting Static Water Level ~::~ Casing Height Above Ground / ¢-~//t~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot /E)O ANCHORAGE (MOA) Authorily Approval (HAA) FEBRUARY 1984 343-4744 Legal Descr~phon: ~ If A, B, C, D.E.C. Approved (Y/N) Yield ~,E2 ~r¢/~,/'-'¢ Pump Set At d~ Sanitary Seal on Casing~;:~N) ~/' Depression Around Wellhead (y,z¢~ /',,,/ ; On Adjoining Lots To Nearest Edge of Absorption Field on,Lot / ¢20 /¢- ; On Adjoining Lots To Nearest Public Sewer Line /J To Nearest Sewer Service Line on Lot ~-~' "~ Water Sample Collected by~,Cj Water Sample Test Results ~ .~/~',¢~-¢'"-¢~t~ '~ ~'/'¢~""~, ¢ ,/'d/'~-~ Comments _/J~-/~ B. SEPTIC/HOLDING TANK DATA Date Installed ~'~-¢E~--~]" Size Standpipes ~/N) y Depression over Tank (Y/~[¢~ Pumping/Maintenance Contact on File (Y/N),/ / Holding Tank High-Water Alarm (Y/N) . Air-tight Caps No. of Compartments y Foundation Cleanout (~rN) y /,,.j/~te Last Pumped ; for ~ , Temporary Holding Tank Permit (Y/N) /"//'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well / To Property Line / To Water Main/ServiceLine To Stream, Pond, Lake Or Major Drainage Course Comments ~"-//Z To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '~.' Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~'- Square Feet of Absortion Area "~'"~ ~-~" Statndpipes Present ~4) .Depression over Field (Y~j:) /"'"] Date of Last Adequacy Test Results of Last Adequacy Test ~¢~T~J,~ ~".,/~--~ r ~ /~/~___ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / ~ ~ To Property Line //C;' To Building Foundation/ '~O /-¢- To Existing or Abandoned System on Lot /4/~4 ; On Adjoining Lots ~ To Water Main/Service Line ,/C:~ /¢' To Cutbacktif present) To Stream, Pond, Lake, or Major Drainage Course .//¢~ :'/' / To Driveway, Parking Area, or Vehicle Storage Area ~ ~' Comments Date Installed "Pump On" Level at High Water Alarm Lever at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~ Vent (Y/N) ~-P'Empic~j.~cles 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 S & S ENGINEERING 17034 Eagle Ri~er Loop Road No. 2n4 Eagle River, Alaske 99577 Date MOA No. Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back / ......... ;. Waiver Fee: $ Date of Payment Page 2 of 2 /.;!2,;,.;.;'-,,~ Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~VATE WATER SYSTEM S & S ENGINEERING 17034 -Cate-Eh, er L~op Mailing ,~f~SRiver, Alaska 99577 Phone No. Cily Stale Mo'. Day Year SAMPLE TYPE: ~J.. Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose SAMPLE NO. LOCATION 31 Zip Code Treated Water Untreated Water Time Collected Collect~]d By Satisfactory Unsatisfactory Sa~mple too long in transit; sample should not, be'' over 30 hours old at examination to,~'ndicate reliable results. Please send neTM sample via special delivery mail. Date Received Time ,Received Analy}ical Method: * No.lof colonies/100 mi. Lab Ref, No, Result* I I--FI FTq Membrane Filter Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD ~'~"' READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LTB Final Membrane F~5~lts Reported By _ ~/./'. c/~2'2.'C~z CoilformllOOml BGB lOOm' a.m. p.m. TNTC = Too Nt~rrfl)erous To Count OB =: Ottl~r CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ANALYSIS REPORT BY SAMPLE for Work Order i~ 9560 Date Report Printed: OCT 5 88 ~ 13:05 Client Sample ID:L64A, PETERSON S/D PWSID :UA Collected SEP 29 88 @ 14:15 hrs. Received SEP 30 88 @ 16:00 hrs. Preserved with :NONE Client Name : S & $ ENGINEERING Client Acer : SNSENGP P.O.~ NONE REC'D Req ~ Ordered By : Analysis Completed :OCT 4 88 Laboratory Supe%v~so% :STEPHEN C. EDE Released By Send Repo~ts to: l)S & S ENGINEERING Special Inetruct: Chemlab gel ~: 2838 Lab Smpl ID: 5 Matrix: WATER Allowable Parameter Tested gesult/U~lts Method Limits NITRATE-N ND(O.IO) mE/1 EPA 353.2 10 Sample ROUTINE SAMPLE. Remarks: i Tests Performed ' See Special Instructions Above UA-Unavailable ND= None Detected "See Sample Remarks Above NA~ Not Analyzed LT=Less Than, GT=Greater Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVlRONNIENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name K~,¢'-'?' '~4:,.:.n_~,ot.t Telephone: Home _b~9''¢~'c2;:,) f~ Applicant Address ,~.~,~ - I _ Z~"o ~" Applicant is (check one): Lending Institution []; Owner/builder E~4 Buyer []; Other [] (explain); Business (d) Lending institution _~..~.ON.~4,~ _~//¢'~_'.¢~"Telephone Address /¢~,/'~/ffj/¢4~',¢ / (e) Real Estate Company and Agent __ Address Telephone (f) Mail the HAA to the following address: ' ,' 8RB 19~C ,;, ,,%~ ~IV.~..~ ALASKA TYPE OF RESIDENCE Single-Family ~ Multi-Family E] Other Number of Bedrooms WATER SUPPLY Individual Well[~'' Community E] Public E] 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 OnsitcOL~ Public ~ Community [] Holding Tank E] Note: If ~:ommunity well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 [11184) ENGINEERING FIRIVI PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORiVlATION 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 Engineer's Seal DHEP APPROVAL Approved for '~-z¢ _~_ bedrooms by Approved X' Disapproved Terms ol Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL(HAA)~ ~ CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: - r WELL DATA Well Classification ~(~'~' ~J,P~T'~ if A, B, C, D.E.C. Approved (Y/N) Date Completed _ ,3'""/,~ ¢' Yield Well Log Present~/,N')' Total Depth ~,,~ /,~,,v Cased to _ *¢'~ ~ r Static Water Level ~'~! Casing Height Above Ground ___ /¢2. ¢/~ Electrical Wiring in Conduit ~'~- Separation Distances from Well: To Septic/Holding Tank on Lot /Ob t "'~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ./O¢) f/"-' ; On Adjoining Lots _ To Nearest Public Sewer Line //4//,,~ To Nearest Public Sewer Cleanout/Manhole "~¢/4 To Nearest Sewe~; Service Line on Lot Water Sample Collected by ~.~ '~ ~ ~4.~t~C-C'~r-~'.',~4 ; Date _ Water Sample Test Results -~ /~'T'[..% ~F~r¢-:~'--o f¢~ y Depth of Grouting Pump Set At //,(,/~---- Sanitary Seal on Casing ~-/N')' Depression Around Wellhead ~ Comments To Water-Supply Well To Property Line _ To Water Main/Service Line Course SEPTIC/HOLDING TANK DATA Date Installed ~"""~ O "~._ Size /.,~ ~,~o ", Standpipes ~- Air-tight Caps DepEession over Tank (~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holdin9 ~ank: /0o ~ No. of Compartments Foundation Clea no u t ~/,N']"'_ /...~,/,~Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata c~"'~ ~'' ,c~ I,i:~,~ Date Installed ~'"-'c:)- O -~ ~ Width of Field '~'~o ¢' Square Feet of Absorption Area Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line ~'~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field --r'7'~ ~ Depth of Field Gravel Bed Thickness Standpipes Present <~:~/.N~' /~,/~te of Last Adequacy Test To Property Line To Existing or Abandoned System on ..~O, ~" ; On Adjoining Lots To Cutbank (if pre~,.~nt) Comments D, LIFT STATION Date Installed Size in Gallons / "Pump On" Level at High Water Alarm Level at I~ Tested for / Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** 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 '~'& ~SREIEMEIINI~F-I~IN¢4196X-.:"' Date/ ~ ~/¢ ~/~ Compad~,,~l-~ ~IVEI~. A~s~A ~ MOA No. PH, 694-2979 Receipt No. ~&~% Date of Payment ~-~5 '~ Amount: $ ~ ¢ Page 2 of 2 72-026 (11/84)