HomeMy WebLinkAboutHENKINS BLK 1 LT 5Henki'Ons
Block 1
Lot 6
#051-292-21
Municipality of Anchorage Page of
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: 5W 9yo` g2 PID Number: 05/-;t
Name:
or�sf E. ,Qur�ec,tr
Wastewater System: ,New ❑ Upgrade
Address: �/errr/ �(.fJL
ABSORPTION FIELD
Phone:
G 9& - aao
No. of Bedrooms:
.3
p Deep Trench 0 Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
soil Rating:
i a
Total Depth from original grade:
5—
GPD/Sq. Ft.
1:571
Lot: Block: Subdivision: s
Lot: /
CO n &/ /'I S /,�
Depth to pipe bottom from original grade:
7 • / Ft.
Gravel depth beneath pipe
J • 7 Ft.
Township:
Range: Section:
Fill added above original grade:
Gravel length: /1
7
Ft.
Ft.
WELL: e cis �t J ElNew ❑ Upgrade
Gravel width:
S
Number of lines:
/
Distance between lines:
Ft.
Ft
Classification (Private, A,B,C): Total De
Cased To:
Total absorption area:
3-75
Pipe material: /ti S-rY%)
F 9161.0363
Trivate, Ft.
Ft.
SQ. Ft.
Driller: Date Drilled:
Static Water Level:
Ins alter: f%/ ,ea S✓" N5 -',J /1
Date installed:
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft. I
Ft.
SEPARATION
DISTANCES
XSeptic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
r-hora A
Capacity in gallons:
/000
From
Tank
Field
Station
Tank
Sewer Lines
yi le�
Well-
11 a�
t
IaS
—
—
1
aS 1-
Material:
Sfee /
Number of Compartments:
CP--
LIFT STATION
WateSurface
/004
/dof
Lot
t
f
Size in gallons:
Manufacturer:
Line
/a0
98
r
"Pump on" level at:
mp off' level at:
High water alarm at:
Foundation
X00
113
Curtain,,
Pump Make del
Electrical Inspections performed by:
Drain
Ivo
f,
h -n
Wki
BENCH MARK
Remarks:
Location and Description:
r—
S/
Assumed Elevation:
too. o Ft
F AL
�4-
rf��••OF
,fC S s
•,
.• �� 01 •:'L�
S&S ENGINEERING t..
17034 Eagle River Loop Road No j_�- �j�;
F.,_. s: 1st
Inspections performed by: �.,.e River, ia9!.0
995��— 9 �;
2nd _5_2- - ? f
...:. =.: ..................,
;'o ROBERT C. COWAN f ?
Department of Health nd Huma ervices apWWI
% CE -8801
1W
Reviewed and approved by: `— Date:
�-� ��a.��"�
72-013 (Rev. 9/91) MOA 25
Permit No. SW940426 Page 2 of 2
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
LOT 6, BLOCK 1, HENKINS S/D 05129221
Legal Description: PID No.:
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE i a `b(-)
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:SW940426
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:BURLEW FOREST E
OWNER ADDRESS:16143 OLD GLENN HWY
CHUGIAK, ALASKA 99567
PARCEL ID:05129221
LEGAL DESCRIPTION: HENKINS BLK 1 LT 5
LOT SIZE: 20909 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED:11/07/94
EXPIRATION DATE:11/07/95
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 (24 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 BY:
ISSUED BY:
4t7v__;n'
DATE: 11 /1 i l q `!
e���� DATE:
October 14, 1994
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS MUNICIPALITY OF ANCHORAGE
Department o6 Heatth and Human Serv.iee4
P.O. Box 196650
Anchorage, AK 99519
SEWER & WATER
MAINEXTENSIONS REFERENCE: Lo.tl., 5 9 6; Btock 1; Henkin4 Subd.ivi4ion
SEWER &WATER Requeat you daaue a pehmit to Lep&e-e the aeptie aystem aeLving the
INSPECTION three bedroom house on the rebereneed properly.
A test hate was excavated and a percotation test per6ormed. The
approximate tocation o6 the test hote .is toeated on the attached Site
AND REPPORTSORTS p
ENGINEERING
STUDIES tan. The monitor cng tube within the test hate has been checked and
Sound to be dry.
Attached ,%s the proposed upgrade de.6ign. we do not anticipate any
WELLINSPECTION adverse e44ect;6 on ne-ighboting properties by the in.6taUat on o6 the
&FLOW TEST proposed septic system.
There are no points o6 contamination within the proposed weU radius
which can be seen on the attached site pian.
SITE PLANS
I6 you have any questions, or require additi,onat .in6ormation 6or your
review, ptease contact us.
ROAD DESIGN Sincerety,
SOIL TEST ROBERT C. COWAN, P.E.
RCC1gk
PERCOLATION ENCLOSURES
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP SUITE 204 EAGLE RIVER, ALASKA 99677
1" = 50' UPGRADE y�
SCALE
Nkm
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ow s pmmm � ,Z— rq K i3' Ui
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�m mm <wmm
a p o vtnzn too M
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r O C is ��5\ b...•
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rn
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NNm1 G"'t� Ad� e C n {5e•JI"" • 6��/
CNK -t N m fl'.a ••'. > J `,•'�jp r
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4F� g—�--f '—="— p �� FFR
it.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTHAUTHORITY
APPROVALS
REFERENCE:Lots 5 & 6; Block 1; Henkin6 Subdivision
SEWER &WATER
GENERAL:
MAIN EXTENSIONS
1. The scope ab this project .includes the .insta tation ob a 1000
gatton septic tank and a 6.ive boot wide drain6.ield to 6erve the
existing three bedroom residence on .the %e6eLenced pn.operty.
SEWER&WATER
The ex.i,stng leach6.ield and tank ane to be abandoned .in place.
INSPECTION
2. ConstAuction 6hatt be ,in accordance with .the approved site plan
and de6.ign drawings, Muni.c.i,pat penm.it with any 6peciat
proviz ions oh conditio" and aU appticable State and
ANDREPORTS ENGINEERINGSTUDIESMuni.ci.pae
wastewaters Disposal Regutat%on6.
3. The contnactoit shall be nespon6 ible bo& obtaining any necessaky
underground uti Pity locates.
WELL INSPECTION
&FLOW TEST
4. Unta.6 speci6.icatty agreed athenwise, the propersty owners 6hatt
be %upons.ibte bon 6.inal grsad.ing an.eas subsequently depressed
6rsom .6oit settti.ng. On att leach6.ield mound systems, the
prsopersty owner shat be nespon.6.ible bon, ensuring a Satis6acto'Ly
SITE PLANS
vegetation growth oven .the mounded area.
5. Contrsa.ctor6 .insta t ng wa6tewaters disposal systems must be
centib.ied by the Municipal Heat th Department bon system
ROADDESIGN
in6tattatcons. Owners .in6taUi.ng theirs own systems must aPso
receive prior approval 6n.om the Municipal Heatth Department.
SEPTIC TANK INSTALLATION:
SOIL TEST
1. A septic tank is to be constrsucted by a eertib.ied septic tank
manu6actursers. Con,tnuction sha ,l .include two 4" cleanouts bon
PERCOLATION
pumping acce66.
TEST
2. The septic tank shall be suAbicientey bedded to prevent
sett,Pi.ng urs sh,ibting o6 the tank.
STRUCTURAL&
3. Att 6tandp.ipea on the septic tank 6hatt extend a minimum o6 12
MECHANICAL
INSPECTIONS
.inches above 6tnal grade.
4. Septic tanks .initalted with less than 4' o6 coven shall be
.insulated.
ON SITE
WASTE WATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Page Two
Lots 5 9 6; Black 1; Henk.ins Subdivision
Uctoben 14, 1994
5. A 6oundation eteanout sha-tt be .instaP,e.ed one to bout beet 4nom the
budtd.ing 6oundation. In the line between .the tank and the leaeh6.ietd
thele shaft be two adjacent eteanout6 (untesa an e66luent pumping system
exists within the septic tank) . These eteanout6 shalt be located on
und.istutbed soft not mote than 10' 64om the tank. The 6.ikst eteanout,
.in .tine, sha.tt be to clean toward the leach6.ield. The second cteanout
shat be to etean toward the septic tank.
6. Final gtad.ing oven the septic tank shaU be such that a positive slope
exists away 6tom the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the design. The
bottom o4 the excavation shalt be within 2 .inches o6 levet. 14 the
stdewaU-6 o6 the excavation become smeared, they must be naked on
scAatched (toughed -up) be6o4e gnavet (sewer nock) placement.
2. Once the gravel .is .insta.tted, the dustAibution pipe is to be instatted
levet with the pet4otation6 6aeed downward. Gtavel is then to be placed
oven the d.i,6tiri.buti.on pipe to pnov.ide a minimum o6 2 .inches o4 covet
over the pipe.
3. A zit bant.ien must be .instatted between the 6.inat gtavet layeA and the
native soft backjitt. Ensure the s -i tt batwiet covets the entice gtavel
6ut6aee be6ote placing back6itt.
4. Monitor tubes shalt be o6 4ouc (4) .inch d,iametet and .instatted
appnox.i.mately .in the locations shown on the design. The portion o6 the
monitoting tube extending through the gtavet shah be pen4otated 6nom
the bottom o4 the tteneh to the .inve4t o4 the distt.ibution pipe. This
is equivalent to the e46eetive depth o6 the gnavet as noted on the
design.
5. Baek4iU oven. .the 4.inat gravel layek must not be leas than twenty -flout
(24) finches. Insu.tation must be .instatted when the back6-f2t depth .is
less than thitty-six (36) .inches. The 6.in.ish grade oveA the trench must
be mounded to prevent the 4o4mation o4 a depness.ion a6tet settting.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed bon tnsta2tation must be consttueted by a
Mun.icipa2ty approved septic tank manu4acturen.
Page Three
Lots 5 & 6; Mock 1; Henkins Subdivision
October 14, 1994
2. The bottow.ing pipe materiatz are approved 4or use .in septic system
.instaUati.ons in the Munic i paP i ty ob Anchorage:
Type o4 Pipe
Per{,orated
Sotid
Cast
Icon
yea
Yea
ASTM
D3034
(PVC)
yea
yea
ASTM
P810
(HDPE)
Yea
No
ASTM
D2662
(ABS)
Yea
Yea
Use ob a type ob pipe other than tilted above must be approved by the
.inspecting engineer.
3. Insutation shati be at least 2" thick extAuded direct burial polystyrene
(Dow Chem.iea2 Company Styujoam HI on equal).
4. Septic tank intet6 and out2et6 shall be 6 tted with wate ti.gh# eouptings
(Caulder, Perneo, on. equal).
5. A permeable nontoxic sift barrier (Typa)t 3401, M.irab.i 140/N, on equal)
must be .installed between the b.inal leaehb.ield gravel layer and the
native soil back4it 1.
6. Alt leaeh4.ield gravel (hewer rock) shall be 0.5"-2.5" screened gravel
with tus than 3% passing the #200 sieve.
7. When sand .is being used as a bitter material, its gradation
speei6ication6 must eon6okm to current M.U.A. or D.E.C. requirements.
INSPECTIONS:
Typ.ica22y .there wiU be a minimum o6 three (3) .inspections required ducting the
.installation ob the wastewater. disposal system. These .inspections witt occuA as
g0ttows :
1. The b.irst .inspection mu6t be conducted agter the excavation ob ditches,
pits, tnenehes, or beds and bebore the .installation og any gravel. A
septic tank may be set .in place, but may not be back6 iUed bebore this
inspection.
2. The second inspection must be conducted agter .the placement of .the sift
barrier, gravel, distAibution tines, standpipes, eleanout6, and
.insulation, but be6ore the placement o6 any other back6 ll.
Page Eout
Loth 5 & 6; Mock 1; Henlunh er,h;.r.; v,ib.ion
October 14, 1994
3. The b.inat .inspection i6 to occur upon b.inae gnading ob the pnopenty.
Osten the&e witt be mote than these 3 .in6pect.Lons nequ.ined, e6pec.i.atty with the
.ins.tatP.ati.on o$ muttipte tnenehez, sand Wtens, pn.es6unized di,6tA%bution
zystem6, etc. Thus, the .in6pecting engineer is to be contacted at .least 24
hours prion. to the 6tant ob eon.6tnuction. Ib necusany, a pn.e-constnucti.on
meeting w.iU take pta.ce on-site. The inspecting eng.ineen wilt not eootdinate,
dineet on. eontAot .in any way the eontnaeton'6 activities.
The owner 6hatt eontnaet with the contAactot to pen.bonm the work outtined .in
these speci6ications and ptans and in accordance with the attached M.U.A.
penm.it. There witt be no eonttraetuat annangement existing between the
contnacton and S & S Eng.ineen.ing. S & S Eng.ineeting 6haU be the ownen.'s
nepn.e6entative and witt .inspect the wonh a6 stated above .to document the
con tnactoa' 6 activitia. F.inat acceptance o5 the con tAae ton' 6 work ne6ts with
the ownex and the M.U.A.
S & S Eng.ineeting shat have no t i.ab.i t ty to the owners on to others bon aet/s on
om.i66.ion6 ob the contAactot ot any other penso" penbonming work on this project
on the baitute ob the contnacton, to canny out the work .in accordance with these
constAuc ion documents. S & S Eng,ineening'6 inspecting eng.ineen wiU not be
ne,spon6.ib.te bo& the eo"tAuet%on means, methods, techniques, sequence,
procedures on the 6a4ety pneeaution6 incident to this project.
CONTRACTOR/INSTALLER
SEAL)
Ct®F:�a
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES n•,,or:' _
825 "L" Street, Anchorage, Alaska 99502-0650 i'
�'n• •sa . tai ea• as .(�I
SOILS LOG — PERCOLATION TEST
CE - 8801`
PERFORMED FOR: ��-%Pry—t-\� DATE PERP§Fi•ISPE'b L�7.••';
LEGAL DESCRIPTION:1 ID Township Range Section:
SVt� 1 �F-,.Vst S
SLOPE SITE PLAN
10 'o WAS GROUND WATER t_
ENCOUNTERED? !"`U
Y
11 1I 0
� �I IF YES, AT WHAT r•s O
DEPTH? P
12-, E
Depth to Water After
13 r. Monitoring?— Date:
. Q
14 .d . �t
15
16
17
18
19
SEET)
�
1
t
0
2
114 le'o
4-
5
5-
6
6-
7-
78v
8-
Q?
9
10 'o WAS GROUND WATER t_
ENCOUNTERED? !"`U
Y
11 1I 0
� �I IF YES, AT WHAT r•s O
DEPTH? P
12-, E
Depth to Water After
13 r. Monitoring?— Date:
. Q
14 .d . �t
15
16
17
18
19
20
PERCOLATION RATE 2 :5- (minutes/inch) PERC HOLE DIAMETER
/r / t
TEST RUN BETWEEN 7 FT AND (4f FT
COMMENTS
PERFORMED BY: S Aw'?64- I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEL IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
'E
20
PERCOLATION RATE 2 :5- (minutes/inch) PERC HOLE DIAMETER
/r / t
TEST RUN BETWEEN 7 FT AND (4f FT
COMMENTS
PERFORMED BY: S Aw'?64- I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEL IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS'APPROVAL
Parcel I.D. 051-292-21, 051-292-20 Expiration Date: I - ;—) I - /
1. GENERAL INFORMATION
Complete legal description Henkins Block 1 Lot 6 Q(,, Lot S
Location (site address) 16143 &16127 Old Glenn Hwy Emile River AK
Current Property owner(s) Smith Margaret Day phone 240-0385
Mailing address same
Real Estate Agent Susan Bickman Day phone 240-0385
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class C Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Received by. z Date.
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 4 4 qD
Date of Payment ib bQ AL3
Receipt Number
COSA# O�Cl3lSL(�
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, 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 NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 10/9/2013
G
6. DSD SIGNATURE s>
.-ice 7
System #1 Approved for bedrooms.��!_ <,.. ,
showet '. 51:151:1System #2 Approved for bedrooms. ,°r
Disapproved. �oCq/l
Conditional approval for bedrooms, with the following stipulations
M
The
Original Certificate
Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations 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. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 9-742. doe
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: 6tfiw' rnz 0," L S Parcel 0:0571 -242 ?20(
A. WELL DATA
Well type _?_ If A, B, or C provide PWSID #
Date completed I.IAlk
Total depth J ft
*mo,4
Date of test
Sanitary seal (Y/N)
Cased to 5s -ft.
FROM WELL LOG
r%/N1C
Static water level
Well production _
WATER SAMPLE RESULTS:
Well Log (Y/N) ; V
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
3 011S
ft. L/3 ft.
g.p.m. S g.p.m.
Coliform g colonies/100 mL Nitrate Z d;:::�mg/L
Arsenic•�6 ug/L Date of sample: 7
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material—S:Vfc.,/ 77eR—r
Collected by: /V -e1
Date installed 5�Z6 15
Tank size OO. gal. Number of Compartments Z Cleanouts (Y/N)
Foundation cleanout (Y/N) _ Depression over tank (Y/N) High water alarm (Y/N) Al
s
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed S Soil rating (g.p.d./ftz or fe/bdrm) . Z System type
Length ft. Width S ft. Gravel below pipe
Total depth ft. Eff. absorption area 3 71f? Monitoring tube V Depression over field Al
Date of adequacy test 3o Ld Results (Pass/Fail) AST —1— For 3 bedrooms
Fluid depth in absorption field before test Z11 in. Water added yJgal. New depth J0 in.
Elapsed Time: 6G min. Final fluid depth 24�' in. Absorption rate >= 56 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION h,4
Date installed Size in gallons
Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOTTO:
Septic tank/lift station on lot
/00 �f
Absorption field on lot
/,J a �f
Public sewer main /00
"f
Sewer /septic service line
25 f
Animal containment areas
SQ .�
SEPTIC/HOLDING TANK ON LOT TO
On adjacent lots /60 �f
On adjacent lots /Q0
Public sewer manhole/cleanout /OC
Holding tank N�
Manure/animal excrete storage areas
Building foundation 5 f Property line 0 =/- Absorption field 5 -if -
Water
f -
Water main / Q 4f Water service line /� rf Surface water
Wells on adjacent lots /00 "f
ABSORPTION FIELD ON LOT TO:
Property line /O 'f Building foundation /,o f
Water Service line / Q '74 Surface water / 0O '/-
Curtain drain f/NlA- Wells on adjacent lots /od
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that f 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 �TF✓F ���
Date�
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COSA brown sheet 10-10-12.doc
Water main /O /f'
Driveway, parking/vehicle storage
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MUNICIPALITY OF ANCHORAGE - -
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel l.D.# 051-292-21
1. GENERAL INFORMATION
Complete legal description
HAA # _
HA 950210
Lot 6: B.2ock 1; Henki.nz Subdiv"ion
Location (site address or directions) 16143 0.2d Glenn Hwy.
Chug.i.ak, AK
99567
Property owner Many Ba tew
Day phone 696-2806
Mailing address- P.O. Box 671963 Chug.iak AK
99567
Lending agency,
Day phone
Mailing address
Agent.
Day phone.
Address
Unless otherwise requested, HAA. will be held for pickup.
2.'' NUMBER OF BEDROOMS: 3
3._ . TYPE OPWATER..SUPPLY:, -
Individual well XXX `
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest -
Ing to the legality and status of system.
"
4. TYPE OF,WASTEWATER DISPOSAL:
Individual on-site XXX
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.
72-M(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 that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify 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 S & S ENGINEERING Phone " a °� -2
17034 Eagle River Loop Road No. 204
Address
Engineer's signature
Date
SOP
ROBERT C. COWAN- t
CE - 8801`_ ;
A
By. / Y v u V Date �►
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 engineers work.
72.M(Rw.1191) Back MOAN21
Municipality of AnchorageMqM
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: genbn5 Parcel I.D.
s//j
A. Well Data
Well type A-, va,ft- If A, B, or C, attach ADEC letter. ADEC water system number`1l
Log present (Y(D AJO Date completed u k Driller (A K
It
Total depth �t 55 , Cased to 5-5 f Casing height /a
Sanitary seal &N) zS Wires properly protected &/N) 25
FROM WELL LOG
Date of test
Static water level
Well flow 9•P•m•
Pump levell��// /n /
- Pe r Ar6 6 WO -1 I/ Pu m
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
`4. d g.p.m.
Septic/holding tank on lot / / a r ; On adjacent lots /00
Absorption field on lot /12.5 ; On adjacent lots
/00 4 -
Public sewer main n a- Public sewer manhole/cleanout
Sewer service line a 5 f Petroleum tank a5 f
WATER SAMPLE RESULTS:
Coliform -i4 Nitrate A & �P_ Other bacteria $
Date of sample: ,S- /7 - 95-- Collected by: S & 5 ENGINEERING
g • Rivir Loop Road No. 209
15agls River, Aierkh "or
B. SEPTIC/HOLDING TANK DATA
Date installed 5_g - 9 S Tank size � / Compartments
Cleanouts (Y/N) 5 Foundation cleanout (Y/N) NQS Depression (Y/N) �o
High water alarm (Y/N) Alarm tested (Y/N)�—
Date of pumping ri leL-- Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot On adjacent lots /DO f Foundation /00
To property line /aD , Absorption field % Water main/service line m f
Surface water/drainage /DO f-
72-02s(aW)•Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed �" Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent(Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE.fyR"6M LIFT STATION TO:
Well on
D. ABSORPTION FIELD DATA
mp off" Level at
Cycles tested
On adjacent lots Surface water
Date installed 5-8-9s Soil rating (GPD/Ftz) a System type "fi'E'nC6
Length _Width S Gravel thickness 3 • Total depth �/ 6 /
Total absorption area 3 75 7 --cleanout present (Y/N) hs Depression over field (Y/N) 46
Date of adequacy test h/A� /1 e w' Results (pass/fail) for rl Bedrooms
Water level in absorption field before test htZ,;2-- After test LI 65 X -
Peroxide treatment (past 12 months) (Y& /10 If yes, give date i h a�
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot X025 On adjacent lots /Od f Property line c
To building foundation 3 To existing or abandoned system on lot S) C)
On adjacent lots 3 f CutbankWater main/service line /0 /—
Surface water /0 G -t- Driveway, parking/vehicle storage area
Curtain drain nope_ L�nowr
E. ENGINEER'S CERTIFICATION
l cenify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
r OF A
,f
/ k' w1R. •sn
i.. ���)•, ._�':�:;��'�: if; awe'' -•
ROBERT C. COWAN
4R .t CE - 88ol
Signature
Engineers Name J t 0 A, ""`
Date ( //-( / 1 S6
HAA Fee $ �vu - --0
Date of Payment 0// g&15
2r)
Receipt Number /%/ 62 /,,/
/�j
VAN
of this inspection.
Waiver Fee $
Date of Payment
Receipt Number
ME Environmental Services Inc.
CT&E Ref.# 95.1952-3
Matrix WATER
Client Sample ID L5 & 6 BLK1 HENKINS
Client Name S & S ENGINEERING
WORK Order
14780
Anal
Parameter Results Qual
Ordered By R. COWAN
Printed Date
05/23/95
@ 10:36
hrs.
Project Name
Collected Date
05/17/95
@ 12:00
hrs.
Project# -
Received Date
05/18/95
@ 10:35
hrs.
PWSID UA
Technical Director STEPHEN C. EDE
Released By—�>
Sample Remarks: SAMPLE COLLECTED BY: RAY.
QC
See Special Instructions Above
Allowable Ext.
Anal
Parameter Results Qual
Units Method
Limits Date
Date Init
----------------------------------------------------------------------------------------
Nitrate-N 1.62 -
mg/L EPA 353.2
---------------------------
10.
05/19/95 CMR
-----------------------------------------------------------------
*
See Special Instructions Above
UA
= Unavailable
Li
See Sample Remarks Above
NA
= Not Analyzed
Undetected, Reported value is the practical quantification limit.
LT
= Less Than
=
Secondary dilution.
GT
= Greater Than
IA M
CT&E Environmental Services Inc.
All&f-LA Laboratory Divisionid►/1®/i/L
Drinking Water Analysis Report for Total Coliform Bacteria 200 W. Potter Drive
t)y Y Anchorage, AK 9951 B-1605
READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTINGSAt11PLE Tel: (907) 562-2343
Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM I.D. 4
K� PRIVATE WATER SYSTEM
Sendesults 13 SendInvoice
5 �.
Water System N=arCompany Name co tact nuns
Prnone,Sumbe, ax ;Su e
amrag ALCress
CIC: StatL Z:p COLL
❑ Send Results ❑ - Send Invoice
company N.- contact namL
C,;, state Ztp Code
SAMPLE DATE: lilif
MonthDay Year
SAMPLE TYPE:
iRoutine
❑ Repeat Sample (for routine sample
with lab ref. no. )
❑ Special Purpose
SAMPLE LOCATION
Nl; �: I
❑ Treated Water
❑ Untreated Water
Time Collected
Collected By
Plcase
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
❑ Sample over 30 hours old, results may
be unreliable
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received �03�
Analysis Be,gan
Analytical Method: ,a"� Membrane Filter
❑ MMO-MUG
' \umber ofcolonies/100 ml.
Lab Ref. No. Result* Anal y t
FTI
Sent to A.D.F. C. Anch Fbls Jun El
Faxed
Date: ,nl-n Time:
Client notified of unsatisfactory results:
a o
Phoned Spoke with Faxed
Date: Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
Dti•IO-,IIUG Result: Total Coliform
E. Coli
Membrane Filter: Direct Count
d Colonies/100 ml
Verification: LTB
TNTC=Ton Name ous To Count
BGB COLIFIRM
Fecal Coliform Confirmation
a
P A RT F oR =Other Bacteria
Final Membrane Filter Results
Two xr)- F'Q aW
Reported By �cta L.
Date Time /6'5-8 hrs
Comments:
- 0 SISMS
Mcmher of rhe Gras Crnuo 1Snri4fts C6nerale de Surveillance)
EASEMENT AGREEMENT
The undena-i.gned, .in considenafii.on o6 mutual agreement set 6o4th. be,tow,
grant, convey and ab6.L4m the 6ottow.ing easement, a66ective thia 15 day 06
June
1995, and agree to .the conditions and tutti.cti.ona as 6oZZowa:
I, Many M. Sun-tew, heneinager ne6erned to as grantors, owner, 06 eentai.n
rea.t property hene.in a6ter %e6e %ed to as "Lot 5; Stock 1; Henh.i.na Subdivision".
According to the ob6ic%at ptat thereo6 jited in the %ecord6 o6 ANCHORAGE
RECORDING DISTRICT, Thi)td Judiciat Diztr.ict, State o6 Ata6ka, do hereby grant
to Many M. SuAtew, heneina6ter %e4erred to a6 the grantee, as owner o6 eentain
neat property heneina6ten reimed to as "Lox 6; Stock 1; Henh i,na SubcVvi6 on"
aeconding to the o56iiciat ptat thereo6 4ited to the aeeo,%4 o6 ANCHORAGE
RECORDING DISTRICT, ThiiLd Judici.at Diatri.ct, State o6 Ata6ka,
An easement bon an on-a.cte wastewater di6posat aystem to be ptaeed partiatty on
Lot 5; Stock l; Henfuna Subdivision, togetheA with %ight to maintain the on -6 to
uaatewater d.iapoaat system to ineZude reaaonabte egreaa and ingreea bon pumping
the septic tank and maintenance o6 the abaorption area. The easement i6.6o,% the
area as shown on the attached con6tructfon ptan dated 10/14/94 and prepared by S
9 S Engineering and with said night to be e66ecti.ve upon the 4i.gni.ng o6 this
agreement by the patties.
1. It .ia underatood and agreed that seweA aerv.iee to Lot 6; Stock 1;
Henh.tna Subdivizion
.is to be
provided by connection
beginning
on Lot 5
and extending onto
Lot 6.
It ,is 6urthen agreed
that the
coat o6
maintenance, o6 the inptace aeweA Zinea ahatZ be boon by the grantee.
2. There ahatt be no charge 6or the use o6 the on -6 to waatewateA d,iapoaat
6ac.• P i tiers so .tong a;� this r.aae-?on,;;:,� in a66eet akil"a a ehaA.ge .i6
arranged between the part.iea o6 the.iA heit6 on aaa.igna on aueeeaaona .in
inteneat by separate wt tten agreement.
3. Grantor makes no warranty a6 to the adequacy ob the ctitita.tewaten dizpoba.t
system and shaU not be Zi.ab,te jot any damaged caused by the 6ya.tem
5aif-i.ng to worth adequatety.
4. The grantor burther covenant and agree6 that .the grantee shaft have
JuZt, Gree and uninterrupted use o4 said ea6ement gor rea.6onab.te
dome6tic u6e as .tong a6 such use does not cAeate an unneaaonab,te,
adverse .impact upon the grantor.
5. Fa.ctwce to make u6e o4 the on -.6 to wastewater di6poba.t sy6tem herein
desc-abed 6hatt not be deemed abandonment o4 the 6atd easement.
6. The grantee 4urther agree to bear att. co6t, tib any, gor the operation,
maintenance and/or abandonment ob the on-site wa6tewater d.i6posa.t
system and/or easement.
7. Thd.6
ea6ement Brom
grantor to
grantee
6haU be
binding
upon the .i.nute
to
the bene6 t
o6 the
pa4tie6
hereto,
theit
he,uca, .tegat
Grantor:
repre6entative, succeasor6 and aastgns, and shah run with the Land.
Grantee:
MAFY M. BURLbW (Lot 5) MARY M. BURLEW Lot 6)
Subscribed and sworn to besore me
thin Il y 03 Ntb'1✓r- 144s- CO -
4o,% Mary M. Bwrtew
My comm-uton expita
Pnno Tien