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Home My WebLink AboutHERITAGE PARK BLK 2 LT 13Heritag Park lock 2 Lot I 050- 211 -67 NAME I,,J MAI LtIyG ADDRESS LEGAL DESCRIPTION LOCATION ~,._~..? MUNICIPALITY OF ANCHORAGE L..../ 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 ONE [ []DPG.ADE Wel AbsorPtion area Dwelling DISTANCE TO: C~)/~1/'~ (~ ~¢) / Manufactu ~-~ Inside length NO. OFB~ROOMS PERMIT NO. No. of c~partments Liquid de~h IF HOMEMADE: Well Dwelling PERMIT NO. DISTANCE TO: Manufacturer Liquid capacity in gallons Foundati~_~ ~ / Total lef~t~ck lines Material beneath tile Depth Well/~ DISTANCE TO: Length o(~:~_~I~ I~ne No, of lines I Top of tile to finish grade ~j ¢ ~.~ Material Nearest I/~i~ ~ Trench-~id~ L'--'--'--~ ~O nches inches Length Width Distance betwe, en lines Total ~a~b~orption area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER SOIL TEST RATING / /' 'NSTALLER~/~O t(jL ./~ ~) .~~ REMARKS PPROVE DATE LEGAL 171 ?¥ F'ERF~ I T NO. RPF'L I CFtNT LOCRT I ON LEGBL 825 '7 , STREET., C,~-~--S I TE ( 8_~:00]:0 ) RNr:HOF.:RGE., RK. ~Sm/,± RFI'¢MOND 0 F'ELLET¢~t~ L±--',: B2 HERITRGE PRRK 67±0 E. ±6TH RYE 99504 TYPE OF SOIL RBSr~F.:F'TiON SYSTEM IS: TRENCH f"IRNIMUM NLIf'IBER OF EE[.,F..UUfl=, = LOT SIZE 5:2:7 - 0 F:'_q. '2 99~ SL-"~LIRRE FEET SOiL RRTING ,::SQ FT,-"E:F.:::,= ±00 THE F.:EL.-.!UIRE[:, SIZE OF THE SOIL RBSORPTINN =-r=TEM I.=,. [:.EF'TH= 11 L E~'-~ E~ TH = '25 ,]~ F-: R %." E L [:.EF'TH= ¢=-; THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). RE[:-. SEF'T l" C: TR~-i~-::: S ][ ZE= 1~---'~£',E-~ ,.3RLi. ,]li~--!:S- F'ERMIT RPF'LICRNT HRS THE RE--']PONSIBILITY TO INF]F.'M THIS [:,EPRRTMENT [:,I_IRING THE INSTRLLRTION IN=-,FEuTILN_-, OF RN'?' WELLS R[:,JRCENT TO THI'-'] PROF'ERT"r' RN[:, THE NLIMBER OF RESI[:,ENCE$ THRT THE WELL WILL '"'";EF.:VE. ~ - U~ T~---~C, .:; 2 ::. I t%t_.F E _-T l- C,~'-.~S ~]F~:F' F-." E,~.~ Lt .'[ BRCKFILLtNG OF RNY SVSTEM WITHOUT FINRL INSPECTION RND RPF'RO',,,'RL E:'¢ THIS DEF'RRTMENT WILL BE SUBJECT TEl F'ROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY:ON-SITE SEWRGE DISPOSRL SYSTEM IS · 00 FEET FOR R PRIVRTE WELL OR ~50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF F'UBLIE: WELL MINIMUM [:.ISTRNCE FROM R PRIVRTE WELL TO R'PRIVRTE SEWER LiNE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS PIR9 RF'PL~. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLBTION. F'EF~:l--'il.'f T E.---. .... F" ][ RE'--] [:,ECEi-fllE:EF: _~::1.. i CERTIFY THRT ±: t RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRV REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS. S I GNE[:,: .... FFLI_.HNT F.'.R"r'MC~N[:, 0 PELLETIN MUNICIPALITY OF ANCHORAGE [] PERCOLATION DEPARTMENT OF HEALTH AND ENVIRoNMENTAL PROTECTION TEST 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S L O P E 14- 15- 17- 18- 19- 20- COMMENTS ~/~ Pz~L~ LATION RATE .E.FORMED.": I ,V 72-008 (6/79) Gross Net Depth to Net Reading Date Time Time Water Drop CERTIFIED BY: · :.~ ":..": {mi'nutes/inch) ':'F.'T~ A N D ' .FI" ? " ,., ' Io-2- ' ' .'~ DATE: ' . !;. ' ~-;..! :~ - .~.., :~.,~ - . Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-211-67 Expirati°n Date: GENERAL INFORMATION Complete legal description HERITAGE PARK BLOCK 2, LOT 13 Location (site address) 19539 LAURA LEE CIRCLE, EAGLE RIVER, 99577 Current Property owner(s) ROBERT & STACEY TANNER Mailing address Lending agency Mailing address Day phone 19539 LAURA LEE CIRCLE, EAGLE RIVER, 99577 Day phone Real Estate Agent KATHI OLMSTEAD Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. NUMBER OF ~BEDROOMS: 3 ~pE OF WATER'S[JPPLY: individuat:weil ..:.~ [] I nd i'~id'ual Wa'ter: StOrage [] C0m~hitY-Ciass" Well [] PUbli(; Water System [] Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer The Municipality of Anchorage Development Services Depadment (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between sPOuses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new wate[.Sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the Validation date 'shown below, I verify that my investigation, based, on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. ! 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 ARC"TERRA CONSULTING, INC. Phone 868-3792 Address 20~41 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name .. KEN_NET~ M.___D_U_FFUS Date 05/21/11 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the COnditions as. of the day. tested. The flow and absorption rates may .change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may .fluctuate during the year and tl~ water usage' of.'the family being served by the system. The operational, life of all well and septic systems afi~ subject, to.these various and dynamic characteristics and are Outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future ~ occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. DSD SIGNATURE __ [-,-"~" Approved for ............ .~_.. .......... Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: ". .................................. 7~. e,?.'L_,, .................................... ~.i_._%~'.~ _~.~ ..... ,~ .. . ~ ~ · ON SITE . ~ ~ WATER AND Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Municipality of Anchorage Development Services ,Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: HERITAGE PARK BLOCK 2, LOT 13 Parcel ID: 050-211-67 A. WELL DATA Well type .~,.IfA, B, or C provide PWSID # WeELog (Y/N) Date completed Sanitary seal (Y/N) Total depth ft. Cased to ft. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform colonies/100mL Nitrate Arsenic: mgll Date of sample: SE, P'nC/HOLDING TANK DATA V~res properly protected: (Y/N) Casing height (above ground) in. AT INSPECTION g.p.m, g.p.m. mg/L Other bacteria Collected by: colonies/100 mL Tank Type/Material ~tic~Steel Date installed 3/8/1983 Tank size 1000 gal. Number of Compart~ments _2 Cleanouts (Y/N) _Y Foundation cleanout (Y/N) ~ Depression over tank (Y/N) High water alarm (Y/N) N Date of pumping 5/20/2011 Pumper J-Rs C. ABSORPTION FIELD DATA Date installed 3/8/1983 Soil rating (g.p.d./ft2 or ff2/bdrm) 100 System type Trench Length 26ft. Width__3 ft. Gravel below pipe 6.5 ft. Total depth 11.8 ft. (Measured5/20/11) Eft. absorption area 338 ft2 Monitoring tube __Y Depression over field N Date of adequacy test 5/20/2011 Results (Pass/Fail) Pass For 3__ bedrooms Fluid depth in absorption field before test 43.2 in. Water added 550 gal. New depth 54in. Elapsed Time: 20 min. Final fluid depth 43,2 in. Absorption rate >= 450+ g,p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NIf yes, give date __ Fo Do LIFT STATION Date installed "Pump on" level at Datum E. SEPARATION DISTANCES Size in gallons "Pump'off' level at __ Cycles tested Manhole/Access (Y/N) High water alarm ievel~t in. Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public.sewer main 75'+ Sewer/sePtic.service line 25'+ Animal containment areas 50+ On adjacent lots 100'+ On adjacent lots 100'+ Pttbl~ ~er man~el~a~ Holding tank, Manure/anim~excrete storage areas ]00'+ SEPARATION*DISTANCES FROM SEPTIC/HOLD.lNG TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main :IO~+ Water service line Wells on adjacentlots UNY+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line :10'+ Building foundation ]0'+ Water Service line :tO'+ Surface water __100'+ Curtain drain _50'+ (Nmte Y~own) COMMENTS Absorption field $'+ Surface water 100'+ Water main :10'+ Driveway, parking/vehicle storage Wells on.adjacent lots 100'+ 10'+ G, ENGINEER'S CERTIFICATION i certify that I have determined through field ~ and review of Municipal reco!~s that the above systems are ~n confommnce with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETI-I M. DUFF[IS Date 5~Zltl:t COSA' Fee $490,00 ' Date of Payment '~'~/~--[;-'i' .......................... Receipt Number ~ ~:5"~)'(-~ / (Rev.. 11f05) Waiver Fee $ Date:of Payment Receipt *Number Municipality of Anchorage Development Services Department Building Safety Division . On-Site Water and Wastewater Program' ,i. ' 4700 South Bragaw St. P.O. Box 196650, Anchorage, AK 99519-6650 .~q'~.~ www.ci.anchorage.ak.us · ' .': e;,: (907) 343-7904 .. ..~ ~ ' Parcel I.D. '050-211-67 '"' 1.'-~GENERAL INFORMATION .' ".'.:Complete. , legaldg~.n.'ption Lot: 13; ..... Location (site a(Jd~:e~'~ or directions) "'"' per~ow~ () Current Pro er s Robert Tanner ':-.. Mailing address SAME Lending agen~ e CERTIFICATE Of HEALTH AuTHoRi" APP:i : ' AL FOR A SINGLE FAMILY DWELLING'. 19539 Laura Lee Cir. .. :~ Day phone Mailing address Real Estate Agent 'Mailing Address ' Unless. othe~v'ise requested, HAA will be held by DSD forpiCkup. ' NUMBER OF BEDROOMS: Day pl'{one "Da~, phone 3 e TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class . Public Water System Well TYPE OF WASTEWATER DISPOSAL:' ' Individual On-site ~ Individual Holding tank [] Community On-site [] _, Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of,Naska. Certificates of Health Authority Approval are required f0{ the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. 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. (Cedificates may be reissued for a pedod of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not respons~le for errors or omissions in the professional engineer's work. - . sTAT'EMENT 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 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 b~ed 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 applica_b, le.Municipal and State codes, ordinances, and regulations in effect?t the time of installation. NameofFirm S & ~ Engineering ' i~'-"''" :' -- Pho'ne~ ·694-2979 Address 17034 N. Ea~le River Loop Ste. 204 Ea~le-River, AK 99577 Engineer's P~;inte~ N'a~e" Robert-C. Cow~ ' "D~te ' .~f./~-]l/~' -~-' ....... Dsb SIGNATURE ' Approved for ~.~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report · Other ~.(?, /"~ O rigina, Certificate Date: -_~'~=~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA Bo Co Parcel ID: O~¢'3' o3/I If A, B, or C provide PW$1D # Well Log (Y/N) _ Sanitary seal (Y/N) Wires properly protected (Y/N). Total depth ff.~sed to .~...__ff. Casing height (ab~e~.~3~~in. FROM W EL'L'-L~ A TIN~..~ Date of test ~~ ~ ~ Static: water level ~~..~,.~ ~ ft. Well production ,.~-~ g.p.m. ~_ ' g.p.m. WATER SAMPLE RESULT$:~' I ~ t th b t I 100 I Co iform . ~ml. Nitrate mgJI. Other~ co onies/ m. Ars.e,~ic~ mg./I. Date of sample: Collected by: '"'""'""'""-,~ S~EPTIC/HOLDiNG TANK DATA Tank Type/Material ~',p4,Z./~'f'~,~ f Date installed 5- Tank size /oOO gal. :Number of Compartments ~ Cleanouts ~/N) Foundation cleanout ~) "//,'~ Depression over tank (Y~I,) ~ High water alarm (Y~) Date of pumping ~ ~, ;~,/ ~' Pumper '-~ ABSORPTION FIELD DATA ' Date installed ~,,J3'//~',,3 Soil rating (g.p.d./ft= o~ /oO System type Length ~ ' ff. Width ~'~ ' ft. Gravel below pipe ~ ' ft. Total depth /O ft. Eft. absorption area ~-~o ftz Monitoring tube 2~ Depression over field /,JO Date of adequacy test ¢-'V"~"~O~ Results ~Fail) ~,'~5~ For .~ bedrooms Fluid depth in absorption field before test ~ ? in. Water added 4~'¢~"gal. New depth/"/~ in. Elapsed Time: ~ min. Final fluid depth ~ in. Absorption rate >= /'¢'5'~-,3 ~' g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ If yes, give date LIFT~~ ~ .......... D. Date installed __ ~lons ~holelA¢~ss(¥/N)' "Pump on" level at in. "Pump o~n. High water alarm level at Datum .~ ~ ~& circuit requirements? E. SEPARATION DISTANCES SEPARATION DI~ES FROM WELL ON LOT TO: Septic tank/lift station on Iot-",~ On adjacenCy|ors ~- .... Absorption field on lot ~"---.._ .~i lots__ Public sewer main .~'"'~'~' ~_ Public sewer~ manhole/~:lean(~ut Sewer/septic se~vic~n'e Holding-halE SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~-"~ Property line ~"~' Absorption field ~ '~ Watermain /O /' Water service line /~---)~ Surface'water' /OO f Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line lo ~' Building foundation Water Service line /0 + Surface water ~/OO '~ Curtain drain ~"/~ Wells on adjacent lots I00 ~ Water main /~) ~' Driveway, parking/vehicle storage F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name "/LJ~z.~- C', ~' D ~4~ Date ~/~ ~i'/0 ~* HAA Fee $ Date of Payment Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number Joo.oo' merits st.tuated thexeon-ste.wlthln the l~'.ope~rt~ad.~aes t.a~~ do not overlap m' encroach on the property lying a. ~acen · e~,-. to, that. no ~ on property lying adjacent lhereto encroac~ On th~ ~ in question sad that there ~ no ~. roadw~yi~ t,-lmsm-l.~on lines ar other visible easementa on ~ propp, r~' ~'~-'~Pt a~ indicated hereon. ~ : · ao~Ea~'c. JO~mSON '~ SCAT.?~' -- Re~tstex~i L~nd Surv~To~ No. 880-LS ' Phcm~ {gO?) 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 JUL 22 ]997 Parcel I.D. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Lot 13; Block 2; Heritage Park Location (site address or directions) 19539 Laura Lee Circle Eagle River, AK et3 Brooks 'L,M&iling.addreS~-, 19539 Laura r,ee Circle ~' L~b'nding agency ....... 'Mai'ling address Agbnt , Bob Van ~r~e~/ Oack Day phone 696-8344. Eagle River, AK 99577 Day phone · 'Day phone 694-5500 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: NOTE:. Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- in~. to the legality and status of system. ,, , 4.' ;FYPE OFWASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer xxx NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72q)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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage 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. $ & $ ENGINEERING Name of Firm 1711~4 Eagle Rjr'er Loop Road No. 204 Phone Eagle River, Alaska 99577 Address Engineer's signature '~,~/~,~.. . ~ Date 7/~ DHHS SIGNATURE ~ Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: ~~,.~'¢/~ ~J/~ 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 EN~IJ~ONM/::N?AL DEPARTMENT OF HEALTH & HUlVIAN SERVICES Environmental Services Division JUL_ 2 825 L Street, Room 502° Anchorage, Alaska 99501° (907)34~'¢~4 r' *', Health Authority Approval Checklist LegalDescription: L./'~ ~, ~F~Y~¢~(c/,P~ ~l?-Jz¢- ParcelI.D.: 0~,¢'O "~ ~1/ '- (~ '? A.,~W~,~L DATA Well ~p~.~ : If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y'/N),_~ Date completed .... ~'/¢'///~ .... ht'bo e round' Total depth /~24~ Cased to ~ ~ gaslng ne~g [a v g ) Sanitary seal (Y/N) ~% ~ Wires properly protected (Y/N) ..... ,NS. C ,ON Static water level . Well production g.p.m. g.p.m. WATER SAMPL~: RESULTS: Coliform Nitrate Date of sample: Collected by: SEPTIC/HOLDING TANK DATA Date installed 3/~/~-~ Tank size 1O(?0 / / (,/ Foundation cleanout ) Depression Date o¢,'Puml~!ng ' , Pumper Number of Compartments /~0 High water alarm (Y(~ ABSOI~PTIoN FIELD DATA .. Da~[~ installed '~ Soil rating (g.p.d./ft~ orft2/bdrm) '/;~75'-F~~ System type ' ,, Length ~ Width ,' ~ ~ ~¢ Gravel thickness below pipe ~ Total depth Effective absorption area ~ ¢~ itoring Tube present N) Depression over field . 'gCs5 For Fluid depth in absorption field before test (in.); bR~ Immediately a~erCJ¢) gal. water added (in.): Fluid depth ~ (ins) Minutes later: ~ Absorption rate '~0~ " _ = ' Peroxide treatment (past 12 months) (Y/N) ~o/JE. ,¢, Nh¢U/'~ If yes, give date 72-026 (Rev. 3/96)* LIFT STATION' Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "P u~ffrn I~..q~. ".~1 eve I at* *Datum~--~ "Pump off" level at* Cycles tested "'~~ E. SE,A,AT,O..,TANCES"----.._ SEPARATION DISTANC'E-S.~M/WELL ON LOT TO: Septic/holding tank on Io~ % On adjacent lots Absorption field on lot ~ On adjacent lets sewer main ~ P~anout Public Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ¢' / Property line [0/4 Absorption field (0''''~' /]' ¢ adjacent lots Water main/service line Surface water/drainage /0 Wells on v SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: /~ ~Jr Building foundation .he/'/' Property line Surface water Curtain drain Water main/service line Driveway, parking/vehicle storage area 0 / Wells on adjacent lots ,~Oo/~ F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records in conformance with MOA HAA guidelines in effect on this date. Signature ,'~///. ,/~Z¢-¢-..--,~ Engineer's Name ~,~,¢.r L". ("o ~,~,¢ Date 7/~- ~/~ 7 HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* " ' ' "· '..:"' /"~-"X'-,'%" :: : .MUNICIPALITY OF ANCHOR GE . : -~¥::.G':::.%'.::?::.::-!...,: : -'_ '., : ;:' ~):~;::DEPARDTvMiEsiN~Tn~fFEHnEvfrL~nHm&eHntUa~MsAeNrv~Ec~CEs`:~:~:.~:~t~k~:.:::~:.:`~ . · · ,. .... On-Site Se cesSection - . '-'. ..' :,'." ....>~ P.O. Box 196650 ,'Anchorage, Alaska 99519-6650 .... _ ' r''' :';:': ." ,',>'': ' .: '-... : ., '.., ',:/..~ CERTIFICATE OF HEALTH AUTHORITY . , U.'. '.-: . ' '" ~ 'APPROVAL FOR A SINGLE FAMILY DWELLING ' ..... - ....... ;_. ::..:.;-,,..1..,- .'.... .: ..... . . ::'_.__.: ..~;.::~.."::,: ...... '-' ' ' ~: .... . ',~." ." ' : '-' "-':, '-:' : .... -'~ ~l~.O~,{~ ,~ ~.;~ ' -,'~;; "';.S%:'.:?'-:.-::1: ...... .... 1., GENERAL INFORMATION ~:.:,-:'~ .................................. ,~ ....... -~.. _~ ................ t ........ , ....... ~;,.. ......... ' ' ' "~ ~3 complete legal descriPtion-:, r.,ot ~Q~ ~Me~J~tage:.¢Par]~ '" L°cafion (site addres~:-&~:~irections) ~ 19539 ~au~a ~ee cJ.~c~e ' '::.'~:_"~L'-' :' :-'-:': : '. ,, -.. ~:'-" . '-.. '-'F ........ -:~ i :'~ . i}:;,?,:Unless otherwise requested, HAA'will be.hbld for .,:, ,:.:: ........:. ,,:,,.~,,:,lndlvldual well :: ..... ~.:::;-~.::, ,,~ :- , .~ ~: ..,:.: .:~,-~::,,~.t~ ~ .... ~ ~: ~:~Communltv well · ~.,~,.~,.~,~:~ ~.: -:: .~.:, .:~ ~,... · ~'~NOTE: :.lf community Well,~ystem;::provtde'wn~en confirmatton fro~ ~ :~ i::,~:,: : inotO' the legalityandstatus ofsystem.':,: ":' :: : '= .~, TYPE OF ~ASTE~ATER DISPOSAL: :-:,,:: ' :::,::IndiVidual on:rote '. : :::.:. NOTEj:,:.::;i~"~-~ni~]¢a~tb~ateh.b)s~em:~ P~ovido~ ~ri.~n'~nfirmation from'state ~D~? ? ~ .' '- ': ' attestt~g to the legahty and st~i~S of s~st~.:, -~: · : ~....~ ' .: . :::..: -:.. ::: : .: : ::.: , : :': . = :, :: : :: . .,.~,.:;¢~,:~'.....::,.' ,-,:.~.: 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, ordinances, and regulations in effect on the date of this inspection. Name of Firm s & $ ENGINEERING Phone - 17034 Eagle River Loep Road NO. 204 Address Eagle River, Alaska ~S77.~' - Engineer's signature : Date 7 ~./ ....? ~ .~'~,~?~-, - . .~o. ~. . ~.~ . .-.,. , . . ..... k ~ .Addltlona., ~mments -_,......,~..-~X/ ,-~-, .; .- . . ~. :-. . . .... . .... . :a~- ~~~ ' "~" ' ' "" Date The MunicipaliW of Anchorage D~aAm'e~t Of .Health and Hum~n"se~ic~s (DHHS) i~ues Health Authori~ Approval Ce~ificates bas~ only upon the representations given in paragraph 5 above by an independent profe~ional engineer registered in the State of Alaska. The DH HS does this as a cou Aesy to purchasem of homes and their lending institutions in order to ~tis~ cedain f~eral and state requirements. Employes of DHHS do not conduct inspections or analyze data before a ceAificate is issued. The MunicipaliW of Anchorage is not responsible for erro~ or omi~ions in the profe~ional engineePs work. ' Well t Log ~ Total depth __ Sanitary seal (Y/N) Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.-0"(- l~.;~/J~ ~. ~-~[Tf~E I~Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller __ Date of test Static water level Well flow Cased to Casing hei Wires properly protected M WELL LOG AT Pump level1 Septic/holding tank on lot FROM~ Absorption field on lot Public sewer main SeWer serv~ WAT.~MPLE RESULTS: ..~elfform . Nitrate J Date of sample:. B. SEPTIC/HOLDING TANK DATA Date installed ''~'" .... Tank size Cleanouts ~/N) ' ' :'Y~S High water alarm iY/~¢) ' Date of pumping SEPARATION DISTANCES FROM'SEPTIC/HOLDING TANK TO: Well(s) on lot ~ ' On adjacent lots To property line [O ~v ' Absorption field Surface water/drainage ~00 '~ g.p.m. ~ ;On ; On adjacent lots Public sewer manhole/cloan~ Petroleum tank Collected by: Other bacteria~ ~(~ ~-~L Compartments Foundation cleanout ((~'N) /~_S Depression (Y/~ /'J/,~ Alarm tested (Y/I~ /"//~- "~/~ h~ Pumper k-~ ~---~ f Foundation Water main/service line I(") CONTINUED ON BACK PAGE 72-026 (3/93)* Front c. Date Manufacturer Size in gallons Manhole/Access Vent (Y/N) "Pump on""n~ev.~at% .--/~"Pump off" Level at High water alarm level ~~y~Oycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANC.~PR~M LIFT STATION TO: Well on Io..~~''~'~ On adjacent lots Date installed 3 ~ D. ABSORPTION FIELD DATA Length ~g / Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) Width Gravel thickness ~ ,,.;~eanou~ present ~/~o :~'.~ Results(pass/fail) %S~ for '~' After test lk~)ol' ~r..3~ ~ If yes, give date SEPARATION DIS'FANCE FROM ABSORPTION FIELD TO: Well on lot /k.)/~ To building foundation On adjacent lots Surface water Cudain drain Total depth (~/O ' ('~ ~' Depression over field (Y/..~ L,-3O On adjacent lots ~-'~(30 'ff Property line [0 ' To existing or abandoned system on lot Cutbank h3/~ Water main/service line Driveway, parking/vehicle storage area (~ / . E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAm gu/defines in ~ ,~ of this inspection. Signature HAm Fee $ 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 ~.~'-~ "~ ~ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision., section, township, range) Location (address or directions) (b) Applicant Name ~ ~ Telephone: Home ~-~ Business Applicant Address ~,~ ~a~/ ~/~ ~,~ ~ ~'~ (c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Othe~ (explain); (d) Lending Institution /~[~, $ ,/~'~ J":/~,~ ,,~ XCq ~ ~ Telephone Address ~'~ ~ ~-~ ~ ~ ~ (e) Real Estate Company and Agent ~ [~ ~ ~ Address ~ ~ ~' ~ ~ (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~' Multi-Family [] Number of Bedrooms '3 Other WATER SUPPLY Individual Well [] Community [] Publi,¢~ Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite'~ 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. Page 1 of 2 72-o25 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 EAJ~LE/~IV~R F/~6!NEE~!N6 SERV!~ES Telephone EAGLE RIVER, AK 9957~ Address Po 0, B~X ~'73294 Date ~'//?/~-'¢ 69a,-5!95 Engineer's Seal Approved ,~ Disapph~'ved ..~ Conditiona~Y Terms of Conditional Approval 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 WELL DATA ~ Dt~Pf. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA~iNViRONM[NTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) 264-4720 Legal Description: Well Classification ·2~' ~' ~ ~ 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 /2'2,/-..),,4 ¢ 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 Adjoining 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 ,,.~-¢~ 7'- To Property Line /~ c- To Water Mai'n/Service Line / g~ ~' Course /'~-~ Size /~'¢ ~/No. of Compartments ~- Foundation Cleanout (Y/N) Date Last Pumped ~/'~e ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ~4;~" To Disposal Field ~¢ / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /"~ oc' --~ Width of Field ,'~ ¢' Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well -~-~o To Building Foundation ~ '~ Lot ,/~/d-,~-~ (L Type of System Design Length of Field 0%), ¢'" Depth of Field ,,,~'d.~" Gravel Bed Thickness o~ · -y' / Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ,~ To Water Main/Service Line /~ ¢' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) Date Installed Size in Gallons "Pump On" Level at Fligh 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 ** I certify that I ha~e checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ,J~:~ Date Company .~,~ ."¢~,.-,'~, ZC,~F~'r MOA No. Receipt No. Date of Payment ~o~c'¢ Amount: $ 'z~ Page 2 of 2 72-026 (11/84) _~. ~.~ . : ONLY ' AppLI(- NT FILLS OUT UPPER HA[ , Property Owner ~ -~ /~/, ~, /~" ~,~/.Z~~. ~"i~//~,c ~ ~ Phone Address ~ /~d ~/C ~ C ~f~//~ Zip Code Lending Institution Phone Address ~ / ~ '! ~ ~ C ~' ~ ~ / .~ Zip Gode 8ealty GO. & A~nt Phone Address C ~/- ~/~~ / ~- ~ ~ /~ ~ Zip Code Street Locat[~ ~ ~ ~ ~ [~ ~ ~ ~ ~ ~ ~ Type of Besi~nce ~gie Family ~ Multiple Family No. of Bedroo~ ~ ~ Other ' Water Supply ~ ~ividual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since ~une ~975. ~Community For wells drilled prior to that date, give well depth (attach Icg if available). g Public Utility ~ndividua[ Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MAY 1 ~ 1983 "Municipality of /',n~horag~ (~APPROVED BEDROOMS *CONDITIONS OF APPR~.0~e~taj Prctsctton" ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* 8oil8 ~tJng D~e ~wer Inslalled Well To Abso~pJion Area Well Log ~eceived ~ ~ ~ ~'~ Well Jo Tank Septic T~k Size 72-023 (3182) APPLIC NT FILLS OUT UPPER HAl ~ ONLY · r. Phone Mailing Address ~ Buyer Address Zip Code Phone Lending Institution Address Zip Code Phone Realty Co. & Agent Address Zip Code Street Locati~ Type of Resi~nce ~ Single Family ~ Multiple Family No. of Bedroo~ ~ Other Wster Supply '~hlndividual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. -~e~ity For we,s d~i,ed p~io~ to that aat., gi~e we, depth (attach log if a~ailable). Sewer Disposal ~'lndividual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date .~ Date Date Date ,~ inspector Inspector Inspector Inspector MAY 1 1 1983 (g) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL Soils B~ting Dste ~wer Insl~lled Well To Abso~lion Are~ Well Log ~eoeived ~ ~ Well to T~nk Seplio T~k Size 72-023 (3182)