HomeMy WebLinkAboutROCKHILL BLK 3 LT 2Rockhill
Block 3
Lot 2
#015-362-19
J \` 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
i
PHONE EW
. ❑ U RADE
,OAMAILINGRE
�S
s
LEGA DESCRIPTION
LOCATIO
f
/V
NO. OFBEDROOMS
Uy
DISTANCE TO:
W �06 / Ab/orp ion�rea/
Dwelling `
PF(R.iVI T IyFJ�
(s (J
wR
Manufacturer � n
Maters ®�
No. of coants
N ~
Liq. gc't in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
O
C7 Z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= Z FQ-
Manufacturer
Material
Liquid capacity in gallons
_=
w
DISTANCE TO:
Well
146
Foundati�t
tJ
Ole
Nearest l
�""3
PERMIT NO /� 7
/S;7
J LL z
Z w
No. of lines
Length of e/
Total lengt o irfs
Trench wi
C1inches
Distance b�tyv 'nes
yam°
� F..
Top of file to finish grade
Material beneath file� �
inches
Total a tiv ption area
LU
Length
Widthl
Depth
PERMIT NO.
a
Q Ir-
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
w
N
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot linePERMIT
d
NO.
Lu
3:DISTANCE
-
TO:
Building foundation
I
Sewer line
Septic tank
Absorption areals)
OTHER
PIPE MATERIALS
,,, 7M
SOIL TEST RATING /-:s
QDI
INSTALLER /f /
REMARKS
APP V D DATE LEGAL
, ^ �1-jr-4 I #___ I )--I L_I '-r"-e #-D F:-
� DEPHRTMENT HEALTH AND ENVIRONMENTAL rk.OTECTION
�v
~t' �25 'L' STREET/ ANCHORAGE, AK 99501
264--4720
��t.-J U_ F;? F --o EF_ F�" rl I ~ /Q��
/ ^ �
PERMIT NO. 810137 ) /��\ L ,,3
,I P.
APPLICANT GOENTZEL BUILDERS INC PO BOX 10238 SO STM 344-9422
LOCATION MAIN TREE & BARRY
LE8HL L2 B] ROCKHILL LOT SIZE 48000 SQUARE FEET |
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH /������/
-
,� � |
MAXIMUM NUMBER OF BEDROOMS = 3SOIL RATING (SQ FT,--E-,R)= 1231' 74 p^ |
'THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
��Fz� _r " - -1 ::L ���" 0 -r " aw 7' 0 F!" V EF I �EE F` _r " = 7'
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF H 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 13RH9EL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F2 E- 1_-� IJ I FR FE F -a =-. F= F=1'r I n::- -F F:� r-4 �1 2! F= P20 I DE 0 L_����
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE,
"7- L4 r_-1 < :120 > I " _�-. F-Im I -E v:� -r 1 0 "!E-. n FR F_: Fl" �GJ L.1 I F? FE U--
BACKFILLINQ OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
108 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM A PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F=�EiFZMI-F �XlF:;l*lF-_oU:!:-5 L.-E",_�EEMOEEF�? -1 S-4 -1L
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WB -L5 AS SET
FORTH BY THE MUNICIPALITY 8F ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE 8N -SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SI0NED: -_______-_-~
APPLICANT Q{�EM�ZEL �}0%LDERS INC
ISSUED V4. 0
�
CJ CV)CA-A r X
4
r
Wel i Log
For.. 0F.- � � . ................ �` �.,:......
......I ................... ..... ...
Location. 1 ..... .........l� ;'� 4'.
ft) 1
................................................. ................. ..........
Datecompleted.........7............... ........................................ ...................... I.... ... ......
Depthof well................................................................................................
Sizeof casing ............... ............................ I ..................... :.........:.................................
Distanceto water............ I ..................................................................................
Distance to water while pumping .............. 6-,./.. ............................... .at rate
of .............. .....................gallons per hour.
Formation (
fr�olm I
to
424 0 L VL
I
"E
-
I
i
!
i
i
!
_.
:............................................................
Driller
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHORAGE, ALASKA 99507
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program s "
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O IS —312 — 19 HAA# n503�3
Expiration Date: % — 3 — O A-
1. GENERAL INFORMATION
Complete legal description l -o t 2/ 3 /e, C
1C 3 R oc tc Ai It S /1h
Location (site address or directions) E2YO
r3 ct r.—i 14L�ln✓e
Current Property owner(s) lfa f t O,e l
Day phone 3 39 —0 "C-1 XV
Mailing address 363o 64e�yanne C74.,Ric? A -k 999'07
Lending agency
Day phone
Mailing address
Real Estate Agent Teane f e wQ l kon
WA;Ae
pe" a. Tack„Day phone 2 H H-7 Z2/
Mailing Address 3601 CePLV-�20*th
1),--1; 7*'Z00�� Ak 9950_7
Unless otherwise requested, HAA will be held by DSD for pickup. P / Doi a COI/ .7 -Pane Fke Zue /[.cc,..
2. NUMBER OF BEDROOMS: 3
@ 2`/`/-722/ when J4.44 u
ready J�;r- f0icic-a10.
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well ®
Individual On-site
Individual Water Storage ❑
Individual Holding tank ❑
Community Class Well ❑
Community On-site ❑
Public Water System ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. 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 Health Authority 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 Ftc4' 7 7'i'C4 n;cu/ - e"Le' Phone 3 `/S-►3SS-
Address f+{S30 Ectio S1f. /r}11cAo,-c'c4,p A4c 99SJ,�r
Engineer's Printed Name '"ih6t�y ,:7�vrP is::. /`tUc7''e Date 7=�r ty
S. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following
Gr; `STAMP t
Vt�.n
�: , (r�TH 1'-� �; x•. it
THEODORE F. MOORE •� k
•• CE -3589 � `� •"
i`,tii'F••••�/o�• Ay
LCA �,
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Gv p Original Certificate Date: 3'- O "Or
(Ra . 77N0)
Municipality of Anchorage
' Development Services Department
Building Safety Division <
On -Site Water d Wastewater Program
4700 South Bragew St.
P.O. Box 196650 Anchorage, AK 9951"650
www.cLanchorage.ek.us
(907) 343-7004
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: l.o f 2j 8/h3, R a c 4 All/ S /JD Parcel ID:
A. WELL DATA
Well type Pl- t If A, B, or C provide PWSID #
Date completed '7/28/81 Sanitary seal (YM) Y
Total depth 6S ft.
Cased to _4L,S ft.
FROM WELL LOG
Date of test
-7/2-6/6/
Static water level
S 2 ft.
Well production
1 g.p.m.
WATER SAMPLE RESULTS:
Coliform ! colonies/100 ml. Nitrate ysy mg -A.
Well Log (YM) Y
Wires property protected (Y/N) Y
Casing height (above ground) 18 in.
AT INSPECTION
7 / 16 / ZOOs-
SS ft.
9.0 -I g.p.m.
Other bacteria 6 colonies/100 mi.
Date of sample: 7 / 16/ Zelo S' Collected by: F /cv /,&d 7-,c4 S d - c
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SeP>`1 G /Sf'r e / Date installed 7 / I / 8 1
Tank size I &CV gal. Number of Compartments �_ Cleanouts (YM) Y
Foundation cleanout (Y/N) Y Depression over tank (YIN) _t\1 High water alarm (YM) N• A
Date of pumping 7 / 2a / 2 OOr Pumper A f
C. ABSORPTION FIELD DATA
Date installed 7/I 9 / Soil rating (g.p.dJW or ftrlbdrm)113 L21 System type TrrncA
Length 29 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth I g9 ft. Eff. absorption area _d9 ft= Monitoring tube Y Depression over field N
Dale of adequacy test *711914'r Results (Pass/Fail) Pyrsi For -2_ bedrooms
Fluid depth in absorption field before test 9 In. Water added 9I gal. New depth=in.
Elapsed Time: 12 min. Final fluid depth __E in. Absorption rate >= HSU g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM S type) IV If yes, give date —
D. LIFT STATION
Date installed
`Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
Size In gallons
'Pump off" level at _ in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 1 or'
Absorption field on lot 12S'
Public sewer main IV - A.
Manhole/Access(Y/N)
High water alar level at
Meets alar b chult requirements?
On adjacent lots > f oo '
On adjacent lots > roo
Public sewer manhole/cleanout N• A.
Sewer /septic service line > S S" I Holding tank N • A .
SEPARATION DISTANCES FROM SEPTICA-101-DING TANK ON LOT TO:
Building foundation 10 Property line "70 ' Absorption field '30 '
in.
Water main N • A. Water service line '> le)' Surface water > 1C,0
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line HD ' Building foundation Y6' + Water main N. A
Water Service line > le" Surface water �> rGu ' Driveway, paddrp/vehide storage
Curtain drain No*,i S`Olin Wells on adjacent lots '> 100 '
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Th Po eJo rt l`
Date Jw 1% 7 Z 2uUS
HAA Fee $ Waiver Fee $
Date of Payment — / t7 Date of Payment
Receipt Number % /2- Receipt Number
(Rev. 12/00)
TH
r' ..........................
.e
1 Two{or�o,.e r. uo.)rr J
vslrtpra,' ^'
1 •
. .A .4• � r.' 1
IT SHALL DE THE IIESPONSIe11M OF THE
0YMN On BUILDER TO PPOYIDE EASDAENT
CELCR197I0-'I% CMTtUWM AND REMIC•
1I::7S WHICH 00 NOT APFCAR 0:1 T71E
FECC:ICSD SUIIDrnSl014 rtAT AND TO VUrifY
ni'OY]SED BUILOINO 9 WE RELATIVE TO
ttNIS:l rA4DE NID UT1U TT CONNECTICttS:
�oserrX�o�
LOT SURVEY CERTIFICATION
Lot , Block --`� Area Sq. Ft.
—rr-erg:
Plat File No. ' Zoning District_'
Anchorage Recording District, Alaska
7`��.tERY r C I G AY+o r,t
5•Zo•Bt.
LEGEND:
Brest Cap MOOOmenl
f�
O Iron Pipe
• steel Pin
0 surrey nue a Toot
I (�^•� Irl r,vl7 wnw-wnf.LM-L Reeldenee of:
{ En S 4040 r .10[77
AY7MO0A7t, LLAIYA
:Oolr: grti� s00,111:w.ati
SCS ReLN
Client Name
Project Name/N
Client Sample ID
Matrix
Sample Remarks:
1054367001
Flattop Technical Siv.
Lot 2, Block 3, Rockhill S/D
Lot 2, Block 3, Rockhill S/D
Drinking Water
All Dates/rimes are Alaska Standard Time
Printed Date/time
07/26/2005 14:26
Collected Date/rime
07/18/2005 11:00
Received Datelrime
07/18/2005 11:48
Technical Director
Stephen C. Ede
Allowable Prcp Analysis
Parameter Results PQL Units Mcthod Container ID Limits Date Date Init
Waters Department
Nitrate -N 4.54
Microbiology Laboratory
Total Coliform 0
0.100 mg/L EPA 300.0 B (<.10) 07/19/05 JEM
coVI00mL SM209222D A (<=I) 07/18/05 TLF
MUNICIPALITY OF ANCHORAGE
• `� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services `r/'`q[ir
On -Site Services Alaska 99519-6650 MFHrgIk , FS o c
F
se, q Cy
P.O. Box 196650 Anchorage, iC Kq
343-4744
Fes O
199,
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # O lS5 "3 f �k — VG HAA #
1. GENERAL'INFORMATION '
Complete legal description' 'hof 2 310c k 3 Roc kh� 11- S /.D
Location (site address or directions) 62 yo C3Gav-r1 4=3z S7`:
Property owner leo6er-t Sal v Day phone
Mailing address 62YO 5cztrry Sfree{ AnGho r5cg A•k 9951
Lending agencyC', AT Mm°"� Day phone 263 'a 7G�
Mailing address 12/ w. F� re uveek �vP, f}nco,- Ak 99503
Agent Jcrcl'r 13i'ccr,� 13e Mcyc Propel^Ae, Day phone 2 76 2 76(
Address 2 600 & (-el54�, ex S� � S u f e l Uc> >4nchofczM Apr 9,9s -o3
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:' 3
3. TYPE OF WATER SUPPLY: -
Individual well ✓
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
72-025(Rev.1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files°and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in complian%ce with all Municipal and State codes,
. ordinances, and regulations in.effect on the date of this inspection:
Name of Firm -rier f /6-P Te( /An ica ( Serv; c e - Phone 3 YS --
Address +k 99SI,�_
r�- -
__ Engineer's signature Date F -es /997
ST.,
ZI..,
n
•.. i1/�,"'fJ�(/j1'a •�s1r�•1��HIaMt//y'/�,�/T y$
�A TWBODOi:O
6. DHHS SIGNATURE539 ,•"
_L
Approved for bedroom. -.
Disapproved. , :.,* -.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By: Date
2
e
CAUTION
The Municipality of Anchorage Department of Health and Human'Services (DHHSjIssues 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,MunicipaIIty, of, Anchorage is not
responsible for errors or omissions in the professional engineer's work.
MUN�C, �1
Municipality of Anchorage rNvino ury oFAn,�
e DEPARTMENT OF HEALTH & HUMAN SERVICESNMENrAtOf�a/c
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 34fk�a4(),
Health Authority Approval Checklist
Legal Description: I- of 2, 611<3, Roc k -A d l S /D Parcel I.D.: o it 31 a 2 1,9
A. WELL DATA
Well type PV / If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Y Date completed 7 /&5 /6 f
Total depth S Cased to /5 ' Casing height (above ground) 2 Z
Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
FROM WELL LOG AT INSPECTION
Date of test 7/ 2 6/ 9 1 1 130197
Static water level 5 2' 56
Well production 10 g.p.m. eS" 7 t g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 c.& I //CsG ✓h Nitrate y 17 mq /..Q. Other bacteria 170179 re�o�lp�
Date of sample: I (3O /97 Collected by: Flaf+�p Tec4 SSI�c
B. SEPTIC/HOLDING TANK DATA
Date installed 7 / / E 1 Tank size 1 uGG 7Number of Compartments 2 Cleanouts (Y/N) Y
T
Foundation cleanout (Y/1) Y Depression (Y/N) N High water alarm (Y/N) N. A.
Date of Pumping 60 27 / 96 Pumper Zsu a cr
C. ABSORPTION FIELD DATA
Date installed 7/1/9( Soil rating (g.p.d./ft2 or 112/bdrm) 123 1a' System type T re n ch
1r"t '" I lxf; P, e Cn ✓ 'to
Length Z9 ` Width 3 ` Gravel thickness below pipe 7' Total depth ilt. r. enFc4-r
Effective absorption area 'Y,96' Pa ' Monitoring Tube present(Y/N) Y Depression over field (Y/N) N
Date of adequacy test 1 l3 ! 9 7 Results (Pass/Fail) Pass For 3 bedrooms
Gelaw --a
Fluid depth in absorption field before test (in.); 7 37 " Immediately after76/ gal. water added (in.): 2 y " 6e( --w
Ce tow Tnt�
Fluid depth 33 (ins.) Minutes later: 3 6 Absorption rate = 7 'Y FO g.p.d.
Peroxide treatment (past 12 months) (Y/1) None Know• Ifyes, give date M, 41
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
"Pump off' level at*
Septic/holding tank on lot I O's ' + ; On adjacent lots > too'
Absorption field on lot 12S, * ; On adjacent lots >
Public sewer main N.A. (> too) Public sewer manhole/cleanout
Sewer /septic service line > 2s'' Lift station V. A,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Is- * Property line 66' ' Absorption field 3o'
Water main/service line > to' Surface water/drainage > too ' Wells on adjacent lots > 100 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Property Line '/P Water main/service line > to '
Surface water > t o6 ' Driveway, parking/vehicle storage area 6a
Curtain drain No ,)e se tn Wells on adjacent lots -> (0o '
F. ENGINEER'S CERTIFICATION m �� ,,•
♦...,� MM d6R g.
1 certify that 1 have determined thru field inspections and review of Municipal reco s thg`r kie abaveA systems�re
r
in conformance with MOA HAA guidelines in effect on this date.
rr i
W1►t+i�exett.aa
Signaturef/I/ /��c�„Y�1..L_ 0:5� x-
.ase...q..♦ .9 N.sonofie
Engineer's Name %?11Go c ---Pore F Mc�o fe- EngiiieU g Seal Hdre.'
C Fav n
Date FC�Yccacry 'i. /997 �M ,k�'
HAA Fee $ 300
J-" q
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
02/03/97 16:08 CT&E ESI ANCHORAGE � 9073451355
C7'&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
CT&E Environmental Services Inc.
970504001
Flattop Technical Sfv.
Rockilill VD -Village Pkwy Est.
1_2 BA 3 RAckhili SID*
DritWt)g Water
Ciient PO#
Printed Date/Time 02/03/97 12:43
Collected Date/Titrte 01/30/97 13:15
Received Date/Titnc 01/10197 '"o
Technical Director: Stephen C. Ede
Released BL%5r—r/,-� - ,
amifie Remarks:
*Front Hose Bib
Atlowable Prep Analysis
ResUlte PQL units Method d _ Limits Date Date )nit
Parameter _, —�—^
SM18 6500 NO3F 10 max 01/31/97 JBL
Nitrate -N 4.17 0.200 m8/l 01!30197 TAV
0 cot/100mL SM18 97228
Total cotiform
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. # L' ' IIr .2 1 c�
1. GENERAL INFORMATION
HAA # VA mal 2MLZ, �2-)
Complete legal description L,,4 2, B (oc k 3 lea c IT AI (I S 1D
Location (site address or directions) * 2 Yo 8 oen y A -v 4
Property owner rio berF Day phone 3'16 - 2Y98
Mailing address 6S2Yo Harry AVen4e, AACAC • A-� 99Sf6
Donn a_ 'or
Lending agency jf, . rT�c J -4k" Pie,hu -t Day phone .�63 -0 Tao
�r
Mailing address IZI IN Frrcuw etas � a,7421AACACr! t AA( -,99503
Agent 1q. A i fie %rnuAc(g) Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site ✓
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 JE 16t FF t",Oe Techn iced Se`icv Phone 3 YS-- l3SS
Address J &15 3 D E04S6 AActhocu -e Ak 995_14�
Engineer's signature - Date —A-4c!� ! 7, 149 Z
6. DHHS SIGNATURE
Approved for
Disapproved.
►�- `\
r:�" 8�
sc* 49T"�1
I : THEODORE K. FAOORE
'•. CE - 3589�. � A
�" AV
-3 bedrooms.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
By:
'304f4 SIM I11� Date
1IITIC
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 N21
Municipality of Anchorage
Department of Health & Human Services_
HEALTH AUTHORITY APPROVAL CHECKLIST 44
Legal Description: LoT 21, "8Lk 31, Rock HILL s/fl Parcel I.D.
A. WELL DATA
Well type PR If A, B, or C, attach ADEC letter. ADEC water system number 1I•A .
Log present (Y/N) y Date completed '7/2W/81 Driller DEUR DR1i L)146
Total depth 65 t Cased to "S 1 Casing height :22 ft
Sanitary seal (Y/N) i Wires properly protected (Y/N) Y
Public sewer main > ioo'
Sewer service line > Sa
WATER SAMPLE RESULTS:
FA
Public sewer manhole/cleanout
Petroleum tank N04C 0'$ 5,6 R VE
Coliform 4 co / 1400Af Nitrate 3.6 eylz Other bacteria O co//tao ir,;Q
Date of sample: 2/6/92 Collected by: FLATTOP TEcbl Svcs.
B. SEPTIC/HOLDING TANK DATA
Date installed 7/((v Tank size 1000 C-4 L Compartments Z
Cleanouts (Y/N) '`% Foundation cleanout (Y/N) Depression (Y/N) iV
High water alarm (Y/N) N; Alarm tested (Y/N) Ist• A
Date of pumping S//7/92 Pumper 3aaemcf
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Wells) on lot On adjacent lots 5' /ao Foundation l 8
Topropertyline > SO Absorptionfield 3Or Water main/service line >20,
Surface water/drainage > too r
72-026 (Rev. 7/91) Front CONTINUED. ON BACK PAGE
FROM WELL LOG
AT INSPECTION
rn7M.
Date test
7�z8 �8I
S l6�92
o z
of
�'>
z Z
Static water level
Sz
55
n
m v
z
Well flow
j t7
g.p.m. > 6.4
g.p.rn fi/r
1
Pump levelS�
m
c
c
M z
Q
E
SEPARATION DISTANCES FROM WELL TO:
y
a Q
C
Septic/holding tank on lot
)10`
; On adjacent lots 5 100
Absorption field on lot
130,
; On adjacent lots > 100'
Public sewer main > ioo'
Sewer service line > Sa
WATER SAMPLE RESULTS:
FA
Public sewer manhole/cleanout
Petroleum tank N04C 0'$ 5,6 R VE
Coliform 4 co / 1400Af Nitrate 3.6 eylz Other bacteria O co//tao ir,;Q
Date of sample: 2/6/92 Collected by: FLATTOP TEcbl Svcs.
B. SEPTIC/HOLDING TANK DATA
Date installed 7/((v Tank size 1000 C-4 L Compartments Z
Cleanouts (Y/N) '`% Foundation cleanout (Y/N) Depression (Y/N) iV
High water alarm (Y/N) N; Alarm tested (Y/N) Ist• A
Date of pumping S//7/92 Pumper 3aaemcf
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Wells) on lot On adjacent lots 5' /ao Foundation l 8
Topropertyline > SO Absorptionfield 3Or Water main/service line >20,
Surface water/drainage > too r
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
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Surface water _
Date installed ILL Al Soil rating 123 G"/BDRM System type TRENCH
Length 29 ` Width 3(o Gravel thickness .7 Total depth
Total absorption area 40(� L-7 Cleanouts present (Y/N) Y
Depression over field (Y/N) Date of adequacy test g A /9 2
Results (pass/fail) PASS for 3 bedrooms
Peroxide treatment (past 12 months) (Y/N) NOKC- kNowM of If yes, give date N
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 130, On adjacent lots �;;- /DO Property line <Z� 30 r
To building foundation
On adjacent lots
> 50
S5�
To existing or abandoned system on lot NA
Cutbank NA Water main/service line >SD`
Surface water �>- /oo Driveway, parking/vehicle storage area
Curtain drain ROKC 0RsfkvED
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 inspection.
Signature 11 - T::
Engineer's Name 7_1*74wdore F.
Date A'ugwF f74 /992
�"WOORE F. MOORE
CE -3539
i
HAA Fee $ Z/ d e-9 Waiver Fee: $
Date of Payment Z— Date of Payment
Receipt Number Receipt Number
r
CHEMICAL & GEOLOGICAL LABORATORY
J _c" A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
LASONAT AY 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2343. FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 56754
Chemlab Ref;# 92.4010 Sample # 1 Matrix: WATER
t;lient Sample iD L2 R3 ROC&HILL EAST HOSE HIR Client Name :FLATTOP TECHNICAL SRV
PAISID UAClient Acct :FLATTOT
;'611- acted AUG 6 92 @ 14:15 hrs. RPO# PQ# :NONE RECEIVED
Rereivad AUG 6 92 U 16:30 his. Req#
Preserved with i AS REQUIRED Ordered By
Analysis Completed : AUG 7 92 Send Reports to:
Lciboratoxy Supexvisox STEPHEN C. EDF. 1}FLATTOP TECHNICAL SRV
Released Ry f "� 2}
�...... z..............q.....-..,................... .
Parametex Results Units Method Allowable Limits
NITRATE -N 3.8 mall EPA 353.2 10
:�ia7n):le ROUTINE SAMPLE COLLECTED BY: CHRIS.
.,a�,.. .:.,.a ....r... ................. r .
1 'Pests Performed See Special Instructions Above UA -Unavailable
ND- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GTWGreater Than
`16INSG7 Member of the SGS Group (Soci6t6 G6n6rale de Surveillance)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date tl4v 196
1.. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lo 2 Bloc l- 3 flack AN S/D
Location (address or directions)
h2Yo 3trry A&ctior C
(b) Applicant Name Rob er f Sr (vtc Telephone: Home 3 y6' '�-Yi'& Business
Applicant Address 6810 Barry /}ue 1 Anchort c -e , Ak W IA'
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ® Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution
A k %JA
pct f;rwdff G{nean
Telephone
"3 -'y5-6'7
Address 7 0
ci-e4l
66?(0n LK -'e
AACAOn51!
9`%So3
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
h6ld .ar Pic k un
2. TYPE OF RESIDENCE
Single -Family G9 Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
3
Individual Well ® 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.
�l
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. 1 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 Fltx fg
J ccAn tta(
Strucco-
Telephone 3'/S- 136-3-
3d SAddress
AddressI Y S30
C-c%O S}.
fC179'-Oc/t
Date . / ly /.?
.,Aa-nw*q
All •o'® � Rao
Ar
n'G) Q9TH
THEODORE F. MOORE •• H
�Vt®c �•.�
CE -3589 ,•,
Q,, o
�
eta�a�so�
6. DHEP APPROVA
Approved for ' 4,f' Ebedrooms by
Approved
Disapp
Terms of Conditional Approval
Conditional
LOW I
MED
CAUTION
Engineer's Seal
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.
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALIT*W;I WMPRITY APPROVAL (HAA)
DEPT. OF HE/CHECKLIST - FEBRUARY 1984
ENVIRONMENTAL PROTECTION 264-4720
MAY 19 1986 Legal Description: /-a � 2 C' �!
60ck (f elf 57D
A. WELL DATA RECEIVED
Well Classification P«f� If A, B, C, D.E.C. Approved (Y/N) N 9
Well Log Present (Y/N) Date Completed 7 / 28 /IT' Yield(_ 0 ver tu
Total Depth G' Cased to Depth of Grouting NSA•
Static Water Level SY' Pump Set At 14^ k
Casing Height Above Ground � Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) N
Separation Distances from Well:
To Septic/Holding Tank on Lot (10 i On Adjoining Lots foo r
To Nearest Edge of Absorption Field on Lot 130 � ; On Adjoining Lots
To Nearest Public Sewer Line N,A To Nearest Public Sewer
Cleanout/Manhole hl, A • To Nearest Sewer Service Line on Lot N, 4,
Water Sample Collected by `rFM// ; Date 3f/6
�f �
Water Sample Test Results ;Cr, S;<Dry ^hv cc',(A "+'' apf"
C
B. SEPTIC/HOLDING TANK DATA
Date Installed 7/1/01 Size I v""aa( No. of Compartments
Standpipes (Y/N) Y, Air -tight Caps (Y/N) `� Foundation Cleanout (Y/N) N
s
Depression over Tank (Y/N) Date Last Pumped 5/17 /gK'
Pumping/Maintenance Contract on File (Y/N) ;for iN16.
Holding Tank High -Water Alarm (Y/N) NPi• Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _ I10 '
To Property Line ;2t .6-0
To Water Main/Service Line
Course ?
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 123 Type of System Design Tree C�
Date Installed 7/1/01 Length of Field 23
Width of Field
Depth of Field H
Gravel Bed Thickness 71
Square Feet of Absorption Area H06 p' Standpipes Present (Y/N)
Depression over Field (Y/N) N Date of Last Adequacy Test SY 66 119C
Results of Last Adequacy Test _Adeyuc4e it 3 bedroc+mf
Separation Distance from Absorption Field:
To Water -Supply Well 1 3 D To Property Line 30
To Building Foundation
Lot N .R
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
To Driveway, Parking Area, or Vehicle Storage Area SO 1
Comments Soil acc!Wji a/ceILet- crf > 3 qa/( pQr minu�G
V r
D. LIFT STATION Ni A,
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) —
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certifythat I havechecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date 184!r
Company j5—&t—Ae rfChnica/ Sir, MOA No. B&.S-o,S-z
Receipt No.
Date of Payment,
0 * 0...
• •*•;S�`'�
Amount: $
AVy�P' Engineer's Seal
%* *49TH i
01
0.�..........,
2 of 2
Page:
..� .�0:::�i
THEODORE F. MOORE ;•
�� �•,• r
CE - 3589 ,•'
72-026 (11/84)A.+
5. LEGAL DESCRIPTION
Lq+
DA..:RECEI ED
INSPECTION APPOINTMENTS
TIME
TIME
TIME
- NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One El Four EJ Other
DATE
DATE
DATE
ER Three ❑ Six
7. WATER PLY
ESU INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
INSPECTOR
INSPECTOR
INSPECTO
depth (attach log if available.)
8. SEWAGE DI POSAL SYSTEM
MU I .OF ANCHOR
INDIVIDUAL/ON-SITE**
. OF HEALTH &
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501 JUL2 r7 1981 n r y
• (,i / 07 CJ I
ENVIRONMENTAL SANITATION DIVISION RECEIVED
Telephone 264-4720
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER n --r(� ^�-
PHONE
MAILING ADDRESS
FLlr L?OK So. 3fq,
PROPERTY RESIDENT (If different fro"above)
PHONE
2. BUYER -
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
Goe-jtf2'leI( (d��� - ��.
PHONE
34 -9�Zz
MAI LING ADDRESS
F-0, Qa} (U2 35? SO C,tq
5. LEGAL DESCRIPTION
Lq+
(Is
STREET LOCATION
u r _! °i-
6. TYPE OF RESIIDENCE
- NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One El Four EJ Other
❑,Two ❑ Five
❑ MULTIPLE FAMILY
ER Three ❑ Six
7. WATER PLY
ESU INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DI POSAL SYSTEM
INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
p
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) _
MI
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
1'
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
6ti Y
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBEPI �
DATE INSTALLED
INSTALLER
❑SepticTankor ❑Holding Tank
Size: /000 If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL _
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
77Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
lff APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
k