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HomeMy WebLinkAboutHERITAGE PARK BLK 1 LT 10 · 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: ~'0 7// PID Number: ~ - ~:~ \ Name: ~~/~ ~W~ Wastewater System: ~New D Upgrade *d~ ~oX ~7/~7~ ~/~.~ ABSORPTION FIELD _ ~eepTre~ch ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION so,..a~i..= To,~ ~e.,h ~o~ Lot: X ~ BJock:/ ~ c~~S~divisi°n: ~__~ ~pthtopipebottom fromodginalgrade:~¢ ~ ' Ft. Gravel depth b~:~e Ft. TowTi~ ~ ~Range:~ ~IS ~ ~ravel length~o e ~Fill added above original grade: ~ ~ New ~ Upg~ Gravel depth:~,. ~ Ft, Numb~of lines: Distancebe~en~/~ ~ines:Ft. 'Drill~ ~ Date Drilled: StaticWaterLevel: Installer: Dat~installed: ~.~ ,,. F,. TANK SEPARATION DISTANCES ~se~ic ~ Ho~in; ~ TO Septic Absorption Lift Holding Public/Privat,Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~ Material: Number of Compartments: ¢/. % . s~r~ NO~E ~ ~¢ M~E ~ "~ LIFT STATION Drain ~0 X r [~ j ~ o ~ ~ P Electrical Inspections pedormed by: Remarks: ¢~/¢ ~/~~ ~ ~ ~ BENCH MARK ~ ~ ~~ X~ ~~ Location and Descrip~ Inspections performed by: ~-~ ~ ~6/~,76~l~Dates: Ist ~/g~]P[ 2nd~ '/// I.~ ~ Department of Heal Hum (vices approval Reviewed and approved Date: ~s~(~ 72-013 0191) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES · ENVIRONMENTALSERVlCESDIVlSlON P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Co /. .0 PID No.: C° 1 72-013 A ~2/9'J) MOA 25 ?,O. BOX 6,650 ANCH, ORAGE, ALASKA 9950~-0650 (807) 264-4111 TONY KNOWLES. ~A YOR DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850711 Lot 10 Block 1 Heritage Park Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy.of Permit ! DIEF:'ARTMEIxIT' OF' HIF-ALTH AND ENVIROIqMENTal- I:'ROTECTION 825 I_ STREi]E"t", ANCHORAGE, AK 99501 264-.4.720 -c, ld'lI t 1'4.~: DATE ~.c~ UE.,). AF)PL.. I CANT': ADDRESS: CON"I'ACT PHONE] LEGAL DEZSCRIP L.OT SIZE: MAX BEDROOMS~ DENNIS HARWO[]D F-'. [],, BOX 6'714'73 CHUGIAK, AK 99567 688-5 17'7 SUBDIVISIC)N: HERITAGE F:'ARK SECTI[]N: '7 TOWNSH I F': 141'4 20000 (SQ. I:::'T. OR ACRES) 4. LOT: 10 RANGE.: :i.W BL.OCI.:::: 1 l, ist. ed l::,elc.tt.~ ar'e:,.t, he OlZrLion's available 'Lo you in des:i, gning your sept:.ic syst. em, Choose t;he Ol:)tiori that. best fi. ts your site, DEPTH '1"0 F:' :I: F:'IE BOT'T'OM (FT'. GRAVE]-. DEF:'TH. (FT,, T'OTAL. OEP'T'H (FT,) E')RAVEL. W]:D]"H (FT, GRAVIEL I_ENGTH (F'I".) GRAVEL VOL..LIME (CU. YDS. ) TANK SIZE (GAl_S) SOIl_ RA"I"ING (,SQ,FT', /BR) 9.0 ~. 4.0 2,5 60.0 30.6 .1., 250.0 '~-'~ :1.50 ~' "f'AN.K MUST ~-.,~c::. A'T' L.,:.A,:~[ TWO [,(J,'II-A~f 1: c:ectii'y t. hat.= }.~ I am famil:i.,'ar' t^~it.h the:, r, eqL~ir'emer~t.s for' ori-'sit, e sCet,,Jar'f5 ar"id wells as , .... , .. . , ' ' Atm. hor,,qe_ (MOA) and the State nf_ ~last.::a ..... ~ ..... '= ~A~i'Lt"i all MOA c:odes arid regulat, ior~s, al]d aft [:c~lplial']6;.i;~ with the design criteria of t.h:i.s permit. 3. I will. adhere 'Lo ali. MOA and St.a:LG~ of Alaska r'i.~qLtir'E, liien~s for 'Lhe set. baCl< clistal]ce~s fi*om air'P/ G?).listil"l(:) well, wast. e~a'Ler disposal sy~tem or pLd:{lic sewerage syst. em on t.h:i.!;s or any adjacent or nearby lot.. 4. I t..u'~der'starKJ t. ha'L th:i.s permit is valid for a maximt..tm of 4. bedr. oom~ arid any (+:.~r'l].ar'gi.:~me~'YL w:i. tl r'G:,qLtire an additional permi'L. ]:F: A LIF'F STATION Iii':; IIqS'I"AL..L.ED IN AN AF;.:EA COVE:RED BY MOA BUlL. DING CODES, T ,., ..... (2 ]"I-~EN (1) AN EL.tEC"I'RICAL. PERMIT' AND INSF'ECTICIN MUS'T' I.:.)E OBTA,.tlEI.); ) AS--BUI!....TS kiLl_ NOT BE AI:::'F'ROVED WITI-t(]UT AN ELEE:]'F;,ICPL. INSF'ECTIOIq REF'ORT; AND (3) T'HE E:I_I£CTFt:~:CAL. WC~'ItJSF BE DC)NE B'/ A I_IC]L:N,.:~E::D IL:LEC]F,:ICIAN, APF:'L I C~}OD - ........ ........................... ,,,.,, ..... Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION:~ /~1 ~ / Township, Hange, Section:  ~ s~oP~ 2 8 9 ..~ %-'~p {r---~_~/~ 10 4~:/~ ~'/Z/~ WAS GROUND WATER ENCOUNTERED? ~0 Gross Net Depth to Net Reading Date Time Time Water Oro~ h > J/V'~ PERCOLATION RATE ~ (m~nute~inch) PERC HOLE DIAMETER ~ TEST RUN BETWEEN ~ FT AND ~ FT COMMENTS ~ ~ ~~ ~ /~/~- ~ ~ PERFORMED BY: ~ ~ ~ I ~ ~~ERTIF~THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; 72~08 (Rev. 4/~) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage,Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~)~'4~) ~ .?-~ I-- ~.~ 1,' GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency 19715 Ivq Hom~ Eaq£~ Rivet, AK Douglas Whit~ Day phone 265- 1112 (w) C/O REAL ESTATE SUPPORT SERVICES 694-1112 (h) 8200 Humboldt Ave. S. Suit& 204 Minneapolis, MN 55431 Day phone Mailing address Agent Address Day phone = Unless otherwise requested, HAA will b~held for pickup. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site '"'' "' '~; Holding tank community on-site NOTE: Public sewer '- · · '- . If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. · .... "- .-- .'::--' 72~)25 (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 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, Name of Firm Address Engineers signature ordinances, and regulations in effect on the date~ec~ion. f . Phone Date ~_~ ~///~/'~ DHHS SIGNATURE Approved for __ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: f__ / Date The Municipality of Anchorage Department of Health and Hu man 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 courtesyto 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-o25{Rev, 1/91) Back MOA~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~© '~V--- \ ~-'~d.~ ~-~/--- Parcel I.D. A. Well Data Well type ~'~ ~ ~ Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height ~/.~ Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION~''~ ~ ~. g.p.rr~'L'l _~ ,~ o~ Static water level Well flow g.p.m. /~ Pump level1 ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot J ; On adjacent lots Absorption field on lot /'"" ; On adjacent lots Public sewer main J Sewer service lin~J WATER SA~ RESULTS: Colifo ~--~h Nitrate Date of samp e: Collected by: Public sewer manhole/cleanout Petroleum tank Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~;?~ Cleanouts {~/N) High water alarm (Y~/ Date of pumping Tank size Foundation cleanout t'7.~--c~ Compartments ~ Depressiop (Y~ Alarm tested (Y/N) PumPer ;:Z-~, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: I Well(s) on lot ~\ ~ On adjacent lots ~[ ~ Foundation '~ t-~ To property line \ ,.~ ['~ Absorption field Surface water/drainage \ c, ~ Water main/service line 72-026 (3/93)' From CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) ..~ Vent (Y/N) "Pump on" level at ~t High water alarm level C~ted Meets MOA electrical codes (Y/N) SEPARA~ LIFT STATION TO: Welkor1-1ot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~c~ \\ ~ ~,~' Soil rating (GPD/FF) Length ~"0 ~ Width '7.--/--~ Gravel thickness Total absorption area Z_/~"-~ '~ Cleanout present Date of adequacY test ¢ ~-~ ~? ~ Results,~;~ail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ /,~o,~ System type Total depth ,,/ Depression over field (Y/{~:). ,,',J / /¢,~r---CJ~ for --~ Bedrooms After test / ~, /,/_~_(o~/'/J' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / Well on lot To building foundation On adjacent lots On adjacent lots ~¢,'~ Property line /o ~ ~ To existing or abandoned system on lot Cutbank "J/,,~ Water main/service line Surface water Curtain drain ! f20 / ''~ Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified, or conform, ed~ MOA and HAA guidelines in effe~!.,O..O.~t~e.d,¢,te of this:inspection. Signature s & $ ENGINEERIN 17034 Eagle River,~~ Engineer's N a~{ile River, 'Ala~7.~ HA,& Fee $ ~), Waiver Fee $ DateofPayment ~'~'~'~ - ?~. DateofPayment Receipt Number ? )?/~"~ ~'_~' '-~' '~f'--~-'"~.... Receipt Number 72-026 (3/93)' Back 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 10; Block I; Heritage Park Subdivision Location (site address or directions) 19715 Iv~f Home Property owner Mailing address Lending agency Mailing address Richard & Kit Cline 19715 Iv~ Home Circle, G.M.A.C. ATTN: Sue Galleon Day phone 552-3269 Eagle River, Ak. 99577 Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water XX 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: XX Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA ~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/orwastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, tfurtherverifythat 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 ~ !; :; ~:~',.::.~,~-~RiN~ Phone 5¢ ~"'~ ¢'7,¢ ] 7034 Eagle River Loop J~oad No. 2Q4 Address Eaqle River, Alaska 9957~_ Engineer's signature DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Hea~th 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl.. CHECKLIST Legal Description: I,-~-¢' ~ c> ~_\ ~.~¢._~.~¢_ Parcel I.D. A. WE LL..~A Well tyCe ~'~:) ~ If A, B, or C, attach ADEC letter. Date completed ADEC water system number Driller Casing height Log present (Y/N) Total depth Cased to Sanitary seal (Y/N) Wires properly protected (Y/N~/ FROM WELL LOG AT~CTION Date of test ____ Static water level ____ ~ ___ Well flow Pump level SEPARATION DISTANCES FR : Septic/holding tank on lot __.,/ ; On adjacent lots Absorption field on lot //'// ; On adjacent lots Z Public sewer main ~ Public sew~ line WAT ~9'A M P L E RESULTS: Ca~tl~ orf~am p e'. Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DAT~A~ Date installed'~/c~'¢ Cleanouts (~'N) High water alarm (Y/4~ Date of pumping Compartments Foundation cleanout~N) y Depression /'J Alarm tested (Y/N) /'///~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~J~/' On adjacent lots To property line I¢ Absorption field Surface water/drainage Foundation Water main/service Dine 72-028 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at~..~.~ High water alarm level Meets MOA~ S~N DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manh~ "Pump off" level at Cycles tested Surface water ABSORPTION FIELD DATA Date installed Length ~i~. ~.~' Total absorption area Depression over field (Y~ Width Soil rating ~, ,~'C)~t/~-' Results~fail) ~, 5 Peroxide treatment (past 12 months) (Y,(~ Gravel thickness -~ 4, ~' ' Cleanouts present ~::YN) Date of adequacy test for ~/~.Z,¢-~ ~,~) C)//-- If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~(~'- On adjacent lots ~]~ Property line System type Total depth :J~ // ' To building foundation On adjacent lots Surface water Curtain drain To existing or abandoned system on lot Cutbank "'[ ~ Water main/service line t,o ~ *' Driveway, parking/vehicle storage area "~' ~" bedrooms 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 5 & ,5 ENGIN~E.R!NG 17034 Eagle River Loop Roa~ No. 204 Alas~:a 99577 Engineer's Name Eagle River, Date 2/~/'~ / HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/9~) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number