HomeMy WebLinkAboutRAYMOND TEDROW BLK 1 LT 5-B2Raymond
Tedrow
Block 1
Lot 5-B2
#050-155-56
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�����JE: �11 :1L � , ',w'. �IF:�- ���11 .11 IE:]l IVR! C!11 IIEH:
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STRE�T, ANCHORAGE, AK 99501
264~4720
K311""ll^- 1 K"JI EE: U�11 ..
PERMIT NO: 840823
DATE ISSUED: 09/26/84
APPLICANT: C/O S & S ENG/G" RANDY GILBERT
ADDRESS: SIRE) 196X
EAGLE RIVER, AK 99577
CONTACT PHONE: 694-2979
LEGAL DESCRIP: SUBDIVISION: RAYMOND TEDROW
SECTION: 12 TOWNSHIP: 14N
LOT SIZE: 8000 (SQ"FT. OR ACRES)
LOT LOCATION: REFERENCE 0-7728 FOR RESUB TO
LOT: S1/2 5~B BLOCK: 1
RANGE: 2W
certi�y that:
1. I am familiar
sewers and
wells as set
forth by
Anchorage (MOA)
and the State
o[ Alaska. '
2^ I will install the
system in accordance with
all MOA codes
and regulations,
and in compliance
with the design criteria of
this permit^
3" I will adhere to all
MOA and SLate of Alaska
requirements
for the set back
distances .1rom any
existing well, wasr
,disposal system
or public
sewerage system on
this or anyadjacent or nearby
lot"
,
SIGNED DATE:
.'�---=-=~�--���
APPLICANT: C/O S�& S �NG/G" RANQY GIL��RT
DATE \/
ISSUED BY : / ''~-�, d'
... ..... ������������������... ..... ..... ..... ���~� ��... ..... �..... ..... ... .. ..... ..... .....��
Certificate of On -Site Systems Approval
Parcel I.D. 050-155-56
Legal description Raymond Tedrow Block 1 lot 5-B2
Site address 17324 Adams
Current property owner(s) Bradden
Expiration Date: 3-12-2023
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By: Original Certificate Date:_
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
MUHMPA UTY OF '-` HC HOo'vAOIE
Development Services Department_ Phone. 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050155560
Complete legal description
Location (site address)
RAYMOND TEDROW BLOCK 1 LOT 5-B2
17324 ADAMS
Current property owner(s) BRADDEN
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑■ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age NA - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for: NONE
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ AD ``AA
Date of Payment 61y��
COSA # 0`JC a �l JAG%
Waiver Fee $
Date of Payment
Waiver #
COSA Application—June 2022
Legal Description: RAYMOND TEDROW BLOCK 1 LOT 5-132
Parcel ID: 050155560
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached) Well production at time of test +3.9 gpm
Date drilled 1984 Total depth 140 ft Water storage tank volume NA gallons
Cased to 140 ft Well disinfected for coliform test? ❑ Yes ❑ No
❑ Sanitary seal is functioning correctly ❑ Coliform bacteria is Negative
❑ Wires are properly protected Nitrate 4.43 mg/L ❑ Nitrate less than MRL (ND)
Casing height (above ground) +12 in. Arsenic ug/L ❑ Arsenic less than MRL (ND)
Date of flow test for COSA 11/30/22 Collected by C&M ENGINEERING
Static water level at beginning of test 104 ft Date 11/30/22
Comments Well pumped down to 125' BTC during test and stabilized at 3.9 gpm at that depth.
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate and.
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings)
Effective depth used in
Effective depth remaining in
N
Comments/Deficiencies: THIS PROPERTY IS SERVED BY PUBLIC SEWER. SEWER LINE FOUNDATION
CLEANOUT LOCATED TO CONFIRM SEWER LINE IS LOCATED AS SHOWN ON ASBUILT SURVEY IN FILE.
COSA Checklist June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
❑ Yes
if No
Community Sewer Manhole/Cleanout > 100'
❑Yes
if No
ft
Dyes
if No ft
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' W Yes
if No ft
Neighboring Absorption Fields > 100'Animal
if No
ft
Containment > 50' FM
if No ft
0 Yes
if No
ft
ft
If tank or field is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
❑ Yes
if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No
ft
Surface Water > 100'
❑ Yes if No ft
Tank to Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes
if No
ft
Private Wells > 100'
❑ Yes if No ft
Water Main > 10'
❑ Yes
if No
ft
Community Wells > 200'
❑ Yes if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
Well wiring conduit at cap repaired.
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm C&M ENGINEERING
Engineer's Printed Name CHARLES BALZARINI, PE
COSA Checklist June 2022
Phone 907-854-5558
Date 12/05/22
ENAAJS
MUNICIPALITY OF F ANCHORAGE
i •
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section N— Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 050-155-56 Expiration Date: 1
1. GENERAL INFORMATION
Complete legal description RAYMOND TEDROW BLOCK 1, LOT 5-B2
Location (site address) 17324 ADAMS LANE, EAGLE RIVER, AK 99577
Current property owner(s) ERNEST L. SCARBROUGH Day phone
Mailing address PO BOX 11161, RENO, NV 89510
Real estate agent Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
n Duplex
(� Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Private Septic n
Private Well ® Holding Tank
Water Storage U Community ❑
Community Well ❑ Public Sewer MI
Public Water System ❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 556 Waiver Fee $
Date of Payment lag/19 Date of Payment
Receipt Number Da 9D Receipt Number
COSA# 05(141,20- 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 ANDERSON CONSTRUCTION&ENGINEERING Phone 345-3377
Address 4661 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N.ANDERSON, PE Date 06/26/2019
Comments:This investigation was completed in compliance with MOA guidelines,regulations,
and best industry practices/methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested.The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface,changes in land use, OF \
local soil characteristics,groundwater levels that may fluctuate during the year,quality of /�� ....` �4�1
construction(workmanship&materials),the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to �G�. �4-
these various and dynamic characteristics and are outside the control of the evaluator of the * :49 I i /N *
well and septic system. Therefore,any estimate of how long a system will function satisfactory ���G II v��-0
for current or future occupants or guarantee that no unseen encroachments,deficiencies or I
discrepancies exist can be given by rurcand Anderson Construction&Engineering.
•MICHAEL N. RSN.
No. ANDE
CE 9489 O
6. DSD1,!.4
6. D •
t 6/26/19
System#1 Approved for 3 bedrooms ssiolos'
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
ill TY(ori�
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'61By: __A � Original Certificate Date: 7- 2 -/
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: RAYMOND TEDROW BLOCK 1,LOT 5-B2 Parcel ID: 050-155-56
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA
®Well log is filed with Onsite (or attached) Water storage tank volume NA gallons
Date drilled 9/1/1984 Well disinfected for coliform test? ❑Yes ® No
Total depth 140 ft ® Coliform bacteria is Negative
Cased to 140 ft Nitrate 4.25 mg/L ❑ Nitrate less than MRL (ND)
® Sanitary seal is functioning correctly Arsenic ug/L ®Arsenic less than MRL(ND)
®Wires are properly protected fwr5
Casing height(above ground) 18+ in. Collected by
Date of flow test for COSA 6/18/2019
Static water level at beginning of test 105 ft. Date of Sample 6/18/2019
Well production at time of test 4.1 gpm
Comments
B. TANK DATA -PUBLIC SEWER C. LIFT STATION
Age of tank(s)years ❑ Required maintenance completed
Tank type/material Age of lift station years
Measured operating fluid level in septic tank Lift station material
❑ Standpipes/foundation cleanout per record drawing Comments:
Date of pumping
D. ABSORPTION FIELD DATA -PUBLIC SEWER •
Which system tested (date installed) Adequacy test date
❑ ALL standpipes present per record drawing Results ❑Pass For bedrooms
Total measured depth from grade ft(max) Fluid depth prior to test in
Measured depth to pipe invert from grade ft(min) Water added gal
❑ N/A—pressurized field New depth _in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time min
depth into effective
❑ Code-required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist.docx
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'
® Yes if No ft ® Yes if No ft
Neighboring Tank> 100' ® Yes if No ft Private Sewer/Septic Line> 25' ® Yes if No ft
Absorption Field on Lot> 100' ® Yes if No ft Holding Tank> 100' ® Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment> 50' ® Yes if No ft
® Yes if No ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main > 75' ® 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 ft Wells on Adjacent Lots:
Property Line>5' ® Yes if No ft Private Wells
> 100' ® Yes if No ft
Absorption Field > 5' ® Yes if No ft
Community Wells>200' ® Yes if No ft
Water Main > 10' ® Yes if No ft
If septic tank is under driveway comment below
Water Service Line> 10' ® Yes if No ft
Surface Water> 100' ® Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below
Property Line> 10' ® Yes if No _ft Wells on Adjacent Lots:
Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No _ft
Water Service Line> 10' ® Yes if No ft Community Wells>200' ® Yes if No
Surface Water> 100' ® Yes if No ft
F. ENGINEER'S COMMENTS
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.
711119
COSA Checklist.docx •
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•trim t,t•r_mei its,. ftrY Tilt* rimy. ;Erman s. a_can-TATM Lam slimier= 6.13-4566 I
\ Municipality of Anchorage
• -- Development Services Department
,.. ,
Building Safety Division
On -Site Water and Wastewater Program ,
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D.0S0-155-56 COSA# GCI C32Z
Expiration Date: / 2 -/ R - O q
1. GENERAL INFORMATION
Complete legal description Lot 582; Block 1; Raymond Tedrow Subdivision
Location (site address) 17324 Adams Lane Eagle River, AK 99577
Current Property owner(S) Virginia Jacobson Day phone
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Vanna Siackhasone / Prudential Day phone 7204663
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
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
El
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (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 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 S a s Engineering
Address 15861 S. Birchwood Loop Chugiak, AK 99567
Engineer's Printed Name RobertA Shafer
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Phone 694-2979
D<
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
NKUUKAM
By: Original Certificate Date:
(RH IIM)
Municipality of Anchoragc a
Development Services Department °
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OFF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: LE 433'/JrJS� /�tn K 4 rM2) &rOMID Parcel ID: iS-0
p
A. WELL DATA
Well type ��'I� / 11A. B,orCprovide PWS�ID�#=
Date completed �iRY Sanitary seal( N( i �S
Total depth Cased to if c-) ft
Date of test
Static water level
Well production
FROM W LL LOG
l 9)V
Y- g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate 3'33 mg/L
Arsenic: AID ug/L date of sample: L 7 j�
B. SEPTICMOLDING TANK DATA"-(�13(AC &j<e
Well Log�fY J) \
Wires property protected)
i u
Casing height (above ground) �Q' in.
AT INS ECTION
If , ft
3• g.p.m.
Other bacteria )O� colonies/100 mL
Collected by:
Tank Type/Material Date installed _
Tank size gal. Number of Compartments _ Cleanouts MN)
Foundation cleanout (Y/N) _ Depression over tank (YIN) _ High wa!9r a n
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length
Total depth _ ft.
Date of adequacy test
Fluid depth in abs9e,
ft.
Elapsed T�ip6. _min.
Pumper
Soil rating (g.p.d./112
ft.
Eff. absor on area _ft2 Monitoring tube
(Y/N)
System type
Gravel below pipe
i`- Results (Pass/Fail)
field before test _ in. Water added_ gal.
ft.
Depression over field _
Final fluid depth _ in. Absorption rate >=
i treatment (past 12 mo.) (YIN & type)
For _ bedrooms
New depth_ in.
If yes, give date
IM
D. LIFT STATION �16
Date installed 111 S¢e in gallons
'Pump on' level at_Cyin. 'Pump -off 1ev`l
Datum cles tested,
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
1`.
at _ in. High water alarm level at in.
Meets alar & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT T0:
Septic tank/lift station on lot L) n
Absorption field on lot N q
Public sewer main
�r
Sewer /septic service tine rt'
r
Animal containment areas d
�UF�44e "&- tore-
On
reOn adjacent lots tiAY)
On adjacent lots lien
Public sewer manhole/cleanout /(7d a
Holding tank Vi f ,
• r
Manure/animal excrete storage areas IGS 1
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Nin
Building foundation Property line _ Absorption Feld
Water main Water service line— —lSu acrf a water
Wells on ad
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: N%A
Property line
Water Service line
Curtain drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have di
review of Municipal ri
conformance with MOA
Engineer's Printed
Date
COSA Fee
Building foundation
Surface water
that
Date of Payment I I J.J I r✓
Receipt Number. oSswc
(Rev. 11/05)
Water main
on adjacent lot .
In
and
Waiver Fee $
Date of Payment
Receipt Number
parking/vehicle storage
cJ TU
L
ra
1457-1
" n
let me know if you think of other questions.
AurlHS 16e18w Nair
0
7-42T MIMIC Ht1
.4ylp-, s lW41r "
rb L N" r9 • // 1 4
v
•a
I
ASMLT-NO CORNERS KT THIS DATE.
STI
I HEREDY CERM -THAT I HAVE SURVEYED THE:
1 ,
FOL J)WM DE7m so PIIOPEIMS Lot i -B2.
Block It Royama TO&OV atmavleiao
AND IMO I16 MIO�EN7S EXIST EUPT AS •
b/2619
MIUTM IT 18 THE RESPOMMUTY OF THE
CLAIM 70 OETOWAK TI! OUTEWI OF ANY
WDD
KAIDMTI COV09AM S OR 1eMMCTNM
R -t EJB AM-
DWI
WH1 Wbr MWM TIK IPA'
YId10N PLAT. DOER MO CMMWM Mau
FW
ANY WIA HUM DE 140 PON OONSTIOMM
22-M
OF FENCE UNW4 OR FOR nU LIS1W DDtam-
DRiay
ANT 11M_
tM
MUNICIPALITY OF ANCHORAGE A
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 /�T
Parcel I.D. # �J —4E5 -sz HAA # 0( 6/2��
1. GENERAL INFORMATION
Complete legal description Raymond Tedrow, Lot 5B-2, Block 1
T14N R2W Sec. 12
Location (site address or directions)
17324 Adam Ln.1i
Property owner
Michael & Loretta Ruppert
Day
phone 694-6772
Mailing address
P.O.
Box 2192, Eagle River, AK
99577
Lending agency
city
Mortgage
Day
phone 563-0700 _
Mailing address
P-0-
Box 92810 Anchorage AK
99509-280
Agent
Lori
Crouse/ReMax
Day
phone 694-4200
Address
16600
Center Field Drive, #201,
Eagle River, AK 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
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 X
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Flev. 1/91) Front MOA 421
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 furtherverify 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 Eagle River Enginnering Seryires Phone 694-5195
Address P.O.ox 773294, Eagle River, AK 99577
Engineer's signature Date 7*/5i
6. DHHS' SIGNATURE
✓ Approved for
Disapproved.
0
4`
qcz
Louis A. But v
f e CE -6736 9
law
O
g80���ROFESS\•�a4c'
bedrooms.
Conditional approval for bedrooms, with the following stipulations:
.4101141
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
E
o Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: )?AYMOND i�DR,6k) Parcel I.D.
L.01 58-2, 81.4rx 1
A. WELL DATA
Well type P121 U,4iC If A, B, or C, attach ADEC letter. ADEC water system number IV 4
Log present(Y/N) y
Total depth
Sanitary seal (Y/N) y
— Date completed d 910/ZF4 Driller Wit-LfAMS
Cased to 140 Casing height /IF
Wires properly protected (Y/N) v
WATER SAMPLE RESULTS:
Coliform Nitrate N Other bacteria
Date of sample: 0 �/�/9/ Collected by: e5• R. 16• S
B. SEPTIC/HOLDING TANK DATA
Date ' talled
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
SEPARATION DISTANCES FR
Well (s) on lot
To prope me
rface water/drainage
72-026 (Rev. 3/91) Front MOA 21
Gt t✓�✓ a .` P41- 05-;116
Tank size
Foundation cleanout (Y/N)
PTIC/HOLDING T
On adjacent lots
Absorption field
pression (Y/N)
(Y/N)
Water main/sir- celine
CONTINUED ON BACK PAGE
0
FROM WELL LOG
AT INSPECTION
_>
Date of test 09/o/ ZZ
_�/ ,/9/
y
U-1
Static water level
Well flow
g.p.m. g.p.m
Q
w
1
LU
d..)
2
JLLJ
Pump level NOT SPEC/h166
()NKNOWIV
SEPARATION DISTANCES FROM WELL TO:
w
Septic/holding tank on lot N%A
; On adjacent lots --N1A
Absorption field on lot
; On adjacent lots 1,11A
Public sewer main 77
Public sewer manhole/cleanout /UD
Public sewer service line
Petroleum tank NfA
WATER SAMPLE RESULTS:
Coliform Nitrate N Other bacteria
Date of sample: 0 �/�/9/ Collected by: e5• R. 16• S
B. SEPTIC/HOLDING TANK DATA
Date ' talled
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
SEPARATION DISTANCES FR
Well (s) on lot
To prope me
rface water/drainage
72-026 (Rev. 3/91) Front MOA 21
Gt t✓�✓ a .` P41- 05-;116
Tank size
Foundation cleanout (Y/N)
PTIC/HOLDING T
On adjacent lots
Absorption field
pression (Y/N)
(Y/N)
Water main/sir- celine
CONTINUED ON BACK PAGE
C. T STATION
Date in ailed
Size in gallon
Vent (YIN )
High water alarm level
"Pump on" level at
Meets MOA electrical codes
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT` -STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Width
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (Past
SEP/ND
Well
To bOna
Su ace water
Curtain drain
On adl�iCent lots
hs) (Y/N)
Soil
Gravel thickn
"Pump off" level
qtz-
Cycles tested
<Surfacewater
System type
s Total depth
Cleanouts � esent (Y/N)
Date of ade acy test —
_for
If yes, give ate
E FROM ABSORPTION FIELD TO:
E. ENGINEER'S CERTIFICATION
On adjacent lots
Cutbank
Property line
To existing or abandoned system on lot
Water main/service line
Driveway, parking/vehicle storage area
bedrooms
I certify that I have checked, verified, or conformed to all MDA and HAA guidelines in effect on the dateofthis inspection.
rt: i. .
�J
Signature
Engineer's Name
Date � � S
J , + ,+..:.... Q 4
HAA Fee $ — 1901, CD
Date of Payment _ 2 Z s -
Receipt NumberX29 (/ 12-1
72-026 (Rev. 3/91)Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
(a) Legal '/6- ipti-� >(inc6, / lot,
Location (address or directions)
(b) Applicants Nam
Application Date
subdivision�a sec��eion, township, range)
1�;Lbyee-7 Telephone__ Home Business
Applicants Address
(c) Applicant is (check one) Lending Lnstitution Awaer- builder ;
Buyer [:::] ; Other [-::I (explain);
(d) Lending Institution _*V 0 c" 4:7- Telephone
Address
(e) Real Estate Co. & Agent
Address
Af opo Aj zj!
Telephone
LJ6 Z_ 9
(f) .Mt the HAA to the `following address:
"\P�LJ 1{Sl
yy.S I�
2. Type of Residence
Single -Family,
Number of Bedrooms
3. Water Supply.
Multi -Family
3
Other (describe
Individual Well r Community Public E::J
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 1= PublicJIny Community = Holding Tank CI
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 21
5.
M
f
Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site grater supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm
Address
Telephone
Date
10
Iffl
•�°w�i. �. .y
(ENGINEER SEAL)
i Q F
s• ., Re bort A. Shafer4"'i 64
DHEP Approval y`fT. No. 1457•e
Approved for iF<2 t�bedrooms IIy
Approved —4-- Disapproved Conditional
Terms of Conditional Approval____ w
CAUTION
THE 'MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY_ UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE 1S NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2] 7-19--84
A.
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Leg . Description: 4579Z - B I�
WELL DATA _A�� /�Gl/dC0 Ll � / Well Classificatio l �L/�i If A, B, or C, D.E C. Approved(Y/N)
Well Log Present (-- Date Completed L� Yield
—G� 27 4 .
Total Depth Z Cased to ?�r�Z> pth of Grouting
Static Water Level Pump Set At e e
Casing Height Above Ground `' Sanitary Seal on Casin(Y
Electrical Wiring in Condui (Y Depression Around Wellhead ( )
Separation Distances from
i
To Sept ic/H T-ank on Lot l On Adjoining Lots
To Nearest Edge of Absorption Field on Lot; On Adjoining Lots /00
To Nearest Public Sewer Line %c) To Nearest Public Sewer
Cleanout/ma-nhe4.e 10CC ` To Nearest Sewer Service Line on Lot '_:70 /
Water Sample Collected By,
Water Sample Test Results
Comments 4170 ,aJ
B. SEPTIC/HOLDING TANK DATA
Date
Size
No. of Compartments
Standpipes (Y/N)'----,Air-tight Caps (Y/N) Foundation. s-&_�ut (YM)�
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File
Holding Tank High -Water Alarm (Y/q),_
Separation Distances
To Water -Supply 4
To Property,,ne
To Waif Main/Service Line
Comments
Holding Tank Permit (Y/N)
ng Tank:
To &iilding Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Receipt # 36� Vic(
Date Paid:
Amount: L_�S «�
(Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
ils Rating in Absorption Strata
Date nstalled
Width o ield
Square Feet of '
Depression over
Results of Last
ion Area
(Y/N)
Separation Distance from
To Water -Supply ill _
To Building Foundation _
t
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present /N)
Date of Last Adequacy T t
tion. Field:
To Proper Line
To Ex' ting or Abandoned Svstem cn
Lot ; On Adjoini g
To Water Main/Service Line
To Stream/Pond/Lake/or Major Draina Ccurse
To Driveway, Parking Area, or Ve cle Storage
Commnts
D. LIFT STATION
Date Installed
Size in Gall
"Pump On" ve
1 at
High W er Alarm Level at
Cutbank(if present)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (YM)
for Pumping Cycles during Adequacy Test. Meets MOA
cal Codes(Y/N)
nts
** Check Permitted Bedrocm Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Si nedDate n__z7— "' � � •" °,�uiG
Company ' , iAg'RIVER. ALASKA '�557f MOA No. �
xiR � ii
eta
KB1/d5/s
2,l rt A. Shafer
No. 1457-f ,<
(Page 2 of 21
2-15-84
