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HomeMy WebLinkAboutKASILOF HILLS BLK 7 LT 4 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ..~-~"~7 ©/ ¢(',¢ PIDNumber:_ /lA/h4 ~' ¢3, ~/~ h/ 7~ Wastewater Syslem: ~New ~ Upgrade Addreae; p. 0. ~ ~?¢~ ¢ ABSORPTION FIELD Phone: ] No. o[ B~drooms: I ~ ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL D ESCR IPTI O N Soft Rating~,~GpD/Sq, Ft, Tolal Depth/,~,lrom ~°rlginal/, grade: Subdfv~lon; , :Depth to pipe boltom from original grade: Gravel depth beneath pipe Township: Range: ~ Section: Fill added above original grade: Gravel lenglh: Gravel w~dth: ~ Number of lines: Distance belween lines: WELL: ~ New ~ Upgrade , ~ Fi, / ~ FL Classification (Private, A,B,C): Total Depth: Cased To:~ T.RA~ Total absorption ar~: Pipe material: Date Drilled: Static Water Level: Installer: Date Installed: ~r,~/~., t~'~/-- '~,'~ ~"~' C,.~'-/~-¢V 3~ ~. ~/~¢/tP,~' d~ ~-./,~- Pump Sel at: ] Casing Height Abov~ Ground: Yietd: .~ GPM , ') ~' (2 Ft. ~ Fl I ,2 . TANK SEPARATION DISTANCES ~ Septic U Holding U S.T.E.P. To Septic Absor¢flon Lilt HoMing ~ubllc/Prlvate Manufacturer: Capacity In gallons: Fram Tank Field Station Tank Sewer Lines ~/'C ~Q~A~ '~F~ Well- / OO (t JO ¢ ~ ~' / Malerlah Number of Compartments: Sudace /[ w.t~r /00 ¢ /o¢~- LIFT STATION Lot / / Size in gallons.. ~ Manufacturer: Line ~' ~I Cuflaln Pump M~ &.M~l Electrical Inspections pedormed by: Drain ~ ~[~LC /~Wd>I .... Remarks: BENOH MARK Location and Description: /Assumed Elevation: Inspections performe~.~ENG~N~ER'~G .... Dates,. 1st ~',~-¢ '7 ~gle Rive~, Alaska ~5~ ~ .... ~ - Department of Heath.and.Human Servmes approval . ~, c~, ....... Reviewed and approved bY: Date: ~- ~ -¢~ ~'"~ a' ~a'~'"'~'" ~'" 72-O13 (Rev, 9/91) MOA 25 PERi'lIT NO. SW9701 66 PAGE 2 OF 2 Municip. c~Li~x,, oF Anchorcme DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.D, ]]ox 196650 ~.._Anchoro, Qe, Ato. sko. 99519-6650 ® Tetephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEH AND/OR WELL INSPECTION REPORT LEGAL LOT 4, BLOCK 7, KASILOF HILLS P.I.D. NO. 015--161--1.3 A B FCO 21.5' 42.0' ST1 26.5' 47.0' ST2 ,34.5' 52.5' DBL1 41.5' 57.0' DBL2 42.5' 57.5' C01 69.5' 68.5' C02 95.0' 66.0' MT1 94.0' 64.0' DBL1 DBL2 NEW / / MT1 C02 NEW 1500 GALLBN -SEPTIC TANK TBM~ L~ ST1 0 ~-© LiJ t~l 8 NEW WELL EXISTING WELL STi ST2/FINAL GRADE~M?i / INSULATION ~91.7' CO1 = 89.9'~ = 88.4' C01 = C02 = N.T.S. MT1 = 77.1'/ & NO WATER FOUND 71.1' B.0.H. SCALE 1" = 40' ROBERT C. COWAN CE-8801 ROBERT C, COWAN, Ri-'. ROBERT A. SHAFER, RI--'. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOWTEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTION8 ONSITE W/~TEWATER D~SPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED 2 1997 Municipality o[ Anohorage Dept. Health & Human SerVices REFERENCE: L~T- The septic inspgctlons for ~he .referenced property were performed on ~/~/q7 and ~/~G/cl7 . Prior %o submi~%ing the On-site Wastewater Disposal System and/or Well Inspection Report we are waiting for the~x'.~-,~/~,3~v~ to be completed. If we may be of further service please contact us. Sincerely, Robert C. Cowan, P.E. 17034 NORTH EAGLE RIVER LOOP ° SUITE 204 ° EAGLE RIVER, ALASKA 99577 ~.~/~/~'"'~"'~',A~. ':. · ' '"" ".' Health'a 14uman;~er~io'es., '.' .j,,.' ' . ' ' '' ..' ,,;;%~-,0 """ · : ".-;:~ SIX INCH WATER WELL DRILLED ........... 'OUT TO THE DEPTH OF ~0~ 'feet; ..... ... . ;',¢;; ~5,'00 " '. '~ '- DRILL[D AT THB RAT~ OF "' P~R FOOT. . '." .' . , . · .;~"-s . PROPERTY OWNer Work nrdere~ by ~r.. Cl~y Bah! o~ N~'"rthridce :Obese.. LOCATION OF WELL'SITR Lt. ~ Bik. 7 [fssi]_of Hills] ,Sub. . ,.. .:....f,.(,;:,;,.,.( .. . '. v..", DRILLER B$'/nie Claus of R;}mpart Drilling Works ....... : W~LL LOG: (') - 1~' Gravel ~: c]py t:o s:Lw feet, then gozng into: s. conElo~[e-r~[t'~.~ock: .... ~.~/~ ,.':ere c. ble to (~rive the steel six diameter ca. sJ.~,.g, the fdtl d. ep. th of elghteen feet, to refuse], et that depth. From ~8 f, ee6. [0: '3OS.f~"6'~'iS/::a~:' ;'',-- j_~ ?.ln~ rock .?].lO,Vet1 for ~ot'~e we. toP .yield' 5.~ ~he f±~st, 150 fS~" . · , . 4 · 'q. Th~ ent&~o hnrehole .v¢~ r~rj.!!e<t ",itl a sJ.x'lnoh drill bit. By 18o to 185 feet, ,.ve were sh0,:'ing thin are'ss 0f granular..~qck.,:;,: '?~oHuci n~. jttrc~ ovo~ 3,/ll ~_r~, B~f ~35 feet, this ;Well h'aO improve¢(.~0;,; a ~t.~ 1 1/2 gpm"from crock,q. ~.'fissures in the rock. (wa(e~" ' .......... " "" ' . ,beaning;.,).. :.'.;.',.. · ';i'ji: ':.,:,~'.' i' m,,, ,.°~n feet, v'e ':/ere sho'.vj, ng two' g,?] ....... Ions ~ minute":l'o'f' water yield.'~:'~"bU'~' ' '~r:'",:JmS ~o".,n to "hou~ 1 3,/L~. gpm o. fter 30 minUtes',,df' pump~n~~' pn~atid"ail~[ ~y fo5 feet, this We!! ,.,os sho,,ving ~'f~]_se reading off thre'e...gk!ibn, s':'pe'r"'~?/ r,H. nuto, bpccuso it ~..,oula not holt] for ,~ full h6dr. (~80 ~al!ons ';till, tbi. a ';/el! "'as looking ]_ike a very goo0 i::r0~flcer. :En'0v'8'~Egh"t 2crier] die show s. good sa~urr, tion of vmter'.in this Weil,, wf'~h back U? to 35 feet of stt~foce. Th!~ Well c~4¢~ pu.m?.'.?.t :thor tim:e';"~,"~.l' i80 , I : '- . .':';".~ .. '; :' ¢.' ~,"-l]ot~: ¢,f '.(':?ter fo~ one hour. :v~ ,"ill' guar?ntfe:the i~tegri, ty 0f' this Well~. -in %h:-t :i.t v,i'].] pro~uco ~* fu].] 1~0 f~llons peu hour v.,lth'¢[n eight h0t~ ~,a?o~] in ~ ~, hour 2, eriod. One horsel*ower sub. pump: ~t 2~'feet bf.f bottom dOST INCLUDES ALL LABOR AND MATBRIAL FOR COMPL~ION OF SAID 'DRILLINg. -.'"'~:' '; ]% ~]obi!iz?.t%on or Om'nob cost. No set-u~ cost. No .oh~hp~,for' pitless WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE 'SUM '0F ~7: 5'~0.00. '. , "-';:~,~" )To ch'~r~e for ~.Te!] extension of c.,~_.bove oroun~ ~ ,. .~ .... . ..... · . ~ . . _ . .. . '., , ~ ' '[" ~.; ,~ ..:. .,. THANK YOU V~RY MUCH. , . .. : . : .. , . ', ~.~.. . .; DATE '~'lt~]t~St ]~.~ ]O~ . '.' ~ · , ~]' . . ~ , . · :: .-~.~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH /MND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ~NCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970166 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:JEMISON MIMS P III OWNER ADDRESS:P.O. BOX 244224 ANCHORAGE, ALASKA 99524-4224 DATE ISSUED: 7/02/97 EXPIRATION DATE: 7/02/98 PARCEL ID:01516113 LEGAL DESCRIPTION: KASILOF HILLS BLK 7 LT 4 LOT SIZE: 31633 {SQ. FT.} NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC T~kNK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72} AND DRINKING WATER REGULATIONS (18AAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: DATE: DATE: 7- 2- ?7 HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN E~TENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & F LOW TEST SITE PLANS ROAD DESIGN SOIL 'I'EST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SiTE WASTEWATER DISPOSAL SYSTEM DESIGN ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. June 19, 1997 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 4, Block 7, Kasilof Hills Subdivision CIVIL ENGINEFRS (907) 694-2979 FAX (907) 694-1211 Request you reissue a permit to drill a well and install a septic system to serve the p~o~osed ~',Vebedroom house on the referenced property. A test hole was excavated and a percolation test performed. the approximate location of the -test hole is located on the attached site plan. The monitoring tube within the test hole has been checked and found to be dry. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/mg Enclosure ~NVi~gN~HTAL 81~vlcE$ DIVISION JUN 1997 REEEi.VED 17034 NORTH EAGLE RIVER LOOP ' SUITE 204 · EAGLE RIVER, ALASKA 99577 1"--60' DESIGN ST17OGANOF DI~IVE SITE-PLAN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 8'LOC.~(' '7 Township, Range, Section: .HI ~z, 5- .5',,),L~ SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20- COMMENTS dO.//, WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT '~ O DEPTH? p E Oeplh Io Water After Monitoring? D~,~ Date: I Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE L/ tmlnutes/~nch) PERC HOLE DIAMETER TEST RUN BETWEEN V FT AND "~' FT PERFORMED BY: ~/v,¢-~. ,,.~,~ ,',.,¥~, LG,~N~&,~ ~G, ~1 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WI~Be~E~~AL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ 72-008 (Rev. 4/85) ROBERT C. COWAN, P.E. ROBERT A. SHAFER, RE. HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL. INSPECTION & FLOWTEST SITE PLANS ROAD DESIGN SOl[TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCEs Lot 4, Block 7, Kasilof Hills Subdivision June 20, 1997 GENERAL: 1. The scope of this project includes the installation of a 1500 gallon septic tank and a leachfield trench to serve the proposed five bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 4, Block 7, Kasilof Hills Subdivision June 20, 1997 Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed--up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending 'through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to 'the effective depth of the gravel as noted on the design. Page Three Lot 4, Block 7, Kasilof Hills Subdivision June 20, 1997 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal)· Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between 'the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. Page Four Lot 4, Block 7, Kasilof Hills Subdivision June 20, 1997 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after 'the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is 'to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering sha].l be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 4, Block 7, Kasilof Hills Subdivision June 20, 1997 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER Parcel I.D. O1~-- ID(- I"~ Municipality of Anchorage Development Services 'Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us ' (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Expiration Date: Complete legal description '-- ~ LO - t EL Location (site address or directions) CtJrrent Property owner(s) ~;~,~4~ '~,.,~;',4 · Mad~ng address. Lending agency Day phone Mailing address e Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: ~-'"' Day phone _ '~ (=f. '2...- ~-&,.f.,..~ TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well ' TYPE OF WASTEWATER DISPOSAL: · E~r Individual On-site ~ [] Individual Holding tank [] [] Community On-site ['-] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners:,.C.ertificates of Health Authority 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.cJf up t~) 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... ~ Municipality of Anchorage ~ .~ ~= DeVelopment Services DePartment ~ ! : Building Safety Division.~ :' ;, ~ '; :On'Site Water & Wastewater Program '~ ~ : ... · ,,4700SouthBragawSt. i::~'i ' P:O. BOX 196650 AnchOrage. AK 99519-6650 ,~ , ~ ,~ .... www.'ci.anchorage.ak.us, , ~ ;(907) 343-7904 ' ' ' ~HEALTH AUTHORITY APPROVAL CHECKLIST ' Al WELU'DATA] ' '!; i,~?: .. : .' ';' ;';'/ '; ~ ', ' '' ' ' ': ' ' ; :i F~i' ;,' :" ~ '' ' Well type. ~ ' ~ : ' "~ '''?~ .... ' ~.- - ::IFA, B, or C prO~/ide.PWSlD # 'Well LOg (Y/N) . ~/ , , i'r ~'~, ~,/,'j ', ' ' i.' , :;!!:'i;! !'i,::,.,: , , Date c°~mpl~i~d pz/,~7. '"~': , Sanitary seal (Y/N) ~ Wires propedy protected (Y/N) "-/ Total,depthf3o_~ ff.' ' ; 'Casedto',!l ~.:;,ff. ' ,. ;: ,,Casing height (above gr0und) ! Z. in. ' Dar6 ~)f tes~: ;i ?i I':!I':i., FROM'WELL LoGz/,.,.:i~? '::~';~;~ '';: ':~T ;'i ':'..: ' AT INSPECTION i 'Z''/I 5'' /O '~ :" Static!Waterlevel ',.~ ,,~;i!,, ,.,' . ' . , ' 'i;i;fl.,' ~,' , . ~ ~2.-: ft. ii, J ! , . ,. t "'l~: ', : '' ~, Well.producbon i . '~ :g.p.m. ' ..... ,, '~ g.p.m. :! i WATERSAMPLERESULTS: ! : ' :;'~': '',~ '" .; . ,. · Coliform ~), '~ colonies/100 mi... Nitrate!~: t I...: mg./I.'! .:. Other bacteria ~-! L). colonies/100 mi. ..... [!:: ~:i-' ' 1 7--'1 ~ .:: Arsenic: i1~ mg./I., ; ' , Dateo~s'ample:~ ~ ~ollectedby: i,.;.~ '" 'ii' ~ I ~' ;':!'~ :' ' ' ~ i~;B. SEPTIC/HOLDING TANK DATA '- ":!!, ;!;i ' ,: " : i : ' __il' ~ ' ' " ! i'.'Tan pe/ tel'iai- .,~,"-' , '. : ·,~ i! ,{: ,I ..... ] i .... li'!,~: :i !:,.., Date installedi q -~ ' Tanksize /.5'/)o gal. : ; ,~','i:' Cleanouts(Y/N) i, !' ! 1; : t ' · . ," ,'~ , :-~ : ~ iy~ !~ i:' Foundation cleanout (Y/N) ~/ Depression over tank (Y/N) .~'~ '. High water alarm N) t'--I :' ~fpurr{p!ng ' 'O~,' -i i: Date' ~ [,i~;1'... Pumper:i!;(w,:c.~.,¢~,..~ ',~[4~-~ r~,~¢~,/~/.,, "' ' I :,!" ' ' I '- ',, i :: ;.!i, ABSORPTION FIELD DATA ' ,' ~ ,:,,;,~. ' ,,i " i . ,i ,":'.' : " ' i " .:C. Date Installedi ;if ' t {~' . ' . ' . · ',: f "2 "2 ~ ' ' : . "-"'" ' ~'7, ,,Sodratmg (g.p.d./fl,orfl/bdrm) L-Z. , Systemtype i ;, .il. : '~" 'i 2.-//.~: ;~ ,i . r, . .~ ..'~: ~==::i=" ;::~ ' ::,,!"''''iff.'' ' Gravel l~elow pipe: ' Length: ft. ,: : Width i: l!; ii!i :i ~:.: ~' ,~' oa,~ ft. · , Total depth l lO.,~, fl. :.Eft. absorption area l~ff~: i M0flitoring tube "] DePression over field 'il: 7'7--- ~_/ ;: :: :.iiti~:~:,:,,': : :~i, !'__ '_, ! Date o{' ade~tJacy test /~'~a"/o'~ "':i'~' R'~'~ult§"(P:~ss/Fail):~-'-'-'-'-'-'-'-'-'-~~' .'," ' :.' 'For ~ bedrooms ~ t , : ' l, ['~ ....... ; .... .'7~" , i :, ' !i - Fluid depth in absorption field before 'test ~iiri." ' 'i; i Water added..~-IO gal.' : .... New demh ~/.~ in. , ' ~ ' i ~ , , : . · , . ~, 'ii : ,~ r' ,' :~ ' . -- ', , .-.. ..... t1., ..... .! . _ ~ , :, Elaps'e'dTime! ~ min. Finalfluiddepth' :z?/ ',in. .!: Absorption rate >= 7'5 D g.p.d. ~ ; I',' t ~ ' , .' "!, I ',::,i! ,: '" :" ' ' , i : i ' Any rejuvenation treatment (past 12 mo.) (YIN ,&:~pe) i i ,'t'.-] o . ' ' If yes, give date V" ,''i: ~ . ' .':. :i:,l ':':' ' ': ' ii ' ; !'. .. .... ' . ,i'f ; i ~ ' ~ ,!, .;.!',. · " i · i ! ' : ' ; '" : SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1037930001 Tobben Spurkland P.E. Lot 4, Bk 7 KasilofHills Lot 4, Bk 7 Kasilof Hills Drinking Water Sample Remarks: All Dates/Times are Alaska Standard Time Printed Date/Time 12/19/2003 7:30 Collected Date/Time 12/15/2003 13:30 Received Date/Time 12/15/2003 15:37 TechnicalDirector~. ?eP~/t~J~ .~/ C. Ede Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Waters Department Nitrate-N 2.11 0.100 mg/L EPA 300.0 B (<=10) 12115/03 JJB Microbiology Laboratory Total Coliform col/100mL SMI8 9222B A (<=1) 12/15/03 DKC Ct, ICII~AC.H i~TA~ FARJ( 'rr.A?~l, TITI.~ DEPT, MUNICIPALITY OF ANCHORAGE . z"~---'~ 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 O15-161-13 '"" HAA # *~t>l ~-~d~,.Q..,,,-. 1. GENERAL INFORMATION Complete legal description Location (site address or directions) NHN Stroqanof Drive Property owner Mailing address Lending agency Mailing address Agent Address Hims P. Jemison II PO Box 244224, Anchoraqe~ AK 99524 Day phone 346-4492 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 5 TYPE OF WATER SUPPLY: Individual well ×Xx 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: 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~I21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regu~i~jrE~"i~¢.~ltl~ the date of this inspection. 17034 Eagle River Loop Road No. 204 ~ ti ~/-~¥R -~ ~/ ~.~,~ ~: ..... ,__, ....... Phone Name of Firm Address Engineer's signature DHHS SIGNATURE V/ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additiona4 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 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~d Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVlOE~U~lcm,~ul~ Environmental Services Division 825 L Street, ~oom 502 * Anchorage, Alaska 9950~ · (907) 848-4744 Health Authority Approval Checklist LegalDescription: gC'r' ~-~ B~,c~o~ '7 l¢~'~/.~,~' H/,r..cJ Parcell.D.: g)/ ,~'~/(~/~1~ A. WELL DATA Well type pR~v~ Log present (..~/N) Total depth ~ ~ ..C Sanitary seal (~N) ¥ Date of test Static water level Well production WATER SAMPLE RESULTS: If A, B, or C, attach ADEC letter. ADEC water.system number Date completed ~ / I ~ / 0/7 Oased to ) f~ ro (].~ Oasing height (above ground) Wires properly protected ~/N) FROM WELL LOG g.p.m. AT INSPECTION g.p.m. Coliform ~L) Nitrate Date of sample: ) ~ / ,~- ~ /'¢/ ~ B. SEPTIC/HOLDING TANK DATA Date installed ~' ] I ~ / ~1 '7 Tank size ) $~O O Collected by: Other bacteria o $ & S ENGINEERING 17034 Eagle River Loop ~,~1 No. 204 Eagle l{Jver, Alaska 99577 Number of Compartments Foundation cleanout (~L~N) x/~ ~ Depression (Y~.!~ /v 0 Date of Pumping ~¥/4- - ~v¢-~ *~' Pumper - C. ABSORPTION FIELD DATA ~,~ Date installed ~/~)q7 Soilrating '~.~t~orfF/bdrm) )' Length ~ O .Width -~ '~ Gravel thickness below pipe High water alarm (Y/t~_~ /v 0 Effective absorption area Date of adequacy test . System type 7- ~% '~ Total depth '7. Monitoring Tube present (~N)_Yf ~f Depression over field (Y~t~ ~' ~ ¢~'~' Results (Pass/Fail) For Fluid depth in absorption field before test (in.); Immedi?ely.~l~ _ez~--.-%~a-q~Fadded (in.): __ Fluid depth ~~le, ter:--'-. ~)rption rate = g.p.d. Peroxide tre~'~ 12 months) (Y/N) If yes, give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at*. Cycl~~- E. SEPARATION DISTANCES Size in gallons .... - .... "Pump on" level~a~*~ .......... "Pump off" level at* .~~'"- *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot / o o t Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~1 Property line Absorption field Water main/service line ! ? Od /cO /-)-- Surface water/drainage. Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line $~-dd Building foundation S~ ~ Water main/service line Surface water ~ ~ 0 -k- Driveway~ parking/vehicle storage area Curtain drain h, o ,v ~. /'~ ~ ~ ~,~ ~'u Wells on adjacent lots / oo )o -¢ I ceRify that I have determined thru field inspections and review of Municipal~,~a~'t~~stems are in conformance with MOA,HAA guidelices in effect on this date. ~ c .... ' Signature ' ' .-.. Engineer's Name Date io / HAAFee $ ~ ~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* CT&E Environ,mental Services Inc. LaboratOry Divim,on 200 W. Potter Drive · An=horage, AK gsa18 Tel; (907) 562-2343 Fax: (907) 56%6501 ChemLab Ref. Client Name: Projec'[ Name: Client Sample Matrix: PWSIO Sample Remarks: Client PO~,: Printed Date/'rirr~: Cellecte~ Date/Time; Received Dote/Time; Technical Dlmc~o~ n/a 10/29/98 14;35 10120/98 10:45 10/~8/98 12:45 $1ephen Ede Pi~'ameIoF Totul Coliform (MF) Nilrate Res~ I~L Unl~ AJIowable Prop Analysis, Me,~Od LimtLs [)ete Dele Irflt ¢~1/'100 mi SMa2~2B 1.$9 0,1 mg~l EPA 300 10,0 10/28/98 KAP 10/Z8/~8 GCP