HomeMy WebLinkAboutLIST LT 2List
Lot 2
#067-301-03
�, MUNICIPALITY OF ANCHORAGE i=
DI FITMENT OF HEALTH AND HUMAN SEF. ..ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name _
/
DISTANCES
/` / A 2 TYL S f
TO
SEPTIC
ABSORPTION
Address
FROM
TANK
FIELD
WELL
'o. a94 22V/ lel e7rfrk X31
Phone(s)
Permit No.
No. of Bedrooms
WELL
/5-6 4
J/
/gyp -/,
.
6�/S-2-17
g6OZ3
t,
-
i
LEGAL DESCRIPTI ON
LOT LINE
440
40
LotBlock
2
ck
Subdivision
L✓/S 7 -C/a
FOUNDATION
/
/
Township, Range, Section
35-
�6
t7 N� ` F 3 ^
c
AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation,
driveway, water bodies, etc.)
TANKS
XI SEPTIC ■ HOLDING
Manulact rer
Capacity in gallons
/�c i-/
Materiae
/t DO
No. of Compartments
/
2
4/o2/Ua:
TYPE OF
SYSTEM
//Xo
/Hl✓
P
7y
ey r
e�
75
+
c'")��
os�o
3��
TRENCH ■ BED
• W. DRAIN ■ OTHER
\
m
3034p/ey/�
,2
-
1/-
Depth to pipe bottom from
original grade /
Total depth from original grade
FT
FT
k.Fill
/
added above ori anal grade
Gravel depth beneath pipe
��
75-b�IL
i'''
.
/ FT
FT
!o
la.7C
`j
�
C
Gravel length •
3 S FT
Gravel width
2- S FT
f
Total absorption area
Distance between line/�
3 80 SQ FT
/1"/ i 7 FT
Number of lines
Soil rating
Pipe material
/25- SQ FT
4-STm D-303
Installer
Date Installed
WELLS
■ PRIVATE ,OTHER (Identify)
Classification (A,B,C)
Total Depth
Cased to
/2. 2 r FT
/2 2 FT
fppp
Installer, j
A';L MLL.IUG-
Date Installed
g
-ic
S
BUILT
/c
REMARKS: 4/&'`/ %��,pjDv
6E6"
by e.I
/
c/ /O OIro2 - T.:—- 2. BZ
f
Scale: / / :74 D
Inspections Performed by:
ENNCCn, EE.ITS SEAL
At,.:,G,'�• A1,f%,.f
Date:
4 n c (-1T•t
S & S ENGINEERING
/
•_<.
SRS 196X certify that this inspection was performed according to all
y i °""""`::
EAGLE RIVER AK 995/7 AUG - 7 1986 I
Municipal and State guidelines in effect on this date:
i r� ;� '"•I,.r d. IF!" -r. . le
1 Na. -71..V,7k . Z*!,
Health Department Approval:
DateP /1I/ L7
s . ,.'
t'r"a, 4"kod ‘ 41P
a
a
0 • . e•. a,
Municipality of Anchorage I
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: /' t t j /1/5 /
LEGAL DESCRIPTION: G 2 Z./ cS 7-
1 1
2
3
4
5
6
7
8
10
11
12
13
14
15
16
17
18
19
20
DEPTH
MT)
(x
.
0 a�
.r y`
«0
`T.
ti
tV
CJ
Fv,
- /25-0/2
•
14 ev4,q„Z4. 21186
DATE PERFORMED: JUL
Township, Range, Section: 77 /E• / E J' S 3 Z
SLOPE SITE PLAN
WAS GROUND WATER / J 0
ENCOUNTERED? /(/
IF YES, AT WHAT
DEPTH?
s
L
0
P
E
Depth to Water iter
�7o1� eip( U `2, Monitoring? o A A/0- Date.
N
P
frr'
r
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/')
///
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER
FT AND
COMMENTS !'s'/` T %/Z/ 8G�
S & S ENGINEERING
PERFORMED BY SR B 196X
�/� /► pp������CCpp a�nn==''y CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WI`YF✓`hL!ERJVERpAKsJ9 57ZUIDELINES IN EFFECT ON THIS DATE. DATE
SCALE
fl
v
Kam Ru ��r✓�
z
z
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m
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MUNICIPALITY OF ANCHORAGE
CONSTRUCTION AND OPERATI o Tif
R 10
At.ASI<A ICJIIIPARTMENT OP ENVIRONMENTAL CONSERVATION .
PUBLIC WATER SYSTEM FAL 31 1986
APPROVAL TO CONSTRUCT RECEIVED
Plans for the construction of /A)1 1 I IQ VN .1 5�7 t O� 5 1) 2 4 J 7-1
rctc"t s
in rC.<5I, t vr—
public water system located
` , Alaska, submitted in accordance with 18 AAC 80.100
by I 11 tt l f S& have been reviewed and are
'K approved.
conditionally approved (see attached conditions).
BY
LV(utts,t,t,1Mevt tu( Ci I ePta6e
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no.
or datcrlptive reference)
Approved by Date
The "APPROVAL TO OPERATE" section must be completed before any water is made available to.
the public.
APPROVAL TO OPERATE
The construction of the ' '/00 )l i is leit5fD
public
water system was completed on_�f t -
(date). The system. Is hereby
gra ted interim approval to operate for 90 clays following the completion date.
TITL DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system: is hereby granted
finl approval to operate n
•
Yvv y fl(eIn-seta sjiiipcv: %"
TITLE DATE -
POUCH 6-650
ANCHORAGE. ALASKA 59502-06b0
(9071264-4111
DEPARTMENT O!= HEAL[H -<D !=NVIRONPAENTAL PROTECTION
.Permit #: 820384
January 31, 1983
TO: Permit Applicant
Subject: Tract C Williams Subdivision(Proposed Lot 2 List Subdivision)
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
PetkUl FINLIHC g=giLL. I -r--e c)F- �P-,g�
DEP�RTMENT/-` HEALTH AND ENVIRONMENTH�'
L ^OTECTION
825 STREET/ HNCHORHGE, HK 99501
264-.4720
C:J!!Nh-~�Ei ��1,-0E.F F.7PE
"I -
PERMIT NO. ( 820384 ) ` "
1 -1 -"PV �»~~�~`^HPPLIC|NT MHRTIkLIST SR 1453 E E. R• c /
694-3915
LOCATION
-]915L[CHTION `ILE 19. 5
LEGAL WILLIAMS S/D TFC PROPOSED LT2 LOT SIZE 54000 SQUARE FEET
A/61- 5/30,
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)= 250
THE REQUIRED SI7E OF THE SOIL ABSORPTION SYSTEM IS:
8�EIEIF" `�[r-4!�
F.D1
��� 5:7_1 FZ. L._ ET. 11:=" 11-41�
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H 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 THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
g5.1U E: FEg g< �:-.7E.7= C C:g FAI ILL IL CD4r4�
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OE RESIDENrES THAT THE WELL WILL sEWOF.
��— T E.J! 1:11 :FS; EE slCm F'flR E: LJ RAF c).
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 H PRIVATE WELL OR 150 TO 200 FEET FRQM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
HYHIAPLF TO INSURE PROPER INSTALLATION.
�f"-;-:.! <2.3 �#"."1 F.7 :3 7.1.... :17.2
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF HNCHORHSE
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT TF THE
RESIDENcE IS REMODELED TO INCLUDE MORE THAN 3 DE.00-.X.DITS.
SIGNED:~~
ISSUED BY_
DATE
V4.0
Russell Oyster
694-2774
O & E ENCINEERING & DEVELOr-MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Performed for: Name• /i4 A /2 / A/ 5 L 7 5 r %� /(
Mailing Address- 5' /g0 X /43 Es ./4 -GGA= Kll%, 44!_ ' 99,177
Legal Description: Ler 2 s L./.cr 5C)g b/J/S/on/
Depth (feet) Soil Characteristics
0
1
2 3p
Earl Ellis
688-2280
Tel. No. 6 91-k` 37/5-
3
4
5
7
8
9 5/j`/
10
11
12
13
14
15
16
Yi (-7.04/ZS E_ 54 -No
/56 FJL_v SGS % o
/to, ,L2 /k./ -s/7--/
-25-' /./,/2,
t5rte,t1 f 12/7 -
Ground Water Encountered: Yes
SLE U,i/f(ic2A./
PLOT PLAN
PERC. TEST
ri.
C? ,41i7✓,/in/
�o //9,&,
No If yes, what depth
Proposed Installation: Seepage Pit- Drain Field
Comments.
giyt
0 p000OflDOOa ocaeo
n.
p l� DD NV. 1/49-t • ���'
�� �1g4
x97 00TH
O
Earl P. Ellis I LT/ of
Performed by
Date -C// Vc7 z
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of
public water system located
in , Alaska, submitted in accordance with 18 AAC 80.100
by have been reviewed and are
approved.
conditionally approved (see attached conditions).
BY
TITLE - DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no.
or descriptive reference)
Approved by Date
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the
public
water system was completed on (date). The system is hereby
granted interim approval to operate for 90 days following the completion date.
BY TITLE
DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
final approval to operate.
BY . - TITLE DATE
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
r
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 067-301-03
Expiration Date:
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
LIST S/D; LOT 2
-3I- l3
30235 LIST CIRCLE, EAGLE RIVER, AK, 99577
EMILY RHOTTS
Day phone 360-6113
30235 LIST CIRCLE, EAGLE RIVER, AK, 99577
JIM MURPHY W/ PRUDENTIAL
2. TYPE OF DWELLING:
▪ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class C Well
Public Water System
3
Day phone
315-5808
TYPE OF WASTEWATER DISPOSAL:
❑ Individual On-site
❑ Individual Holding tank
Community On-site
❑ Public Sewer
n
n
Received by: t.
COSA to be released to the engineer. unless otherwise requested by the engineer.
Date:
COSA Fee $
4+10 v�IL{ faS i Waiver Fee $
Date of Payment 110175 ce
\/ Date of Payment
//��v
Receipt Number clis5as v��ya-1tG Receipt Number
COSA # CbC t'b 1318
Waiver #
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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, gmundwaterlevels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how Jong the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for
7/74.7!3
rn e55'
E -
m
0
'2 •p
7/3ocq
4�dpo nooco
4000�6tt
�0OF�C
1/4
.QPy
0
�.
�JON-SITE �2
�WATER AND
11:-
o moi
WASTEWATER (S
3 PROGRAM C .
bedrooms, with the following stipulations
)))))))»»))))\
By: `/(11 G Original Certificate Date: 7- :31- /3
The nfar ality or orage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS: /
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 11/05)
Nitrate Advisory
Arsenic Advisory
Other
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
LIST S/D; LOT 2
A. WELL DATA
Well type COMMUNITY
Date completed
Total depth ft.
Date of test
If A, B, o
Parcel ID: 067-301-03
rovide PWSID# Well Log (YIN)
Sanitary seal (Y/N)_
Cased to ft
FROM WELL LOG
Wires properly protected
Casin
(above ground) in
AT INSPECTION
Static water level ft. ft.
oduction g.p.m.
g.p m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 1.79 mg./L. Collected by: GEG Ltd.
Arsenic: ND ug./L. Date of sample: 7/19/201.3
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 8/7/1986
Tank size 1000 gal. Number of Compartments E Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A
Date of pumping 6/24/2013
C. ABSORPTION FIELD DATA
Pumper JR'S PUMPING
*BELOW EXISTING GRADE
Date installed 8/7/1986 Soil rating (g.p.d./fthor/bdrm 125 System type TRENCH
Length 38 ft. Width 2.5 ft. Gravel below pipe 5 ft
Total depth *9.9 ft. Eff. absorption area 380 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 7/25/2013 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test DRY in. Water added 450 gal. New depth DRY in
Elapsed Time: = min. Final fluid depth DRY in. Absorption rate >= 450+ g p d
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date —
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at
Cycles tested Meets alarm & circuit requirements?
wa er alarm level at in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
containment areas
On adjacent lots
On adjacent lots
COMMUNITY WELL
sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 150'+ COMMUNITY/100'+ PRIVATE
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 5'+
Curtain drain NONE KNOWN Wells on adjacent lots 150'+ COMMUNITY/100'+ PRIVATE
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that / have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's PritedjName JEFFREY A. GARNESS
Date 1 Z& ( 2
(Rev. 11/05)
P tNi f +4-c;
1
S9O1 LT
MUM
tEREOT CERTIFY •THAT 1 HAVE SURVEYED THE
LLONING DESCRIBED PROFS/Ty:
vrreAeir Ler Z
2 THAT Nottoopa&iturs Ivor ran AS
SCAT= IT IS THE RESPONSIBILITY OF Tie
e TO DETERMINE TME IDOSTENCE OF ANY
3EMENTS, COVENANTS, OR RESTRICTIONS
CH DO NOT AFAR ON THE =ORM SUMP.
/ON PLAT. UNDER NO CIACDIASTANCO SNOW)
- mooloonE win FOR coNsTRUCnON
2E7= LINE% on FOR ESTARLISHING ODUND -
LINCS.
SCALE;
no
ASSOCIATES J4ND SURVEYING 694 0022_
Atsr
' te,*.•
•
DATE;
rAcs-4.
GRID!
Ave, Z
79"
DRAWN,
-oar
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska
343-4744
ECEIVED
N 0 2 1998
99519-6650 MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # if -N1 Win\ -f?,
1. GENERAL INFORMATION
Complete legal description
HAA # lea C\$C(‘) \. *\
Lot 2; List Subdivision
Location (site address or directions) 30235 List Circle
Eagle River, AK
Property owner Terrill O'Cocharty Day phone 694-3916
Mailing address 18139 Kantishna Eagle River, AK 99577
Lending agency Day phone
Mailing address
Agent Bob Wambolt/ Remax of Eagle River Day phone 694-4200
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing
to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
xxx
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify thai 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.
5 & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Name of Firm
Address
Engineer's signature
6. DHHS SIGNATURE
Phone G y- a 61 7
Approved for %kl v"e bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Date S' /3 0 / `I g'
-` O F Ai
t, ;...r.% ' il :-
`A •
'R 'koeE2r
', CE
C. SCOWAN:+ f C i4
- 8801 `A d
N
Additional Comments
By .1(# 7°614-
UTION
Date G - / -2 ' (/q
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 921
RECEIVED
Municipality of Anchorage JUN 02 1998
DEPARTMENT OF HEALTH & HUMAN SERMIOE&PAUTY OF ANCHORAG
Environmental Services Division ENVIRONMENTAL SERVICES MVO
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: LOT [ I `moi S jn Parcel I.D.: 0 ( 7 : o
A. WELL DATA
Well type Commui4.0-9 If A, B, oCattach ADEC letter. ADEC water system number
Log present (Y/N) Date completed
Total depth Cased to Casing height (above ground)
Sanitary seal (Y/N) Wires properly protected (Y/N)
FRO LL LOG AT INSPECTION
Date of test
Static water lev
Well uction g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 1 • (1 Other bacteria 0
S & S ENGINEERING
Date of sample: g6 Collected by: �� S F i R-- 1703 d No. 204
✓/ Eagle River, Alaska 99577
B. SEPTIC/HOLDING TANK DATA
Date installed P77-/i3� Tank size /600 Number of Compartments 2 Cleanouts ON)
1 J.iOE G�:AwtSfl<1
Foundation cleanout (�iN) Depression (Y( N o High water alarm (Y/6) 106
Date of Pumping
9t Pumper J c
C. ABSORPTION FIELD DATA
Date installed r (o Soil rating (g.p.d./ft2 o ft2/bdr 1 g.5 System type "TL-1%'Nc-1.4
i ( / zsPi6 Fl"
N� Width 2. Gravel thickness below pipe Total depth Ptr�,'r
Effective absorption area ?f30 t t Monitoring Tube present ON) Yk- S Depression over field (YR 100
Date of adequacy test , Results
Fluid depth in absorption field before test (in.); 0
Fluid depth 0 (ins) Minutes later: 0 vv---.)1,Absorption rate = g.p.d.
Peroxide treatment (past 12 months) (Y/N) f\f O -N -g, K 0w1J If yes, give date
72-026 (Rev. 3/96)*
6-c) For i1-124.--1✓ bedrooms
11
Immediately after,
gal. water added (in.): C)
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" - at* "Pump off" level at*
High water alarm level at* *Datum
Cycles tested
E. SEPARATION DISTANCES
F.
SEPARATIONSTA
CES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer man cleanout
Sewer /septic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Ica` + Property line 10' Absorption field J 4
Water main/service line 101 } Surface water/drainage 10014 Wells on adjacent lots / 50 /4 CL416 C.
l00'' pel via -re
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 10 t Building foundation ID Water main/service line 1614
4.
Surface water IICO Driveway, parking/vehicle storage area b r
Curtain drain -) (, K'ND-NrA Wells on adjacent lots %5�% :9 CG -n t`
//:1))7:11L
OO rpg i vRrr
ENGINEER'S CERTIFICATION �;:;,--„401. a,��
.4'...„..„.1,-;,-,401.‘‘‘‘
OF(1! lgt
I certify that I have determined thru field inspections and review of Municipal reo, Odle a6ve,� fgms are
in conformance with MOA H44 guidelines in effect on this date. .1 ) ' `� -r' ° 1 dl,
%/ .0' `,"'.7'
•
v `a tt��
Signature • `�-- ;� :: (J_
i
Engineer's Name /C 00 �� T C, CD, /'f /✓ �� ry� ROBERT C. COWAN 4
G3 CE'- 8801.,•••• ; /
Jj�. q
$���14swo ..................................................
mi-::\ `�
Date
7eIV
HAA Fee $
Date of Payment
6
Receipt Number 03 t 0/1 7 )
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
lex
06/12/1998 08:34 9076941211 S AND S ENGINEERING
JUN -12-1998 08:18 CT&E ESI ANCHORAGE
Afek CT&E Environmental Serviette Inc
CT&E TteF.I' 982615001
Client Name S & S Engineering
Project Name/A' La; 2 Us SID
Client Sample ID Lot 2 List 8/1)
Matrix Drinking Water
Ordered Ity
PAGE 03
9075615301 P.04'05
Client nu
Printed Date/Time 015/11/98 19:48
Collected Date/Time 05/29/98 t3:02
Received PaltefTime 05/29/98 14'35
Technical Director Stephen C. Ede
PWSID 0 Keleaaed By
amp c anon
Parameter
Tgtgl Coliform
NltrateA
Results
0
1,19
Allowable Prep analysis
PGL Units Method Limits Pate Pate lnit
co1/100mL 5M18 92228
0.100 rtir/L
EPA 300.0 10 max
05/29/98 TMU
0$/31/98 05/31/95 RMV
M.. Laboratory Divi$ion
mo/•r• •IYMIP ■•.Uf.
200 W. Potter Drive
Drinking Water Analysis Report for Total Coliform Bacteria Anchorage, AK B9818.16o&
7e1: (9072 -
READ INSTRUCTIONS ON REVERSE SIMSLFORE COLLECTING SAMPLE°' Fax (ti07 662661.2343 307
e
MUST BS COMPLETED BY WATER SUPPLIER
G
rv$L[C WATER SYSTEM ID,
PRIVATE WATER SYSTEM
,frail en ^ 0 Soil Invoke
�IM��.
MirNNW
,1 r: r'
SAMPLE TYPE;
Routine
G *l trSa Sample (for routine sample
ib lSpecial Purpose
SAMPLE LOCATION
Comments:
TO BE CQMPLE ' D BY LABORATORY
Anil sis shows this Water SAMPLE to be:
Satislaorory
O Unsatisfactory
17 Sample over 30 hours old, results may
be unreliable
Sample too long in transit: sample should
nOt be over 48 hours old al examination
to indicate reliable results. Please send
new sample via spag'al delivery mail.
D ate Received
Time Received
Analysis Bagga I
Analytical Method: AMtmbtane Filter
o MMO-MUG
• Number of coloairs/100
seesss
O Treated Water
a Untreated Water
Tithe Collected
Collected By
.a„' ". *SS r
r+Oil P/!7 Pima**
Route
Analyst
Fahr
Da: Call
aim dotlfled of uniatisfaetory remits:
❑
0
Maul Spoke w1114 Furd
Date: Thug:
Time:
Jun
F` r;rd
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMQ•MUG Multi Total Canino S. Colt
Membga* ]Lenten Met Coal
verification; LTB BGB
Feral Conform Confirmation
, in nii.ru�a�w
Fleet Membrane Fitter Remits
Colonies/100 mi
COL WIBM
Conform/100 mt
Riper ed By Time bre
Trot• rr•Mrwnevi rn fr m
PR raE4r in4rir
II Member or the Spa Group (Seal.% Generale de Surveillant* C' ( t10
EHVINQNM rA FAMOUS IN Af.4t:;rA, C1UfCRNfA, flpalC+t. !((jNOq%
~wow
MARYLAND, MICHIGAN, MISSOURI, NEW,
eAim11�"M�
TOTAL P.05
c