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HomeMy WebLinkAboutRIVER VIEW ESTATES BLK 5 LT 20 Municipality of Anchorage Page /~ o! DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 e Telephone: 343-4744 On=Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ,hz;t:__.._; .... ' I.o. of Be(rooms: LEGAL DESCRIPTION -'~/nship: i Range; Subdivision: Section: WELL: :New [] Upgrade Clas~ation (Private, A,B,C): 1 Total Depth: '~ased To: i Ft.L __ Driller: _ _.b Ft. Yield: P~rnD Set at: 1 Casing Height Above Ground: GPM Ft.Ft, SEPARATION DISTANCES To From Well Surface Water Lot Line Foundation Curtain Drain ~emarks: Field Tank Number: ~::~~ ~ Wastewater System: ~,~e~w _ El_UPgraded ABSORPTION FIELD ;~-,D'~ep Trench [] Shallow Trench [] Bed [] Mound [] Other Soil Rating: ~), 8_ GPDISq. FI iT°tal Depth from original gradeq [ Depth to pipe bet(om Imm original 9~d~: Fill added ubove original grade:Gravoilength: ~ Ft, Gravel ,tion area: dler: "~"Ft. mbe.~lof lines: )ist~nce belween lines: :)ate ("stallecJ'~ 0 ' q '~I TANK ~ Holding [] S.T.E.P. ianufacturer: lumber of Compartments: LIFT STATION Size in gallons: I ManUfacturer: ~;el at~- [ High water alarm at: Pump Msk~~t le s~ec.'ons per~'~o rmed bY: BENCH MARK tLocation and Descrip~on: [~ Assumed Elevation: ~ Inspections performed by:~C'~L~ ~¢-_.,kt~.L~l/'J~ ,Dates: l st_.(-¢'4'~-'[-'~ : Department of Health and Human Services approval Reviewed and approved by: Date:_ /' SHAFER, P,E, 72-013 (1/91) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION of ~' P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report 72-013 A (2/gl) MOA 25 0 c~ 0 0 ,-] ~ ~ ~ ,-,] ~} :--] 0 0 0 0 0 0 0 ~R m m PAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910089 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:LUPER CHARLES F OWNER ADDRESS: 1611 EASTRIDGE DRIVE NO. 302 ANCHORAGE AK 99517 1 OF 1 S Pi I DATE ISSUED: 5/08/91 EXPIRATION DATE: 5/08/92 PARCEL ID:05079213 LEGAL DESCRIPTION: RIVERVIEW ESTATES BLK 20 5 LT LOT SIZE: 43827 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: THE ATTACHED APPROVED DESIGN. 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 (iSAAC80). THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO ALL INSPECTIONS. ----- / ISSUED BY: 40[ql~[ ~/~/~ DATE: DATE: April 29, 1991 ROBERT SHAFER, P.E. ROGER SHAFER CIVIL ENGINEERb; (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SiTE PLANS ~ ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage D~PARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Al~ka 99519-6650 REFERENCE: Lo~ 20; Block 5; Riverview Estates PERMIT REQUEST NARRATIVE At present ~he lot is vacant. The southeast portion of the lot is a high fl~ area. The neighboring wells of concern are on the mo properties to the nor.~h. Since .~he lots in this area are large, we foresee no negative impa~t on neighboring properties by ~he inst~llation of the proposed well and septic systems. 'BERT A. SHAFER, P.E. JS/gm 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE // Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 lO 11 12 13 14 15 16 17 18 19 2O COMMENTS EN, GINEBR'~%¢I~AL :. ,,.,:...,,,,.,..:..,,;,;,.,, ~X~¢I~ Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? s IF YES, AT WHAT O DEPTH7 p E Oeplh Io Water AI~., / Monitoring? _'t.,,/~ 7-- Dale: Gross Net Depth to Net Reading Date Time Time Water Drop PERFORMED BY: , ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELIN~ON 72 008 (Rev. 4/85) PERCOLATION RATE ~'~'"~ (m,nutes/,nch) PERC HOLE DIAMETER ~., ~4 TEST RUN BETWEEN D ~ _ FT ~".('ad ~'~0, ;/~':~1 ~~CERTIFY THAT THIS TEST WAS PERFORMED IN THIS DATE. DATE: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMEO FOR: LEGAL DESORIPT,ON: L:F~:::~ ~ ~' -- ~.~_ I~:5~' SLOPE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? SITE PLAN s L IF YES, AT WHAT O DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN .~___~2ND ,~,¢~ FT COMMENTS PERFORMED BY: ~r~9~i.CA~ok~.~ ' ~1 ERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPALGUIDELIN~~ ~D~ DATE: 72-008 (Rev. 4/85) PERFIiT NO. FIPF'L I CRNT LOCFIT I ON LEGFIL JOHN GROSS L. 2E~ B5 F.'.IVER',,,'IEH ESTFtTES PO DOM t:L6t E. R, 65~4--.9:~2:8 6;94-9:LZ.':8 LOT SIZE 999999 SQUFIRE FEFZT T'¢F'E OF SOIL FIE:SORPTION SYSTEM IS: DRBII'.~FIEI_D t','IR',:.::IMUM NIJME:ER OF' E:EC, ROI3MS = ]: '.SOIL. RRTING THE REQUIRE[:, SIZE OF TFIE :SOIL FIBSOF.'.PTION Z,'¢STEM IS;: 'T'HE L. ENGTH DIHENSION IS THE: LENGTH (IN FEET) OF THE TRENCH OR [.',RFIII'.4FIEI_I}. 'TFIE DEF'TH OF FI TRENCH OF..' PIT IS THE E:,ISTFINCE BE'['HEEN THE SURFF:ICE OF THE GF..'OIJNE:, FII'.,II} THE E:OTTOH OF THE E::.:',CflVRTION ,::IN FEET). THE GRFI',,,'EI._ [:,EF'TH IS THE I',IZNZHLIH [:,EPTH OF GRR',,,'EL 8ETHEEN THE OUTFRLL F'IF'E FIIqE:, THE E',OTTOM OF THE E',:.~',CFI',?RTION (IN FEET). PEF..:MIT FIPF'LiCFINT HFIS THE RESPONSIBILIT'¢ TO INFORM THIS DEPARTMENT [:,URING 1"HE INSTRLLFITION INSF'EC:TION5 OF FINV HELL':; R[:,.TACENT 'FO THIS PROF'ERT'¥' FIN[:, THE NUHBEF.': OF RE$:;I[:,ENCES '¥HFI]' THE HELL H IL.I_ SERVE. HFFF. L , H[_ FJ'T' THIS BRCKFIL. L. ING OF FIN'¢ :T.: FE~I HITHOUT FINFIL INSPE]T[)N FIND "" '~'""- I}EPFtF.'.TMENT HILL BE SUBJECT TO F'ROSECUTIOI'.L I"'IINIFIIJH [:,IS'rRNC:E E:E"I"HEEN FI klELL I:~i'-,IE:, FIIq'T' F~N-':;ITE _:,E[IH.~E g,Z'_:.':F'EISFIL :,?_,TEl1 I'.'5 :L6~F~ FEET FOR FI PF.:IVFITE HELL. OR "LSE~ "I'F~ 2:'C~C~ FEE'I' FRFd'"I FI F'UBLIC NELL DEPE:NE:,ItqG UF'ON THE T"r'F'E OF F'UE:LIC HELL. MINIMUM E:,ISTFII'.~CE FROH F:t PRI',,,'FITE 1.4ELL TO FI PRI',,,'FITE SE']I4ER LINE IS 2?; FEET FII".4[:, TCI FI E:OMMLINI'f"~" '.5E[,.IER LINE IC; 75 FEET. HELL LOGS FIF::E i;.:EL::.!LIIF:E[:, FIND I"IUST E:E RETURNEE:, TO 'THE [:,EF'FIRTMENT HITHIi'.,I ]:R DFI"r'S OF THIE HELL COMPI_ETION. OTHEI'::: F':E(PPJIREHIENTS I'"lR"r' FIF'F'L"r'. SPE]IFI"ZRTICfl",IS FIN£:' '::NSTF.:.::TI3N E:'IFIGI;..:FIHS FIF.:E FI',,,'FI I L. FIE:LE TO :[ N'=;URE F'F...'OPER I N':iTRLLRT I O1",1. F' E: F;;: ]"""t ~[: 'T E ::":.'. F' Z F-: EE '-23 [:" EZ C: g i'-1 E: E F: ]C-": ::L .., i "-:.-~ E: ]: :[ CERTIFY THRT i: I RI','I FFfl',IlLIFff;'. HI"FH THE F.:EC!LIIREMENTS FOR ON-SITE SEHER$ RhlD HELLS FIS SET FORTH Bb.' ]'HE HUNICIF'RLITh.' OF RNCFIORRGE. 2: I HII..L. iNSTFtL. I_ THE S'T'STEH IN FICCORE:,FINE:E HITH THE CODES. ~: I IjNDERSTFtND THFIT THE CH-SITE SEHER :,~_,]EH HFIV REP IRE ENLFIRGEMENT IF THE RE%IDEF,ICE I~ REMEE:,Ek. EB, TO INCLUDE HORE THRN 3: E:EDROOMS. S I GNED: ~-- .~:~ ........................ ( ~:'F'LICFIN'F JC~N GRO:E;S ~/' ,Permit {I: 820179 January 31, 1983 TO: Permit Applicant Subject: Lot 20 Block 5 River View Estates Subdivis on A permit issued by this department for an individual well and/er on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipa]- Ordinance. If you have drilled the well, a well log needs te be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-bud. Its for our files and documentation. If there are any further questi_ons, please ca]_l thi£ office at 264-4720. Sincerely. Robert C. Pratt, R.S. Acting Program Manager Sewer and Water' Program RCP/ljw enc: Copy of Permit S WP / 057 PERMIT [:,EF'RRTMEI,.IT 0r HEFILTH FII,.I[:, ENVIRONMENTRL F "CITECTION b,-,o ~ "L 99. .:..~ STREET, RNCHORRGE., FIK. J- ~64- :-1- ,' ~0 [L,4ELL fl I".-.1[:, il31"-.,,i--.%~3 X TE :,EL4EF-. F'EE."IPl T T o.-.I.j,' , 24. ) FIPPL I CFII..IT LOCflT I Ol..i LEGRL UR0.:, :, ..TOHI,.~ L .... L20 E,.~ RIVER VIEW ESTFITES PB °R .... ll~l E.R. ~ ~., _ ,.., I~ _ _.._ ,' ¢ LOT SIZE TYPE nF S01 L RE,_,UF..F T 101,'4 S"r'STEM I S: E:'RFI I NFI ELD I',IR,%IMUI,I NJI,1BEF.'. OF E:E[:,RIZn3MS = 99999-~ SQUFIRE FEE"i' ,- i =,E I L RFIT I NG FT/'BR) = THE REQIJIRED SIZE ElF THE SOIL RESORPTION SYSTEM IS: [)EF"T F-I= '7~ LE I'-,t GT H--' -~:--: L="- E~ R R %,," E L- DEF'TH= _~c THE LENGTFI DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCFI OR PIT IS THE DISTRNCE BETWEEN THE SURFFICE OF THE GROUI,'ID FIND THE BOTTOM OF THE E,'.<CFIVFITION (IN FEET). THE ]'"~;."EF~CH I-4 I [:,TH I S 5. EIOE~ FEET. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRFIVEL BETWEEN THE OUTFFtLL PIPE FIND THE BOTTOM OF THE E::~:CF¢,/FITION (II,.i FEET). F:EL-~JJ ][ ~;:[:ZD SEPT :[ C: PERI,tIT FIPPLICFINT HFiS THE RESPONSIBILIt'¢ tO INFORI,t THIS DEPRRtMENT DURING THE INSTFILLFITION INSPECTIONS OF FtNY HELLS FIDJRCENT TO THIS PROPERTY FIND THE NUMBER OF RESIDEI,.ICES THFIT THE WELL WILL SEF:VE. 'T'b..~FJ ,,~ 2 '-:' I II.'.ISPEI:;T I CII'-,tS Fil~." E F.:Eg~.LI I BRCKFILLINO OF FINY SYSTEM WITHOUT FINFIL INSPECTION FIND RPPROVRL BY THIS DEF'FIF.'.TI,"IENT WILL BE c;UBJECT TO PROSECUTION. I'IINII'lUI,4 DISTFIIqCE BETHEEN R WELL FIND RN'-r' ON-SITE SEI4RGE DISPOSFIL SYSTEM IS ::LO0 FEET FOR R PRIVFITE WELL OR :L50 TO 280 FEET FROM FI PUBLIC 14ELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM FI PRIVRTE 14ELL TO FI PRIVFITE SEWER LINE IS 25 FEET FIND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS FiRE REQUIRED RND MUST BE RETURNED TO THE DEPFIRTMENT WITHII,'4 3:0 DFIYS OF THE WELl. COMPLETION. OTHER REQUIREMENTS MFIY AF'PLY. SPECIFICRTIONS FIND CONSTRUCTION [>IFIGRRMS RRE RVRILFIBLE TO INSURE PROPER INSTRLLRTION. F"EF-:I'-I ~ qr E~---:P I F.:E$ [:.EOEI"-IE:EF: ~::1 ..... i982 I CERTIFY THRT l: I FII"I FFIMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS fiND HELLS FIS SET FORTH BY THE MUNICIPRLIT'¢ OF RNCHORRGE. 2: I WILL INSTFILL. THE SYSTEM IN RCCORDRNCE WITH THE CODES. 2;: I UNDERSTRND THFIT THE ON-SITE SEWER SYSTEM MFIY REQUIRE ENLFtRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 3. BEDROOMS. S I GNED: .... ~ ..... R~F'EICflN'r JOHN L GR']SS Russell Oyster 694-2774 Performed for: 5~ 6~ 7 8~ 9~ 10__ O&E ENG,,,IEERING & DEVELOF ,dENT CO. Box 90, Davis St., Eagle River, ALaska 99577 694-2774 or 688-2280 SOIL LOG Earl Ellis 688-2280 Name:- /'~'~ Legal Description: ~>~ Depth (feet) Soil Characteristics 11__ Ground W~ter Encountered'. Yes~ Proposed Installation: Seepage Pit_ ~ain Field. Comments: PERC. TEST Performed by: No J"//: If yes, what depth_ --:-:'" ,-' ?, ~ .'~-:~J'?;; :-~ -"Di~iSi0n°f - -- ' , ...... · ....... -:~.. ........ ~' .... ,' ' Se~ cos Sect ..... ?.,~.~; ::~.. ;~ .:,~ ,-,.~ .... , . :. · .~_ ~ ...... OR-Site ........ . .--..::~.:;~;r:; :... ::.::::./:~..~;_:~ --:r.'~'rp O BOX 196650 ~' Anchorage, Alaska,.,,9951~650 -: ::~?[ -..:~/,.9~ :::.::.-<:::.,_:-:-::::/,.: '-.:::::: :_-?:~,.: :?i~.,.:- ' .~::,: '/"/.~ :- :.~'.: :-: ;'~ · -:.: : :-:: ._...:"-'...--: _' :'"APPROVA:-FORASlN6LEFA~:: : · _.-. parceli. D:~.3 o~o..?q ~-:7: . . ...... ..::._::..~_::.::.::.w:.~._.: ..... :<,~ ._: ._::~:~.::?..:~i~F/~.:,;~::1,~?::0~-~.::?:f~:::~:::,,,:.: , ~ ,'Comn~ete-,e~a~.~escr,~t.°n. ~': ::.'-'~::::~:::-::::~.:?.-.,~.:L,~-:::.-..:.::.,:::?.::~-'::~:~-:'::- ~--''' '~-::- ..... '. :. :-~;::::?::::',.:.::.~::Malling address r,; : ~: .......... . ....... '-"~ '-: :'::':: -: .' .,-"' 3. ::'.-' ~PE OF.WATER SUPPK..:-.'-' :.: .. ~..:._.<.:,:-,:., :....: 7~25 (R~.1/91) Front MOA~I ' :.: ,: : :::X: : -, :: :.- 5.~ :' STATEMENT;OF INSPECTION BY ENGINEER .?..,:-. -*-.~. ~ -~ ..... ~. ..... . -_ '. -...- .~,~_ , ~..,...~ ' '"' investigati°i~'~Of this Health'A~ith~r"i~ :A'ppr~'i-~l~Piicatioh' Sh' ows t~att~:~n~site wa~er Supply- ~ and/or Wastewater dispo~l system is ~fe, functional andadeqUate ~{~'~'"n~ber of b~rooms and ~pe of structure ind cared herein, fu~her veri~ ~hat based on the information obtain~ from ' ~the~u~i~iP~ii~-~f'~h~ag~'~es'and fr~m my invest~ation'~nd insp~fi~ ,.theo~;site Water- supply and/or wastewa~e~'dis~o~l ~ystem iSin compliance with all Municipal and State codes, ordinances, and reg~i~ti~ns-i~ ~ff~t'On the date Of this inspection, .-. '. Name of F~rm · ; ' '~ ~ ":'~ ~ z:~:";' ",";', - '.".. ;' i '-~ "' ";';" ~ ' ' · ' · ' ' ..... '" .~ ~.-.., _'. i - :,;-,,. --: ,.. ·-,~:..-S:--k--.-.a*':x- .~-~ ' ', ~:'.:;-' ;-_'i-. · .... ...,- ' . ' ;; :'"': -:": i": ;., '. '-,, .':' -, ~*'-1k;~*t.;l'{~S;.:t.7*{:','... ~.., :.}.¥:- :-./:,~ .' -". l~ C'.. ;-l~,;. ',~'; '. P.'","l/'JfT'"m~"-:'"X~''*~ ":'. -'*,'-. *: ~-4..-- -- Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A, Well Data Well type Log present ~N) Total depth Sanitary seal {;~;~N) Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number ,/ Date completed Cased to FROM WELL LOG Date of test Static water level L¢,o ~ Well flow ~", ~ ~ ¢1 Pump level1 / ~S- ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~,-Z..-o t Absorption field on lot \~ ~ Public sewer main ~//> Sewer service line ~' 7--~ Casing height Wires properly protected (~,1) AT INSPECTION ._ %-~,5'~ g.p.m. "-5,~-.,~' ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform C~ Nitrate Date of sample: ~ - \ I ¢ c~ ~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts ~) High water alarm (Y{~)._. Date of pumping Tank size \ oc~::~ Compartments ~-~ Foundation cleanout~N) ~ Depressio~ (Y~) Alarm tested (Y/N) ~[/k '3 -¢1C' Pumper "~.. , ~ f,~%,[ L~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~"2.-~ ' On adjacent lots To property line . \~ ~ Absorption field Surface water/drainage \ ~ o Foundation Water main/service line 72-026 (3~93)° Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons "Pump on" level at Manufacturer NCE FROM LIFT STATION TO: Well on lot On adjacent lots Manhole/Access (Y/N) ~at Surface water D. ABSORPTION FIELD DATA Date installed \ o--~'~, -~ ~ Length ~" L~ ~ Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~) Soil rating (GPD/FF) ©.~ / ~-.-¢"--- System type ~"2~-~--~' Width ~ ' Gravel thickness %- ~ Total depth ~'"-'L~"~ '~ Cleanout present i~N) '~/ Depression over field (Y/.~ L~ ~ 13. ~'S'- Results;;;[~ail) ~P~.-~% for ~ Bedrooms {~ After test r~ ~ ~.4_._ ¢..,.~.:,~t ~ If yes, give date Well on lot \ ~ o To building foundation On adjacent lots .~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots \l-bL~~¥ Property line "7~ ~ To,existing or abandoned system on lot Cutbank ¢'\¢. Water main/service line Sudace water Curtain drain 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 p~Ae:~J.~o.f this inspec¢on. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number  Environmental Servioo8 Ino. CT&E cT&~ Ref.# 95.1367-3 Matrix W~T~R Clle~lt Sat~p].e ID L20 BLK5 RIVERV~W client ~am6 ~ & $ ENOINEERINO WORK Order Ordered By KAY SHAFER Printed Date Project Nam~ Collected Date Proj~ct~ Roceived Date PWSID UA 13837 04/17/95 ~ 13:27 hrs. 04/11/95 04/11/95 Technical Director STEPEEN C. Sampl~ Remarkm: ROUTINE M~4PLE COLLECTED BY: RAY. QC Allowabl~ Ext. Anal para~eter Resul~ ~u~l ut~it~ M¢~hod Limi~m Da~e Date Init ~lt~ate-N o.k0 U In~/L ~PA 3~3,2 10. 04/13/95 ~MR See Special Instrucbion~ Above UA = Unavailable S~ Sal~pl~ R~t~ark~ ~bov¢ NA = Not Analy~d Und~c~d, Reported value l~ the practical ~uan~i~i~a~ion limit. LT = L~es ~an 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 1. GENERAL INFORMATION Complete legal description LOT 20; BLOCK 5; RIVERVIEW ESTATES Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Chuc~ Luper P,O,Box 772972 Day phone Ea~l~ Rive~, Alaska 99577 Day phone 696-5060 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well Public 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: XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev 1/91) Fronl MOA ~t21 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/orwastewaterdisposal 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 Ad d tess Engineer's signature 17034 Eagle River Loop Road No, 904 ~,~ ~577 Phone DHHS SIGNATURE '~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: J(DI--kN ..~ i71. ( ('-(-/- Date 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) 8ack MOA #21  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~:~-'¢ 7~-~-~ ~,,~/_,~ Parcel I.D. A. WELL DATA Well type _.~,\,4 h-<'~¢.~ if A, B, or C, attach ADEC letter. Log present (~YN) _ "]. Date completed _ Total depth ~¢~-2 ~ Cased to ~"7,~ Sanitary seal ~TN) FROM WELL LOG ADEC water system number Lc ~'z~o ~(~ \ - Driller Casing height Wires properly protected ~) _ AT INSPECTION Date of test ~ -~-~o ~ \ Static water level b~::~~ Well flow ~'-. O ~%%. g.p.m. Pump level _~ ~, ~ SEPARATION DISTANCES FROM WELl_ TO: Septic/holding tank on lot ~ ~ ~ ' On adjacent lots , Absorption field on lot Public sewer main ~ J,~ Sewer service line '7--~' ~ '~ WATER SAMPLE RESULTS: Coliform ~ z..~.~,/~ ~= ,., j. Nitrate_ Date of sample: '~, ~ \ c~ ~ct ~ B. SEPTIC/HOLDING TANK DATA ; On adjacent lots Public sewer manhole/cleanout .. ~J/~ Petroleum tank Date installed_ ~ ¢~ ~c~ I Collected by: Cleanouts ~/N) . High water alarm (Y~j) Date of pumping ~ /.~.~,~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~.?C~ ~ On adjacent lots J I::)'0 ~ 4- To propertyline_ 1, o~'~ Other bacteria . $ & $ ENGINEERING 17034 E~lgle River Loop Road Eagle River, Alaska 99577 Surface water/drainage __ Tank size \ Foundation cleanout/~/N) _ Alarm tested (Y/N) Compartments '7...- Depression (Y~ Absorption field. Foundation_ Water main/service line 72-026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE C, LIFT STATION Date installed Manufacturer Manhole/Access (Y/N) Size in gallons ,, ,, Vent (Y/N) "Pump on level at j~level at High water alarm level ~ycles tested SE~TANCE FROM LIFT STATION TO: 'CORdon lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed lC) ~ ~ ~c~\ Length '-~ Lcd,,, Width Total absorption area Depression over field (Y~) Results (pass/fail) ~l,~- Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot_ To building foundation On adjacent lots Surface water Curtain drain Soil rating ~'~ Gravel thickness Cleanouts present~'N) '~/ Date of adequacy test .for If yes, give date System type '~¢~¢-.~F' Total depth On adjacent lots _ ~,6>-~ ~ ¥' Property line '"'~,O ~ To existing or abandoned system on lot Cutbank__ ~/,/k, Water main/service line_ \ ~::~ ~ Driveway, parking/vehicle storage area bedrooms 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 S & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Engineer's Name Date Eagle River, Alaska 09577 HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment ./ Receipt Number CHEMICAL & GEOLOGICAL I iBORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907) 561-5301 ANALYSIS RESULTS for INVOICE ~ 51288 Chemlab Ref.~ 92.0683 Sample ~ 1 Natrix: WATER Client Sample ID ?WSID Collected Received Preserved with L20 BLS RIVERVIEW EST. UA FEB 19 92 ~ 09:00 hts. FEB 20 92 @ 16:00 hrs. AS REQUIRED Client Name :S & S ENGINEERING Client Acct :SNSENGP BPO# : Req$ : O~dered By :RAY PO# :NONE RECEIVED Analysis Completed : FEB 21 92 Labozatory Sup~vior3~TEPHEN C. EDE Send Reports to: I)S & S ENGINEERING Pazamster Roeults Units Method Allowable Limits NITRATE-N ND(O.IO) ~/1 EPA 353.2 10 Sample ROUIINE SAMPLE COLLECTED BY: RAY. Remarks: t Tests Pe~fo[med ' See Special In~truetione Above UA=Unavailable ND~ None Detected "See Sample Remarks Above NA~ Not Analyzed LT-Less Than, GT-Groate~ Than Member of the SGS Group (Soci(~t~ Gbnbrale de Surveillance)