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Home My WebLink AboutKASILOF HILLS BLK 1 LT 7A MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS [ LEGAL DESCRIPTION DISTANCE TO: fl II I Manufacturer Liq. capacity in gal DISTANCE TO: IF HOMEMADE: Well l Absorptionarea ~E Dwelling Material Inside length Width Dwelling DISTANCE TO: Well No, of lines / Lengtt of each line Top of tile to finish grade Length Width Foundation Total length of lines Material beneath~ti e Depth Materia] Sewer line/ [] NEW .~UPGRADE Nearest lot line NO. OF BED,~.OOMS '-"/ ¢ ~' '' '~ PERMIT NO. (~t/O3 ~tj No, of compar.tments Liqaid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller DISTANCE TO: Building foundation Distance to lot line PERMIT NO, Septic tank [/~-~/ Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING //' C:) REMARKS APPROVED / ~.~-'/' Ill DATE LEGAL / PERH I T NO: DRTE ISSUED: ,] I F"F:IL I 'T".~r" OF: E:,EPRRTHENT OF ~HERLTH RN[:, ENVIROHI"~EN'f'RL PROTECTION 825 L STREET, RNCHORRGE., RK 264-,$720 RF:'PL. I CRNT: RE:'DRE%$: CC)NTRCT F'HONE: C,.."O PRRTT CONSTF.:. JOSEPH I"IILLEF.*. ±SEiL~. C II'.JD'¢ LEE LRHE RNCHOF.:RGE., RK S.~ L=., 50 ? 562-5~82 LEGRL [:,ESCR :IF': LO'T S I ZE: LOT LOCRTION: SUB[;,I',/I'-.'iION: KRSILOF HILLS SECTION: 24 TONNSHIP: ~C~:=':~5 (SC4. FT. OR RCF.:ES.':, GLRZFIHOF DF.:I VE LOT: 7R RRNGE: E;LOCK: ::L I CERTIF'¢ TFIRT: ±. I RI"I FRMILIBR WITH ]'HE RE6!UIREHENTS FOR ON--SITE SENEF.'.S RND NELLS RS SET FORTH B"r' THE I"IUNIC:IPRLIT"r' OF RNCHORFIGE (I'"IOR) RND TFIE STRTE OF RLRSKR. ;:". I NILL INSTRLL THE '.'-]"r'STEH IN RC:COR[:'FINC:E NITH RLL. HOB CODES RN[:' REGULRTIONS., RND IN COI'"IF'LIRNCE NITH THE DESIGN CRITERIR OF TFIIS PERI"IIT. 3. I NILL R[:,HERE TO RLL. HOR RHD ':;TRTE OF RLRSk::R REL.':~.UIF.~EHENTS.FOR THE SET BRC:K' DI-?,TRNCES FROf'~ RN"r' EXISTING NELL, NRSTENRTER [:,ISF'O2;RL $'¢STE1"1 OR PUBLIC SENEE'.RGE Sb'STEP1 ON 'THIS OR RN"r' R[:,JRCENT OR NERRB'¢ LOT. IF R LIFT STRTION IS INN~;TRLLEB' IN RN RRER COVEF.:E[." B'T' NOIR BUILDING E:ODE2;., THEN (&;) RH ELECTRICRL PERHIT RN[:, INSPECTION Nt.I:ST BE 08TRINE[:'.~ '::2;' RS""'E:UILTS NILL NOT BE RPF'RO',/ED 1.4ITHOUT RN ELECTRICRL INSPEI]:TION REPORT.~ RND (]:;' THE ELEC:TRICRL NORK NUST B~[:'ONE E:'¢ R LICENSED ELECTRII]:IRN. _, t ............. ~1_~_~~ .................... RF'F'L~CRNT: E.,..'El PRRTT L. UN~,TR. .~r~'~EF'H I',I~LLER Department MUNICIPALITY OF ANCHOrAgE ~ Health and Environmental ~rotection Street, Anchorage, AK. _3501 Permit % ~c Applicant: Location: Legal Description: Type of Soil Absorption System Is: Trench: ~/ Drainfield: Maximum Nuraber of Bedrooms: ~-~ / 825 264-4720 ~ ~ * HANDWRITTEN PERMIT * * * WELL AND/OR 0N-SITE SEWER PERMIT ~//~-~/~. Mailing Address: ~ ~4-c- DEPTH Phone Number: /~/~'~- /~--/X LOt Size: Seepage Bed: Holding Tank: Soil Rating(sq.ft/br) /C~' The Required S~ze of the Soil Absorption System Is: LENGTH /~. G/ GRAVEL DEPTH ~- C:/ WIDTH The length dimension is the length(in feet) of the-trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trench~so The gravel depth is the minimum depth of gravel between the outfall p~pe_~nd the bottom of the excavation(in feet). installation inspections of any wells adjacent to this property and the number of residences that the well will serve. ~ ~ * TWO(2) INSPECTIONS ARE REQUIRED Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 8 X F* * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as (2) (3) S igne~: Applicant ~'j/ ~ ~*" 0,~: &/~cj~ /dO~ ~"~/~,~' ~'~'~?~- Date: ~'~( set forth by the Municipality of Anchorage. I will install the system in accordance with codes. I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Issued by: >¥:c~.~-~- MUNICIPALITY OE ANCHORAGE DEPARTMENT OF NEALTH & ENVIRONMENTAl_ PRO'FEC~I ION ENVIRONMENTAl. ENGINEERING DIVISION 825 L. Street- Anchorage, Alaska 99501 Telephone 264-4'120 ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELL INSPECTION REPORT iP,ON T ,~NEW f UPGRADE DISTANCE TO: I ' Manufacturer Liq. ~ DISTANCE TO: IF HOMEMADE: Well Dwelling DISTANCE TO: No. of lines . 'Top of tih; to finish grade ~ / /~// Length Width Orib diame[er DISTANCE TO: Depth Building foundation Type of crib Abs°rpti°nar°~.~ 0 /' [Material..c~. /'/I inside length Length of each IL~e/ f Total level, f/lines Material beneath tile Depth Crib depth Building foundation NO. OF BEDROOMS No. of compartments Z Liquid depth PERiVIlT NO. Liquid capacity in gallons P E PdVtlT NO, Total effective absorpti~ al;~a .% PERMIT NO. Nearest lot line Class Driller Distance to lot line TPERMI-r NO, DISTANCE TO: Sewer line Septic tank 1Absorption alea(s) PIPE MATERIALS OTH E Re/ SOIL TEST RATII', / REMARKS APPROVED DATE LEGAL ~(~X J~(~ ,~TAR ]~:)UT]E ./k ANCI~ORAGI-~:i~ ALASKA SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF zoo 7e.~L. DRILLED AT THE RATE OF_ f;,2,~,00 PER FOOT. PROPERTY OWNER WELL LOG: 0 ..... MUNICIPALITY OF ANCHORAGE Co~-L o/E ,D;oL.L-L~t¢: ,j22.00:2e~. fioa.L X 250 .~e.e..L: ,'5'5500.00 MUNICIPALITY OF ANCHORAGE RECEIVED COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAIl:) DRILLING. ;53o0. oo WRITE CHECK PAYABLE: TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH, DATE BERNIE CLALJS OF RAMPART DIT~LLING WORKS Eii:~-:OUi',E:, l:::!?J,[} "['H~; [?,E!T'TOi"! 01::: THE 'F!..,IE:?~:E ];?; NO :!~;ET !,.!:f:DTH FOR 'T'F~:IENE:HE:~; THE; Eu;)T'f'OPI 0!:::' 'Fi'!E; F'{i:-::tZ:I::I',,,'F!7' ~X ~ X'' / here~,o~ t~ t~ ~ovom~=~ e~y lines o~J do ~ ~er~ ~ o~zo~ i~w~e~ on ~1~ ~dy ow'l~p ~ enoch ~ 1ho promiso~ e : ~O"x ~' rebor ~ this ~urvoy ~j ~ ~; o~ ~,~'~ ,,, ,~ in ~1~ ~ th~ fhme are ~ r~dwoys~ utili*y eQ~ on said ~y exce~ Pr~red MUNICIPALITY OF: ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST 5 SLOPE SITE PLAN ~r~:~'~' 10 -- 11 ~'--:12 '~'"¢~'' '~, 13 15-- ~16 17 18-- 19-- 20-- WAS GROUND WATER , ~ S ENCOUNTERED? ~1~ O L O P E IF YES, ATWHAT DEPTH? Reading Date Gross Net Depth Io Net Time Time Water Drop ; Allen W. PERCOLATION RATE I ~' '~ ~ O ~%~ utes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: ~ . ~.~.~'~ ~'"'~-~ CERTIFIED BY: 72-008 (6/79) 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 I - O _~ NAA # GENERAL INFORMATION Complete legal description ~,~, I L.~ F' [~L I LL 5. Location (site address or directions) II ~ 8 I ~ [~ ~' Property owner Mailing address Day phone ?~ ff~- 2-7/7.- Lending agency Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for plckr]p. NUMBER OF BEDROOMS: 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 NOTE: Public sewer If community wastewater system, provide wri'iten confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. ~TATEIViENT OF INSPECTION BY ENGINEER. ordinances, and regulations in effect on the date of this inspection. NameofFirm -T~'¢/~/¢.,_.~ ~ ~.~.~ Address ~ .% Engineer's signature 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, 6. DHHS SIGNATURE Phone Date Approved for (¢'! /-'/-~- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Note: The well for this property meets existing State and Municipal Codes. ~J~ere ~ n~s present. Tr i~ ~,~ge~ted that periodic testing be performed to insure the wells continued suitability. Current nitrate ......... , .... o ~= g/1 ' g/1 More information on nitrates is available from the On-site Services Program, P~-3-~3-4744. Additional Comments By: 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 D H HS 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. RECE[VED Municipality of Anchorage DFPAF{TMENT OF HEALTH & HUMAN SERVICE~ Environmental Services Division MUNICIPALI1Y OF NCHORAC~______[~ 825 L Street, Room 502 · Anchorage, Alaska 99501 .~9(F~4~IcEs Legal Description: Health Authority Approval Checklist Parcel I.D.: c3 A, WELL DATA Well type Log present (Y/N) Total depth Y If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~'.~ ¢' Casing height (above ground) ID Sanitary seal (Y/N) Wires properly protected (Y/N) X Date of test Static water level Well production FROM WELL LOG g.p.m. AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample'. Nitrate ~. d~) ~ ~/"/~ Other bacteria Collected by: /4. ~. B, SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping c~./~ Tank size I~ ~ Number of Compartments ~.- Cleanouts (Y/N) . ~ Depression (Y/N) ~ High water alarm (Y/N) p-I Pumper 'l .4 ¢. ¢- c.~ C. ABSORPTION FIELD DATA Date installed Length ~-&~/ Width Effective absorption area Date of adequacy test _ Soil rating (g.p.d./ft2 or fF/bdrm) I~ Gravel thickness below pipe System type =- Total depth Monitoring Tube present (Y/N)__/%/ Depression over field (Y/N) Results (Pass/Fail) For -% Fluid depth in absorption field before test (in.); ~ Immediately after~Z.Ogal, water added (in.): __ Fluid depth ,~,~ (ins) Minutes later: I ~ Absorption rate =. ~ '7'~ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date ~'~ bedrooms 72-026 (Rev. 3/96)* LIFT STATION ~""~/~.~ Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I,?..O Absorption field on lot Public sewer main Sewer/septic service line ~ ,2....~ On adjacent lots //~) On adjacent lots I I ¢ ¢ Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ¢~. ~ ~ Property line Z¢ O ' + Absorption field ! Water main/service line /~,,~, Surface wateddrainage I"~/c) Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation ~'o ~ Water main/service line /~ ,,¢--,.~- Driveway, parking/vehicle storage area J O Wells on adjacent lots J I/.~ 'f' ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the above systems are in conformance with MOA HAA gu/defines in effect on this date. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Chem Matrix Oudcred l oboen !~pu~kiaad LT 7A Bk ~ Kasilof Printed Date/t ime O6,j :,98 2j:4 :; ( ~dlected Dilte; i'ili~t Received i)ate/Time Technical I)U ecn:-r: Slvpheu t. ~,dc 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 7A; Block 1; Kasilof Hills Subdivision Location (site address or directions) 11081 Glazanof, Ancho~-age¢ Alaska Property owner Mailing address Jerry Swanson 11081 Glazanof, Anchorage, Alaska Day phone 99516 243-1121 wk 346-2570 hm Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUNIBER OF BEDROOMS: 5 TYPE OF WATER SUPPLY: Individual well xxx 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: 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 ~'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/orwastewater disposal system is safe, functional and adequate for the number of bedrooms and typeofstructureindicated herein. Ifurtherverifythat 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 $ & 5 ENGINEERING " ' ,N'c, ,ma Phone 17034 '~ag e River Loop rtoar. -- · Address '-n.-jta River, Alaska 99577 Engineer's signature D~/_~S SIGNATURE . Approved for/? cr~-~5 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: AdditionalComments Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It ls suggo~od ~hsf ~ p~riodic~testing be performed to insure the wells continued suitability. Nitrate concentration is 5.91 mg/1. EPA %aximum ccncentration i~--!0.0, mg/1. 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 DH HS 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 Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description; LO'~ 7-/~! ~/( I¢ ~--?~/..0fc W(¢ /;/~arce, I.D. ~?/'-~--' A. WELL DATA Well type ~'~\~)¢~7E. Log present Total depth Sanitary seal (~N) _ Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. ADEC water system number ,/'~,~ Date completed 5-/~- ~'~ Driller Casedto .L~ r Casing height /0 FROM WELL LOG Absorption field on lot Public sewer main Sewer service line SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /0(~ '¢ /00 'f t Wires properly protected (~/N) g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~.) Nitrate Date of sample: I0 ~24-~- Collected by: Other bacteria B. SEPTIC/HOLDING TANK/DATA Date installed ~~lg-~_~./'-¢-~O-g~f Tank size Cleanouts ¢~N) F~--':'~ _ Foundation cleanout ~7.~N) High water alarm (Y/(~ Date of pumping /dO0 (:'4¢ Compartments . Depression (Y/~) Alarm tested (Y/~ /('} -.~O- ~ ~ Pumper X /' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / (..,) 0 '/- On adjacent lots To property line _Absorption field I Surface water/drainage Foundation ¢?--O % Water main/service line /¢0 '/' __ 72-026 (Rev 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION ~.~/,~ Size in gallons Vent High water alarm level ~..----"-"---~ ~ Cycles~tested ~ Meets MOA elect~__~_ D. ABSORPTION FIELD DATA/ / ~O Date installed ~¢/~'~ .~ -~0-~? Soil rating ./¢~" ~¢ ~¢ ~System type ,en,th ,dth * / th.c n . ; Tot .de,,h Total absorption area ~Z' // ~&~( Sr Cleanouts present CN) ~ , Depression over field (Y~ ~O % ~o Date of adequacy test Results (pass/fail) ~¢% for ~ bedrooms Peroxide treatment (past 12 months)(Y/~ ~- ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ( Well on lot /00 ¢' To building foundation On adjacent lots Surface water / Curtain drain On adjacent lots /00 -/ .Property line LeO ~/ To existing or abandoned system on lot Cutbank /'J/,4- Water main/service line Driveway, parking/vehicle storage area /0 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 Date $ 8.. S ENGINEERING '17034 Ea~ie River Loop l~oa~J NO, 20.~ Eagle River, Alaska 9~577 HAA Fee $ ~ ~ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number CHEMICAI_,& GEOLO(,ICAL LABOIL4TOR) ~ 563~BS1ReE, ANCHORAGE, ALAoKA 99518 7ELEr'HONE~gC'7) 562.2343 FAX: (gO~ 561-5301 ANALYSIS ~EBULTS for I~VOIC~ i 60069 Client Sample ID PW$ID Collected Preleive~ with OCT 26 92 BPOi : Ordolcd By ;~. POS :NO~ RECEIV]i Released NI?L~r~-~ 6.91 ~y/1 ]?A 553 2/,~,20.5 8ample gOU'/IN~ MANTLE COLLgCT£D BI: J,~. MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) II o ~ / dc f c, -c cm¢ .,z' Dr-. (b) Property owner Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address '~d'OO Business '~ 70'- 2.70'/ Telephone (e) Mail the HAA to the following address: (or check here Ri, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family ~ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ' :: As certified by mysealaffixed 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. NameofFirm i~-(a ~-/-~/¢ 7-¢c~ n'~ er~f ff, e,'o'~'¢.~, Telephone ~¢¢~'/~¢-~ Address Date Engineer's Seal 6. DHHS APPROVAL Approved for ;2 bedrooms by Approved _ ,/~, _ Disapproved Conditional Terms of Conditional Approval Note: The well for this property meets existing State and Municipal Codes. There are nitrates present, however, it is suggested that periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 5.5 mg/1. EPA maximum concentration is 10.0 mg/1. The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated 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 satisfycertain federal and state requirements. Employees of DHHSdo not conduct inspections or analyze data before a certificate is issued. TheMunicipalityofAnchorageisnot responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: /-o I< , / o f /¢-d O A. WELL DATA Well Classification j~r'f ~, ¢(~¢ Well Log Present (Y/N) ¥' Date Completed ~/ Total Depth '85-O Cased to 5-3__Depth of Grouting Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) If A, B, C, D.E.C. Approved (Y/N) IV, Yield .~ o¢'.'2~'/~w, ~¢-~J SEPARATION DISTANCES FROM WELL: Pump Set At ~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /~' To Septic/Holding Tank on Lot 1!? ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line N,A. '1'o Nearest Sewer Service Line on Lot ; On Adjoining Lots ~ too ' /'f'o' ; On Adjoining Lots _~ /oo, To Nearest Public Sewer Cleanout/Manhole N,,4. Water Sample Collected by T. ,'%. Water Sample Test Results Sc~/'o'.,-~7~'c-/-o r'/,'' Comments ~ c,~:(! ,.,-¢('ocu /~'¥/' B. SEPTIC/HOLDING TANK DATA 7/Ecx/Sy' Date Installed .5'//E_/,Cg- Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) hi, iooo c/,~/ f a~2~/ No. of Compartments Air-tight Caps (Y/N) /¥ Y' Foundation Cleanout (Y/N) Date Last Pumped _ Ii //3 ; for ,N, A, Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well 11~ t To Building Foundation To Property Line 5*0' To Disposal Field To Water Main/Service Line ~ ~5' ' To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 5-/fo/ /6 ~ Width of Field '/,'~¢.~(','~ Type of System Design Length of Field 3d' -e Depth of Field / ,-r' / Gravel Bed Thickness ~' ' Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test ,4 d~C,u af~' .,z~j r- SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well I ~o' To Building Foundation ff'$' Lot h',,4. Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ;> :z~,' To Water Main/Service Ling To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutback (if present) /v, (Oo ' D. LIFT STATION h/,,4, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **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. ;¢ W Z z.;.;~ ~ .~ -, ....~ ,? ~ Engineer's Seal -- Date of Payment /- /~ -- ~ Waiver Fee: $ Amount: $ /~. ¢¢ Date of Payment ~-0~ (R~v. ~/~) B~c~ Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~X 56~:3 B sTREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 Vj~'o'.~'o.~,~s~% FEDERAL TAX ID # 92-0040440 ' ~.~.~.~ ANALYSIS REPORT BY SA)~PLE for Work Order I: 18125 Date Report Printed: NOV 9 89 8 12:42 Client Sample ID:KASILOF HILLS L7A Bi PWSID :UA Collected NOV 7 89 ~ 13:50 h~. Received NOV ? 89 @ 15:30 hxe. Pzeserved with :NOTHING Client Name : FLATTOP TECHNICAL SRV Client Aect : FLATTOT P.O.t NONE RECEIVED Req t Ordered By : TED MOORE Analysis Completed :NOV 8 89 Send Reporta to: Laboratory Supe~E!HEN C. EDE 1)FLATTOP TECHNICAL SRV. Released By : ~d'.~ 2) Special HOLD EOR PICK-UP UPON COMPLETION. Inatruct: Chemlab Ref ~: 8435 Lab Smpl ID: I Matrix: WATER Allowable Parameter Tested ' Result Unite Method Ll~lts NITRATE-N 5.5 mg/1 EPA 353.2 10 S~ple ROUTINE SABLE Remarker SAMPLE COLLECTED BY T.F. MOORE, I Tests Pc:formed ' See Special Inetructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above NA- Not Analyzed LT-Lees Than, GT-Greater Than MUNICIPALiTY OF J2{CHORAG~ DIVISION OF ENVIRON}~i~£AL HEALTH DEP~'~,IENT OF I~AI,TH A~ Ei~-VIR()~NTAL ~O.~LCTION i?PLICATION I OR nr,l~..,~.l:~ A~HORITY APPROVAL CERT~i'ICATE (a) Legal Description (inclnde lot~ blocl% subd~?ision, section, township~ Appli~a~ N~e.~_~..?~/~_,L~/~'!::~ 2'/2[i .................. 'r~,3~9~hone ~ Home ~' Business Applicants Address (d) Landing Institution ~ele~hone Address (e) Real Estate Coo & Agent Address (f) Telephone Mail the I~AA toc~e~'- following addras,,~: ~ J . - .... ,: ..O// 2. T~y~l~a of Residence Number of Bedrooms Other (describe) Note: If community well system~ 0~ust have ~,,rtitten conf:[.t~mation fro~a the State Department of Env:£ron~enta! Conse)~ation attesting to the legality and status° Onsite ~/.~. Public I=-~-.~.[ Communi~:y ~=~ Holding Tank IiiT~[ Note: If community wall system~ must have ~,~'i!:ten copfirmaL'ion from the State Department: of Environmental Conservation attestinU to the legality and status° -[Page 1 of 2] Engineering ~J'irm Providin~ Insoections~ Tests~,. File Searc~,_ Data and -' =' .... As certified by my sea]. affi:~ed hereto and as of the validation date sho~.~ below~ f. verify that my investigation of' this Health Authority Approval shows that the om.~site wager supply and/or l~stewater disposal system is safe, functional and adequate for the mmber of bed]:ooms and type of structure indicated herein~. I further verify thee, based on the info~:'mation obtainc~ from the ~,tmicipality of Anchorage files and from my investigation and inspe¢~ion~ the on=site water supply and/o~.~ wastewate~~ disposal system is in compliance vrlth all Municipal and State codes, o~:dinances, and regula~ tions in effect on the date of this inspection° Name of Fi~.nn 27'?f' ~> "? ~' :~ ' '~',-L, ~" ~ ~ ...... ':' /Z Date I:' Approved fo~: 'c..:_:' ~ bedrooms By CAI~ION THE MUNICIPALITY OF ANCHORAGE DEPAR'fMENT OF HEALTH AN]) ENVIRON~ff']NTDLL PROTECTION (DHEP) ISSUES tlEALTH AUTHORITY APPROVAl, CERTIFICATES BASFD SOLELY UPON T~iE ~JZ.'_.PRESENT.~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE, BY BN INDEPENDENT FROFESSIO~IiL ENGII~qZER REGISTERt0) IN TILE, STATE OF AIgSKAo TRE DHEP DOES %~-!IS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR I=END!NG INSTITUTIONS IN ORDER TO SATISFY CERTAIN ~DERA], AND STATE REQUIRE~ MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANAI,YZE DATA BEFOKE A CERTIFICATE, IS ISSUED, r~ MU~'ICIPAL!TY 0F ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN 'l~ ~ROFESSIO~&L ENGINEER'S WORK° (DHEP ov^~ ~ RR4/ej/D18 [Page 2 of 2] 7 =19-84 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAI~NI¢IPALI~Y OF ANCFIO~GE DEPT. OF HEALTH 8, CHECKLIST - FEBRUARY 1984 ENVIRONMENTAL PROTECTIOj~ 264-4720 RECEIVED Well Classification Well Log Presen Y~) Total Depth ~.~'~ ! _ Cased to ;~,~ / Static Water Level ..,,~,,~ ! ~) Casing Height Above Ground __ ~,~ / Electrical Wiring in Conduit/~N) If A, [3, C, D.E.p, Approved (Y/N) '~ Date Completed ~t'~/~ Yield Depth of Grouting A/~- Pump Set At ~ ~ Sanitary Seal on Casin~N} Depression Around Wellhead) Separation Distances from Well: To ~eptic/Holding 'rank on Lot /,~.'Z.- '"' ~ ; Oil Adjoining Lots To Nearest Edge of Absorption Field on Lot _ . ; On Adjoining Lots To NeareSt Public Sewer Line /'~,'~ To Nearest Public Sewer Cieanout/Manhole _ .//.//-'¢ To Nearest Sewer Service Line on Lot //"///'"'¢ Vat . Oo,, ct d._ Water Sample Test Results Comments '~~~ ~ ~ ~, 1,~1 / i ~ -.~. ~,t ~--~-~ , B, SEPTIC/HOLDING TANK DATA Date Installed /~,,?-, ¢/~, Size ,/~,..5-O ¢ m¢~) No. of Compartments ~ t / Standpipest~) Air-tight Caps~N) Foundation Cleanout~C~)N) Depression over Tank (Y/O. 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:, ~_T ;~-'r~~/ TO Water-Supply Well ~f~ /~' ~' ¢~' o Building Foundation_ To Property Line 5~?~ t' ~.Z TO Disposal Field To Water Main/Service Line ~ ~'~ t ¢(._. 'I'o Stream, Pond, Lake, or Major Drainage Course "' O~1 Y':i Page 1 of 2 C. ABSORPTION FIELD DATA Square Feet of Absorption Area Depression over Field (Y/f~ Results of Last Adequacy Testt...,-- ~__~.~ Separation Distance from Absorption Field: To Water-Supply Well / ~/'/g2 ";;~'~ Soils Rating in Absorption Strata /~2~) ~ Type of System Design Date Installed /¢~'~ ¢ /~ Length of Field ~ ~ ¢~ Width of Field ~,1~ ~ ~~ ¢ ~ ' Depth of Field ~~ Gravel Bed Thickness ~ ~ ~ ~ ¢~ Standpipes Prese~N) Date of Last Adequacy Test To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Property Line ~-~ / To Existing or Abandoned System on ; On Adjoining Lots ¢-- ,:.~<::2r '" To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storacle Area Comments '¢¢'"~~ ~ ,~¢'~¢/'/~/E,¢~:;2 LIFT STATION Date Installed ] ~ Dimensions SizeinGallons / / ~cc~ "Pump On" Level at ~ // ///~~"Levelat .... High Water Alarm Level at /~.~~ ~-uVmep~'tn(gY~)c Tested for I . eets MOA Electrical Codes (Y/N),~''~ Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h.a~e checked,.verified, or conformed to all MOA~nd Hg, A guidelines in effect on the d Signed ~ ~ Date Company/ ~¢ ~MOA No. Receipt No. ~-~ Date of Payment ~-~L~ Amount: Page 2 of 2 72-026 (11/84) ALASKA UIRO[qmC[qTAL CO[1TROL SCI ulC $, I[1C. ~nqincerinq & ~nuironmcnlol ~ludics MIKE PRATT 1809 Cindy Lee Lane ANCHORAGE ALASKA 99507 SELLER-SAME MIKE PRATT ANCHORAGE ALASKA MAY 23 1985 50235 LEGAL:KASILOF HILLS BLOCK 1 LOT 7A FLOW TEST ON WELL WELL FLOW DATE-MAY 23 1985 A FLOW TEST WAS PERFORMED ON THE WELL. 780 GALLONS OF WATER WAS PUMPED AT A RATE OF 6 GPM OVER A DURATION OF 2.7 HOURS. THE DRAWDOWN WAS 73.15 ' WITH A RECOVERY TIME OF 30 MINUTES AND THE STATIC WATER LEVEL WAS 52.2 FEET. THE WELL IS ADEQUATE FOR THIS 5 BEDROOM HOME. 1200 IJJcsl 33rd Aucnuc, Suil¢ ~. A,choraqe. Alaska 99503 .(907} 561-5040 APPLI(' NT FILLS OUT UPPER HA! ONLY '"' Phone Address Zip Oode ~ealty Co. & Agent Phone Address Zip Code Type of Resi~nce ~lh~lo Faro ~ ~ Multiple Family No. of Bedroo~ ~ Other Water Supply ~n~ividual '~~:~- A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community /~ ' ~ 1. / i ~ (._ .r ~ ~ ~. For wells drilled prior to that date, give well depth (attach log if available}. ~ Public Utility Sewer Disposal ~.dhdividual 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 Date Date Date Date Inspector Insp~clor Inspector inspector Field Notes: MUNICIPALITY OF ANCHORAG~ ,-I'd'> ~ D:~T C~ i~'~r'~" ~NVh .,Il :[. 1,.; ;0 F 7~ [ ECEi [D ( ~APPROVED BEDROOM8 ~ 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' Soils Rating Dale ~wer Installed Well To Absorplion Area ' ,~ .a , Well Log Reoeived /, ,> .J':. / 6- t,' ? , .~_ , / Well lo Tank f ,: :,) ,,, Septic T~k Size 72-023 (3182)