HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 12
•
Municipality of Anchorage 4-w
On-Site Water and Wastewater
) 343-7904 Page REPORT AUG 2 3 2018 of
ON-SITE WASTEWATER INSPECTION
Permit Number:
OSP 181138 PID Number:050 211 68
Multiple (SF and/or D) Project: ❑ New 0 Upgrade
Dwelling: Q Single Family (SF) ❑ Duplex (D) ❑ p
Name: ABSORPTION FIELD
STEPHEN THOMPSON
Address ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
19553 LAURA LEE ❑ Other
Total depth from original grade
Phone Number of Bedrooms Soil Rating Ft.
5 - GPD/SF
Depth to pipe invert from original grade Gravel depth beneath pipe
LEGAL DESCRIPTION Ft. Ft.
Subdivision Block Lot -
HERITAGE PARK ESTATES 2 12 Fill added above original grade Gravel length
Range Section
Ft.- Ft.
Township
Gravel width Beds:Number of Lines Distance between lines
Ft. - - Ft.
SEPARATION DISTANCES -
Total absorption area Number of trenches Dist.between trenches
To Septic 'Absorption Holding � Sewer — Ft.
From Tank Field
Lift Station I Tank Line - Ft2 —
_ TANK 0 Septic 0 S.T.E.P. 0 Holding 0 Other
Well - - - Manufacturer Capacity
GREER 1500 Gal.
Surface Water +100 - Material Number of compartments
Lot Line +10 - -
NA STEEL 2
LIFT STATION Capacity
Foundation +10 - - I Manufacturer
Gal.
Curtain Drain - - High water alarm at
Pump on level at Pump off level at 9
Remarks TANK REPLACEMENT ONLY --
in.
OLD TANK HAULED OFF FOR DISPOSAL -- in. in.
Pump make and model Electrical Inspections performed by
Tank to
PIPE MATERIAL House to tank 3034 drainfield 3034
Installer Dfeld EXIST COIMT3g34
FLINTSTONE
Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation)100 ft
Location and description
Inspection 15i 716/18 2nd
dates: BOTTOM OF SIDING AT HOUSE CORNE
3rd 4mR
Engineer's Stamp
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL +'�����,k• !
.+ EOFq 4,
Conditional Approval _ —— Date__ >;.•9 T /4 :••.s ,#*
- P. ......, .*,
0e ;• , :.Wont .
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Date g a3��ul •� l s ♦'�
Approved a – 4°l04
Inspection Report 9-1-12.doc
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MERIT/ �i1`rA.:•. ill i/A .•F�Ci
SEPTIC AREA l F�pROFESSI��P1�
BLOCK
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HERITAGE PARK
BLOCK 2 LOT 13
HERITAGE PARK SEPTIC AREA
BLOCK 2 LOT 12
/
5 8R /
HOME / /
NEW 1500
GAL TANK. /
DECK /
• ii'210NEW A
TANK CLEANOUTS // /
.DRIWWAY• '\ f /
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/ SWING TIES
I EXISTING / A B
APPROX. 10 VDD\ RELD LOC'N / / C 39.5 27.0
.. \ WATERLINE £gS£M£Nr \ APPRO�/tFE O\• og/
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J'LAN - S' ALE 1" = 40'
FOUNGLEANOUT
CLEANOUTDATI MONITOR T1.IBEX9.3
-BM: +100.0' NISHED
BTM SIDING GRADE
3.8'COVERt
INSULAR••
•4.71
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NEW I 1•
GAL TANK
SCHEMATIC ELEVATION — SCALE: NTS
LEGAL DESCRIPTION: HERITAGE PARK ESTATE 82 L12
C&M ENGINEERING SERVICES OWNER: STEVE THOMPSON I DATE:8/01/18 I REV:O I DRAWN: CBI REF:
907-854-5558
SITE PLAN
�oai��vn�irr0 MUNICIPALITY OF ANCHORAGE �ne„t
' On-Site Water&Wastewater Program �o ,-Sc.',.......c PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
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On-Site Wastewater Disposal System Permit
Permit Number: OSP181138 Effective Date: 6/26/2018
Work Type: SepticTank Upgrade Expiration Date: 6/26/2019
Tax Code Number: 05021168000
Site Legal Address: HERITAGE PARK BLK 2 LT 12 G:0055
Site Mailing Address: 19553 LAURA LEE CIR, Eagle River
Owner: THOMPSON STEPHEN & MOLLY Lot Size in Sq Ft: 20029
Design Engineer: C & M Engineering Total Bedrooms: 5
This permit is for the construction of:
❑ Disposal Field ECJ Septic Tank 0 Holding Tank ❑ Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: (;7:17
ISO Date: 6P-----0
Issued By: ,a.K .4 / Date: e6 00
V
EPUIRMS
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 050 211 68
Property owner(s) Steve Thompson Day phone 223-3485
Mailing address
Site address 19553 Laura Lee
Legal description (Sub'd., Block & Lot) Heritage Park Block 2 Lot 12
Legal description (Township, Range & Section)
Lot Size 20029 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(Z all that apply)
Absorption Field I 1 Initial ❑ Single Family (SF) U
(w/wo ADU)
Septic Tank 0 Upgrade
Duplex (D) [
Holding Tank ❑ Renewal ❑ Multiple Dwellings E
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
none Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 4 245 Waiver Fees:
Date of Payment: /Pit 102 Date of Payment:
Receipt Number: 05-874D Receipt Number:
Permit No. 06i911?613Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
6/25/2018
RE: Proposed Septic System Modification for Heritage Park Block 2 Lot 12
Dear Reviewer,
The above referenced property is currently served by a 5 bedroom septic system.
A Recent inspection revealed that the tank is structurally compromised and needs replaced.
We are proposing a new 1500 gallon MOA approved tank be installed by a MOA certified installer.
To keep the proposed tank outside of the foundation soil bearing prism, the top of tank shall be set no
lower than the toe of the footing and no closer than 5’ to the foundation if the tank is not set further than
10’ from the foundation.
The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover.
Dual after tank cleanouts shall be installed.
All work shall be performed by a moa certified installer in accordance with MOA requirements.
The engineer will inspect the tank before backfilling.
Repair of the proposed system will not negatively impact adjacent lots.
A site plan is include with this request.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181138, Deb Wockenfuss, 06/26/18
CHARLES G BALZARINI
CE-13854R
EGISTEREDPROFESSIONALE NGINEER6/25/18
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181138, Deb Wockenfuss, 06/26/18
/
L_~. MUNICIPALITY OF ANCHORAGE --, /r
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
~NEW
E~UPGRADE
MAILING ADDRESS
PO. [~o×
LEGAL DESCRIPTION
LOCATION
DISTANCE TO: I lOC)
Manufacturer ~
[Liq. capacity in gallons I IF HOMEMADE
/~
I No oflines .~ ~ ILen~thofe~chline
Top of t~e to finish grade
Length Width
Type of crib Crib diameter
I ~Lr.--~
DISTANCE TO:
Class Depth
IAbsorption area_ ~ Dwel
I Material
Inside length A/A IWidth
Material
Nearest lot line // ,"
Trench w~ti inches
NO. OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
,~welling
Total len~Lth o~ lines
PERMIT NO,
Liquid capacity in gallons
PERMIT NO.
Distance between lines
Material beneath tile /
2-z~/' WA~JH GRAu-c~- ~,0 ~
Depth
Total effective absorption area_ _
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
~ev~er line
Distance to lot line
PERMIT NO.
Absorpt on area(s)
Septic tank
OTHER
PIPE MATERIALS
SOIL TEST RATING
/oo
INSTALLER
R EMAR KS
'
72-0~3 (
LEGAL
Department~ 7 Health and Environmenta? ~rotection
· · -~ 825 x~ Street, Anchorage, AK. ~50~ 1
~ 264-4720
Permit ~ , ~ ON-SITE SEWER PERMIT
Location: Phone Number:
Legal Description: ~O~/~ ~/~~/~ Lot Size:
Type of Soil~sorption System Is:
Trench: ~. Drainfield: Seepage Bed: __ Holding Tank:
Maxim~ N~ber of Bedrooms: ~.. Soil Rating(sq.ft/br)
The Required Size of the Soil ~sorption System Is: '
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the m~im~ depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEP/IC(H~G) TANK SIZE = /~ GA~ONS * *
Permit applicant has the responsibility to info~ this department during the
installation inspections of any wells adjacent to this property and the n~ber
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Min~ distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minim~ distance from a private well to a private sewer line
is 25 feet and to a co--unity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. 'Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 51, 1 9
I certify that:
(!) I ~ f~iliar with the requirements for on-site sewers and wells as
set forth by the Municipality of ~chorage.
(2) I will ins~~yst~ in accordance with codes.
(3) I und~rst~hat th~s~e sewer system may require enlgrgement if
~~~~e more~~~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG - PERCOLATION TEST
SOILS
PERCOLATION
TEST
PEF,'FORMED FOR:/~Z/~'".,' /~.~/-~
12
13
15
16
17
18
19-
20-
SLOPE
COMMENTS
L]
ENCOUNTERED?
DEPTH?
Reading Date Gross Net Depth to Ne!
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND __ FT
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 C&M ENGINEERING
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI
6. DSD SIGNATURE
Phone 854-5558
Date 8/10/18
« 3F A� e j
System #1 Approved for 5 bedrooms
System #2 Approved for
Disapproved
Conditional approval for
bedrooms ARLES G BALZARIM
_ bedrooms, with the following sti
pR0�Eg514N�` .�
BY: (� Fl��.( �� Original Certificate Date:`
t
The Municipality of Anchorage Development 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 � - c
If more than 1 septic system is on the lot:
COSA Checklist# 1 oft
Structure served by this system 1
t
Legal Description: HERITAGE PARK BLOCK 2 LOT 12 Parcel ID: 050 211 68
A. WELL DATA
Well type PUBLIC If A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate
Arsenic ug/L Date of sample:
ft.
g. p. m.
mg/L
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/ STEEL
Tank size 1500 gal. Number of Compartments 2
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping NEW TANK PumperN/A
C. ABSORPTION FIELD DATA
in
g. p. m.
Collected by:
Date installed 7/16/18
Cleanouts (Y/N) YES
High water alarm (Y/N) NO
Date installed 6/21/83 Soil rating (2 or ft2/bdrm) 100 System typeTRENCH
Length 50 ft. Width 3.5 ft. Gravel below pipe 8' ft.
Total depth 13 ft. Eff. absorption area 575 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 7/20/18 Results (Pass/Fail) PASS For 5 bedrooms
Fluid depth in absorption field before test 0 in. Water added 750 gal. New depth 0 in.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 750 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
D. LIFT STATION
Date installed N/A Size in gallons _
"Pump on" level at in. "Pump off' level at
Datum Cycles tested
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot
Public sewer main
Sewer /septic service line
Manhole/Access (Y/N)
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10' Property line +10' Absorption field 5'
Water main +10' Water service line +10' Surface water +100'
Wells on adjacent lots +100'
ABSORPTION FIELD ON LOT TO:
Property line +10' Building foundation +10' Water main +10'
Water Service line +10' Surface water +100' Driveway, parking/vehicle storage +5'
Curtain drain +50' Wells on adjacent lots +100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that l 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 CHARLES BALZARINI
Date 8/21 /18
COSA canary sheet_2-6-15.doc
F A
CHARLES G BALZARINI
CE-13854
PP.0FcSSti'�';``�'1
�Ey Electric Meter/Outside Power
Gas Meter Deck
'S; Septic Water Valve
coTelephone Pole 4.T Tel. Ped.
-o- Fence L.E., Elec. Ped.
0 Concrete -0- Light Pole
General Notes: 0 15 30 60
1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws.
2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. Scale In Feet
3. All measurements/setbacks are to the visual/apparent building footprint.
4. All dimensions to property lines are plus/minus 0,1ft.
OF q(gs�flll
09TH i
Frederic W. ner
N0. L.S.-9946
X.
7/17/2019
7/17/2019 •=
Ii/i
rltl�?0t\\\\ONA�
PROFESSIONAL SEAL
This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and
conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any
inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the
existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances
should this document be used for construction or for establishing a boundary or fence line.
As -Built Survey of.•
Lot 12, Block 2 Heritage Park Subdivision
1, Frederic Wagner, hereby certify that this Mortgage Inspection Survey was performed by me, or
under my direct supervision on July 8th, 2019.
Frontier Surveys, LLC FRONTIER,
650 W. 58th Ave. Suite E Anchorage, Alaska 99518 Surveys.,
907.460.1686 - info@frontiersurveys.com
www.frontiersurveys.com
es0-vk--(2
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section ALITY OF ANCHORAGE
P.O. Box 196650 Anchorage, Alaska 99519_665~NVlRONMENTAL SERVICES DIVISION
343-4744 JUL 3 0 1997
CERTIFICATE OF HEALTH AUTHORITY
^PPROVAL FOR A S,NG'E AM,'Y DWE'L,NG RECEIVED
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address.
Agent
Address
Day phone
Day phone
Day phone.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~ ~,l
TYPE OF WATER SUPPLY:
Individual well
Community well ~
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSALi
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev.'l/91) Front MOA #21
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 suppJy
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
A~aska Water &
Name of Firm Wsstewater Services /
.tLff/ipr~okr,dgv Dr. I/ Phone
Address / ,.,.,..f,/F///~,~tCyAK~ ' ~.,.~
Engineer's signature L_..,-////,~///~-'"~/~/--~ Date
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91 ) Back MOA ~
JUL $ 0 ]997 ~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICJ~E (~ E i V E D
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
C. ABSORPTION FIELD DATA
Date installed ~/~l/~ ~
I
Length ~O Width
Effective absorption area ~"7~ + Monitoring Tube present (Y/N) V
Soil rating (g.p.d./fF or fF/bdrm) /~) System type ~)~
I
~ 4, Gravel thickness below pipe ~ Total depth
. Depression over field
Date of adequacy test For
Fluid depth in absorption field before test (in.); SO. ~; i, 10/5
Immediately after gal. water added (in.):
Fluid depth ~ ~ (ins) Minutes later: .4. 144-O Absorption rate = -~--'~'~ ~' g.p.d.
/
Peroxide treatment (past 12 months) (Y/N) ~o~- I,J ~
~_.~0%,.4v,~ If yes, give date
"7/,~'/~::~ :~- Results (Pass/Fail) P~ ~'- bedrooms
72-026 (Rev. 3/96)*
Legal Description: [o "T- f '2-j ¢~.- "Z Parcel I.D.:
A. WELL DATA ~,.
. Wel~pe ~ If A, B, or C, a~ach ADEC leper. ADEC water system number ,
Log p~ Date completed
r
Total d~h ~ Cased to~ __ Casing heightened) ~
Date ~
Static water level ~ ~/ ~ .
Well production
g.p.m.
Coli~/ Nitrate ~ Other bacteria ~
~mple: Collected by:
B. SEPTIC/HOLDING TANKDATA
Date installed ~/~¢/~ Tanksize
oun tio. o . no t
Date of Pumping '~//~/~ ~ Pumper
D.
Date installedL~~ .__ ,, , Size in gallons
Manhole/Access (Y/N) '~~ ~ "Pump off" level at* __
E. SEPARATION DISTANCES
SEf~B~TION DISTANCES FROM WELL ON LOT TO:
Septic/holding ~ On adjacent lots
Absorption field on lot ~ ~ -'~
Public sewer main / Public sewer man~l'ToteCcteanout
Public sewer man anout
S ee~cCF~r/septic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line /~) ¢'¢'' Absorption field ~'
Water main/service line ~.~'~'-~'4- Surface water/drainage /O~ /
'~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
ENGINEER'S CERTIFICATION
in conforman/o~ wit¢/C/1~A~/gu alines in effect on this date.
Signature/k---...-.~/I X////~/'~//"~" ~"
Engineer's Name
Date
/
// ~ Building foundation -~ ! '~-'' Water main/service line
_
Driveway, parking/vehicle storage area ~ /4.
/
/00 4- Wells on adjacent lots /00f '~ '"¢--~ '~'~
are
HAA Fee !$
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Parcel I.D. #
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 AU3'HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot 12; Block 2; Heritage Park
Eagle River, AK
Location (site address or directions) Laura Lee Road (19553)
Property owner
Mailing address
Lending agency
Mailing address
Robert Hvisc
Day phone
167 Kinqswood
Vacauille, CA 95687
Day phone
Agent Barbara Crittenden/JACK WHITE C0
Address 11823 Old Glenn Hwy Eagle River, AK
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 5
TYPE OF WATER SUPPLY:
Individual well
Community well
XXX
Public water
NOTE:
Day phone
99577
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
XXX
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
NOTE:
72-025 (Rev. 1/91) Fronl MOA #21
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 inves_ti_gation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and re~u~,a~.;i~l~c~,on the date of this inspection.
' ~ Phone
Name of Firm 17034 Ea~jle River
Address
Engineer's s~gna~
DHHS SIGNATURE
//''~ Approved for -~'
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 engineer's work.
72-025 (Rev. 1/91) Back MOA#21
Municipality of Anchorage ~'~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~(~ ~'¢ \"2~ ~-~-,.-.~ -/---- ~, ~F.-~..CParcel I.D.
A. Well Data
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
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
Date of test
Static water level
Well fl0w
Pump level1
SEPARATION DISTANCES FROM W~k~
Septic/holding tank on lot
Absorption field on lot /
Public sewer main ,~
Sewer service~_
W~T~/8~AM P LE RESULTS:
CD~t'j~sample: Nitrate
AT INSPECTI~ MUNiCiPALiTY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
gI 'CEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ~. ~' ~ '-~
Cleanouts ~IN) ~
High water alarm (Y~)
Date of pumping
Well(s) on lot ~
To property line /'o
Surface water/drainage
Tank size \~-~ ' Compartments
Foundation cleanout ,~N) "'/ Depression~t~i)
Alarm tested (Y/N)
Pumper '~-~-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots ~,--~ 1 ~.~
Absorption field /'~ f
Foundation
Water main/service line
CONTINUED ON BACK PAGE
72-026 (3/93)* Front
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
~...--~
Vent (Y/N) "Pump on" level at "Pump off" L.~e.vel~t~-~
High water alarm level Cyc e~e~E'~
Meets MOA electrical codes (Y/N) ~
SEPARATION D~ LIFT STATION TO:
Welf~'~ lot
On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed \~--'~ ~ '~ Soil rating (GPD/Ft2)
Length ~"o ~ Width "¢~' ¢--'"' Gravel thickness
Total absorption area'5'?~'~ ~ ¢ooCC¢~¢~.Cleanout present~Ti) ',~
Date of adequacy test ~ -" ~/4 ~1"5 Resultsd~[~Pail)
Water level in absorption field before test
\~/¢'¢---- Systemtype 'T'~¢-¢~(~
~ ~ Total depth I O ~
Depression ever field (Y~ ~
for ~ Bedrooms
After test ~ ~ ~ ~ ~
yes, give date ~ ~ ~
Peroxide treatment (past 12 months) (Y~J)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot '--/--,.~ ~ ~
To building foundation
On adjacent lots
Surface water
Curtain drain
adjacent Jots ~'Lt ,p, Property line
To existing or abandoned system on lot
Cutbank ~.,~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, orco~OA
Signature
Engineer's Nam~7034,
Date
and HAA guidelines in
HAA Fee $ ~';:;~ ¢20 .z~ e
Date of Payment
Receipt Number ~'~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 12 Block 2 Heritage Park Subdivision - T14N R1W Section 7
Location (address or directions)
Laura Lee Road
(b)
(c)
Applicant Name Bob Huisc Telephone: Home 694-8798 Business
Applicant Address % Box 773294 Eagle River, Alaska 99577
Applicant is (check one): Lending Institution []; Owner/builder ~ Buyer []; Other [] explain);
(d) Lending Institution First Interstate Bank Telephone 276-7200
Address 716 West 4th Avenue~ Anchora_~e, Alaska 99502
(e) Real Estate Company and Agent Sandy Russo. Re/Max Realty
Address
(f)
Telephone 694-/`200
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~x Multi-Family []
Number of Bedrooms Five(5)
Other
'¢//// I \"
WATER SUPPLY
Individual Well [] Community [] Public ~
Note: If community well system, must have written confir:mation from the State Department of Environmental ConservatiOn
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite E]~x Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone
Address
Date
Engineer's Seal
DHEP APPROVAI~
Approved for i f'[v~ (5) bedrooms by
vember
Approved xwwww ~ Disapproved Conditional
Terms of Conditio'nal AiSp~'Oval
1985
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
~\..~.~ MUNICIPALITY OF ANCHORAGE k.~_~
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date '/°/a~/~cC
GENERAL INFORNIATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 12, Block 2 Heritage Park T14N RiW Sec.7
Location (address or directions)
Laura LeeRoad
(b) Applicant Name Bob Huisc Telephone: Home 694-8798 Business N/A
Applicant Address. c/O box 773294 Eagle River AK 99577
(c) Applicant is (check one): Lending Institution []; Owner/builderyi~]; Buyer []; Other [] (explain);
(d) Lending Institution First Interstate Bank Telephone
Address 716 W. 4th Anchorage AK 99501
(e) Real Estate Company and Agent RE/Max Realty- Sandy Russo
Address Eagle River AK.
276-7200
Telephone 694-4200
(f) Mail the HAA to the following address:
Pickup
TYPE OF RESIDENCE
Single-Family~ Multi-Family [] Other
Number of Bedrooms¢'~4~ *~-- ¢~'~ ,~'4,.
WATER SUPPLY
Individual Well [] Community [] Public ~ 2'~ '~"¢' '
Note: If community well system, must have written Confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [~ Public [] Communi'ty [] Holding Tank []
Note: If com munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (1 lJ84)
Page 1 of 2
5. ;NGINEERiNG FIRM PROVIDIN~G'~r~PECTIONS, TESTS, FILE SEARCH, DA'i~.~ND 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. ~ further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm EAGLE RIVER ENGINEERING SERVICES Telephone
EAGLE RIVER, AK 99577
Address ~. 0," .........
Date ,/Z2/~//,~ .¢- 6~14-5195
Engineer's Seal
DHEP APPROVAL h ~ )/
;;:rj;;:C~ Ap_~rova~iSapp rove~ Con~it'o
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements, Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
DEPT. OF HEALTH
ENVIRONMENTAL Pi~CTECT[O? I
WELL DATA
Well Classification )"~ ~ )' '~
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground __
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
(~'2~¢,,q) If A, B, C, D.E.C. Approved (Y/N)
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoiging Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) ~/ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
/0
To Property Line
To Water Main/Service Line ! ~
Course
Size '/-~--¢ ~ No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped /¢~/~
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation <~¢/~;
To Disposal Field ~ /
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
~'2-026(11/84}
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /9,¢' ~
Width of Field &/.,2 ''¢
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ,~J'"~ ''~
To Building Foundation
Lot
Type of System Design
Length of Field ~'-~ /
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test ,,,'¢~'/2j~ .t-
To Water Main/Service Line /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line //' "'
To Existing or Abandoned System on
; On Adjoining Lots ~='~--' ¢'
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~.-~.~- Date
Company ~,'~ ,'4¢ ¢ -.¢ MOA No.
R ce pt
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
APPLI(._ NT FILLS OUT UPPER HA: __i UNLY
PrOperty Owner P~Ot'I' S General Services Phone
99577
'Mailing Address P.O. Box J,212 Eagle,
Zip
Code
Buyer
Address Zip Code
Phone
Lending Institution
Address Zip Code
Phone
Realty Co. & Agent
Address Zip Code
Legal Description L12 B2 Herritage Park C ~
Street Locatic~
- Type of Residence ~
~[Single Family 5
[] Multiple Family No. of Bedrooms
[] Other
Water Supply
~d Individual ATTACH wELL LOG. A well Icg is required for all wells drilled since June 1975.
~(._ ~---,(~ ' For wells drilled prior to that date, give well depth (attach Icg if available)l
XX Community
[] Public Utility
Sewer Disposal
Individual Year Individual Installed:.
Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQOEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector inspector Inspector Inspector
' ~ / ~ ~VIRONMENTAL
~PPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
