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ROLLING HILLS VIEW ESTATES BLK 3 LT 5
Onsite File Rolling Hills View Estates Block 3 Lot 5 #050-322-21 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211268 PID Number: 050-322-21 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New R Upgrade Name BILL HIRST ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19202 MCCRARY RD, EAGLE RIVER ❑ 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 Gravel depth beneath pipe Subdivision Block Lot ROLLING HILLS VIEW EST. BLK 3, LOT 5Fill Ft. Ft. added above original grade Gravel length Township Range Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Lift Station Ft. Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ftp Ft. Well 100'+1 5 01+ TANK © Septic ElS.T.E.P. [IHolding [:]Other Manufacturer Capacity Surface Water 100'+ GREER TANK 1000 Gal. Material Number of compartments Lot Line 10'+ NA PLASTIC 2 Foundation 10'+ LIFT STATION Manufacturer Capacity Remarks TANK DECOM. PER UPC Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield DENALI Drainfield CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assume(Jelevation) 100 ft Inspd tion ction is 7/21/21 2"tl 7/22/21 Location and description Std 4'h TOP OF MH ON-SITE WATER AND WASTEWATER SECTION APPROVAL En Q;e; 4k' p r 4 (DF A� Conditional Approval: Date 1p • ' � 'Ir I $r 49TH ;*�r 0 • MICHAEL N. ANDERSON `k P r ��••, CE- `� Septic System Approved Date 4 9 .• . 41�`�'?� •'��"� 3fy Note: this approval�includeermit requirements, o i\ OF S,kzo`4 tppv nrungtim Permit No. OSP201268 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ROLLING HILLS VIEW EST. BLK 3 LT 5 PID No.: 050-322-21 MARK � B 42 35 TC01 45 43 TCO2 CO2 5046 CO3 1500 25 I �W DRIVEWAY \ i AR I � / I I I WELL ` ASBUILT SCALE: 1"=50' SEPTIC SECTION N.T.S. BENCH, MANHOLE LID T 2 01 CO3 \ W 10 GAL \\PLASTIC TANK 0 I I I I I i DF 49TH o �. �...j+.}... I/.... ...AD... A&.. ..... MICHAEL N. ANDERSON: No. CE 9469 �8-3-21 .•' MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program ft't PO Box 196650 4700 Elmore RoadAnchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997http://w .muni.org/onsite Depament On -Site Wastewater Disposal System Permit Permit Number: OSP211268 Effective Date: 7/22/2021 Work Type: SepticTank Upgrade Expiration Date: 7/22/2022 Tax Code Number: 05032221000 Site Legal Address: ROLLING HILLS VIEW ESTATES BLK 3 LT 5 G:0255 Site Mailing Address: 19202 MC CRARY RD, Eagle River Owner: HIRST WILLIAM M Lot Size in Sq Ft: 36590 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3 This permit is for the construction of: ❑ 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 Received By: Issued By: Date: Date: MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 S� ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-322-21 Property owner(s) BILL HIRST Day phone Mailing address 19202 MCCRARY RD EAGLE RIVER, AK Site address SAME Legal description (Sub'd., Block & Lot) ROLLING HILLS VIEW ESTATES BILK 3 LT 5 Legal description (Township, Range & Section) Lot Size 36,590 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) 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. (Signature of property owner or authorized agent) Permit/Rush Fees: to 0 2l( S 1J Date of Payment: N/Z Receipt Number: 0091 - Permit No. C 5'9,11 1� (I - Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc July 16, 2021 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Re: New septic tank permit Legal: ROLLING HILLS VIEW ESTATES BLK 3 LT 5 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. This new tank will be placed more that 100 feet from the existing well, see site plan. This new tank replacement will not impact any of the neighboring systems or wells. We are planning for a new COSA therefore a new survey will be submitted with the next application showing all of the required off-sets. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211268, Rebecca Carroll, 07/22/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211268, Rebecca Carroll, 07/22/21 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 [] UPGRADE MAI LIN G A~.~I~SS ~'~'~ ~ ~*~ ~'~'"¢~ LEGAL DESCRIPTION LOCATION ~&~e ~Prigc NO. OF BEDROOM~ "~ DISTANCE TO: J Well/~ 9 I Abs°rpti°na,r~/ Dwelling2~ /~ PERMI~~ ~ ~ Manufacturer Mat~ No, of compartments Liq~Bgall°ns IF HOMEMADE: Insid~length Width ~. Liquid depth ~ ~ DISTANCE TO: Well A// .Dwelling PERMIT NO. ~ Manufacturer Material Liquid capacity in gallons ~ Well Foun~6 Nearest Io, li~ Ne. of lines / D istancebetw~/~ -- Length~jh l,,e Total ,e~ l'*s Trench w~/~ inches Total e f fectiv~,aSso rpti~rea ~ ~ ~ T°P °f the t° finish grade ~ Length Width , / Depth PERMITNO. ~ ~ Type of crib Crib diameter ' Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class ~ ~) ~gDepth/~' Driller Distance to lot line PERMIT NO. ~m DISTANCE~ ~ TO:t .-~ ~uildfn~fo~nd~n Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING REMARKS / / / APPR DATE LEGAL F'EF.:M I T NO. FIF'F'L t F:FINT L..EIE:RT Z ON LEGFIL t'-'~L.il'-.t :[ £: :]: F__%FtL :[ T%r" C.,F FII'-.IE:H~F-:Fti3E [:,EPFIRTMENT ('. ' HEF!LTH FIND EI",P,,' I RIDNMENTF-tL ' LFFEtT.:T I I]l'.,l 825 "L"' STREET., FINCHOF.'.FIGE., FIK. 264.-4720 t..-~ E L. b FIt ~'-~ IE::. C, lP.t -- ."E; ,:.' 82:F~555 ) JOSEF'H R. FE[:,ERICI _.-.~,~_-~._, HRTI_. E:L',,,'[:, SP#66t LOT F, BLk -:", ROLLING HILLS VIEW ~_o~& LOT SIZE - -"-- ' .... IS T"r'F'E OF SOIL ME,.=,URF~I .iq S"FSTEM : TRENCH 2.:]:8-77±5 '9~'~'9'~D SQUARE FEET i"'IRXiMIJM NUI"IE:EF.: f]F EEE,R_-_-MS = Z4 SOIL RFtTING '::SQ FT,,"BR)= ±50 THE REg!UIF.:E[:, SiZE OF THE SOIL FIBSORF'TION :,-r:,FElt t'-:'-, [:.E F" T ~4 = :t. 2 L E.' ~'-~ ,]~ T' Fi = 29 ,_~.n ..... -"~ .- "~-- r_~_ [:, E F" TI4 = ---- THE LENGTH DIMENSION IS THE LENGTH (IN FEET;, OF THE TRENCH OR DRFIINFIELD. THE DEPTH OF R TRENCH OR PiT iS THE DISTFINCE BETWEEN THE SURFFICE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTF'FIL[~ PIPE AND THE BOTTOM OF THE EXCFIVRTiON (iN FEET). F'ERMIT APF'I_tCFINT HFIS THE RESF']NSIBtLIT'¢ TO INFORM 'THIS DEF'FIRTMENT [:,LIRING THE iNSTFILLFITION iNSF'ECTiONS OF FIN'-r' WELLS FtDJFICENT TO THIS FRLFEF..T"r FINE:, THE NUMBEF.: OF RESIDENCES THFIT 'THE WELL WILL SEF. t'¢E. Tik-.lCi ,:" L-"Z ":. .I t'-.I=.F E _.T '¢ £,i'-.t~. RF:~ F.: [--_ ,;,.ltJ .~ BFtCKFILLING OF FiN'-r' .:~.:TEtl WITHOLIT FINAL tN:FEL. TILN FIND FIF'PRO",,'FtL E:¥ THIS DEF'FIF.:TMENT WILL E:E SUBJECT TO F'ROSECUTION. MINIMUM DtSTFINCE BETWEEN FI WELL FIND FINY ON-SITE SEWFIGE DISPOSFIL. SYSTEM IS i00 FEET' FOR FI PRI'¢F!]"E WELL OR i50 TO 200 FEET FROM FI PUBLIC I,.IELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTFINCE FROH FI PRIVFITE WELL TO FI PRiVFITE SEWER LINE IS 25 FEET' FIND TO FI COMMUNI'T~' SEWER LiNE iS 75 FEET. i.4ELL LOGS FIRE REC~UIRED FIND MUST BE RETURNED TO THE DEPFIRTMENT WITHIN _~0 DFI'.r'S OF THE WELL COMPLETION. OTHER REQUiREHENTS HFI'T' RPPL'¢. SPECIFICFI'TtONS FIND CONSTRUCTION DIFIGRFII"IS FIRE FI',/FIILFIBL. E TO INSURE PROPER INSTFILLFITION. i CEF.:T I F'-r' THFIT i: i FIM FFIMILtFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS FIS SET FORTH B"r' THE MUNI.5iPFILiT'T' OF FIi",tSHOF.'FIGE. ,~:: ~. WILL INSTALL THE :,'r:TEli It",i FICCOF.:[:,FINCE WITH THE ::ODES --":: I UN[:,ERSTFIND THAT THE ON-SITE .=,EI~EF...='r.=,TEH MW'r' F.'EL--.'~IRE ENLFIRGEMENT IF THE RESIDENCE IS F. tEHOE:,ELEE:, TO INCLUDE MOF.:E THAN ]: BEDROOMS. S i GNED: ................................................. FIPF'LICFINT .]'OSEF'H R. FEDERICI PEJ~li~ r NO. L.L~=RrION DEP Tli = '1-2 LENGTH------ 25~ CiRFI~)E:L DEPTH"" '~'"'~OUNG RND T~ 80TTOM ~ THE :E~R~RTION (IN ~E~). ] THE ~R~ ~TH [~ T~ D][N[~IU~ ~H ~ ~ ~DE~RRT~PE~NT HJ~ ~ ~UJ~JECr T~3 PROSECUtiON. ~ -H[NI~JU~4 DISTRNC~ EET[4E. EN R 'I4ELL FiND RNY ON-~JTC ~_~J, IRG~ OISPOSRt 5~TEFt tS f. UPON T~ TYPE ~ PU~IC ~L ~ [ C(RT~FV THRT MUNICIPALITY OF ANCHORAGE DEPARTM;~NT OF HEALTH AND ENVIRONMENTAL PROTEC'FiOF~ TES', L. Street, Anchorage, Alaska 99501 2G4-4720 SOILS LOG -- PERCOLATION TEST ~G~- ~q~O COMMENTS PERFORMED ~'/: .... ND WATER NTERED? Depth to ! Net Water i Drop AT WHAT 'H? Gross N Reading Date Time Ti~ PERCOLATION RATE (minutes/;m;n) /' TEST RUN BETWEEN FT AND FT U N I A� T YY O �� RAGS. r e�awcaz�ceaa�roa�+erF:�zre�a�s.�rs�r-^`^"��t�^�aus4ur P11r;rte:9t3 3A .904 )r'!- :ic, 1jl�aif C 'v�1 rlSf� :"'Jc`i c'i' F,`:llC}rl ;-fir: Certificate of On -Site Systems Approva Parcel I . D. 050-322-21 1. GENERAL INFORMATION Expiration Date: 2 Complete legal description ROLLING HILLS VIEW ESTATES BLK 3 LT 5 Location (site address) 19202 MC CRARY RD, CHUGIAK, AK Current property owner(s) Mailing address Real estate agent BILL HIRST SAME 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: CCSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ .5-50 Waiver Fee $ _ Date of Payment -_ g 6 oZ0,2 Date of Payment Receipt Number Q0 6 0 Z Receipt Number. COSA # 0±5c2-01-157 Waiver # 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 8-5-21 OF Al';'i• P. . �a.•�...� ¢t� 6. DSD SIGNATURE fir: 49TH .�- ..1, a System #1 Approved for 3 bedrooms �..........:............ System #2 Approved for bedrooms / VO MICHAEL N. ANDERSON69 :4 ' Disapproved t��1f.•...CE%9r Conditional approval for bedrooms, with the following stipu�FFS$14��t�"` .ttllllltttl(((((i.. 8Y Original Certificate Date: g 7 The Municipality of Anchora 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 Checklist blue sheet COSA Checklist Legal Description: ROLLING HILLS VIEW ESTATES BLK 3 LT 5 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 6/26/83 Total depth 318 ft Cased to E+ --ft ❑� Sanitary seal is functioning correctly Q Wires are properly protected Casing height (above ground) 20"+ in. Date of flow test for COSA 6/23/21 Static water level at beginning of test 58 ft. Comments B. TANK DATA Age of tank(s) new years Tank type/material Measured operating fluid level in septic tank new 0 Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA Which system tested (date installed) 8/27/83 X ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A —pressurized field ❑� Monitor tubes go to bottom of effective. If not, state depth into effective ❑� Code -required soil cover over field Parcel ID: 050-322-21 Structure served by this system _ Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes No X Coliform bacteria is Negative Nitrate 3.66 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L N Arsenic less than MRL (ND) Collected by MNA Date of Sample C. LIFT STATION 6/23/21 ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 6/23/21 Results Q✓ Pass For 3 bedrooms Fluid depth prior to test 40 in Water added 500+ gal New depth 48 in Elapsed time 1440 min Final fluid depth 40 in El system presoaked Absorption rate 500+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) _ date of test) Gallons introduced 0 gallons If yes, enter date Comments/Deficiencies: 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' Community Sewer Manhole/Cleanout > 100' ❑v Yes if No _ It 2✓ Yes if No _ ft Neighboring Tank > 100' Yes if No _ ft Private Sewer/Septic Line > 25' EZI Yes if No _ ft Absorption Field on Lot > 100' ❑✓ Yes if No_ ft Holding Tank > 100' ❑v Yes if No ft Neighboring Absorption Fields > 100' ✓❑ Yes if No _ ft Animal Containment > 50' ❑✓ Yes if No ft Community Sewer Main > 75' [D Yes f No _ ft Manure/Animal Excreta Storage > 100' R✓ Yes if No _ ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑v Yes if No _ ft Surface Water > 100' ❑✓ Yes if No _ ft Property Line > 5' 0 Yes if No _ ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No _ ft Private Wells > 100' 0✓ Yes if No _ ft Water Main > 10'v❑ Yes if No _ ft Community Wells > 200' ❑s Yes if No _ ft Water Service Line > 10' Q 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' Yes if No _ ft Wells on Adjacent Lots: Water Main > 10'✓❑ Yes if No _ ft Private Wells > 100' Q Yes if No _ ft Water Service Line > 10' ❑v Yes if No _ ft Community Wells > 200' ❑v Yes if No—ft Surface Water > 100' v❑ Yes if No It F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION3� OF At- X q R 1 certify that / have determined through field inspections and review yip' ........ ' • • of Municipal records that the above systems are in conformance with o * ; 497 H /� MOA COSA guidelines in effect on this date. , • .......... J...... • ......... J. v0 MICHAEL N. ANDERSON ; 10 CE 94 9W COSA Checklist yellow sheet ,t1j PRpFE�c��tt����-r 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. # 050-322-21 \~ 1. GENERAL INFORMATION Complete'legal descri]~tion Rolling Hills View Estates Lot 5; Block 3 Location (site address or directions) . Eaqle River, AK 99577 Prope~y owner ~a~b=~ .q~ ~ 1 i wat¢r. Day phone Mailing address c/o Jack White Real Estate Anchorage, AK Lending agency Day phone Mailin. g address .... Agent Judy Rosenberg/ Jack White Day phone 563-5500 Address "3201 "C" Street Suite 200 Anchorage,--AK 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xx Community well Publio water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site ×× Holding tank Community on-site Public sewer NOTE: 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 Name of Firm Address Engineer's signature STATEMENT OF INSPECTION BY ENGINEER As certifie~d 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 Ancho_rage files and from my investigation and inspection, the on-site water supply and/or wastewate~ disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. AI.i)~ WATER & WASTEWAI'E~ Phone 6901 DEBARR ROAD, SUITE 2B ~ANCHORAGE, ALASKA ~ Date Z/_ ¢_ ¢ ,~ Alaska Water & Wastewater Consultants, Shall be PAID $ ~'~% ~ or prior to, closing for the Engineering Services Provided. DHHS SIGNATURE ~ Approved for--''~ '~,~ ~- o Disapproved. Conditional approval for bedrooms. 7953 bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of'Health and Human Services (DHHS) issues Health ^uthodty 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 es 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 RECEIVED Municipality of Anchorage APR 19 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division M~JNICIPA~TY,~JF 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)~N3v4~4'~~'sE"glc~J=~'Illsi~ Legal Description: L-o'~ A. WELL DATA Health Authority Approval Checklist NILL~ ~IE(~..~ .._~Ol~'~,',O~; Parcel I.D.: 050 -~2Z~ ZI Well type JgC, r,h~.'T'~' If A, B, or C, attach ADEC letter. ADEC water system number I'~ Casing height (above ground) Wires properly protected (~N) Log present {~N) ~/E<~ Date completed Total depth '~\0 Cased to /~)t t- Sanitary seal ~)/N) ~ Date of test Static water level Well production FROM WELL LOG g.p.m. AT INSPECTION 1 Iq'z g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: ,~/I)/ Nitrate /, ~.~ 2 ~ //-. Other bacteria Collected by: JS,,,g,3. b.J.C.. ~ I ~,1~. B. SEPTIC/HOLDING TANK DATA Date installed ~'/~ ?/~ Tank size Foundation cleanout (~)'N) ~- Date of Pumping .~/~/~ ~ I~,o Number of Compartments Z_ Cleanouts~N) Y~--~ Depression (YX~[~ /X]o High water alarm (Y~ Pumper '-~ P'- C. ABSORPTION FIELD DATA Date installed ~/~ -//~ Length '~°t Width ._~ Effective absorption area /-}50~ Date of adequacy test .g/Il ' Ig4q Fluid depth in absorption field before test (in.); Fluid depth O~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y~). 72-026 (Rev. 3/96)* I~=~¢ Soil rating -(-~(~ o~ Gravel thickness below pipe Monitoring Tube present (~/N).Y~, Depression over field (Y~ Results (Pass/Fail) ~)~.~.5 For -~> bedrooms O,~ Immediately afterqSG gal. water added (in.): IC ~,~ L~ l) ~0 Absorption rate = ~0~ g.p.d. ~ ~¢~ If yes, give date D. ,LI RT.-~$ATI~N ~ Manhole/Access (Y/N) ~~D~~-- "Pump off" level at* ig w~ d *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot ( On adjacent lots I O~?'J' On adjacent lots Public sewer main ~J //~ Public sewer manhole/cieanout I~/~, Sewer/septic service line 'Z'-~t ~' Lift station SEPARATION DISTANCES FROM SEPTIC/J,~i~TANK ON LOTTO: Foundation I o~- Property line -t- Absorption field Water main/service line Surface water/drainage I coif' Wells on adjacent lots J co 14 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ~ o t 't'. Building foundation I o I .~ Surface water 1 ookf'' Water main/service line Curtain drain ENGINEER'S CERTIFICATION ,nconforrnanc~ with/;~uide Signature I ~,,//"/11 J"'\ ...-..., Engineer,sUaTe/11 . Driveway, parking/vehicle storage area Wells on adjacent lots It inspections and review of Municipal re. cj~.~-~ ~. are ne.~sineffect on this date. HAAFee $ ~r~ , ~ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number R~ck Mystrc~. /Vl~ Vo r Mtmicipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.ci anchorage.ak.us April 15, 1999 Jeffrey Gatfiess, PE Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2B Anchorage, AK 99504 Subject: Revise waiver #WR930021 Dear Mr. Garness: Your request for modifying waiver #930021 from 95' to 90' has been approved. The new approved separation distance is 90 feet. Originally, 17.2 points were granted for this waiver. This modification will reduce the points to 17, which is still well within the range of acceptability. This waiver approval applies to the existing on-site wastewater disposal system to private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department.' If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Donna C. Mears, E.I.T. Civil Engineer On-Site Water Quality Program Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B N Anchorage N Alaska 99504 Phone (907) 337-6179 - Fax (907) 338-3246 April 8, 1999 Municipality of Anchorage Department of Health & Human Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED APR 9 1999 Municipality ot Ancr~orao$ Dept. Health & Human Servicos Subject: Modification to Waiver for Lot 5, Bk 3, Rolling Hills View Estates Waiver # WR930021 To whom it may concern: Application for Health Authority Approval on the subject property was submitted by Tobben Spurkland, P.E. and approved by D.H.H.S. on May 28, 1993. A waiver was requested and granted for the separation distance between the septic tank to the private well at 95 feet, copy attached. On March 11, 1999, Alaska Water & Wastewater Consultants, Inc. performed a well and septic test on the subject property. On the day of our inspection we found the distance between the well and septic tank to be only 90 feet, see attached asbuilt survey dated May 10, 1993. Request you modify the existing waiver # WR930021 to read 90 feet between septic tank and private well. If you have any pquestio~ns, lease contact me at 337-6179. this matter. ~ ~s~nAt~amess, P.E., M.S. Thank you for your consideration in ~t~ CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 990940001 AK Water & Wastewater Consultants Inc. Rolling Hills View Lot 5 Blk 3 Outside Hose Bib Drinking Water Sample Remarks: Client PO# Printed Date/Time 03/18/99 16:51 Collected Date/Time 03/11/99 14:12 Received Date/Time 03/12/99 12:40 Technical Director: Stephen C. Ede Parameter Results PQL Units Allowable Prep Analysis Method Limits Date Date Init Total Coliform Nitrate-N 0 1.62 co[/lOOmL SM18 9222B 0.100 mg/L EPA 300.0 10 max 03/12/99 KAP 03/12/99 03/12/99 SCL RECEIVED APR 9 ]999 MUnicipality ol Anct~o~aoe Dept. Hea/th & Human ServJce~ 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 0~0 "~ '7'o ~Q~- ~-~ HAA# ~c~ 1. GENERAL INFORMATION Complete legal description L~+ ~' ~ P~K_3 Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address Day phone J 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- ing 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. 72-025 {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 compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofF rm Phone ! Engineer's signature DHHS SIGNATURE N Approved for ,~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST If A, B, or C, attach ADEC letter. ADEC water system number Date completed J ~ ~'~ Driller L;ased to i ,r,,5 D~ Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test / ~ ~ ~ Static water level / ~ Well flow ~ g.p.m. Pump level '~O .~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ///.,,O '~ Public sewer main ~'~//~ Sewer service line '~ ~ O WATER' SAMPLE RESULTS: Coliform '~ Nitrate Date of sample: '~/'~ / ~ ?~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cieanout Petroleum tank r9 ,q Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) y Tank size Foundation cleanout (Y/N) Y Compartments ~' Depression (Y/N) N High water alarm Date of pumping Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ? ~) To property line ~' J Surface water/drainage On adjacent lots Absorption field / (--,'~ Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION //.-~ Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/~- 7/ Length ¢-~ Width Total absorption area Dep~'essi0n over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating / ~ Gravel thickness (~ Cleanouts present (Y/N) Date of adequacy test System type Total depth /01/7-. for '~ %"1 If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~ I~) ~ On adjacent lots ~ / ¢IL~ Propertyline To building foundation ~ ~ To existing or abandoned system on lot On adjacent lots Surface water Curtain drain Cutbank ~ ~O Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on-the.date of this inspection. Signature ~"~~ Engineer's Name ' ~ [~[~ u,! ~,'~J¢~/~,CLt~'~-~ Date HAA Fee $ ,/~ ~-~ Date of Payment ,- '~- //-~ Receipt Number ~/~/~ ~-~¢ Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE ,, Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ WR930021 PID# 050-322-21 HA~ Date Received: May 4, 1993 Legal Description: Lot 5 Block 3 Rollinq Hills View Estate Subdivision Engineer: Tobben Spurkland, P. E. 203 West 15th Avenue %206~ Anchoraqe~ Alaska 99501 Applicant: Chris Kleinke Waiver Requested: Well to septic tank - 95 feet Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: ~x< Waiver is NOT Granted: List Conditions or Reasons for above: ~_~-~ /~_~-7g~'~/~W~ ~ r BIZ: ~f~e v i e we Rec %: 24652/7718 Amount: $ 410.00 Date Paid: May 4, 1993 Tom Fink, Mayor un pality Anckorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 May 28, 1993 Tobben Spurkland, P.E. 203 West 15th Avenue #206 Anchorage, Alaska 99501 Subject: Waiver Request for Lot 5 Block 3 Rolling Hills View Estate Waiver Request ~WR930021, PID ~050-322-21, HA930229 Dear Mr. Spurkland: Your request for waiver(s) of the required 100 foot horizontal separation of a septic system to a private well has been approved. The approved separation distance(s) are private well to the septic tank of 95 feet. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, Daniel J. Roth Civil Engineer On-site Services DR/ljm -7.,l /Z2 ANCHORAGE, ALASKA 99502-3904 (907) 248-5095 D:L vi s~.i. (::~r"~ cY,c Er",,vi r"c:,r'm~errt:a], i...l~<.:a][ D~::~l:xa~,"t.m~::,r'r~: o.F He:,alt. h and Soc::[a]. E~2() L. Sub :j ¢,:,c:i: ::t::~E:{EUES'f' EOF: ~*fl:~ t VEl::;: OF SEF'¢~Rf:~T F'RIV~::(I"IE WE]....L. 'TO SEPTIC L. CYf' 5 ~ Ed.,.J3CK 3; ,~ F;;CJL. I,... I NG H I L.[...S V I E:~4 ES"f'P(TE Ei(). ()2. C). Pl.::,r" rn~'::,a'~b :J. i :i. 't':. y Gr"ad i S(:.::,p a r" a'{:. :[ 7 ,, 5 MUNICIPALITY OF ANC, HORAGB ENVIRONMENTAL SERVICES DIVISION RECEIVED 0 '¢': C: Ot"l '{:: Y:< fR J. {"~ ~'e, ..... 1 I £0 0 ~0 40 60 80 SCALE = 40 FT elev, ¸O7 1 O0 1~0 TD3BEN SPURKLAN9 P,E, 203 ~ ]STN, AVENUE ANCH, AK, 99501 LOT $ ~LOCK 3 ROLLING HILLS VIEI~ EAGLE RIVER KRIS KLEINKE SEPTIC SYSTEM LAYI] D^TE, MAY 4, 1993 SHEET, 1/] KIRK AVE. 19445 19446 19624 12525 ~ccRATY ptoM~'STt/AD ~ 19306 9424 MEADOW SKYLINE /'? D CANYON NW 255 82 88 87 -.~> 89 COPYRIGHT 1989 JMR 95 Eagle RiverlChugiak Area Reference Map--lC 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 GENERAL INFORMATION (a) Application Date April 25, 1986 Legal Description (include lot, block, subdivision, section, township, range) Lot 5; Block 3; Rollinq Hills View Estate Location (address or directions) (b) Applicant Name Chris Kleinke Telephone: Home 694-6765 Business Applicant Address SRB 7404, Eaqle River, Alaska 99577 (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); 786-1002 (d) Lending Institution Lomas and Nettleton Telephone Address Anchoragg_r Alaska (e) Real Estate Company and Agent none/refinance Address Telephone ..Ho id (f) -,ICallthe HAAtothefollowing address: S & S Engineering SRB 196X Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Number of Bedrooms 3 Other WATER SUPPLY Individual Well E~k Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite ~ Public [] Community[] Holding Tank [] Note: tf community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND I,NFORMATION 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 ~ & $ ~NG.~NEER!HG Telephone Address sr~ B 196X Date F. AGLE RIVER, AK 99577 ~"--' / DHEP APPROVA~ ~--'~,.~.~// / .. Approved ,,~ Disapproved Conditional Terms of Conditional Approval . ' CAUTION .'..".. ,The MUncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority ~...ApprO;Val certificates based solely upon the representations given in paragraph 5 above by an independent professional engin'eer 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 (MO~/ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Lega, S- a ECEIVED MUNICIPALITY OF DEPT, OF HL/,L ENVIRONMENTAL 0 2'19 6 WELL DATA Well Classification Well Log Present Y~4~ Total Depth "~ I ~2, ' Cased to Static Water Level [ ~ I Casing Height Above Ground Electrical Wiring in Conduit~/H') Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed ~/.~ - 'Z- L~ ~ ~'~ Yield Depth of Grouting Pump Set At ~,~O~.~ i Sanitary Seal on Casing ~N')" Depression Around Wellhead,~¢~ ; On Adjoining Lots To Nearest Edge of Absorption Field on l~ot \ ~, '~-~; On Adjoining Lots To Nearest Public Sewer Line ~f"~ I~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ~¢ ~:~,~-"~/'6 ~/1~ ; Date Water Sample Test Results ~",~,-~r~s ~-~-~ Comments B. SEPTIC/HOLDING TANK DATA Date Installed ¢¢ ~ '1- ~/"¢ Size /'~,)00 No. of Compartments Standpipes (~¢)N,)~ Air-tight Caps~¢~)/4~ Foundation Cleanout .(~N~ Depression over Tank ¢t~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High-Water Alarm (Y/N) -"--- Temporary Holding Tank Permit (Y/N)" Separation Distances from Septic/Holding Tank: To Water-Supply Well ,/cO ~ 'f To Building Foundation To Property Line / ~' '~ To Disposal Field To Water.4~C~C~ervice Line '~ '~ r ~- To Stream, Pond, Lake, or Major Drainage Course Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ..~1'~,..~? WiOth of Reid Type of System Design "~/~--~ Length of Field ~ ~ ~ Depth of Field ? ~ / Square Feet of Absorption Area Depression over Field ~/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Welt To Building Foundation '~ Lot '"J'/~ Gravel Bed Thickness Standpipes Prese nt~/~ Date of Last Adequacy Test To Water'Mafrr/Service Line ~ ~ t ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at 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. S & $ ENGINEERING 5'-~ / ~ ~ ~ Signed Date SRB 196X MOA No. ,~ C°mpany~:J,~[l= RIVER, AK Receipt No. :_:~ ~ "~ ,'~ F ~ Date of Payment ~' ~ o~ ~o~ ~; Amount: $ ~ ~'7~'~ ~ Page 2 of 2 72-026 (11/84) 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 4-~'/'JO '"' ~' GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) ApplicantName-"~'~' ~"~.~¢~,'¢-~! Telephone:Home ~¢,'¢¢~,"~.~Z.- Business Applicant Address .~--- ,'~ ~7 4¢ ¢ ~ ~'~.%z~-¢~ Z..ET /~¢:~! (c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain); (d) Lending Institution ~ (:2 ~ ,~ Telephone Address (e) Real Estate Company and Agent Address T. elephone (f) M'afl the HAA to the following address: TYPE OF RESIDENCE Single-Family.~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Weil~l~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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. PRat, I ,'-,f 9 72-025 (t'1/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown betow, I verify that my investigation of th~s 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 ~ ~ ~ 'E:'~J~EERt~,.~ Telephone Address '~:~ ,Q].~ ~ ~S~ ~;~7~ Date Y~3~ 7 /~.~ / Approved for,~-¢.--~ bedrooms b ~' ~ Approved ~ Disapprovb"d Conditional- Terms of Conditional Approval 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. MUNICIPALITY OF ANCHORAGE (MOA) DEPT. HEALTH AUTHORITY APPROVAL (HF~tRONMEN~AL Legal Description: ~ r~ WELL DATA Well Classification Well Log Present~N) Total Depth '-~ ~ [;~ / Cased to ~'~ Static Water Level 'J F~C~ / Casing Height Above Ground ~_~. Electrical Wiring in Conduit ~) Separation Distances from Well: To Septic/NeNt~,~ Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by . ~ ~ ~ Water Sample T~st Results ~,~/7 5'/¢~b~'' Comments If A, B, C, D.E.C. Approved (Y/N) Date Completed ~¢ '~-~ -' ~¢ % Yield Depth of Grouting ' - Pump Set At ":'~¢':~'~ Sanitary Seal on Casing f~N) Depression Around Wellhead (Y/4~ ; On Adjoining Lots i [.%" / ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on ; Date B. SEPTIC/H~:~M~G TANK DATA Date Installed g:~,~'7- Standpipes Depression over Tank (Y(~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-water Alarm (Y/N) "~/,A Separation Distances from Septic/..~e!d!.,~cTank: To Water-Supply Well I To Property Line },('~ To Water Main/Service Line Course '~/,A. Size ! ~-,2:~ No. of Compartments Air-tight Caps~N) Foundation Cleanout~---,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 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ¢~ Width of Field "~:~ '~ Type of System Design Length of Field ;~"~/ Depth of Field /2 Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ~/~* To Water Main/Service Line CE:~ l~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Gravel Bed Thickness Standpipes Present<~]) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) ~"'//~ Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at 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 S gned ~ r~ ~ E,,IGINEER,N~" Date ~/~-' 7/~ ~ Com~y;~E ~IVER. A~SKA ~957~ MOA No. ~ ~ ~ ~ ~ PH, 694-2979 Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) effect on the date of this inspection. APPLI ' ',NT FILLS OUT UPPER HA/ ONLY Propertj~.(~,~ner ~.~ ,~ ~ ~T~ ~.~.~(~ t Phone Mailin~Addre~ ~ ~ ~ ~ V- ~ ~.~ ~ Zip Code ~;'~ (y.5-- ~/~ Address Zip Code Realty Co, & A~nt Phone Address ~' /g Zip Code Type of Residence ~ Single Family ~ Multiple Family No. of Bedroo~ ~ ~ Other Water Supply ~lndividual~' ~ A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community / ' For wells drilled prior to that date, give well depth (attach log if available,. ~ Public Utility Se~er Disposal ~dividual Year Individual Installed: ~ ~ ~ '~ ~ Public Utility When Connected to Public Utility: _~ . /~ ~ ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time ' Inspector Inspector Inspector Inspector ~,~/ // Field Notes: ~ ~ ~ ¢~w~r- ('O[..{r.~ MU~ICIPALI~ OF ANCHO~GE % ~, OF HF/,LTH ~. ~,O' ' ~NVI~ONMENTAL P~OTECTION ( ~ APPROVED BEDROOMS *C~DITIONS OF APPROVAL ~ ( , DISAPPROVED ~ ~'~ O ~ a~ ( ) CO.O T OhAL A..ROVAL* Soils Rating Date ~wer Installed Well To Absorption Area / ~ o ~ · Well Log Received ~ ~ ~ -~ Well to Tank ~ o % Septic T~k Size ~' APPLIC ,qT FILLS ouT UPPER HAL ONLY~ Address Zip Code Address Zip Code Realty Co. & Agent Phone Address /~ ~ Zip Code Type of Besidence :' - [~S-~n g le Family [] Multiple Family No. of Bedrooms [] Other W~er S~pp,y I~lndividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility ~'lndividual 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 ~ime / Time Time Da,e Da,e Date /S--'83 Date _ Inspector Inspector Inspector ,, ,,~?.~., Inspirer ~ieldN°tes: ~~ ~ C''~' ~ ' DEPT. OF HEALTH ~o n~ ~'~ ~-~~ ' . ~v~ox~T~?oN RECEIVED *OONDITIONS OF A~ ( ~D BEDROOMS ( ) CONDITIONAL APPROVAL* t ~ ~ ~ ~ ~ Soils Rating Date ~wer Installed Well To Absorption Area J ~0 ~ Well Log Received ~ ~:fi;' ~-'=~- ~ Well to Tank ~,~ ~ Septic T~k Size