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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