HomeMy WebLinkAboutKENO HILLS #3 BLK 5 LT 3
'r~ '""'"' ,, ~ MUNICIPALITYOFANCHORAGE
~/,,~ ~ .~_,~; ~i'~:DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
~[/,~ ~r"~il/ ' ' ENVIRONMENTAL ENGINEERING DIVISION
,~~/ ,,, 825Lstreet. Anchorage, Alaska 99501 Telephone264-4720
~~ ON.~'~E sEWAGE DisPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~AME . / ~.: .... J / IPHONE / ~NEW
~AILING AdD~ES~.~
LOCATION~ ~ / '
~, Materia~ C ~of'co~ept,
~ Manufacturer ~~ Inside length Width Liquid dep,h
Well Dwelling ~ERMIT
~ ~ DISTANCE TO:
~ ~ Z Material Liquid capacity in gallons
Q Well ~ :oundation Nearest lot line PERMIT NO.
~ DISTANCE TO: Total~t~o~lines Tren~ Distance ~lin~s
~Z ~ inches Total eff~~on area
~ m No. of lines~ Length,of ~ch line
~ ~ ~ Top of tile to finish grald Materiarbeneath tile ~ ~ inches
Q PERMIT NO.
Length Width Depth
~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE TO: Well Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line >ERMIT NO.
~ Absorption area(s)
m Building foundation Sewer line Septic tank
~ DISTANCE TO:
OTHER
PIPE MATERIALS
iNSTALLER~ ·
,
~ DATE LEGAL
Rev. 3/78J
~ FIF'PL I CFINT
LOCFIT I CIN
LE~ML
J~EML]' I'"1 ': ' .: EN'v' I R(
[:,EPFIR]"MENT F~ ' ' I. It 4[,
;q ;..-,.'-:i "L '" 2..;TF.'.EET., FINCHCd:;.:FIG~
,-z~,4- % ,' ,r'- D
HAl. HOFHE I
GOLE:,EN V I Et.4 [:,R.
L.T. 4 E:LI<. 5 KENO FIILL::"3 S,-."D.
TYPE OF SOIL RBSORB"rION SYSTEM IS: TRENCH
MFtXIMUM NUMBER OF BEDROOMS = ]: SOIL
THE REL:).UIRED SIZE OF THE SOIL RBSORPTION S"r'ST
,=,NC:Hk >: F:,:, E E/CJ.
,'.4r. IEI'.n"RL P~"rEC:T ZOl'.4 d/,JZ
,,------.m._-~
N C:H ':2';;' E-... 4 2 4
L,:,T
. 3 lC
F-ITINC':i <SQ FF,.'6R:: ...... .:L~: .....
'.5:
I1~ %," EF.'..". L. lIE:, E..":E F" -1F E.,.-~ ==
].'.BE LENGTH [:,IMEN'_RIOI",I Iz, THE LENG'rH <Ii'-,I FEE] ':, OF THE TF, ENL. I-I O1:;:: [:,RF:IINFIEL[:,.
"~'-"~TH~'"'"[:,E.F'Tt"I OF R TRENCH OR PI'r IS THE [,IqTRN]E
8E'TI.,.IEEN
OF
THE
GRCIUNE:, FIND THE E:CITTOM OF THE E'::.::L-:FI',/FqTIOi'.,I ,.'.If' FEET).
,-- ,..z" _.FIE z,
THERE I'z, NO _,E.T I'.II[:'TH FER TREN .... -
THE GRFI"/EL. DEPTFI IS THE: MINIML.IM F:..'EF'TH OF GF R%"'EL E,'E:TI.,.IEEI",I THE OLt"FF'FIL.L F'IF'E
RNE:' THE BOTfJI1 OF' THE EhIL'.:R'v'RTION '::IN FEET"
PERMIT RPPLIC:FINT HI=L"-q THE RESPONSIBILIT"r' TO INFORM THIS DEF'RRTMENT [:'LIF.:INCi THE
INSTRLLRTION IN.=,FELJII N.';, C)F F:IN"r' klEL. L.S F~[:'JP]CEN] ]"iD THIS PROPERT'¢ FINE:' THE
NUMBEF.: OF' RE.::"',I[.ENCE.. THI;:IT THE NEL.L HILL '.=.;ER'v'E.
BFICKFILLING L]F FII",t'¢ .=~'.:,TEi'I WITHOUT F]:NIZtL INSPEC
i~f:EFHRTI'IENT HILL E,E .':,LIE, JEL.[ TLI F'F..O.z, EL. UTIUt',L
I N I MUM [:, I S'FFINCE E:EIHEEN Ft NELL FIND FqN~/ ON-S I '[ E SEHFIGE [. I _.,F LI_,~ IL. S'¢S]"EM I S
E : F.IN THE TYPE OF' F'LIE:L.[C HEL. I. ....
THE DEPFIRTMEN"f' H I TH 1 I'.,t ]:C."l E. I I ~
1 ,rrHER REQUIREMENTS I'ql::l~r' FIPPL.'-r'. SPEC:IFICFtTZON$ FiND CON'5]"RLtCTION DIFIGF.':RHS FIRE:
~.t/HILHBLE ll_l IN_,UF..E FF.'.UFEF.. IN..,TRLLHFION.
F_:ERT I F'T' THRT
: t F-IM FFIM]LIRR HITH THE F,::ELT.!UIREMEN"f'S F"."F:' ON.....EITE .m, EHEK;:, FIN[:, 14EL..L.'.Z tqS '.E;E]~
iOF.'.IH 8'¢ IHE MUN I C I F'F-IL I T"r' IJF RNCHORFII3E.
: I 14ILL INL-":;TRLL. THE S'~'_-";TEM IN RCCORDRNCE HI i.-I THE CODES.
,: I UNDEF:.--,THND ]FIFll' THE LIN-~'s, IIE ..".',EHEF:. z,~TEH MFI'T' REI$!UIRE EF,ILFII~:I3EMENT IF.' THE
F-~ f,7.." E F4.'. EE E.T:~ LJI ][ IFE." E:E E> ..................
] IOH RN[:' RF:'PRO'v'RL E'"F THIEi;
2
3
4
5
6
7
I~IL~NICIPALJTY OF AI~ICHORAGE ,
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650o Anchorage, Al~ka 99502 276-2221
SOILS LOG -- PERCOLATION TEST
PERCOLATION
TEST
8
10¸
11
13-
14-
15-
16-
17
18
19
20
zttT~l
SLOP
r
i ,
I
WAS GROUND WATER S
ENCOUNTERED? L
Pi
IF YES, AT WHAT .
DEPTH?
SITE PLAN
~'D.
HO. 1823-E
PERCOLATION RATE (minutes/inch}
TESTR.N.E~EEN ? .TA"D il~ ,.T
COMMENTS
PERFORMED BY-' CERTIFIED BY: DATE:
~' Fourth Floor West
825 L Street
· ~' . Anchorage, Alaska 99501
.~ 264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
SEPTIC TANK:
DISTANCE
FROM WELL/ 0
NUMBER Of
COMPARTMENTS
LIQUID CAPACITY/~ GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL
# of Lines
/~;~) ' FOUNDATION /~' OF LINE ~'7
.NEAREST LOT LINE /O /~ TOTAL LENGTH /
DISTANCE BETWEEN UNES ~//~ TRENCH WIDT~ IN. TOTAL EFFECTIVE
ABSORPTION AREA 3/~ SQ. FT. LENGTH OF EACH LINE ~7 I
, OEP~' OF FILTER g ~
DEPT't: TOP OF TILE TO FINISH GRADE _ ~ MATERIAL BENEATH TILE ~ABOVE TILE ~ IN.
SEEPAGE PIT:
DIAMETER . OR WIDTH ., £ENGTH . DEPTH
Log Crib- Rings Crib Size: DIAMETER___DEPTH DISTANCE FROM: WELL ,.
-- TOTAL EFFECTIVE
NEAREST LOT LINE___ ABSORPTION AREA (WALL AREA) SQ. FT.
BUILDING FOUNDATION ,
Well
Class:~(g~ Depth:
Well ~stance To: Lot Line
Bldg: Sewer Line:
Pipe Materials:
# of Bedrooms: ~ ' '
Installer:
Remarks:
PERMIT NO.
APPLICANT J-MRR~ FETER-~UN
LOCATION ASHLAND DRIVE
LEGAL
P. O. BOX I ,,~.~ ..~
,/0- .5 ? L~,I,T S I ZE
L3." B5 KENO HILLS SUB,'"DIV
98888 =.i~.UMRE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENC:H
MRXIMUM NUMBER OF BEDROOMS
~OIL RATING
c- ,, .".1 ~'T'S E
THE REQUIRED SIZE OF THE SOIL AB.~UF..FTICN =. -T M IS:
DEF'TH= ~L2 LEF~GTH= 27 GRR'..-'EL C, EF'TH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIEL. D.
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 TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN "rHE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REC:~U I RE[;, SFPT I C TA~,~I< S I ZE= 1000 GRLLOr-,~S
TWO (:2) I NSPFE:TICI~$ ,q~F RE~IJIRED
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 R PRIVATE WELL OR 200 FEET FOR R PUBLIC WELL.
WELL LOGS ARE REQUIRED RND MUST BE RETURNED TO THE DEPARTblENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
PERi'I I t ~"RI I ii:.. FCIR IDNE ~r'ERIR FROI'I I ::.::.LIE
I CERTIFY THAT
i: I Arq FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSOLD THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE I~ REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
SIGNED:_ ~ --,
Ap~I~TLRRRYPETERSON
RF'F'L ~ E:RNT LFIRRY ' '"I'E'i~"::.]t'J
LOL':FiT I ON FI~HLRND [:,F.: ~ ',,/E
L. EGFIL L.]]~ B5 KE:.I"~L HILL=, SUE
M I N ~ i"lJM r:, ~ STRNCE B,EiTNEEN R NELL..~,RND RNY
:t. EiEE FEET FOF.: FI F'F.'.I ,,,RTE: L4EL. L_ OR ,=:.Ei(~ FEET
NELL LEGS FIRE RE6!UIF.".EE:' RND MLIE;T ETURNE
OF THE NFLL. COMF'LETION.
- : C:r" NE.]TF.'.UCT I ON
LqF'EC I F I E:FIT I UN_, AND
E:X 4-::L294
344-'96,5:1.
SQURRE FEET
7'EH IS
N ~0 DRYS
14ELLS; FI'-=; E;E'I"
~;REATER ANCII01<A(;L Al(LA
u'~partment of LnvironmenLal (lual"~l~y
3330 "C" Street
Anchorage, Alaska 99503
N()iI,S l,()(; - PEROI,ATION TEST
Oate Perfonaed
Perfonled for ~ ~_ ~.~
Legal Descrip~'i-o-n:_~-]~-~d]~ck ~ ~fJ(O ~' / .....
lhi.s fom reports:' Soils log. ~--~- PercolatiOn test
Depth
Feet
10-
ll-
Was ground water encountered?
0
2
If yes, at wl)at depth?
Reading Date Gross Time Net Time Depth to Water
Percolation rate
-Proposed installation:
Depth of Inlet
COMMENTS:
Net Drop
mi nute.
Seepage Pit Drain Field
Deptl~ to bottom o-f'-pit or trench
/OS Cfi,
Date:
Performed
Certified .By:
~"~'~'~DEPARTMENT OF HEALTH & HUMAN
'~" ":' 'r : ' - CER~IFICATEOF H~LTHAUTHORI~
~ APPROVAL FOR A SINGLE FAMILY~DWEL~NG
P~el i:D."~''A O = O I ~ f ; 2 ~::;~}t3:~i¢~,:H~:$
OF,wASTE1/~ATER DIE
i wrltten confi._rrnation from ~tate
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 th;t t~'~'Site water supply
and/or wastewater disposal system is safe, functional and adequate for the n,u.mber of bedrooms
and type of structure indicated herein. I further Verify that based on the inform,.aU?n obtained from
the Municipality of Anchorage files and from my invest.~ation and inspection;the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal andState codes,
ordinances, and regulations in effect on the date ct this inspection.
S & S ENGINEERING*
Name of Firm
Address
Engineer's signature
Phone
Date
.... '*:"' :~"~"~' ";';;':: -';' : :~ ......... Dat~-~- 2 ~ -/./ '
.... co~nduct 'inspeCtions or analYZe data" before a certificate is issued. The Municipality of Anchorage is not
"i 're_~o,sibie for errom
· · .;,~ ,..:
ROBERT C. COWAN, P.E.
ROBERT A. SHAFER, RE.
Ju~e 2~
~995
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SBNER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOWTEST
SITE pLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
W,~STEWATE R
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Dcpar~ent of H~alth and Human S~rvic~s
P.O. Box 196650
Anchorage, AK 99519
RECEIVED
JUN 6 1995
Munimpality of Anchorage
Dept, Health & Human Services
REFERENCE= Lot $; Block 5; Keno Hill~ Subdivision
A Conditional H~alth Authority Approval (HAA) was issued on 11/9/94
for the referenced property. All work required for the Conditional
HAA has been completed.
Please issue a full H~alth A~thority Approval at this time.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
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. # ~3-O -('71
1. GENERAL INFORMATION
Corn plete legal description
Lot $; B~Oe~ 5;' K~no Hi~. S~bdivi~ion
e
Location (site address or directions)
Property owner Ch¢,~¢ P~:e.~son
Mailing address
Lending agency
Mailing address.
Agent
Address
17401
Anchora_g~,
Day phone 243-6919 (h)
AK 99502 279-2401 (w)
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup. '
NUMBER OF BEDROOMS: $
T~PE OF WATER SUPPLY:
Individual well XXX
community well
Public water
NOTE: If cor~munity well system, provide written confirmation rom State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL: -
c0'mmunity on_site
NOTE: 'If ,ystem, prowde wrttten confirmation from
attesting to the legality and status of system. ~-~ ?~:-~:~:i.:
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.
Phone ~'2.~-~
Name of Firm $ & s ENGINEERING
! 7'034 Eagle River Loop Road No.
Address =:jl,, rev..; ~1.,.~,, 9e~'/~ _..,
Engineer's signature t v t - (j--
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for :"3
bedrooms~ with the following stipulations:
ICY ~RIVE~AY CONDITIONS PREVEN~ SEPTIC TANK PUMPING AT THIS TIME.
A, HOME SERVICES HAS BEEN CONTP~CTE~ TO PUMP TANK BY JUNE I, 1995
A ~ou £
BE ?/- ~ t E _l') //.,
Date
',:., ,T, he Mum(J~pahty of ,/ Department of Health and Human Setv~css (DHHS) issues Health Authority
?Aooroval (~rtificat~ b~sed only upon the representations given in paragraph 5 above by an independent
profess!opal engtneer reg,stered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending mstitut ons n 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 profe~ional eng neer's work. -~.;~ ~?.
· '- .~: .' -.,'~' .:;, ...~:: t . :-.~,~ .i, .,. "'
-' '/2432~(Rev, 1/~1) ~ MOAii~I _ ,~.- .' :' :, _ ~* '"-
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L.o/- ~ ~T__.~ ~" ~'L~J(3 /'t~U-~¢' 5/bParcel I.D.
o 3-o - I?/- 3.'z
Well Date
Well type /~CIV/~''~
Log present (Y~)
Total depth
If A, B, or C, attach ADEC letter. ADEC water s~ystem number
Cased to Z~O~. Casing height
Sanitary seal'N)~/~c-~
Date of test
Static water level
Well flow
Pump level1
Wires properly protected(~/N)
FROM WELL LOG AT INSPECTION
g.p.m.
SEPARATION DISTANCES FROM WELL TO.'
Septic/heldh~ tank on lot /0(~ t ~
Absorption field on lot 1 (~O f'~
; On adjacent lots
; On adjacent lots
Public sewer main ~'/7
Sewer service line
Public sewer manhole/cleanout /(~
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: /0//~ / ~r.~
Nitrate
~'~' /~'/"~ Other bacteria 0//O0 ~
Collected by: ~-~-'w~' ~ t~,'~_/A.) ~
SEPTIC/.H~aL-t~q~ TANK DATA
Date installed //~ /
Cleanouts ~)N)
High water alarm (Y~
Date of pumping
SEPARATION DISTANCES FROM SEPTIC/I~iOL'OtN~ TANK TO:
Well(s) on lot .//'_~r) ~'-~
To property line /C)
Surface water/drainage
72-026 (3/93)* Front
Tank size /('?C)O ~'/q(-- Compartments
Foundation cleanout(~N) ~'(~ Depression (Y/~
Alarm tested (Y/N)
Pumper /~ -.]- ~O/Vl~'
On adjacent lots ~/0~ i'~7~'''' Foundation --~ ~-
Absorption field ~' ~ Water mai n/service line /~/-/'-
/Oh
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
. "Pump on" level at
Meets MOA electrical codes (Y/N) .~
SEPARATION DISTANCE~ON TO:
Well on ~ On adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer ~
Manhole/Access (Y/N) ~
J ~' Level at
.~l'~cles tested
Surface water
Soil rating (GPD/F¢) /0~-/zy/~,~'d System type T-',~C-'~L~/--/-
Gravel tt'iickness (~ r Total depth / (B /
~ Depression over field (Y/~). ~
for Bedrooms
After test /~
Date installed /O/~-//
Length ~"~ f Width
Total absorption area ,..~f--{- Z~ .Cleanout present(~l)
Date of adequacy test Resu ts a,I
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N) __ /Z~I~.JL~J/--J If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
/00
On adjacent lots /(DOD f'-/- Property line
To existing or abandoned system on lot
Cutbank ~'0 /¢'~ Water main/service line
Driveway, parking/vehicle storage area
Well on lot
To building foundation
On adjacent lots
Surface water ?
Curtain drain /L./L)
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.
EO/J~/T/O/,J/~L_ ~/'a/'a/Eo~/4C.: D~'c~ 7-~ ICY' D,c~IL~OJ~
tj < ~ ROBERT C CO
H~ Fee $ ~ ' ~ Waiver Fee $
Date of Payment ~O - ~ ~ Date of Payment
Receipt Number ~ ~?~ Receipt Number
72-026 (3/93)* Back
Commercial Testing & Engineering Co.
Client Sample ID =L3 $[~5 KELSO HIL~ S/D
~trtx : NA~I~
Environmental ~boratory Services ~
5633 B Stree!
BEF~JRT O~ ~ALY~S Anchmage, AK 99518-1~
~94.535~-~ Tek (997) 562-2343
Fax: (907) 561-53G1
~-~'~ole Remarks: ROUTINE
WORK Or/let : 10199
Printed Date ;10/20/94 @ 14:30 hrs.
Collect~ ~ate :10/18/94 ~ IStO0 hrs.
Receiv~ ~te ~10/18/94 ~ 17:00 hfs,
Director :S~EP~ C. ~E
QC Allowable g~t, Anal
Parameter Results t~al Units Meth~ [,,imltt Omte Dmte Init
Nl~rat e-N 0.55 ag/L ~PA 353.2/300,0 10 10/19 [iCE
,gee Special lns't;~uctions Above UA = L~navailable
See S~ple Be~rks A~ve NA = Not
~Ir~eteet~, ~e~ v~ue 1~ the practical ~ntificatlon limit. LT = Less
~eco~ dilution. GT = Greeter
Member of the ~ Group (Soo~I6 G~n~rale de ~urwill~ nce)
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIOA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
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 5; Block :5; Keno Hills~Subdivision ~
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
17401 Ashland Drive
Anchoraqe, AK
Larry P~t~rson Day phone
17401As~and Drive Anchorage, AK 99511
345-1544
267-1338
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
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:
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 #27
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 regulations in effect on the date of thi.s inspection.
Name of Firm ~ Phone ~'/7/~'~ ~'
Address '""°' "--' " - :- /~ /~
Engineer's signature
DHHS SIGNATURE
~ Approved for -~
Disapproved.
Conditional approval for
bedrooms.
Date -'¢ ""/7 -"~ ~
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragrap~ 5 above by an independent
professional engineer registered in the State of Alaska. The DH 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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: [_oT ,~ I~LI(~ /~£P~ I-(IU..$ ~/~) Parcel I.D.
A. Well Data
Well type F
Log present (Y~_~
Total depth
Sanitary seal ~)N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed I~ r/~ (~/'~'~-~Driller LoYP
Cased to ~3/-/- Casing height
Wires properly protected~N) YE'..?
FROM WELL LOG
g.p.m.
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septid~,c~=,n.3 tank on lot
Absorption field on lot / ('.~O
/,../._
Public sewer main
Sewer sewice line ~_~'
AT INSPECTION
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
g'p'm~',/~R '1 8 1994
RECEIVED
;On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform (~//~ ~
Date of sample: ~.~/,~ /
Nitrate
Collected by:
B. SEPTIC/H~'DtN~TANK DATA
Date installed /0 J q-/q ?
Cleanout~q)
High water alarm (Y~
Tank size /~.~) ~e,q.~ Compartments ~"
Foundation cleanout (Y~) /-/o Depression (Y~.))
Alarm tested (Y/N)
Date of pumping /O/
SEPARATION DISTANCES FROM SEPTIC/~TANK TO:
Well(s) on lot /'("~) / ¥' On adjacent lots ./._/')(~ ~'-/'-
To property line /('~ ('-~ Absorption field
Sudace water/drainage ./d'b?~ (-'/-
Foundation .,~
Water main/service line / (~ ~"--
72-026 (~3)-Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N) ~
SEPARATION DISTAN..CE--FR'~M LIFT STATION TO:
Well ~ On adjacent lots
Manufacturer
Manhole/Access (Y/N)
~' Level at
Surface water
D. ABSORPTION FIELD DATA
Date installed /0/~ / r~ ,~
Length ~. 9 ( Width
Total absorption area 2! `5.6
Date of adequacy test ~/////
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft
Gravel thickness
Cleanout present ~)N)
Resu,sd a,)
System type
Total depth /
Depression over field (Y~
for ~7-/~ Bedrooms
After test
If yes. give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / O~-~
To building foundation
On adjacent lots
Surtace water /~
Curtain drain
On adjacent lots / ~ 0 r-F"- Property line
To existing or abandoned system on lot /,-)Of, J~- /~F~.-.~--/~7-
Cutbank /,jo/,J~. /~/'&&-5'~-/dT- Water main/service line
Driveway. parking/vehicle storage area /O ~,-/-
E. ENGINEER'S CERTIFICATION
I certify that I have c~nformed to all MOA and HAA guidelines in effect on the date of this inspec~on.
Engineer's N p Road No. ·
Eh~r,
Alaska
9
HAA Fee $ ~-o~<DD d-"<~
Date of Payment
Receipt Number
72-026 (~)' Back
Waiver Fee $
Date of Payment
Receipt Number
CT&E Ref.#
Client Sample ID
Matrix
ClientName
Ordered By
ProjectName
Project#
PWSID
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~'J~'~'~'J~'~'~'fJ'~'~'JJ~'J~'~
LABORATORY ANALYSIS REPORT
94.092%5
L3 B5 KENO HILLS S/D
WATER
WORK Order 76283
S & S ENGINEERING PrintedDate 03/07/94 ~ 10:38 hrs.
R. SHAFER CollectedDate 03/03/94 ~ 15:25 hrs.
Received Date 03/03/94 ~ 16:00 hrs.
UA Technical Director STEPHEN C. EDE
Released By:
Sample Remarks:
Parameter
N~e-N
ROUTINE SAMPLECOLLECTED BY: S.S.
QC Allowable ExL Anal
Results Qual Units Method Limits Date Date Init
0.98 mg/L EPA 353.2/300.0 10 03/04/94 CMR
* See Special Instructions Above
** See Sample Remarks'
~ U= Undetected, Repo~te
~ D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Less lhan
GT = Greater Than
** See Sample Remarks Above
U= Undetected, Repo~ted value is the practical quantification limit.
§633 B Street, Anchorage, AK 99518-1600 --Tel: i907) §62-2343 Fax: (907) §61-§301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
I MUNJCIPALiI ~ ~r r*~ ............
~-../ :'~/ ENviRONMENTAL SERVICES DWISION
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ,EALTH & HUMAN SERVICES MAY 2 9 1987
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL D ~
OF ON-SITE SEWER AND WATER FACILITY . .--.,..., ,~ ._ P~ L. C E iV F_. D
264-4744 ~'~ ~
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner /%/"~' ---~J~'~-~-":
Mailing Address
Telephone: Home
(¢,.¢.0/'7/;;z-I
Business ='<'-~'-~- c"~c"Z~
Telephone
(c) .Lending Institution
. :, Mailing Address
'Add,;ess
· , Telephone '~.~""~.-- ~/
(e) Mail th~ HAA to the followin~ address: or: Check here I-1, if hold for pick up.
List c0n}act person and day phone number below,
/
TYPE OF RESIDENCE
Single-Family~
Number of Bedrooms
WATER SUPPLY
Individual Well/~ Community [] Public
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite,,J~ 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.
Page 1 of 2 72-025 IRev 8/861 Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site 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 ~'.~'"~ ~--~--¢"~-/'~'~/-¢/~./','¢/' Telephone
Address ~'oX ~-'/~'~'~7-~'- .'"¢2~-~/-' ~2F~/¢'
./
Date ~"-- '~ '°c/-
DHHS APPROVAL
Approved for ?~/¢/.~'~(~/)bedrooms by
Approved .~/~.~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
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.
Page 2 of 2 72-025 (Rev 8/861 Back
MUNIC[PAUTY OF ANCHORAQE
ENVIRONMENTAL SERVICES DIVISION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
284-4744
Legal Description: ~ ~'
tViAv 2 9 1987
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth J"/'~' Cased to '~¢¢ ~-~' Depth of Grouting
Static Water Level /¢-~-~ /'~/~//~P'~
Casing Height Above Ground //Z ~''
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
. Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results ~
If A, B, C, D.E.C. Approved (Y/N)
Date Completed 7~- /'~:~;' Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots z,/~° .74.
; On Adjoining Lots .,-'~ ~`'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed _~'~
Standpipes (Y/N) .,)/ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~ ~ ~
To Property Line ~ ~
To Water Main/Service Line //t///,~
Course ,,¢~4'Z~'
Size ./~.¢i,'~ No. of Compartments ~'
/',',',',',',',','/ Foundation Cleanout (Y/N) ~ ~
Date Last Pumped -~---~,/- ¢¢'7 /
; for --
Temporary Holding Tank Permit (Y/N) ~
To Building Foundation ~:"~'~"'~
To Disposal Field -/~¢'
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2 :
72-026 fRev. 8/86~ Fro.hr
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ~-'~ /
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~'~'
To Existing or Abandoned System on
; On Adjoining Lots .../~, o ~
To Cutbank (if present)
Comments ;¥
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that~.?/~.v~.,.~..~/~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed .~.~/..~/:~',~ Date
Com pany'~"~/7 ~".-¢~,/~' MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026 fRev 8¢861 Bacl<
BEVAN ENGINEERING
P.O. Box 1t2852
Anchorage, AK 99511
(907) 522-13S3
MUNICIPALITY O1: ANCHORAGE
ENVIRONMENTAL SERVICEs DIVISION
MAY 2 9 1987
RECEIVED
Hugh
600 UNIVERSITY PLAZA WES]', SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Bevan Engineering
Box 112852
Anchorage, Alaska 99511
Source: L4, B5, Keno Hills ~3, 87217-WS
Sample ID~: A052187-4
Date Arrived:
Time Arrived:
Date Sampled:
Time Sampled:
Date Completed:
5/21/87
1425
5/21/87
1300
5/22/87
Parameter Unit Result ADEC MCC
Nitrate-N mg/L 0.66 ¢' 10
MuNtCIPALITY OF ANCHORAGE
eNvIRONMENTAL sERVICES DIViSiON
MAY 2 9 1987
RECE Vrr. D
, Vice-President
* MCC = Maximum Contaminant Concentration
INSPECTION APPOINTMENTS
DATE DATE
,ENVIRONMENTAL FROIECTION
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street- Anchorage, Alaska 99501 ~E 0.1 9 t979
ENVIRONMENTAL SANITATION DIVISION RECEIV~E~
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER , I ~ ~ . . ~ .. ~, ~ PHON
MAIL~NGADDRE~S · -- , I '~ , ' . ,
MAILING ADDRESS
i
4. R~ALTOR/AGENT ~ PHONE
MAILING ADDRESS
~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATF~RvSU PPLY
INDIVIDUAL*
/[] COMMUNITY
[] PUBLIC UTILITY
[] One [] Four
Two [] Five
Three [] Six
[] Other
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8' SEWAGE DISPOSAL SYSTEM ~[~'~__~ '
INDIVIDUAL/ON-S~TE** YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
1
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Veri'fied LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~.0 ~ (~
Connection Verified INSTALLER
[]Septic Tankor [] Holding Tank
Size: i~-~-0 If Tank is homemade SOILS RATING
give dimensions: J ~"
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL ~ /
4, DISTANCES Septic/Holding Tank /Absorption Area Sewer Line J Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
~ APPROVED FOR ~ BEDROOMS
~/CONDITIONAL APPROVAL (letter must accompany certificate)
~ DISAPPROVED /
DATE B Y
72-010 (Rev. 6/79)
'~' APPLI T FILLS OUT UPPER HA[.~ONLY
~rof~erf~/Owner
Address · Zip Code
Address Zip Code
Address
Zip
Code
Legal
Description
Type of Resi~nce
8ingle Family
Multiple Family No. of Bedroo~.
~ Other
Water Supply ,.
~' Individual A~ACH WELL LOG. A wall log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give welldepth (attach log if available).
~ Public Utility
Sewer Disposal
~ 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
Date Date Date
Date
Inspector Inspector -Inspector ~C~L/t ~ I ~..~/~
'
RECEIVED
( ~PPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
gATE j ~J~ ~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~ ~ ~ Well to Tank Septic T~k Size