Loading...
HomeMy WebLinkAboutKASILOF HILLS BLK 4 LT 15 · i by z'.... DOG CO. dba 'SULLI,VAN WATD ' P.O. BOX 670372,'CH~G~AK, ALASKA 995a7 o TELEpHoNE 688-27~9 LEGAL 'DESCRIPTION ,.. ' I~ well [~ated atjapp~vad per,it location. ~ Yes ~ No ' Oepth ~well: ~.,.~ ' Casing Type ~Wall Thickness , ~'0 inches Diameter_..~Il inches, depth_~O/ ~ /~ feet ,Casing Stlckbp'A~ove.gr0uhd: ~ ' fed "'"S[~'i;'Water Level (from ground level): ~ I feet Pumping level: feet after hrs pumping gpm Recover Rate: ~ ,. · gpm Method of Testing: ~ Well Intake Opening Type: ~ Open End ~ HoPe ~ Screened; Sta~ feet Stopped feet Grout Type: ~~, *F~ Volume .... Depth: from feet, to feet Pbmp Intake Depth: feet Pump Size .bp Brand Name Well Disinfected Upon Completion? ~s ~ No BORE HOLE DATA DEPTH Cornqe ts: [ c, ,W ATTENTION: It ie the respon~ibili~ of the prope~ owner to submit a copy of ~he well log to the p~opc: of A~chorage; Department of Health & Human Se~ices and/or Oepaitment of Environmental Conscr'-. ' -: Depadment of Environmental Con~eNation. EEIVE D MAY '18 1999 Munic~pality of Anchorage Oept. HeaLth & Human Services £d WdEP:PO 666~ ~0 'RoW : 'ON 3NOHd MUNICIPALITY OF ANCHORAGE DE RTMENT OF HEALTH AND HUMAN SER'~. ES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Address ~ho~,Isl /-~eTnn~,I No -'- INo o/Ihed LEGAL DE~BIPTION WELL LOT LINE FOUNDATION DISTANCES SEPTIC TANK ABSORPTION FIELD WELL TANKS ,~ SEPTIC [] HOLDING TYPE OF SYSTEM TRENCH [] BED 'F~W. DRAIN [] OTHER ong,n,, grade ¢'~'~" [~) FT (..¢, OFT G~avel depth benealh p~pe Fdl added above ougmal grade 1&5 FT WELLS PRIVATE ~ OTHERIIdentif¥) FT] cased to Dale Inslalled REMARKS: FT AS-BUtL'r DIAGRAI~I (Show Iocabon of well. sopbc system, property hnes. Ioundallon, Inspecbon~ed by: Mueicipal and 81ale guidelines in ellecl oe Ihis gale; cerlily thai Ihis inspeclien was pedormed accerdinp Io all )}I:i}:F:'AR'TPIIii]',I'f OF' I'"iEi]AL'[,'-'I AND IEIxlVIRONMEIqTAI.. t32','5 I... ?]IREET, ANCI'II]RAI31E ;?, 6 4."" .~1.'? 20 F::'fiiZl:;fl"l :[ T I',1[] ::, DAI'E :I:SSt.IED~', 02/03 CON'f AE;T [..I<GAL D[!i]SE;R I F': LOT !3:1] ZE :', MAX I:i::.,'.~GL.[i!: R :[ VEq::t, AK 694 ...-2. 9 '79 SUBI) IVtS.1;ON: KASILOF HIt..LS S[!i:C'f' ;I; Obi: 24 'I"(.)WIqSH ;1: F:': J. 30()()0 ( .':i~(;',! ,, F:'I'. (:)R ACRIES ) 4 I.,.[IT: :1, 5 BI,,.OCI<: 4 F;:ANI31i::;: ;];W :01!!i1:::"I"t'1 '1'0 I:::' :1: I:::'IE BOTTi]!M (I:::'T.) GRAVEL Dli:i]?TI''] (F'F.) 'TOTAl. DEF::'I']"I (F::'f',) GRA'v'I:~]... W1]D'['H (F'T.) li'}R(~¢v~EL LENGTH (F::'I'.) GRA'v't}i]....VOI..IJMI!}i; (E;U. YI}S,, )' TAhlI< SI Zl:ii: (GAI...S) SO I: L RAT ;!: I".tG ( S(;;! ,, FT ,, /BR ) 4-,, 0 4 ,, 0 4 ,, 0 2 ,, () (). 5 2. ,, 0 6 ,, () 4 ,, 5 6 ,, 0 2 ,, ',5 29 ,, 0 5 ,, 0 31 ;2 ,, 0 .){'.~ 55 ,, 0 1 '7'.JJ ,, () .~:~..~(. 72 ,, 3 ',:..'J9 ,, :[ ~31 ,, ]. ;I., 2~'5(),, ().~--~:. :l. :, 2t50 ,, 0 .~{..;~. :!., 250 ,, () ¢~..~. :::~; 1 ;?. 264 3:1. 2 · ;~-.~:. GI.;~AVIEI,,. I..liii]',l(-.iTl,l > /'5 I::;'T ,, Fd]ii:i:i'!U ;1: F:i:li!:S MUI..'T I F:'LI~: I::;;I.JI',IS (t',11]'1 Iii; X Cli:~;EiXi:):1; I',IE.i 75 F:T ,, IEACI.I ) · l(..?~ 'IAI'.IK MI. IST I. IAVE AT I..E:AS'T 'T'I,'.,IO fc:~r"Ll'l by 'LI"i~?)I"h.u'i:Lcip,~:I:i. ty of Ar'lc;llc)ratj~..:, (MOA) and thc:, S'LaI:..(<, (::if' AZl. asi::a,, i:':~l'l(::l :i.I] (::;(;:~ill[:) ]1. J.~U'I(::E.., b,tj.t['l 'l.:.l'ie~ c:lc.:¢!B:i.l.:Jf'i E:I' J. t621' :[?:.'t 3. 1 t..,~:i.].l ,':,(::ll"~,z)l'~:..~ to, ali MOA ar'id S'l:.c, Le (:)f A].aska /.I.,, ][ tXltd(x~l's't.¢::tlid '['..['h.&t 'Lh:Ls permit :i.s w:~l:i.d for a ;I;F' A I..II::'T S'I"A'I"ION :f:S ;[IqS'I'AI.J...I]i:D II',l AIq ARlii}:A CI]gI:i:RIEO BY MOA BUIL..D:[IxI[') CODIES, T'HI:::N ............... ( I ) AI',I F'I F::'( IR '11'~, ~ ......... ~ I :'I:::RI*I]" ] AND T I',1c, ...... I:::'I::T']', ...... T iN Mt lc:FI', J..' ............... I:::' (")F' 'TAT t~)I:::'D':, f.,'? ................. ) A ::-.-'I." t Jl'l 'lX::~,.. W:I:L.I... NOT BIE AI::'I:::'F:~:OV~3;~ W]]]~I...IOUT AN IELI]~X]'I'R:I:CAL. I NSPI~DZ;"I'I(:]I',I RIEF;'OFCI", AND (3) 'I'HIE I]~]..E(]'II::;~;~:E;AI.. t,qOl::;;l< FliP, ST );)I]~Y/D_OI'',IE BY A I...]:CENSE~) IEI..ECTRIE;tAIq,, ' .... ..... ................... AF::'I::'L ~CAN'I~ S&~E~NI3 - ~fi~neor]nc~ ~. MPUTATION SHEET / DATE_: SHEE~ BY CKD OF .. (.-. /;?.So ¢ ,~ e Cv~VlPUTATION SI"IEEI' DATE: SHEET BY CKD OF Fo? ¥ h /I ..,q D ,g / T'/ o ~,J ,,'9 (. J:,-: l /. 4 ,.~/_. o/9 E SOILS LOG PERFORMED FOR: MUN c P A I ,'%, IVIUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL DEP~'~ 825 L. Street, Anchorage, Alaska 99501 264-47~OTECT~"~ONMENTAL~TECTION SOILS LOG - PERCOLATION TEST ~ ~'-;:~ RECEI Robert Hammond DATE PERFORMED~" LEGAL DESCRIPTION: Lot 15~ Block 4, Kasilof Hills Subdivision FIBROUS PEAT w/ORGANIC SILT Brown SILTY SAND, w/GRAVEL SP-SM, moist Brown SILTY SAND, SP-SM to SM moist Random GRAVEL SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2o COMMENTS PERFORMED BY: WAS GROUND WATER NO S . - ENCOUNTERED? QL IF YES, AT WHAT None observed Decomposed BEDROCK DEPTH? to 13'-4" 7/16/82 Reading Date Gross Net Depth to Net Time Time Wate~ Drop I 7/16/82 11:22 0 38-3/4" __ 2 7/16/82 11:52 30 min ]9-3/4" 1" 3 7/16/82 12:22 30 min 70-1/8 3/8" 1~,,4 7/!6/82 12:52 30 min 70-7/8 3/4" ~ 7/16/82 1:22 30 min )1-1/4" 3/8" ~ 7/16/82 1:52 30 min 92-1/2" 1-1/4" _ 7/16/82 2:52 30 min 94-!/4" 7Z8" _ ~¢p!'" 7/16/82 3:22 30 min 95-1/4" 1" TOTAL DEPTH OF BORING - 14.5' . ,%: '¢~,~ J.-,~',,':.,.T',~~ /, ~~ PERCOLATION RATE 3~ (minutes/inch) 6.O 7.0 TEST RUN BETWEEN FT AND FT Revised 11-2-84, water level 13.0'. Roy McDonald/Mark Hall CERTIFIED BY: John M. Lambe DATE:July 30; 19_82 /O R PE p fd F3 OF Ak,,�CHORAGE lscz' a' �i Em - Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-131-17 I. GENERAL INFORMATION Complete legal description Kasilof Hills 134 L15 Location (site address) 10541 Rezanof Circle Expiration Date: W `.2,r0 —Z% Current property owners) Pam & Mike Lapointe Day phone Mailing address Real estate agent 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic E Water Storage ❑ . Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless othenr✓ise requested by the engineer. COSA Fee $ CJ Waiver Fee $ Date of Payment %/ 1Z Date of Payment Receipt Number 0 52 3 G Receipt Number COSA # O S C 21 1 3 12 Waiver # MENT OF INSPECTION BY ENGINEER J by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or water disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated jin. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and spection, 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone.P.E. Date 12���Z— OF A�,qs�� COP 6. DSD SIGNATURE ?�' 4 _H Y �,... ... ... ... System #1 Approved for bedrooms Stev ;i POIin0112 System #2 Approved for bedrooms fA F . CE of 9 �;. Disapproved Conditional approval for bedrooms, with the following stipulations: ��-�v�QP g ON -S m� WAST'_vVATER oz_� P IVI J� J�J�iFNT SER��G����,` Original Certificate Date: 7 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 blue sheet COSA Checklist .,al Description: Kasilof Hills B4 L15 Parcel ID: 015-131-17 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 1998 Total depth 320 ft Cased to 20.33 ft ® Sanitary seal is functioning correctly 1r Wires are properly protected Casing height (above ground) 25 in. Date of flow test for COSA 5/7/2021 Static water level at beginning of test 28.8 ft. Comments B. TANK DATA Age of tank(s) 8 years Tank type/material Measured operating fluid level in septic tank FIE -1 Standpipes/foundation cleanout per record drawing Date of pumping 8/13/20 D. ABSORPTION FIELD DATA Mounded Bed Which system tested (date installed) 1212012 X ALL standpipes present per record drawing Total measured depth from grade 2.5 ft (max) Measured depth to pipe invert from grade ft (min) Q N/A — pressurized field 0 Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test 1.5 gprn Water storage tank volume 150+ gallons Well disinfected for coliform test? Q Yes ❑ No Q Coliform bacteria is Negative Nitrate 2.83 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L © Arsenic less than MRL (ND) Collected by PES 4/27/21, 4/29/21, 5/5/21 Date of Sample S�enbwe C. LIFT STATION Z Required maintenance completed Age of lift station 8 years Lift station material Steel Comments: Adequacy test date 5/7/2021 Results �(✓ Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 0 in Elapsed time 0 min ® Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 1600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) No date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: Drainfield was installed with 2" of rigid insulation and has >1foot of oroundcover 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' LLJ Yes Community Sewer Manhole/Cleanout > 100' ✓Q Yes if No ft ❑✓ Yes if No Neighboring Tank > 100' E Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No Absorption Field on Lot > 100' [71 Yes if No ft Holding Tank > 100' 2✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' F✓l Yes if No Z✓ Yes if No ft Yes if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft ❑✓ Yes if No ft ft ft ft III From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5 LLJ Yes if No ft Wells on Adjacent Lots.- ots:Absorption AbsorptionField > 5' El Yes if No ft Private Wells > 100'✓(] Yes if No ft Water Main > 10' ✓0 Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' E✓ 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' 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'✓Q Yes if No ft Private Wells > 100' ®✓ Yes if No Water Service Line > 10' 0 Yes if No ft Community Wells > 200' R Yes if No Surface Water > 100'✓Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION OF A�.4 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. ..... ' ' . ' 2tC) t2--...................... teven R. annone rE fl. ^G �SStglyt,, COSA Checklist yellow sheet ft ft VIUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this t Day of _T,3� of 20 2-1 ; by and between herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance Nvith Anchorage Municipal Code (AMC) 15.65.365. In consideration Of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as ]located( at (legal 4description) 2. MaiIltenaIlce, Repairs and AlteratioIls. (Owner is required to read, understand and initial each section) ��G% Throughout the term of this Agreement, the Owner shall enter into a service agreement Nvith an AWWTS service and maintenance provider approved by the Municipality or the manufacturers representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval f:or operation in the Municipality. -� It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to S600). G- Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. t/� Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainheld replacement. (rev. 05/18/2018) Page I of 3 f41 6L Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for thiling to maintain and repair an AWWTS may be assessed in accordance with AMC 1.4.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. ONv17er agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing -uidelines for the construction, maintenance and repair of the Owner's AWWTS. ✓�� Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. "Perin. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failtn'C of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Lay. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid. by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNER: By �� (signature) Date: 1,zlo ��yiy1 G.;• Zeb-t (print name) STATE OF ALASKA ) ss. THIRD JUDICIAL DISTRICT ) The forc(Toing i-�strument was acknowledged before me this qday of 20 by NOT.Y P` 13L OR ALASKA� � �'�'� �q+ �<��' � pp �° .•°�, O a�IA�KAP., ;. My Commission expires: M90" Am mumu pc _ Daray N. t� 11y f arrnissl 1r 3 m MUNICIPALITY: By:(signature) Datc: 2 (0 Z� rint name) Title: (rev. 05/18/2018) : Page 3 of 3 0=,'1='.''2?E_t2Fi 17:2,_ 116867,Cj HFLUS F GE 05 [jkavanTexv Field MalntOflanceftport Annual Insp ��icn Anchorag�Tank � 947-272-3543 Property Owner/rracking 0 Opo for Mike and Pam Lal: ointe Larry Betts Sha adore» FConl=ryryne10541 Reaanof Ci -,►e, Anchorage Aid 99507 868-1114 Ax $)1e ID 8 Caunly IDV Poo 0RTU iNL kr! Ia3pettivn AX -130726 OSP121396 415799 2019 Retrieve O&M into Dally flow Reclre ratio— rimer settings: Perform Field Samp ng/Observations NTLJx(('15 s NTUs) P '(6-9) DO (2-6) �4 Odor of Sample TypicalMu, t L-1Earthy ❑ Moldy Non -typical 7� Sulfi( ) ❑ Cabb lge ❑ Decay Oily film in PVU I_ Yee No Foam In tsnk [_ Yes No Cheep Control panel Rociiirc Amps Discharge Amps Audible and visual alalr is —nK Dia) torte telemetry on �► 7Yes Inspect/Clean Pum r>„gstem Inspect Riser/Lid ........ . .. ....... . . Splice BO) .......... ......... Float Cards ......... ......... 01 Floats .............. .........Vill tV Pump .............. ......... liI Siotube' Filter ....... ....– Biatube Pump Vault .. _ .. , , , . , , [ Recirculating Splitter th vo. , , . , . , Comments Signature; "" ❑ No Clean Meosure Sludge/Scum Sludi istCompartment Curmnt Previous Cutnt Pmvious 2nd Compartment Current Previous Current Previous Insp®ct/Clean AdvanTex Filter InpQ�,t Clean Odor. Normal ❑ PunArnt L9terals/Orifices 17, h Blomat: 1 Normal Excessive Pod Bottom l Bridging/Ponding: None/Minor ❑ Edoesslve Intake Vent V T" inspect/Clean Discharge Pump System Inspect inspect Clean Rlser/t_ldFloat_c _ Splice bods 1,4 Pump Float cords 7 Inspect/Service (:ether Systern Components Inspect Clean Inspect Clean Disinfection Equipment ,0 �El Dispersal Laterals/orirtces7— Observations Additional Services Rendered ❑ Cleaned textile, sheeta? ❑ Replaced UV Items? ❑ Replaced/Used other Items? Parts Used: W = Warranty, 6 = Billable (✓ appropriate aeleotion) W B Item Number Descrintlon Flnal/Safety Inspection RSV reinstalled Manifold rewnnoctad; flush valvrg closed Summary/P, ecoltlmendations Ii System performing; no further action nordrd ❑ Cali for service Lids bolted on Control panel reactivated ❑ Tank nocds pumping ❑ Other? — rax Ut'ilit' Pleteo Torm to 1-866-384-7404 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. # ~_~/~' ~' -~. - '~ ,'~ I - / --~ HAA # 1. GENERAL INFORMATION Complete legal description Lot 15, Block 4, Kasilof Hills Location (site address or directions) Rezanof Circle Property owner Mailing address Wilco Contractors Day phone 16701 Ransom Ridge, Anchorage, AK 99516 345-6288 Lending agency Mailing address Day phone Agent Address Day phone Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: xxx 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: XXX 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 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm s & $ ENGINEERING Phone ~> i70~,4 Eagle River Loop Road No. '-,04 Address Eagie River, Alaska 99577 Engineer's signature '"~/'~ .~.~ Date DHHS SIGNATURE Approved for -/~-///2/~c//%, bedrooms· Disapproved. Conditional approval for 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. 72A)25 (Rev. 1/91) Back MOA #21 xl:CEIVl:u Municipality of Anchorage UA¥ 1 8 1999 DEPARTMENT OF HEALTH & HUMAN SEI?~r~ oF ^NC~O~^~ Environmental Services DivisionENVmONMmfAL SERV~C:[S OJVlSIO 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: LoT- I ~- 13Lo ccc ~ /~4.¢Jl. oF 14~ ~_~f Parcel I.D.: A, WELL DATA Well type ¢°,f4~ Log present (~:/N) Total depth Sanitary seal ~,N) '¥,.~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to Casing height (above ground) Wires properly protected (..C/N) ~'"~J' FROM WELL LOG Date of test Static water level '-P I Well production ~ . g.p.m. WATER SAMPLE RESULTS: Coliform o Nitrate 0 · 6'- Date of sample: $~'// $'~ / ~ ~ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~.// Foundation cleanout (~)/N) ¥ Date of Pumping ~'/8 AT INSPECTION Other bacteria 0 g.p.m. S & S ENGINEERING 17034 If. agie River Lu,cp .... Eagle River, AlaSka 99577 Number of Compartments '2~ Cleanouts~N)__ Depression (Y/(~I~ /,, 0 High water alarm (Y~-~ ,~,., 0 Pumper C. ABSORPTION FIELD DATA Date installed ',~/13/ ~ Length ] ~ ~- Soil rating (g.p.d./fF o ~ I 2, System type ~0r4cWidth ~- Gravel thickness below pipe ~] Total depth Effective absorption area ) ;~ S- Orr~ Monitoring Tube present CN). yr~j Depression over field (Y~I~ Date of adequacy test/v / ~ . Results (Pass/Fail) For Fluid depth in absorption field before test (in.); Im~atFWa"~l'~-~-~-e-(~ (in.): Fluid depth __ (ins) Min_u~ffi~~"~~ Absorption rate = .g,p.d. Pe~rmqidetFe~t'"m~ent (past 12 months) (Y/N) If yes, give date bedrooms LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons ~ ........ "Pump on" level at* ~mP'~'''~off'' level at* Cyc!~~ E. SEPARATION DISTANCES F, SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station /~o ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~' 'Y- Property line ~' 'Y Absorption field Water main/service line / o + Surface water/drainage /00 '~ Wells on adjacent lots 1o 0 /o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /_j._ Property line / o Building foundation / (2 Water main/service line Surface water / 0 0 ' Driveway, parking/vehicle storage area Curtain drain ,~ 0 ,v ru ~ ,'¢ O ~ ~ Wells on adjacent lots i o 0 ENGINEER'S CERTIFICATION ~- · I certify that lhave determined thru field inspections and review of Municipal record.,.s~.~'~.,?~,,~.,.~C~,s are ...... ~,% ........... ,~.WfJ ~ in conformance w/th MOA H~A gu/defines ~n effect on this date. ~ ~ /' A %, ~,~.~ Signature ~t~ ~ ~'~ HAAFee $ ~::~'~ "~ ' '""' Waiver Fee $ Date of Payment ,..¢-- ///Z ReceiPt Number O 72-026 (Rev. 3/96)* Date of Payment Receipt Number PHONE NO. : MS, U. ~4 1999 04:,42PH P2 REZANOF CIRCLE