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HomeMy WebLinkAboutLOMA ESTATES BLK 1 LT 7Lama states lock I Lot 7 020-092 -21 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: ~lx.) ~/J © !/O ~ PID Number: ~ ~ ~J Name: ~i~ ~ ~o~e~ ~~ WastewaterSystem: ~New ~Upgrade ~dress: -- ] -- ~O. ~x ~1 ~7 ~E ~ ~~/I ABSORPTION FIELD Phone: No. of Bedr ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION so, Rating: ~ Total Depth from original grade: Lot: ~ Block:/ Subdivision:~o~ ~ ~ ~Depth to pipe bottom from original~ grade: Ft. Gravd depth beneath~pipe Ft. Township:~g~ ~ Rang~ Section:~ _~ Fill added above original grade:~ Ft. Gravel length: ~ Ft. WELL: ~ New~ ~ Upgrade Gravel depth: Number of lines: Distance between lines: Classification (~ivate, A,B,C): ~ Total Depth: Cased T~: Total absorption area: Pipe material: ' - ' Da{e Drilled: Static Water Level: ~ller: I ~ ~ , Date installed: Y~dd:' I Pu~ Set at: ] Casing Height Above Ground: / ~ GPM ~ ~ Ft. ] ( 2 '~ .,. TANK SEPARATION DISTANCES ~Septic D Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ub[ic/Private Ma~ufactu~r: ~ ~, Capacity in gallons: From Tank Field Station Tank Sewer Lines ~C~r~_ ./~K Well ]~0~ ~0~'1 ~/~ ~ /~/~ Material: ~[ Number°fO°mpa~ments: Water ( GO p (00¢ ~ g g ~ LIFT STATION Ou~ainDrain ~ ~ ,, Pump Make & Model Electrical Inspections pe~ormed by: Remarks: BENCH MARK Location and Description: / ~ ENGINEER'S SEAL Inspections performed by: (~ ~ Dates: 1st ~ ~_.~o~ I ' ' Department of Healt~d Huma~ervices approval ~~~¢ Reviewedandapprovedb ~ - Date / Permit No. ..%~/9/b/b-~ Page '~- of '~' Municipality of Anchorage 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 PID No.: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910103 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:BENESCH DUDLEY & OWNER ADDRESS:P. O. BOX 111572E ANCHORAGE, ALASKA 99511 DATE ISSUED: 5/16/91 EXPIRATION DATE: 5/16/92 PARCEL ID:02009221 LEGAL DESCRIPTION: LOMA ESTATES BLK 1 LT 7 LOT SIZE: 54390 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1. THE SUBMITTED DESIGN DOES NOT INCLUDE A LIFT STATION. IF A LIFT STATION IS REQUIRED, AN AMENDED PLAN AND SPECIFICATIONS MUST BE SUBMITTED PRIOR TO INSTALLATION. 2. INSTALL MONITORING TUBE IN TRENCH. 3. ENGINEER MUST PROVIDE PROOF THAT WELL ON LOT 7 WHICH PREVIOUSLY SERVED LOT 8 HAS BEEN DISCONNECTED. May 10, 1991 ROBERT SHAFER, P.E. ROGER SHAFER CIVIL ENGINEERS (g07) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 7; Block I; Loma Estat~ Subdivision; PERMIT REQUEST NARRATIVE The existing w~ll on the referenced property w~ originally drilled to serve the adjacent Lot 8. There now exists a new w~ll for Lot 8. The proposed septic system is to be constructed on a higher flat portion of the property. As can be seen from the a~tached site plan the slope of the lot increases w~st of the proposed a~ernate trench site. The lots in this area are r~latively large and we do not anticipate any adverse ef~ on neighboring prop~rti~ by the installation of the system. ~gm A. SHAFER, P.E. PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17- 18- 19- 20- Township, Range, Section:-'~l I T~ PLAN SLOPE WAS GROUND WATER ~, ENCOUNTERED?[%Jl~ S L IF YES, AT WHAT O DEPTH? p E Deplh to Water After ~,e.itori.,? ~ ,at~:~"t~' Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE -- (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN ~ FTAND FT COMMENTS. / / S & S ENG, INEERIN~ ~ERFORRDE~END BY: 1..~'O_qe'~-_ ~-AI~L~;~L~gc~5.~a~__-I .A.~,..~A~/'/ / ~ ~ ~ CERTIFY THAT THI~ TEST WA~ERFORMED IN CCO CE WI~L'~T~ AND MUNICIPAL GUIDELi~~ ON THIS DATE. DATE: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: L-~\ LEGAL DESCRIPTION: L'"'~ ~"~--~ ~'~'~ DATE PERFORMED:. ~:~t,,,'?/~, -~SqT. Township, Range, Section: --~ ~ I J ~-- 1 2 3 4 5 6 7 8 9 10- 11 12 13- 14- 15 16 17 18 19 2O SLOPE WAS GROUND WATER ENCOUNTERED? I s IF YES, AT WHAT ~ OL DEPTH? \~ p E Depth to Water After. ~ Monitorino? ~"'¥ "~'~ Date: L SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ''''~ ' ''~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ AND '7 FT COMMENTS PERFORMED BY: = --. - : ..... ~ ...... . IJ _/_.~7"' ' CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WI"~'I'~,~LeLJ~¥,~-'E~:XJI~U~gAL GUIDELI~"~IN~FECT ON THIS DATE. DATE: .BOx 1669, ~TAIt ~_~OI.~TI~ ,~[ ANCHORAGE..'~[[,,Aliil/A 99fiO2 SIX INCH WATER W[gLL DRIL. LE:D AND CASED OUT TO THE DEPTH OF .. ~_P~ P~OPERTY OWNER ~ S~m~ DRILLER __~e~e ~e o~ ~[ ~]]&~ WELL LOG: 0~2~'~ ~lay~with ~0Jg gravel anct aeverA1 small bou~ders, 2.,~.;~* 8And~ ~*avel with 20~ ola~r binder. 3~---~0' ~lty, sandy materlal producing some water, 59---60' ~ore algrm of water i~ a broken rock m~terial. 60---78' A brokea rock ~rea. 78.-.18t' ,Bed.~ook. A eedimenta~y rock. X81-18~' A water bering porous rock producing of su~faee. 10 (3P~ wtt~ a reoover~ wit~ 50 feet OCT 7 1991 [ViUDJcJD~ji~V 0'~ /~['~Ch Deof 14~:',;~. Z,, ,,orage _ '~,.- ~ ~uman Serv ces THANK YOU VERY MUCH, .. BERNIE CLAUS OF RAMPART. DRILLING WORKS SERVICE CHARGE O F 1 ~% PER MONTH WILL, B~ A ED ONSET DUE ACCO~TG, Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O 2,g,' - O 9 2, - ~.1 GENERAL INFORMATION Complete legal description ,, Location (site address) Current Property owner(s) Mailing address Lending agency Expiration Date: /j"' /'~ ~/~ Day phone ~ ~ ~ -- ~. ~ ~'~ Day phone Mailing address Real Estate Agent Mailing Address unless otherwise requested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: /~ TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class ~ Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site System's 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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 of up to 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. 4. 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 ~'i~j"i~/~ 7"'~'~/~;~¢~r/ ~¢~"'~,"~o~./. Address ) "/,J'L~' ~ ~ Engineer's Printed Name .5. DSD SIGNATURE ~ Approved for L~ Disapproved, Conditional approval for bedrooms. ' · ' ¢" ti ulat~ons ~, , Attachments: COSA Checklist Septic System Advisory Well .Flow Advisory Nitrate Advisory (Rev, 11105) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other /'~d~/'--~Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Lt'~ 7,, I~ l~'c in:: l.t /-.,ol, Ot ,~,~' /'ta t'~../ ParcellD: Legal Description: A. WELL DATA Well type Pi//' Date completed 7/"//'7' 7 Total depth I,~/ ft. Date of test IfA, B, or C provide PWSID # ~ g.p.m. Sanitary seal (Y/N)... Cased to .'~ q4~ ft. FROM WELL LOG ft. Nitrate ~, 14~mg/L Static water level Well production WATER SAMPLE RESULTS: Coliform ~o~ ~_. colonies/100 mL Arsenic: /-. &'" ug/L date of sample: 'X./.2~ ! B. SEPTIC/HOLDING TANK DATA Tank Type/Material _~/~ ~ ~ / _~"~ ~/ Tank size J ~ gal. Number of.Compartments. Depression over tank (Y/N) __ Pumper. Foundation cleanout (Y/N) Date of pumping ~'./~ / C. ABSORPTION FIELD DATA Date installed 7/t/9! Soil rating (g.p.d./ft2 or ft%drm) I, ~, ~ Well Log (Y/N) Y wires properly protected (Y/N) Casing height (above ground) AT INSPECTION ft. ~, ~/"f' g.p.m. Other bacteria Collected by: --' ~colonies/100 mL System type Gravel below pipe ~ ft. Depression over field For /-/ bedrooms New depth,:rg3,~in. Absorption rate >= ~ o ~j g.p.d. Mc, nd tc.~ o~.,,/', If yes, give date t~. Length ,5"~' ft. Width ~n/<' - ~,c, ~. ~ ft. Total depth ! O ft. Eft. absorption area,,5-~,~ ft2 Monitoring tube . Date of adequacy test 7' / 2,~ / t'~ Results (Pass/Fail) Fluid depth in absorption field before test ,¥~ in. Water added ~.~__.~gal. Elapsed Time: J ,~ min. Final fluid depth ~/~' in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) · 'Z. 'Z in. Date installed 7 / I /) I Cleanouts (Y/N) High water alarm (Y/N) ,'~, ,4,, D. LIFT STATION ~J. ~-. Date installed "Pump on" level at~ in, Size in gallOns "Pump off" level at~ in. . Manhole/Access (Y/N) · High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: SePtic tank/lift station on lot '~. IO0 Absorption field on lot ~' ,J~ I Co ' Public sewer main j~. Sewer/septic service line ~ 3.5'' Animal containment areas ~,,~"~' ' On adjacent lots . On adjacent lots ~. l~,,c, ' Public sewer manhole/cleanout Holding tank /~/. Manure/animal excrete Storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation '~"~ Water main Wells on adjacent lots Property line ~ ' Absorption field water service line ';> ~ ' Surface water Ge Property line I ~' Water Service line .'~ ~.o ' Curtain drain ~o/~a ~-,~,,n Wells on adjacent lots _~. 4~' ' COMMENTS ENGINEER'S CERTIFICATION / certify that I have determined through field inspections and SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation '~, 4o ~ Water main I~,/t, Surface water '~, ~.4~ ' Driveway, parking/vehicle storage review of Municipal records that the above systems are conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name ~~~ ~. ~~ COSA Fee $. Date of Payment Receipt Number (Rev. 11/05) Waiver Fees Date of Payment Receipt Number F- O 3 r" mo X X ,~9'0~ [ l x p X 3 ,,gt,,~O. O0 g 61.4' -- ~z mr.- LANTECH x 0 ~ g X r o 56.1' ,O0'OOL 3 ,,g§,~O. O0 S F-- 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 7; Block 1; Loma Es~ Location (site address or directions) I 7135 Belarde. Avenue. Property owner Mailing address Lending agency Mailing address Agent Ad dress Lisa Be. he, ch Dudley Benesch Day phone P. O. Box 111572 Anchor~.q~, Alaska 99511-1572 Day phone 272-3461 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: XX Public water 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 NOTE: '- Public sewer If ~omm'unity waste water system, provide Written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by myseal 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/orwastewaterdisposal 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 flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date.of this inspection. Name of Firm s & 5 ENGINEERING Phone C~ Or ~ ~-~ "/~ lY03q' Eagle Ri,vet Loop Road N67'2U~s,_ Add tess Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE ~___ Approved for z~__. Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements· Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /~f ?;~'~K I~ /--o?!A ?'-~.R~-bParcell.D. A. WELL DATA Well type c=~[t~:~flf A, B, or C, attach ADEC letter. ADEC water system number Date completed Log present (Y/N) t.~, Total depth ~ _~ Sanitary seal (Y/N) Cased to /-'itC)''/- Casing height / 2 Wires properly protected (Y/N) Date of test Static water level Well flow Pump level g.p.m. Absorption field on lot Public sewer main Sewer serVice line FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot )r~O t ; On adjacent lots On adjacent lots Public sewer manhole/cleanout Petroleum tank /~ o~)~ t WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ~A.J/l~/-<,_.~,c-'~o/u /AJ.~.'~ Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed '~- O~- c~ Tank size Cleanouts (Y/N) 6( High water alarm (Y/N) pumping ~ )/IA Date of Foundation cleanout (Y/N) [1 /~) / (/~ Alarm tested (Y/N) (~Jc u.)) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage Compartments Z Depression (Y/N) /0 Absorption field foo -/- Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed ~ Size in gallons ~ Vent (Y/N) _"~p on" level at High water alarm level iq ~ (& Meets MOA electrical codes (Y/N) W SEPARATION DISTANCE FROM LIFT STA~tO%N TO: Well on lot On adjacent'lo~s D. ABSORPTION FIELD DATA ~, Manufacturer Manhole/Access (Y/N) t'Pump off" level at Cycles tested Surface water Date installed -~ - O~ ~ R / Length ~0 Width "'% ~ Total absorption area _%-'-C)0 '¢ Depression over field (Y/N) p~ ) Results (pass/fail) bJ] IA Peroxide treatment (past 12 months) (Y/N) Soil rating ]. 2 ~,0,~ ,/F'4 :~ System type 'T~c:,,Jc_ ~ / Gravel thickness ~' Total depth Cleanouts present (Y/N) Date of adequacy test fi/_tA ~A)C~ for -- bedrooms Id If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / ~¢3 On adjacent lots / Well on lot ~ _ _ ! To building foundation [ 0 On adjacent lots ¢'~0 '''¢' Surface water ~ Curtain drain &) [ ~ Property line To existing or abandoned system on lot Cutbank xJ/J~ Water main/service line Driveway, parking/vehicle storage area 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. Signature Engineer's Name Date $ & $ ENGINEEEING Eagle River, Alaska 99577 ' Waiver Fee: $ Date of Payment Receipt Number 274 6~02 ( :,FLAT.T.OP TECHNICAL CIVIL & ENVIRONMEN'IAL EN(iLNEERLNIh: ,~ ENERGY CON,'-;ERVATION & ANALYSIS 'J'm:ODOa~: )'. MOOre:. ~'.~:, ,June l I. 1990 14sa0 ~:CHO PH: (907) 345-1355 ANCHORAGE, AI.,A,~KA 99516 Gar.v Madsen Nova Properties 551 ~)~Dtmond Bix fl. ,~nchorage, AK 99515 Dear Mr. Madsen: Per your request, on May 25 we conducted a yield test of the well on Lot 7, Block Loma Estates, at 17135 Belarde Rd. Jn Anchc)rage, i! is my understanding that this lot presently owned by the Alaska District, Engineer's Federal Credit Union. The well presently serves tl~e residence on Lot 8, but may be disconnected in tile future and reconnected to a new residence ¢)n Lot 7. There is no driller's log on file at the Municipalit.~ but the well was probably completed j;{ 1977 at tile tin)e the residence on l,c.)t~was built. On the date of our test the static water level stood at 30 feet below the top of the casing. After pumping 608 gallo)ns c)l' water from the well at the maximum pump output of 6.9 gpm, the %rater level was drawn down to 67 feet, and it slowly recovered after the flow of water was turned tiff. Based on this test, we concluded that the total sustainable yield of lhe well is in excess of 3 gallons per minute which is adequate for municipal approval of any single family residence, and also meets the FHA criteria of being able to supply water at the rate of 3 gpm over a 4 hour period. Water samples taken on the date of the test were satisfactory, showing t) coliform bacteria per I ti0 mi and non=detectable nitrates. Please give me a call if you have any questions on this report. Sincerely, Ted Mc)ore, P.E. MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel !.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Mu. st be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~'¢¢~r,~1 d'r-~¢,4, t Mailing Address ¢ o. Cox (c) Lending Institution ~ ¢; Telephone: (home) Telephone Business Mailing Address (d) Real Estate Company and Agent /Vc,~'~ ~o~r/~ -- Address .~'..4'"/ ~. ?"~mo,~¢~( S/u~ ~ ~ ~0~ ~ Telephone ~ ~ - ~ 7~ (e) Mail the HAA to the following address: (or check here [], if hold for pick up.) List contact person and day phone number below: '7~¢~' ~oor-~ G' Y.~- /-~.4"5-' 2. TYPE OF RESIDENCE /4o~. b¢.,l{ cz/- -/-ALt -]--r~ ~ Single-Family E] Number of bedrooms ~ 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If.community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGEDISPOSAL N~n~' c~¢' /'h'~ ~-,~ ~ ~;~(I /2,z On-site [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. 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 F{~H~'~ Teo6n }cc~( _¢er,.*;¢..'-.; Telephone Address /~-~ .~¢_.4o ..C/...~ /,~¢~.,60F~-( ,, /)~- Date Engineer's Seal 6. DHHS APPROVAL Approved for [%~/Y~ bedrooms by Approved .~. Disapproved Terms of Conditional Approval Date Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 6/18/90 TO ALL PARTIES CONCERNED Ail parties concerned are advised that the subject Health Authority Approval for Lot 7, Block 1 Loma Estates is being approved with the following notations: 1. The well iocated on the subject lot is currently serving a single family house on adjacent lot 8. At such time as the well is used to serve the subject lot, use of the well by lot 8 must be discontinued. 2. This approval is only for the purpose of attesting to the proper construction, yield and quality of water produced from the well. This document does NOT constitute approval for use of this well by any structure~than the single family house located on lot 8. ~ WELL DATA Well Classification Well Log Present (Y/N) MUNICIPALITY OF ANCHORAGE (MOA) Health Autho_rity Approval (HAA) N Date Completed Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Legal Description: L. ot 7~ /~loc/-~ .~, If A, B, C, D.E.C. Approved (Y/N) Yield '~ -~u~,P~ TotalDepth~67' Casedto'~~'7' Depth of Grouting ~'/,,~- Static Water Level ~0' Pump Set At ~ ~"z ' '~ ~" Sanitary Seal on Casing (Y/N) k' Depression Around Wellhead (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 To Nearest Sewer Service Line on Lot 7-ech Water Sample Collected by Water Sample Test Results Comments 'Th~ uuell SEPTIC/HOLDING TANK DATA /v ; On Adjoining Lots ; On Adjoining Lots :~. ~oo' To Nearest Public Sewer Cleanout/Manhole _("c, cj' ; Date ,Z/2d'/PO No. of Comp~rtments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped Date Installed Size StandpiPes (Y/N) Depression over Tank (Y/N) ; for Temporary Holding Tank Permit (Y/N). Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) To Building Foundation To Disposal Field SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA &(,/~. Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion 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 Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D. LIFT STATION N. 4. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA qj.l~,s~ effect on the date of this inspection. ~'~z.¢~. U~" /4~ ~ ~. ¢ ...................... ~,.,'~ Engineer's Seal Date 7~e % /¢¢o MOA NO. Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back ~ ?I-IEODORE F. MOORE Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 Date g~pozt ~.~,nted: },9, Y 3J. 90 ~ 13:27 P?~SID :Uk CoJ. l~ct~a] MAY 25 90 ~ 13:30 1~. Received 1,~Y 25 90 ~ i6:1.5 hfs, ¢tient Nal~e : F!.~%~OP TECHN£CAL ?.0.~ ~]0~ 901553 Lab Sinpl ID: i Matzix: Aiiowabi~ ~e~teu ~e~uit Units Method