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HomeMy WebLinkAboutHIDEAWAY LAKE BLK 1 LT 6H'I'deaway
Lakes
Block 1
Lot 6
#015-471-30
01/221'2013 02:07 5072330742 AWPS. :tic. PAGE 03/
a•'ity� N..,
Wayar
Well Drilling i'ermit Number: SYV
Parcel identification Number:
I.c�alAescr"ptinn 1
Pump Imstalbdon Date: 1-14-1^1x
Puutp Intake Depth Below Tap of Well
Pump'Hanufaetua'er'sName.,
Pump Model: �O �j// 0615 tt —
Pump SfzP 0+ lip
Pitless adapter Burial Dept':x: /[j feet
Pitless Adapter Al;mufacturer's Name:,, �
ip Installation Log
Date of Issue:
I�Pro ett't
' Owner Vacate & Address':
O ,ak
<1dgc7
: -�7 feet
a
..r+el] Li;:ts''ect;• l -poo L 1'c
;Sfethoa. of DiiAn.ecticm:
4C:2, -
Comments:
I
Pump iinstnller Name:
Fax.
Attention: —he pump insiab'.er shall provide a
76th Avenue
Alaska 99518
37-243-0740
installation log to the DSD within 30 Jays of pump in;°al2tior,.
61r" p
Municipality of Anchorage Page I of 2 -
[DEPARTMENT OF HEALTH AND HUMAN SERVICES
V
ENVIRONMENTAL SERVICES DIVISION c
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: —_ :5;W9`1012I PID Number: O/Set7//0
Name:
M 42G -ARS �T E'm E -
Wastewater System: ❑ New ZUpgrade
Address:
//090 1�/AE"RwAy L,��E �.
ABSORPTION FIELD
AN�HOI�AGc� K 7 ISMO
No. of Bedrooms:
y
❑ Deep Trench ❑ Shallow Trench ❑ Bed ound ❑Other
LEGAL DESCRIPTION
Soil Rating:
ff from original grade:
GPD/Sq. Ft.
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
_
Gravel depth beneath pipe
//--,,
//�/
lD / t=iiW, LF}kt=
Ft.
Ft.
Township:
Range: Section:
Fill added above original de:
Gravel length:
Ft.
Ft.
WELL: ❑ New ❑ Upgrade
Gravel width:
Number of lines:
Distance between lines:
I
Ft.
I
Ft.
Classification Privat A,B,C): E-X/S'7'
Total Depth:
Cased To:
Tota sorption area:
Pipe material:
2�a/VRTE-
Ft.
Ft.
SQ. Ft.
Driller:
Date Drilled:
Static Water Level:
Installer: X 17 — 6 -74
Date installed:
Ft.
C AJ (fol,)S-
Yield:Pump
Set at:
Casing Height Above Ground:
T'AN K
GPM
Ft.
Fl.
SEPARATION
DISTANCES
❑ Septic AHolding v ❑ S.T.E.P.
To
Septic
Absorption
Lit
Holding
Public/Private
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
NC 6 1
4600
Well'
,7 Q ,
_ l
2S +
Material:
Number of Compartments:
STEEL
1
SWater
--
--
/DO`)
LIFT STATION
Lot
—_
Z.5
Size in gallons:
Manufacturer:
Line
If
Foundation
__
y
"Pump on" level at:
"Pum evel at:
High water alarm at:
Curtain_
—.. N
Oti7 E'
OWN
PumpMake a
Electrical Inspections performed by:
Drain
Remarks: P/L IJ4IVez GaRvrEt�
BENCH MARK
Location and Description:
m - To? OP S Erb RT 1�—EFI 12 OF Liouzg-
Assumed Elevation:
/00.0 -
ENGIt4EER' 'SQA
+� a
by ( �
A k
pr; t 1 ,'
17034 Eagle River Loop Road, No. 204
Inspections performed by, Eagle River, Alaska 99577 pates: 1 st ?_/&_99
2nd
ate; 3.;
Department of Health Hu rvices apyal
Reviewed and approved by: Date: 3 `,
79.n13 IFev Q/011 MnG 9F
Permit NO.SW940121
Page — 2 of
2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 9 Anchorage, Alaska 99519-6650 o Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Descriptior�IDEAWAY LAKE SUBD; BLOCK 1, LOT 6 01547110
PID No.:
�Coi
t
SCA111; I" = 40':
72-013 A (1193) -
C)
LARM
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940121
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:EMPIE MARGARET J
OWNER ADDRESS:11080 HIDEAWAY LAKE DR
ANCHORAGE, AK 99516-1145
PARCEL ID:01547110
LEGAL DESCRIPTION: HIDEAWAY LAKE BLK 1 LT 6
LOT SIZE: 57153 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 5/11/94
EXPIRATION DATE: 5/11/95
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED B
ISSUED BY:
DATE: j Z j
DATE:-
LOT-
ATE:
Lor- LAVE. oj,Alllc�z_ ro �,f' (--7,elhv F�_�, 47wK�1-1111/e
Muni ipality ®i .A c1.orage
K
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
May 11, 1994
Robert Shafer, P.E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
a
Subject: Waiver Request for Lot 6 Block 1 Hideaway Lake Subdivision
Waiver Request #WR94001.8, PID #015-471-10, SW940121
Dear Mr. Shafer:
Your request for waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 2.5 feet from the east property line to the
holding tank.
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
Si erely,
J mes Cross
Civil Engineer
On-site Services
ljw#7
MUNICIPALI IY Of ANLHUt�At,;Id
ENVIRONMENTAL SERVICES DIVISION
MUNICIPALITY OF ANCHORAG_
Department of Health and Human Services „(��Z 15 1994
On-site Services Section
Waiver Review Worksheet RIVf,D
WR#I_PID# 015-471-10 HA# _ Permit if LYA'kwQ\
Date Received: April 14, 1994
Legal Description: Lot 6 Block 1 Hideaway Lake Subdivision
Engineer: Robert Shafer, P.E., S & S Engineerinq
17034 Eagle river Loop Road, Suite 204, Eagle River 99577
Applicant: Margaret_ J._Empie
Waiver Requested: Lot line waiver of 2.5 feet from east property
line to holdinq tank.
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: Waiver is NOT Granted:
List Conditions or Reasons for. above: N 0 " vE._ S -E C-&iA/%7 GYA ,
Rec Amount: $ `�� ���� Date Paid:
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TIVOS
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April 12, 1994
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-12.11
HEALTH AUTHORITY
APPROVALS
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 'L' Street
P.O. BOX 196650
SEWER &WATER
MAIN EXTENSIONS
Anchorage, Alaska 99519-6650
SEWER&WATER
REFERENCE: Hideaway Lake Subdivision; Block 1; Lot 6
INSPECTION
Request you issue a permit to install a holding tank to serve the
ENGINEERING STUDIES
AND REPORTS
existingfour bedroom house on the referenced
ceproperty. Also request
you issue a 2.5' property line waiver on said property.
The property is encumbered by a creek, lake, pond and the 100' well
WELLINSPECTION
radius. Therefore, a 4000 gallon holding tank is the only feasible
&FLOW TEST
option for the referenced property.
A 2.5' property line waiver is requested in order to maintain pond,
creek and foundation setbacks as can be seen by the attached site plan.
SITE PLANS
We do not anticipate any adverse effects on neighboring properties by
the installation of the proposed holding tank.
If you have any questions, or require additional information for your
ROAD DESIGN
review, � se contact us.
Sincerely,
SOIL TEST
i
015 rt A. Shafer, P.E.
PERCOLATION �-
TEST
S/LSU/jk
V
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
ON—SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: Hideaway Lake Subdivision; Block 1; Lot 6
Cq"ZL7:I�F
1. The scope of this project includes the installation of a 4000 gallon
Holding Tank to serve the four bedroom dwelling located on the
referenced property. The existing 1000 gallon septic tank is to be
excavated, pumped, crushed and abandoned in place. The existing sump is
to be abandoned in place.
2. Construction shall be in accordance with the approved site plan and
design drawings, Municipal permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater Disposal
Regulations.
3. The contractor shall be responsible for obtaining any necessary
underground utility locates.
4. Unless specifically agreed otherwise, the property owner shall be
responsible for final grading areas subsequently depressed from soil
settling.
5. Contractors installing wastewater disposal systems must be certified by
the Municipal Health Department for system installations. Owners
installing their own systems must also receive prior approval from the
Municipal Health Department.
HOLDING TANK INSTALLATION:
1. A holding tank is to be constructed by a certified wastewater holding
tank manufacturer. Construction shall include a 6" cleanout for pumping
access and watertight manholes.
2. The holding tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
3. All standpipes on the holding tank shall extend a minimum of 12 inches
above final grade.
4. Holding tanks installed with less than 4' of cover shall be insulated.
Page Two
Hideaway Lake Subdivision; Block 1; Lot 6
April 12, 1994
5. The holding tank shall be equipped with a high water alarm which
registers both visually and audibly inside the dwelling. The alarm
shall be positioned to allow at least 450 gallons of storage after the
alarm has been activated.
6. Final grading over the holding tank shall be such that a positive slope
exists away from the holding tank.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any holding tank proposed for installation must be constructed by a
Municipally approved holding tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Type
of Pipe
Perforated
Solid
Cast
Iron
Yes
Yes
ASTM
D3034 (PVC)
Yes
Yes
ASTM
P810 (HDPE)
Yes
No
ASTM
D2662 (ABS)
Yes
Yes
Use of a type of pipe other than listed above must be approved by the
inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Company Styrofoam HI or equal).
4. Holding tank inlet shall be fitted with watertight couplings (Caulder,
Fernco, or equal).
Page Three
Hideaway Lake Subdivision; Block 1; Lot 6
April 12, 1994
INSPIETIONS:
Typically there will be a minimum of two (2) inspections required during the
installation of the wastewater disposal system. These inspections will occur as
follows:
1. The first inspection must be conducted after the tank has been set;
lines, cleanouts, standpipes, and insulation are in place and prior to
backfilling.
2. The final inspection is to occur upon final grading of the property.
Often there will be more than these 2 inspections required, especially with the
installation of multiple trenches, sand filters, pressurized distribution
systems, etc. Thus, the inspecting engineer is to be contacted at least 24
hours prior to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractor's activities.
The owner shall contract with the contractor to perform the work outlined in
these specifications and plans and in accordance with the attached M.O.A.
permit. There will be no contractual arrangement existing between the
contractor and S & S Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to document the
contractor's activities. Final acceptance of the contractor's work rests with
the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or
omissions of the contractor or any other persons performing work on this project
or the failure of the contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer will not be
responsible for the construction means, methods, techniques, sequence,
procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
MUNICIPALITY OF ANCHORAGE
i DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC ON
\ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE
W IIiC n m�iv >b �Z!�OUPG
MAILINGADDRESS
ADE
10CrI Iclocl-2r� oae,f
LEGAL DESCRIPTION
Lot- GIG 10(k)
H'. dcc.v, �t IrP Si 1 i' 'sly
LOCATION
lI ,I y�
7�FII '-flue lC�
NO. OF BEDROOMS
I lir P
Well
DISTANCE TO:
Absorption area
Dwelling
PERMIT NO.
U
_X
I- Z
h
Manufacturer
Material
No. of compartments
LU
y
Liq. capacity m gallons—
IF HOMEMADE: Inside length
Width
Liquid depth
LW
0 z
Z
i
ell TO: Well Dwelling
PERMIT NO. 4
Q
�- _ bLiquid
nu
Mafar: turer Material
capacity in gallons
2
DISTANCE TO: Well Foundation .m Nearest lot line
PERMIT NO.
w
No. of lines Length of each line
Total length of lines Trench width
--
Distance between lines
_�
ccH
Top of file to finish grade
inches
Material beneath file
O
inches
Total effective absorption area
Length
Depth
w
PERMIT NO
(7
LType
of crib
Crib diameter
Crib depth Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance t o lot line
PERMIT NO.
w
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOI L TEST RAT ING�jat;
Q F A/��
1d
e.t
INSTALLER%� •..�� � •. A
REMARKS ® ' 4 (9•�
•....
.. . a•.a�
':. "
NO. 986-E
h
.C��
/_7
00'
;
U
101
APPROVED ATE LEGAL
72-013 e .3[78) T d'
MUNICIPALITY OF ANCHORAGE
® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROI"ECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 9950"1 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHOfVE [])W
y7
^JUPGRADE
---- r`"jI`j
MAILING ADDRESS -
LEGAL DESCRIPTION
�1—�—
LOCATION¢
�( NO. OF BEDROOMS
DISTANCE TO:
Well
Absorption
Dwelling
PERMIT NO.
U
�t
AZ
F
Manufacturer
Material—
-
No. of compartments
W
Liq. capacity in gallons Inside length
IF HOMEMADE:
Width
Liquid depth
PERMIT NO.
Y
Z
Z
DISTANCE TO:
Well
Dwelling
Q
7: F'
Manufacturer
Material
Nearest lot line
Liquid capacity in gallons
PERMIT NO.
Lu y
DISTANCE TO:
Well <7.f
Foundation
LU a Z
Zw
No. of lines Length of *aWline
Total length of lines Trench width
Distance between fines
h a
to Top of file finish grade
Material beneath rile _inches
-Total effective
absorption area
w
Length
9 Width
Depth ��'
PERMIT NO.
Q
Q� f_
Lu
Type of crib
Crib diameter
Crib depth
Total effective absorption area
wi
y
DISTANCE TO:
WeII
Building foundation
Nearest lot line
J
J
Class
Depth
Drifler
Distance to lot line
PERMIT N0.
LA
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption areas)
OTHER
P.KT"
PIPE MATERIALS
nn
S01 L TEST RATING
INSTALLER
O
—
REMARKS
_3 1 tom, a-t- Q,
U_ 4. C'-Q.A,
vita% nJ
=3-- - s S14 i� 0
APPROVED LEGAL--
1 (�{DATE
y9_ntZ fRo„ vnvt —
rol It-) V-4 I C', T F'-'� r- ��ft-ru f_'y PA K'-" "-. I A�r
DEPHRTM�NT OF /.�HLTH H�K." E�YIRO�MENTRL P�i
825 'L' STREET, ANCHO�A��. �K nnm�
U��EVLVL U�U�U0
PERMIT NO.
HPPLICANT WILLIHM EMPIE
LOC�TION HIDEHWO� LK
LEGRL L6 B1 HIDEHWHY LAKE
�.�����`����' �.�`� ~�°,�
264~47��
. . "
14�� H STREET ' '_�/ �v�o 278 1177
LOT SIZE 57499 SQURRE Ff��~��
TYPE OF SOIL ABSORBTIONSYSTEM ISTRENCH `
�
MAXIMUM NUMBER OF BEDROOMS=, SOIL��TING
THE RE8UIRED SIZE OF THE
SOIL HBSOR .TION SYSTEN`-:
�� �� �������� ��`���
THE LF-ENG7H DIMENSION IS
THE LENGTH ifOF
R DRHINFIELD.
THE DEPTH OF H TRENCH
OR PIT IS THE DIST\Fl�.�)
BET���m URFHCE 0F THE
GROUND HND THE BOTTOM
OF THE EXCAY�frION
PEET.
THERE IS N8 SET WIDTH
FQR TRENCH`
THE GR�YE� DEPTH IS THE
-
MINIMUM �,
EPNlr_
rm�� `
F GR8��/ BETWEEN THE OUTFH|L PIPE
RND THE BOTTOM OF THE
BXCRYHTIC` (IFT)
��V �.�V. F'" 'T��
Jr F= J -z P:,: I �IF=,l R.����
PERMIT APPLICANT HrtS THE
RES ITY TO
FORM TS D
11IEPHRTMENT DURING THE
INSTALLRTI0N INSPECTIONS
OF R WE S HDJHC
T TO THIS PROFERTY HND THE
NUMBE� OF HT
T4ELLU'/ILL SEFw�
"T 04 P-11 �-V ��� ���������
BRCKFILLING OF ANY SY�TEM WITFI., SPECTION AND RPPROVRL BY THIS
MINIMUM ` AN
8NY ON-SITE SEWHGE DISPOSHL SYSTEM IS
100 FEET.FOR H PRIVATE WELL/ Cl'K
150 TO 200 FEET FROM H PUBLIC WEI-^^ NDING UPON THE TYPE OF PUBLIC WELL
WELL LOGS ARE RE8UIRED HND MUST BE Rr�uRNED TO THE DEP�RTMENT WITHIN 30 DHYS
OF THE WELL COMPLETION,
OTHER REQuIREmENTS �FVY APPLY. SPEC: IF I CHTI(]NS O�� CONST���TI(]N [>IHGRRMS HRE
�VHILHBLE TO INSURE PROPER INSTALLATION, ~
I CX.RTIFY THAT
1� I AM FAMILIAR WITH THF ��QUI��MENTS FOR 0�-SIT� SEW2RS ANF.', �ELLS RS SET
FORTH BY rRE MUNICIPRLI7f OF 8NCHORRGE.
2� I WILL INSTHLL THE SYSTEM IN RCCORDHNCE WITH THE CODES
]� I UNDERE"THN f THAI THE ON-SITE S1-WER SYSTEM MRY REQUIRE ENLHRGEMENT IF THE
RESIDENCE IS [�EMO0rl-ED TO INCLUDE MORE THAN ] BEDROOMS
_i - I---J------t_i
WSiL OWf (B]ITICAH
I hereby certify that the following described
property has been surveyed by myself, or under
my supervision, and the corners shown on this
drawing are existing as of tile
'�date of Survey
/ ' l (' - f
l_ -7
r
0
t-- I /.1 Vv, –V l K-
�'�. 0.5 -71 "
1 1 \
�Pt20Po�'c,D
ou LW--
`
• LEGEND•
It is the responsibility of the owner or
-\
0
B.L.M. Brass Cap Monument Fnd.
builder,prior to construction,to verify
proposed building grade relative to fin-
,
L
ished grade and utility connections and
Subdivision
^y,
Iron Pipe Set— Fnd._
to determine the existence of any ease-
AN (,
s�e'�x$�n Rebar Set_Fnd.�
ments,covenants, or restrictions which
do not appear on the recorded svbdivi-
RECORDING PRECINCT,ALASKA
r3
Survey Hub &, Tack Set— Fnd._.lon
�S
111-79 0'
N I DE,6AN4Y k �
N arm: t7-�-v15� 4-Iov� wcA�t ors .
7 12•-7 �i 1�f41
OF 44�e��
p
all Is
0
®ems r49iH
7 F: Forl D. Kwynto �e c
NO. 3254-5 1
Q�O! °p•weeeji• 5 �
�pfvlCScv7tY Al �4y�
—LOT SURVEY CERTIFICATION—
• LEGEND•
It is the responsibility of the owner or
Lot- Block— I
0
B.L.M. Brass Cap Monument Fnd.
builder,prior to construction,to verify
proposed building grade relative to fin-
,
Brass Cap Monument Set__Fnd.—
ished grade and utility connections and
Subdivision
O
Iron Pipe Set— Fnd._
to determine the existence of any ease-
AN (,
s�e'�x$�n Rebar Set_Fnd.�
ments,covenants, or restrictions which
do not appear on the recorded svbdivi-
RECORDING PRECINCT,ALASKA
I7
Survey Hub &, Tack Set— Fnd._.lon
plot.
FOR
UNW1N*SCHEBEN*'1%%0RYN'1 'A
CONSULTING ENGINEERS and SURVEYORS 2515 A St. Anchorage, Alaska 99503
DRAWN �151 SCALE I e7' DATE 7 1 Z �`� W.0.7q aj� FB47-55GRID z&,IOD
G� JUILS LUG
MUNICIPAI..rry OFAn�IIORAe1:_
a 4a_ ,
�C
DEPAR"TMEN T OF I I EALTH AN4` NVIfiONMFN TAL PROTECTION
EHCOLAI ION
/
<<S v`
Pouch 61550, Anchora9a, Alask: 19,02 -,7;G 22.2`
I r_.T
SOILS LOG PERCOLATION T EST
PI-WORNIF1)FOI: _
11A F! rFIiPOR
v(C- �-
LGGAI_ PESCHIPl ION.
� I
��` A \
r N
FFI T�
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I
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---10
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l^LNS t=;IiOUNU FVA I L R
LNCo F,IVTERFD'
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DEPItl
13
Real nq
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-
^Jct__—�
I I
I
I u.
Ir,n
Incl Drop
+I
I
I
'
7
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- _ •1
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MUNI JPALITY OF.' ANCHOR, .3E
1) 1 ME I'll T OF PUBLIC WoIr:%)I<s
CONSTRUCTION DIVISION
TFS1-
PROJECT DATE
CONTRACIOR
MATERIAL.
LOCATION SjA tvWi- 1= D BY 4
L)-6 Lai YLi
COMMENTS
IV/ Li j'�
REPORTED
PLOTTED BY CHI:(-"KFD BY MAR V I SOR
TIRIALS SUPF
S4 -VE ANALY.SiS
NUMBER{ SIZE OF OPENING IN INCHES Of MESH PER INCH u S. STANDARD
loo f-
(4--
7
S2 60
5 0
Ld
-------------
LL]
5o,
A
20--
f------
10
%L
0 0 0
C) 1r) M LO if) 11) coloZ1111in P) C\j
(;RAIN SIZE IN MILLIMETERS
mm FINE
GRAVEL "T
COBBLES 7,1E
—A,-.--- SAND
INSPECTORS COMMENT s
0
H
jkj F-
T
(9
Ji
3:
40
fr
W
50 U)
0
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ME
MEW
GA]
� 100
cr)
0
MU NkAf"A! _ IT OF-ANCH0R/-AuE_
DFIVIFNT OF PUB1_IC WORKS
CONS1 =lIJC; j 10N DIVISION
7 '—Ul.� l E S I N 0.
F'ROJEC r_L b1h I _ - DATE fau , /SQ/
CONTRACTOR
MATERIAL. SOURCE__-_--
L.00ATION SAM-)( I'D ):-trth— _ -- --
- 13Y
COMMENTS
flic__4;f,r�r_urltctfictffL_is=:aL�Lt_--
REPORI I'D
PLOTTED BY ('HECrE.D B\/ MATERIALS > SUPERVISOR
--
8D
-- -- - -5f
1
f
INSPEC-
SIEVE1 ANALYSIS
SIZE_ OF ORENING IN INCHES _l iUh1(lFR OF MLSH f
100 0 7 M (VV N — R)v -N _ ro i 9 (_o
77
INCH U.S. STANDARD
m
- 30 r
- w
40 }
_ m
— m
50 U)
— a
0
---60 'Z -
, J
LA
l-O 1- T
r
1A
r'
i
L
n
a
ali
yup----
Vi
0
1
2
3
4
5
6
f-
7
8
9
10
11
-12
13
14
15
16
17
18
19
20
21
22
23
24
25 -
Sol ILS
5
SolILs
PROJECTrLa b
CLIENT Bob Sparks
W. 0. 77897
SHEET 2 OF 15
TEST HOLE NO. 2
ELEV. TOP OF HOLE. --B 5 Z
DATE 11/28/77
2
3
4
5
6
7
B
10
11
12
3
4
5
6
7
8
9
0
1
22
23
24
25
Peat PT
rg a n- c s a n y
Damp, brownish red
silty gravel, GM
Damp, brownish grey
gravely silty sand, SM
Damp, brownish grey
silty sand, SM
Grab sample
Damp, brownish grey
sandy silt, ML
(traces of gravel)
%11
®POF A4
•;®
Bottom of Hole
J7M ® 1
�4. �oiMwss ae•u•�pase•soae o°ee •
Earl D. Korynta i!�
d
N9. 1823•E
x�T�iree'e
a••, 61 1
NOTE:
1. No ground water table
at time of drilling. ?
2. Field perculation
test results - 6.3 min/inch.
2
3
4
5
6
7
B
10
11
12
3
4
5
6
7
8
9
0
1
22
23
24
25
yn�^-err 17 M
G� Su X1:30
7'3": yo
Gyt
/do :C/o
S" /y8" /0; 3
Olr-F
77
OF 4/ 4�,
DD°
n�0
�D x w u° .aaaoa °aooDoa0000 as o
Far D Korynta ck; w
NO. 1823•E �r
�'ROFESS\ON'g4v
P�QGut,,on� T -T` lefl�/°
zsO,77
5Y L� �vt4L! ,�T�iL�iNG
/r�sT rc�A-s Al2��l�rrt �
5 10ft -res )vs0 /0%Wwa ef t, *v&e tJ
xSUNICIPALITY OF ANCHORAGE
DIVISTON OF ENVIRONMENTAL HEAI'L'li
DEPARTMENT OF IIEALTH AND ENVIRONMENTAL PROTECTION
APPLICA'T'ION FOR HEALTH AUTHORITY APPROVAL CERTTFICA'CI
i. Geaeral Information Application nate
(a) Legal Descr.tption-(Include lot, bl?cIc,ubrJi v-Lsl on, section, townshl,p, range)
Location (addre,ss or directions) E
1
t l
(b) Applicants Name �, �'1� fl �� -(sit t Telephone Rome;;�,�.,� '- Business,
Applicants Addressv
(c) Applicant: is (check 'o - no) Lending Institution j Owne-/bulkier �) ;
Buyer I—] ; Other G -1 (explain);
(d) Lending T.nsti.tut.ion v Tcleshone
Address
(e) Real Estate Co, u Agent
Address
Telephone.
(f) Mail the HAA to the following address:
r"
1
2. Type of uesi.dence
Single-Lami.ly
Multi-•Pamjly Other (descr.ibe
Number. of Bedrooms
3. (dater SunpJ.'/
Individual. Colrnix nity PubLi.c -
-
Notes If colmeunity we J.J. system, must have written confiriaation Lrom t-I,e skate
Depart:ment o` i:nvironmenCal Conservation a ttr�sttng to rile lega i.ty
4. Sewage Disposal_
Onsite �__,.i ;?ublic. Community I Holding iala:.
J 1, g
Note: If COGIFIvIn I.Ly Well. 13yst.elll, must l rtllr . 4irltl' ..@111 coo irmaLion frol± '31-a Le
Departwom: of :.nviroomental. Coilsorvation (1C ti''.:it i;15 to the legal'_ty BSid srh:t ls.
[Pat,e J. of 2]
5. Engineering Firm Providing Inspections 'Pests, 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 tiles 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 regula-•
tions in effect on the date of this ipspection.
Name of Firm
Z;
Address r` �_-t I 1-��/F'�f� fl C j
Date
(ENGINEER SEAL)
6. DHEP Approval
Approved for 4�bedr.00ms By
Approved T� Disapproved
Terms of Conditional Approval
CAUTION
Cond:it:ional.
Telephone_`, L 6_ � ,,d
l� r
-r....
0 .,
Date /!;.
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENV IRO LNI? ENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. 'PHE DREP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS, EMPLOYEES CF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFCCATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSI35E FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of. 2] 7-•19•-84
A. WELL RATA
a UNIOWALI W O
DEPI. OF HLALm t.
ENVIRONMENTAL PRGTLCIION
MUNICIPALITY OF ANCHORAGE (MOA)- 1964
HEALTH AUT[IORITY APPROVAL ( HAA) RECEIVED
CHECKLIST - FEBRUARY 1984
Legc]l Description:
Well Classification riVa4 If A, B, or C. .E.C. Approved(Y )
Well Log Present (Y/N) No Date Completed UNKNO WJS(Yield-
Total Depth UN &W4 Cased to QN KNo kV�J Depth of Groutin_^
Static Water Leve]. It Pump Set At Lt/V1 Kih(�l,Yh _
9--AVL—
Casing
Height 9 Above Ground Sanitary Seal on CasingYy )
l:
Electrical Wiring in Conduit � N) V Depression Around wtillhead (�t2
Separation Distances from Wel
To Septic/Holding Tank on Lot R©� ; On Adjoining Lots + 0o r
To Nearest Edge of Absorption Field on Lot q0 -*"# ; On Adjoining Lots a-/pp�
To Nearest Public Sewer Line --&/A— To Nearest Public Sewer
Cleanout/Manhole Alp, To Nearest Sewer Service Line on Lot � J}
Water Sample Collected By Q Date '76'd�(' m(g�/
_
Water Sample Test Results ,n lt.<Pnnr i .
s.wriva�.�s
B. SEPTIC/HOLDING TANK DATA
Date Installed %j -']R Size 10©U (i No. of Compartments
_
Standpipes Y ) Air -tight Caps ) 5 Foundation Cleanout (Y p
Depression � Tank (X (i Date Last Pompe
Pumping/Maintenance Contract on File (Y/N) /� A for
Holding Tank High -Water Alarm (Y N) _ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Wall _Q� To Building Foundation IZ.�
To Property Line ©' To Disposal Field 51
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course ./ So'
Comments * e(- MoA Ida-, • * -)(- 0 oori AivA 6 _Pr.,4 A -
[Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 2? - 0 M * Type of System Design _4YR�7K
Date Installed F) -2(-)-Z2 k Length of Field �10` 'K
Width of Field jo ;��(�os 'K Depth of Field /O,
Gravel Bed Thickness `% ` 'r
Square Feet of Absorption Area Q y O Standpipes Present /N)
Depression over Field (YAN) AO Date of Last Adequacy Test rl 5e
Results of Last Adequacy Test, 01 l �011iQ .
Separation Distance from Absorption field•
To Water -Supply Wbll 4 To Property Line
To Building Foundation /Z� To Existing or Abandoned System on
Lot NIA J On Adjoining Lots 4- SOI
To Water Main/Service Line 50 To Cutbank(if present)
To Stream/Pond/Lake/cr Major Drainage Course 100 1
To Driveway, Parking Area, or Vehicle Storage Area /01
Comments -71 p.vr _ri()A J: , * * QAmv-d b�4 NFr- K. Pray 8-20M
D. LIFT STATION NI J
Date Installed
Sizs\in Gallons
"Pumj�On" Level at
High Vater Alarm Level at
Tested for
Electrical Codes
Conmients
"Pump Off" Level at
Ve nt
Cycles during Adequacy Testt. ets MOA
** Check PermittedBedroom Rating Against HAA Request **
I certify that I have checked, verified, or confortred to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed Date
Company Ofy(�,1tA ie 06ax'xaFtt oS MOA No. >Ta `?'-o36�'
KB1 /d5/s
[Page 2 of 21
ENGINEERS
SEAL
r
2-15-84
ISAACS PUMPING SERVICE
(Norm Tibbetts, Owner)
6218 Quinhagak Street DATE
ANCHORAGE, ALASKA 99507
Phone 563.3300
TERMS
PLEASE DETACH AND RETURN WITH YOUR REMITTANCE
INVOICE NUMBER / DESCRIPTION I CHARGES
STATEMENT
CREDITS BALANCE
ISAACS PUMPING SERVICE /�� D 4
/1 G7 ,� ( jury �� PAY LAST AMOUNT
�VJ ,1UfllV l v � IN THIS COLUMN
,r
CHEMICAL & G.f GLOGICAL LABORATORIE6 OF ALASKA, INC.
uww�ro^'[e TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENT!.R
w_ 5633 B Street
Drinking "i Analysis Report for Total Coliform Bacteria
TO BE COMPLETED PY WATER SUPPLIER
WATER SYSTEM: I I I i (') See It on back
I.D. NO.
Water System Name Phone No.
ls�(4 C TU�o� S�� boy
Mailing Address
City
State
Zip Code
SAMPLE DATE: ' "fJ LF' I b_i
Mo. Day Year
SAMPLE TYPE:
�1 Routine
17 Check Sample (for routine sample
with lab ref, no. ❑ Treated Water
❑ Special Purpose 0 Untreated Water
SAMPLE
No.
LOCATION
_—�
-1
Time Collected
Collected By
2
1 _�
J
3
4
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
TO BE COMPLETED BY LABORATORY
/Aj�aly:;is shows this Water SAMPLE to be:
L3 Satisfactory
❑ Unsatisfactory
EJ San-fle too long in transit; sample should
not [ie over 30 hours old at examination to
indicate reliable results. Please send new
sarn•)le via special delivery mail.
Date Fleceived P C/
Time flecelved
Ana!,ri!cal Method:
Farmentatlon Tube
ZZ.1"Membrane Filter
Lab '-tef. No.
QS//
Result' Analyst
� ice`
-1
ED
�—
aT
.Nt. Of colonies/ 100
ml or NO OI Paanive Do,00ns
061220(b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rey. 1063
Membrane Filler. Direct Count
Verification: LTB
BG 3
Coll fonnll00mI
Final Membrane Filter Results 0 /Coollforml100ml
Reported ByDate_
Time. �� � _ a.m.
p.m.
TNTC = Too Numerous To Count
u
DEPT. 01� ENVIRONNIENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
October 19, 1984
Mr. Stan Brust
Corwin & Associates
1549 E. Tudor Road, Suite 204
Anchorage, Alaska 99507
BILL SHEFFIELD, GOVERNOR
2.74-2533
Subject: Waiver Horizontal Separation between Well and Septic Tank,
and Absorption System, Lot 6, Block 1, Hideaway Lake S/D
(8521 -WA -051)
Dear Mr. Brust:
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 80 feet and
the well and soil absorption system to 90 feet on the subject property for
a 2 bedroom single family residence only.
Sincerely,
ruce E. Erickson
District Engineer
BEE/msm
CORWIN & ASSOCIATES, INC.
CONSULTING ENGINEERS
1549 E. TUDOR RD., SUITE 204 ANCIAORAGE, ALASKA 99507
(907) 561-6151
October 17, 1984
Mr. Bruce Erickson
Alaska Department of Environmental
Conservation
437 E Street
Anchorage, Alaska 99501
Re: Lot 6, Block 1, Hideaway Lake Subdivision
Dear Mr. Erickson:
This will follow up our discussion of October 15, 1984, regarding
the distance of the stream to the on-site septic system on the
above referenced lot.
An inspection of the property was made on October 15, 1984. This
revealed that the high water mark on the stream was not closer
than 101 feet from the sump at the drainfield. The septic tank
cleanout was 168 feet from Hideaway Lake.
A copy of the October 15th inspection report and a copy of the
August 20, 1979 inspection report are enclosed for your use.
I trust this is the information you require.
Sincerely yours,
CO WIN & AS CIATES, INC.
Stanl Brust, P.E.
SB:kjh
Attachments
cc: Keith Bandt, DHP
William Empie
Municipality of Anchorage
On -Site Water & Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 015-471-10 Expiration Date:
1. GENERAL INFORMATION
Complete legal description HIDEAWAY LAKE S/D; BLOCK 1 LOT 6
Location (site address) 11080 HIDEAWAY LAKE DRIVE, ANCHORAGE, AK, 99516
Current Property owner(s) RICK & ANN POLLOCK Day phone 243-7828
Mailing address 11080 HIDEAWAY LAKE DRIVE, ANCHORAGE, AK, 99516
Real Estate Agent VALERIE WHITMORE W/ PRUDENTIAL Day phone 562-6464
2. TYPE OF DWELLING:
E Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual On-site
E
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
Received by:lrYc, Date:
GOSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
t `10
Date of Payment
101 to lis
Receipt Number
b? IRli`vl
COSA# 05C13153o
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name
Engineer's Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG, LtD_ attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSO 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, groundwater levels 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 long the system will continue to meet the
operational requirements ofthe 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
i� System #1 Approved for bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
337-6179
Date f a l L 113
oo6opp�
ado �F........... s�0o
o* 9 T
........ ... ....... .......1
l
l
(74.�.,i..f ....Gornes.:..
9. CE -79 „p
�4 o rofessio�oo
%IY OFAAr,
bedrooms, with the following stipulations:
ON-SITE
WATER AND
WASTEWATER
PROGRAM
Original Certificate Date: / () 1, -13
The lilrrhicf/5ali tArchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the rep tations 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. 11105)
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: HIDEAWAY LAKE S/D; BLOCK 1, LOT 6 ParcellD: 015-471-10
A. WELL DATA *PER GEG INSPECTION. **ASSUMED BASED UPON SURROUNDING WELL LOGS.
Well type PRIVATE If A, B, or C provide PWSID# N A Well Log (YIN) NO
Date completed UNKNOWN Sanitary seal (YIN) YES Wires properly protected (YIN) YES
Total depth *39+ ft. Cased to **40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
AT INSPECTION
10/4/2013
39
6.96+
g.p.m.
WATER SAMPLE RESULTS:
Coliform o colonies/100 ml. NitrateL2�mg./L. Collected by: GEG, Ltd.
Arsenic: _Yag./L. Date of sample: 10/4/2013
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material HOLDING/STEEL q, Date installed 8/16-17/1994
Tank size 4000 gal. Number of Compartments i� l Cleanouts (YIN) YES
Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) YES
Dateofpumping -7ig b3 Pumper A+ µ,,.rd ,Wivlcot.S
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft or ft /bdrm) _ System type
Length ft. Width ft. Gravel below
Total depth ft. Eff. absorption area ft2 Monitoring tube Depres
Date of adequacy test Results
Fluid depth in absorption field before�fluid
in.
Elapsed Time: n. Finaldepth
rejuvenation treatment (past 12 mo.) (YIN & type)
Water added _gal.
1. Absorption rate >_
ion over field
For bedrooms
New depth _in.
If yes, give
...
D. LIFT STATION
Date installed
"Pump on" level at in
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y/N)—
"Pump off"level at wa er alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100'+
Absorption field on
Public sewer main
Sewer /septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation *4 Property line **2.5' Absorption field
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 75'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
F. COMMENTS
Building foundation Water
Surface water
Wells on adjacent lots
storage
*PER 1994 INSPECTION REPORT. **WAIVED AT TIME OF CONSTRUCTION, #WR940018
G. ENGINEER'S CERTIFICATION
t certify that i 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 Printed Name JEFFREY A. GARNESS
Date (D/IA?
(Rev. 11105)
Municipality of Anchorage
• `� Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 015-471-10 HAA
1. GENERAL INFORMATION Expiration Date:
Complete legal description _Lot 6. Block 1 Hideawav Lakes SID
Location (site address or directions) 11080 Hideaway Lakes Drive
Current Property owner(s) Bill Embie Day phone 244-7075
Mailing address 11080 Hideawav Lakes Drive Anchorage AK 99516
Lending agency Day phone
Mailing address 22
Real Estate Agent Oi Q -p n inn; r Day phone oyq-7075
Mailing Address
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS: 4
3. 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 Department of Health and Human Services (DHHS) Issues Certificates of Health
Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional
civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DHHS also Issues HAAs upon request to home owners. Certificates of Health Authority Approval are
valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. 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 Health Authority Approval Guidelines for 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Eng. Svc Phone 272-8218
Address P.O. Box 102954 Anch AK 99510
Engineer's Printed Name Steven R. Pannone P.E. Date 6/29/2005
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious
engineering analysis of the system in accordance with MOA DI II IS Guidelines & Regulations. The
reported results describe 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 soil condition, ground water levels 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 this system. All systems eventually fail and satisfactory test rcsulty
do not guarantee future performance of the system, nor do they guarantee that there arc no hidden defects
or encroachments. PES can therefore not provide any warranty for future performance nor give any
estimate of how long the system will continue to meet the operational requirements of the ADEC or
MOA DI11IS. 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.
5. DHHS SIGNATURE
V-'� Approved for 14 bedrooms.
4
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
81
0
NotW.,ThC _WFA,for-tbj"roperty meets existing State and I\Iunicipal Codes. There are nitrates
present. It is suggested that periodic testing be performed to insure the wells continued suitability.
Current nitrate concentration is 7.32 mg/l. EPA maximum concentration is 10.0 mg/l. 1llorc
information on nitrates is available from the On -Site Services Program, at 343-7904.
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
By:
Expiration Date:
(Ft. 11/49)
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 2-11-0E
Reissue Date:
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -SM Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 198050 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907)343.7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT 6. BLOCK 1 HIDEAWAY LAKES SID Parcel I.D.: 01547140
A. WELL DATA
Well We PRIVATE
Date completed =k,4.txd ✓
Total depth 40+ ft
If A, B, or C provide PWSID #
Sanitary seal M
Cased to 4 ft
FROM WELL LOG
Date of test V41kN Ow,v
Static water level ft
Well production 9 -p.m
WATER SAMPLE RESULTS:
Ccttfonn 3�coloniesH 00 ml Nitrate 713R mgA
Date of sample: 6/27/2005 Collected by: SRP
B. SEPTICIHOLDING TANK DATA
Well Log No
Wires property protected=
Casing height (above ground) "_in.
AT INSPECTION
6/2712005
39 It
5.5 g.p.m
Other bacteria =C=�---colonies/100 ml
Arsenic ,QQ± MOA
Tank Type/Material STEEL
Date Installed 994 Tank size 4000 gal Number of Compartments
Cleanout XS Foundation deanout XS Depression over tank NO High water alarm YES
Date of pumping _61912005 Pumper A+ HOME SERVICES
C. ABSORPTION FIELD DATA
Date Installed _ Soil rating (g.p.d./flz or fe/bdnn) _ System type
Length ft Width ft Gravel below pipe ft
Total depth _ It Etfective absorption area _ftp Nbnitoring tube _ Depression over fleld
Date of adequacy test 6*7/2003 Results (Pass/Fall) PASS For 4 bedrooms
Fluid depth in absorption field before test _ in Water added_ gal. New depth_ in.
Elapsed Time: _ min Final fluid depth _ in
Any rejuvenation treatment (past 12 moa (Y/N & type)
(Rev.1 Vee)
Absorption rate >= _ g.p.d.
If yes, give date
D. UFT STATION
Date Installed Size in gallons Manhole/Access
'Pump on" level at _ In"Purnp off level at _ In High water alar level at _ In
Datum Cycles tested Meets alarm 6 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankililt station on lot NIA On adjacent lots 100+
Absorption field on lot NIA On adjacent lots 100+
Public sewer main NIA Public sewer manhole/cleanout NIA
Sewer /septic service line 53 Holding tank 78
SEPARATION DISTANCES FROM wl HOU)ING TANK N LOT TO:
Building foundation 4 Property line 2.5 Absorption field NIA
Water main NIA Water service line 55 Surface water -100+
Drainage 50+ Wells on adjacent lots0,, 0+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line N/A Building foundation Water main
Water Service line Surface water Ddveway, parking/vehide storage
Curtain drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
�• �\' �....w.;;ir#4
1 car* that 1 have determined through held Inspections and
review of Municipal records that the above systems are in
l..
conformance wffh MOA HAA guidelines In effect on this date.
Engineer's Printed Name Steven R. Pannone. P.E.
�j. �i�Sleven .. nnone
r �� E 149
Date g'� 05
es4C%ES9a .O•
HAA Fee $ 4:3 • �
Date of Payment T 1710.5
Receipt Number
(Rev. 11M)
Waiver Fee S _
Date of Payment
Receipt Number
0
FLAT NOTE STIPULATES
TKE CREEK €ASEMENT
WILL BE CENTERED ON THE
E70STINC CREEK
LOT 7
f
1
............
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SHED Q DRIVE
SHED
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111
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HID
1
S71'39'40'E-
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Bll–L EM PIE
with DYNAMIC PROPERTIES
111y r __.._.___.
440 WEST BENSON BLVD. p 103
eturHORAGE. ALASKA 99503
WORK ORDER NUMBLN: °OL.
CT. 29. 1998 1 X50'
98—L— P013 •'" en cmtmo By
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BB KEN 2640
HIDEAWAY LAKE
FLOATING
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EXCLUSION NOTIt is the owners responsibility to determine
ES:
the existence of any easements. covenonts. or ftslrfcUans
S�e•R0 w/CAPOe a/e' aB
�YONUMENT
which do not appear on the recorded subdivision plot. NOTE:
any data � bs used lof
]23, AL MON
TACK O
no
a la snob, ahinq property IMes.hould
construction, circumstances
,Under __ x
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to
SURVEY CERTIFICATION: LANTECH hos conduato o
SURVEY
survey of this properly os shown on this
OVERHANG -
OVER DECKS-
physitd
drasica and that lM I nprovsments at lore
within the Properly lines and no entlOOCh�T
CONCRETE
[—
M are
menlf exist other IhOn noted.
GRAVEL -
SEPTIC STANDPIPES -
TANDPIPEAS—BUILT
AS— UILTOF: LEGAL DESCRIPTION:
WATER wELI_
NCINEERS
561-6626
LOT 69 BLOCK 1,
562-5291
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