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HomeMy WebLinkAboutROBIN HILL #3 BLK 3 LT 7 ®r�*_Municipality of Anchorage AV Q�*j On -Site Water and Wastewater Program _ (907) 343-7904 5 f E T Y Certificate of On -Site Systems Approval Parcel I.D. 017-394-11 1. GENERAL INFORMATION: Expiration Date: 0//7AI Complete legal description ROBIN HILL #3; BLOCK 3, LOT 7 Location (site address) 13001 Mountain Place *Anchorage Current Property owner(s) Jane Crane Day phone 440-487-9226 Mailing address Real Estate Agent 2. TYPE OF DWELLING: © Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 9_56 Date of Payment. Receipt Number 06201 G COSA# 0_f -C_ Z 1 1231 Waiver Fee $ Date of Payment Receipt Number Waiver # H 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 lu Engineer's Printed Name: Jeffrey A. Garness Date: -'� -1 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 �0 ooOF industry practices. The reported results describe the condition of the system/s on the date/s of the o 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 t 9 V workmanship),9 Y 9 Y Y. ........... 1 . .............:. �. 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 (i . • the well or septic system. GEG makes no representation whether an alternative well or septic system V/ _Z.Je 'r A. crness G can be installed on the property in the event either of the current systems fail to perform adequately in 019. CE 79 3 p the future. The content of this report is for the sole benefit of the person/party that retained GEG to `�sfF .;�,IvZ•1 j perform the evaluation. Reliance upon the information provided in this report by any other person or 10�ed Eo party (including subsequent property purchasers) is not authorized, nor will it confer any legal right �oresslov� whatsoever. #AECC884 6. DSD SIGNATURE System #1 Approved for _ `' bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: =:0/02-1 The Municipality of Anchoge 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 A Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 0-" COSA Checklist Legal Description: ROBIN HILL #3; BLOCK 3, LOT 7 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 6/23/97 Total depth 260 ft Cased to 260 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 4/15/21 Static water level at beginning of test 215.5 ft Comments B. TANK DATA Age of tank(s) 24 years Tank type/material ­11—TEE Measured operating fluid level in septic tank 50" ❑ Standpipes/foundation cleanout per record drawing Date of pumping 4/21/21 D. ABSORPTION FIELD DATA Parcel ID: 017-394-11 Structure served by this system Well production at time of test 5,6+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes F No F Coliform bacteria is Negative Nitrate 7.61 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L FE -1 Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 4/15/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: N/A Which system tested (date installed) 6/29/97 Adequacy test date 4/15/21 ❑® ALL standpipes present per record drawing Results Q✓ Pass For 5 bedrooms Total measured depth from grade 11.0 ft (max) Fluid depth prior to test 28 in Measured depth to pipe invert from grade 4.16 ft (min) Water added 860 gal ❑ N/A — pressurized field New depth 42 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 120 min depth into effective 6.25' ❑ Code -required soil cover over field Final fluid depth 35 in F1 System presoaked Absorption rate 750+ gpd (Required if vacant for greater than 30 days prior to NONE Any rejuvenation treatment (past 12 months) date of test) N/A Gallons introduced gallons If yes, enter date N/A Comments/Deficiencies: THERE IS A SINGLE PRE -TANK CLEANT OUT & t OF 2 POST TANK CLEANOUTS THAT ARE PRESENT BUT NOT SHOWN ON AS -BUILT SURVEY COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Q Yes Community Sewer Manhole/Cleanout > 100' If absorption field is under driveway comment below M Yes if No ft M Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' 0✓ Yes if No ft Absorption Field on Lot > 100' [Z] Yes if No ft Holding Tank > 100' 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' M Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *51+ ft Surface Water > 100' ®✓ Yes if No ft Property Line > 5' ✓/ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No 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' Q Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 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' M✓ Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100'✓0 Yes if No ft F. ENGINEER'S COMMENTS ("MET CODE AT TIME OF INSTALL - TANK IS APPROXIMATELY 4 FEET FROM SHED- TANK IS UNDER DRIVEWAY. A BOULDER WAS PLACED IN THE CENTER OF DRIVING AREA TO BLOCK CARS FROM PARKING/DRIVING OVER TANK (SEE ATTACHED PHOTOS). SEPTIC SYSTEM IS ADJACENT TO CLASS B WETLANDS. 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 1 #AECC884 eoa MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org Nitrate Advisory Certificate of On-Site Systems Approval # OSC211231 Subdivision: Robin Hill #3, Block: 3, Lot: 7 A water sample revealed a nitrate concentration of 7.61 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. GLOT 6LOT 8LOT 20(74-147)LOT 21C(2005-175)OHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHULOT 7LOT 6BLOCK 4MOUNTAIN PLACE30.0R.O.W.WSSSSSSPAVED DRIVEWAY100' WELL RADIUSN89° 58' 00"E 329.43S00° 03' 14"E 160.00S74° 11' 42"W 268.67L=85.06R=275.00L =1 2 5 .4 1R=2 1 2 .5 2 S00° 02' 00"E 37.62SHED SPATIO25.372.088.151.167.5GRAVEL PARK ING 12.216.223.517.09.022.22.611.113.59.3 3.47.32.16.07.316.1 9.212.2 3.213.6 15.121.1 E4.9Lot 7, Block 3Robin Hill Subdivision Unit No. 361,689 Sq. Ft. +/-13001 Mountain Place3 Story Wood Frame HouseWith Attached 3 Car Garage10' UTIL. ESMT.EDGE OF GRAVELPREPARED BY:FRONTIER SURVEYS, LLC650 W. 58th AVE. SUITE E, ANCHORAGE, AK 99518907-460-1686DRAWN BY: CHECKED BY: DATE: SCALE:DRAWING ID: SHEET 1 of 11.Excepting for gross negligence, the liability for this survey shall notexceed the cost of preparing this survey. Dimensions to property linesare plus/minus 0.1ft.2.This document is created by Frontier Surveys for the purpose of an asbuilt survey for Alexandra Donald, only.3.This document is based on Plat No. 74-56, Anchorage RecordingDistrict.General Notes DisclaimerLegend1. This survey complies with the ASPLS Mortgage Location Standards. The survey represents visibleimprovements and conditions at the time of the survey. This document does not constitute a boundarysurvey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is theresponsibility of the Owner to determine the existence of any easements, covenants, or restrictionwhich do no appear on the record plat. Under no circumstances should this document be used forconstruction or for establishing a boundary or fence line.PS1" = 30ft04/20/202121-230KCScale 1" = 30'AN AS-BUILT SURVEY OFLOT 7, BLOCK 3ROBIN HILL SUBDIVISION UNIT NO. 313001 MOUNTAIN PLACECONTAINING: 61,689 Sq. Ft. +/- (RECORD)RECORD PLAT: 74-56Electric MeterSeptic Telephone PoleOHUOver Head UtilitiesSWWater Well ConcreteDeckGas Meter GES T A TEOFALASKA49THROYEVR U SDNALLANOISSEFORPDERETSIGERPierre M. StragierNO. LS-98124/21/2021 , ' 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 Permit Number: ...%t~.~ ~.Oocf'~ PID Number: ot--~- Name: Wastewater System: ~New ~ Upgrade Phone: No. or, rooms: ~ ~ ~_ /~ ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Lot; Block: Subdiv~ion: ~ Depth to pipe bo~om from original grade: Gravel depth ~eneath pipe Township: ~ Range: Section: Fill added above original grade: Gravel length: Ft. WELL: ~ New ~ Upgrade Gr~ve~ width: , Numberer lines: Distance between lines: ~ Ft. ~ Ft. Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: [ P~mp 8et at: Oasin~ Height Above ~round: SEPARATION DISTANCES ~Septic a Holding ~ S.T.E.P. To ~ Septic Absorption Lift Holding Public/PrivateManufacturer: Capacity in gallons: Material: Number of Compa~ments: su.~c~ - LIFT STATION Eot Sizein gallons: Manufacturer: Foundation ( ~ I / ~ ~ ~ ~ "Pump on" level at:~ at: High water alarm at: Cu~ain __ __ _ ~ ~ Pump ~ [ ~ctfi~p~.~s pedormed by: Drain BENCH MARK Remarks:- . Location and Description: Assumed Elevation: 72-013 (Rev. g/91) MOA 25 PERMIT ND, SW970097 I es°C~"i,v e LT, ~4 AS-BUILT WASTEWATER ABSORPTION SYSTEM LOT 7, BLOCK 3 ROBIN HILLS S/D P,I,]], NO, 017-39-411 // / \ \ \ set;-bmck New I)r~ln 55' long, 6' eF wli;h C,D, ~ e~c & Monitor Tube See Page 2 L6, C,\Work\7-3RO]]IN,clwg PREPARED FOR' Mr, Lowwet Crane 13001 Mountcin Pl:ce Anchorage, AK 99516 (907) 265-1544 I]ESIGNI Pert Rm~e, 4 MIn/Inch Soil RccWng, 1,2 gpct/sF [5 'B,R, 685 SF :Eequlmed ~eep Trench 10' Tot~[ 9epth, 55' Long 660 SF To,mt PANNDNE ENG,. SVC P, 0, BOX 142025 ANCHORAGE, ALASKA 872-821B 99514 BATE, 1-5-9B I AS-BUILT ~CALE' 1'=100' DETAILED i PLAN C~\~/ork\7-3ROBIN,dwQ l~ONV395 J. nONU~90 PREPARED FBR~ Mr, LowweL Cr~ne 13001 MOUNTAIN PLACE AnchoraQe, AK 99516 (907) 865-1544 PANNDNE ENG,,SVC, :' P, D, BDX 148085 ANCHDRAGE, ALASKA 99514 874-0308~ 878-8818 FAX DATE, 1-5-9B NBT TD SCALE AS-BUILT Depth in feet from ground surface . , f;'. TO ~ IV~ - ¥'4' I~RILLING~ P,O, Box 110378.e 10330 Old Seward Highway (11107) 349-8535 DRILLING LOG Well Owner EZLL :"~'~"" Docatlon (address of: Township, Range, Section, if ~own; or distance main road ....... ~ ~ ALASKA S~e of c~g~Depth of Hole_ 26 0 . feet C~ed to~eet Static water level 205 Jr. ~*~" ~low) l~d surface. ~in~sh of well (cheek one) open end ( X Screen ( ); Perforated t ~.. Describe ~ereen or perfor,~ion. Wen pumping test at ~5 gafi~hs ~ ~ (m~ute) for- 1 hours with t00~ of drawdown from static ie~h: Date of completion 2 3 ~'' ~'' ~' ~ Gfg"d~{,~?. 6f formations penetrated, size of material, c~vnd~ss - i'".- f" ' "' uept Health & Human ~e~ice~ - ~:~.~:.,.[.i~: , . :-~ , · ,, '. GREY,. :.Sl~,ly C, RAVA~L: SI'r/P¥ WIg:l{ RRWON ~.LAY LEN,.qES ); ft. Use o W .............. C- PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970097 DESIGN ENGINEER:STEVEN R. PANNONE OWNER NAME:QUINTON DIANE L OWNER ADDRESS:13001 MOUNTAIN PL ANCHORAGE, ALASKA 99515 DATE ISSUED: 5/16/97 EXPIRATION DATE: 5/16/98 PARCEL ID:01739411 LEGAL DESCRIPTION: ROBIN HILL #3 BLK 3 LT LOT SIZE: 61689 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED B ~ ~~ Steven R. Pannone, P.E. Consulting Engine, or (907) 272-8218 April27,1997 P.O. Box 142025 Anohorago, Alaska, 99514 (907)272-8218 Fax Municipality of Anchorage Dept. of Health & Human Services On-Site Services Section P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 7, Block 3 Robin Hills Subdivision Well and Septic Permit Gentlemen: My firm was contacted to investigate the possibility of installing of a new system at the above referenced property. Currently the lot is undeveloped. Two test holes were excavated on April 4, 1997. The soils report and percolation test results are attached. Ground water was monitored for fourteen days. No ground water was encountered or monitored. No bedrock was encountered in either test holes. The lot is approximately 1.4 acres in size. Lot 7 slopes to the east at a rate of approximately 15 to 20 percent on the western portion, then flattens out to approximately 0.5 percent. The proposed installation will be located on the northwestern portion of the lot. The proposed location will be greater than 100 feet away from the proposed well serving this property and 25 feet from the water service lines. The surrounding systems are located greater than 100 feet from the proposed installation. The proposed installation will not impact the future development of the surrounding lots. See the attached design. If you have any questions about the proposed installation, please contact me at 272-8218 Sincerely, ~ne~-P.E~. Attachments: C:\WORK\7-3ROBIN. 001 L7, 84 Undeveloped L6, D4 Cl\Work\7-3RODIN,dwg ese~ 'ye DESIGN WASTEWATER ABSORPTION SYSTEN LOT 7, ]]LUCK 3 ROBTN HILLS S/I) L6, B3 Exls'~, Sep'tlc System / 1500 / / Line Proposed Dr(zlr td --55' tong, 6' tlve with C,0, @ end & Monitor Tube ~ld01te, See Sectl pnge 2 ~osed Wetl Exist, Well DESIGN~ Pert R:te, 4 MIn/Inch Soil Rating, 1,2 gpd/s? 5 B,R, 685 SF Requlrec~ Deep Trench 6' E??ectlve, 2' ~lde, 10' Total Depth, 55' Long 660 SF Total PREPARE]3 FOR, Mr, Lowwel Cr6ne 12111 Portage, ])rive Anchor(zge, AK 99515 (907) 265-1544 PANNDNE ENG, SVC P, D, BOX 142025 ANCHORAGE, ALASKA 272-8218 99514 DATE, 4-14-97 I DESIGN SCALE, 1'=100' I ]]ES~GN DETAILS WASTEWATER ABSDRPTIDN SYSTEM LOT 7, BLOCK 3 ROBIN HILL~ ~/D lnON¥393 N~]IIYRNNO~ CI\Wo~'k\7-3RD~IN,~I~g PREPARED FOR' Mr, Lowwel Crane 12111Por~ge, Drive Anchorage, AK 99515 (907) 265-1544 u~ tt~oJ I,I I PANNDNE ENG, SVC, I P' 0, BDX 148085 I ANCHDRAGE, ALASKA 99514 I 874-0308~ 872-8218 FAX IDATE~ 4-14-97 I INnT TD SCALE DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ::;': (ENG NEER'S'SEAL) PERFORMED FOR: DATEPERFORME LEGAL DESCRIPTION: 2 3 4 5 8 10 19 13 ~4 16 ~8 20 Township, Range, Section: SLOPE COMMENTS WAS GROUND WATER ENCOUNTERED7 S L IF YES, AT WHAT O DEPTH? - " E Depth to Water After Monitoring? "~ XZ:'-,: hale: SITE PLAN Gross Net Depth ~ (~= Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN __ (minutes/inch) PERC HOLE DIAMETER FT AND ~" FT ~-'-x ~A ~/A-r-~__-I~ m~. 'rTM ...-~'t ~,~ PERFORMED BY: ~:~,~""~ ~'~/~/M; ~ ~l%J. ~-; ~ ~-., l- ~J~:~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES tN EFFECT ON THIS DATE. DATE: ~"~/~-/~ ~ 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: DATE LEGAL DESCRIPTION: L "~_ _~'~ .~ 4 5 6 7 ,8 10 ~2 ~3 '14 17 19 2O Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? COMMENTS L IF YES, AT WHAT ~ O DEPTH? p E Depth to Water Alter /,,t/1~l~ ~ Monitoring? ~:::~ ~'"~' Date: SITE PLAN ' N Gross Net Depth 'a~ ~ Net Reading Date Time Time Water Drop PERCOLATION RATE /"/ (minutes/inch) PERC HOLE DIAMETER ~'~. TEST RUN BETWEEN ~ FT AND C~ FT PERFORMED BY: ,,.,~.~__.'~b~{~..~ '~...~.~ jf~_.. ! ~[::3. ~:;. I ~~--~~ CE"RTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE: ~.~t/.~..~ ~ ~ 72-008 (Rev. 4/85} Parcel I.D. # 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 ~ ['C~__"~ c~_ &,//{' HAA# ~t~ ~ O~ '(~ (~"~,(~. ~--~')'' 1. GENERAL INFORMATION Completelegaldescription £o-L ':Tr~;/..~el/-~ ~_o~(~c~ ~-~LL~ ~,~ Location (site address or directions) ¢ ~ c~ I M ~o~,-z--~,~,~, ~---"-'-'-'-'-'-"~&c ~ Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: individual on-site Holding tank Community on-site ' NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25(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 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 E~;::~'O,*~P~¢'¢--- /~'~'o~._t-/ /~,oo~/-~ IAI( EngineeCs signatu r~'~'q~ Date DHHS SIGNATURE ' J 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 #~1 Municipality of Anchorage C E IV E D DEPARTMENT OF HEALTH & HUMAN SERVIC~-~ -- Environmental Services Division )J~3 -)54z~998 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907 -4 Municipality of Anchorage Health Authority Approval Checklis~apt' Health & Human Services Legal Description: Parcel I.D.: (:~t~z- ,'.~ct -4/// A. WELL DATA Well type ~:;~t~UJA''rYe Log present (Y/N) Total depth '~--~"~- ~-- Sanitary seal (Y/N) Date of test Static water level Cased to FROM WELL LOG IfA, B, or C, attach ADEC letter. ADEC water system number Date completed ~, --&-"3- ~ '~ ~-~. ¢.~ Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Well production WATER SAMPLE RESULTS: Coliform '* ~ ~ Date of sample: ///~ / B. SEPTIC/HOLDING TANK DATA Date installed ~ t'~ ~[q. ~ Tank size Foundation cleanout (Y/N) Date of Pumping AJ ~ C. ABSORPTION FIELD DATA Date installed ~' [~ ? [ C~ Length ,-~'~ Width Effective absorption area Date of adequacy test ~ ~-(--~/' Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) g.p.m. Nitrate ?~, ~i l Other bacteria Collected by: !,_~-c~cD Number of Compartments __ Depression (Y/N) ~ Pumper ~ g.p.m. ~_- Cleanouts (Y/N) '-(' High water alarm (Y/N) ratin~or fF/bdrm) I · ~-- System type ~ T Soil '~ ~ Gravel thickness below pipe ~,, t Total depth Monitoring Tube present (Y/N). ~'~ Depression over field (Y/N) Results (Pass/Fail) '~:::~A 5'q For ~ Immediately after~ gal. water added (in.): ~ Absorption rate = ~ .g.p.d. ~ If yes, give date bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed ' // Size in gallons ~//~~'""'""~"~'~"Pump off" level at* Manhole/Access (Y/N) E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout ~t~'~/~ Lift station / Property line Surface water Curtain drain SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation / ~ t Property line ~-/q' f Absorption field Water main/service line '77¢-C~ Surface wateddrainage ! c~:~+Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ~! ~- '~ ~ Building foundation -/~..~' ~ Water main/service line / ~o''¢ F, ENGINEER'S CERTIFICATION f ~Z-~ Driveway, parking/vehicle storage area Wells on adjacent lots / ~ ~ I certify that I have determined thru field inspections in conformance with MOA HAA guidelines in effect on this date. Signature.~'~~ -- ~ Engineer's Name Date ! HAA Fee $ ~(~), Date of Payment Receipt Number ~_~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number