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HomeMy WebLinkAboutLAKE RIDGE TERRACE BLK 9 LT 14 Tom Fink, Mayor tun[c pal ty Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 September 23, 1992 Edward F. Walters 18108 Fish Hatchery Road Chugiak, Alaska 99567 Subject: Lot 14 BLock 9 Lake Ridge Terrace Subdivision Permit 9SW910300, PID 9051-323-01 The subject permit, issued September 23, 1991 by this office for a single family well and/or on-site wastewater system, has expired as of September 23, 1992. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as-built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $200.00 for an on-site wastewater permit; $75.00 for a well permit and $275.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. / Sin,cerely,,, / ~ogram Aanager ~n-site Services enc: Copy of Permit PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910300 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:WALTERS EDWARD F & OWNER ADDRESS:18108 FISH HATCHERY RD CHUGIAK, AK 99567 DATE ISSUED: 9/23/91 EXPIRATION DATE: 9/23/92 PARCEL ID:05132301 LEGAL DESCRIPTION: LAKE RIDGE TERRACE BLK 9 LT 14 T15N, R2W, SEC 36, SM LOT SIZE: 21063 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: IF EXISTING WELL IS RETAINED NOTE SO ON NEW WELL LOG. CROSS CONNECTIONS ARE PROHIBITED, ONE WELL MAY NOT FLOW INTO THE OTHER. IF THE EXISTING WELL IS ABANDONED PROVIDE WRITTEN CONFORMATION WITH THE NEW WELL LOG. DATE: DATE: and do no~ overlap or encroach on th~ property lying adjacent tl}~r0to, ,ha, no improvements on property lying adjacent ther~m encroach ~he premhes in question and tha~ there are no readwavL Ir ~slnn hereon. Dated at Anchorage, Alaska, this _ ~1 ~ · day ot SRA Box 60, Anchorage, Aleska 9950~ NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONIVIENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-S TE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT 7~NEW [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION oZ~ Manufacturer ~.~,~ ~,/ TO: IWe'' DIS~^NCE TO: Wa" / C't_O NO. of lines / Length o,~a~ne Top of tire to f~] grade Inside length_~__, Dwelling [F°undati°~7~/ Z " Total ~h~ of lines Material beneath tire Depth Length Width Type of crib Crib diameter DISTANCE TO: Y DISTANCE TO: Depth MUNICIPAI_II~ Building foundati(~:~vt' L. ENVIRONME.~ Building foundation [~H,~rNCHORAQ~, TAL PROTEC'I-IO~.J Dwelli2..~ /" IWidth ~- Materia] Nearest I,~,~.u~e .~ TrenchJa~dtl~ ~(--~' inches 'inches PE IT No. of compartmentsZ Liquid depth PERMIT NO. Liquid capacity in gallons Distaneeb . j · Total ef c 've absorpti n/area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS DATE LEGAL F'ERH ! T N('] · DWFE !SSLJr:i%, · I:~PF:' '[--,", i"" CONT?iCT PHCiF,!E ' I...EGF!L DESE:,'-'~'. ! F:': I...OT ET2%' I'"llq ::':; E F:2F,F' E '- H'F ' ED." ;'..;.' :i~;,!i~:;~; ENEi i N'EEF?. i ERC~iL..E R i ',,,'El:;;:., F:IK '..'i;,5~5'?';:' 6; 9 q.---.;29 '79 L. EFf': l,=,i Rt.XiNGE: ;214 Et. OC:K: 9 L ! STED E:E!...OI4 RI:;;:E THE DPT '[ l']l'.J~!; .:::.'v'R T. I::IE 1. i:3' TO y(]llj ]: N DES ;.(GN I NG YOUR S£EF:'T I C S'¢STE.hi. C:HCI(]S'iE TH.E OF:'!'ZEd"~ THF:iT E',IECT F'~T'.E; '.,.'FI_IR S Z'TE. DEF'TH T'O PIF'E [?,CFi"TOM' ,:.'I:::'T. 1:, 5.'E¢ 6. 0 5. 0. GRR',,,'E!_ E:,EIZ"TH (FT. > 4.. 0. 0. 5 ~f. El "t"O'TRI.... [:,EF'TH <F"F. ::, 9. 0 6;. 5 8. 0 G~;:F¢,,/E!.... kf!!i:,TH ,::FrT. ::, 2. 5 22. E~ 5. El GRFI'v'EL L.ENCCFH <F:'T. ) 78. (~ :+::+: 42. 0 7]:. 0 GRR'.,,'EL. 'v'Ol...t.tME (CIJ. YDS. ::, 22. 5 ]~:4. 2 ,,~7'. ~: TR!'.,IK SZZE (GFiL. S> ::L., (~EI6. El e:s., i., 812iEt. () $:+: J..., 800. El :+::+: SOl L RF!T I NG < SCL FT. ,-'E:R::, ;266; 20J.. 206; :+::+: ]F;:F:IS/E;!.. LFf]'.,!C:i'Ti.-! :::. '?5 F'T. F:iEg!IJ]'.PE'~; t"tUL."!"ZIZ'I_E Rl_hl% ,::h!CFT' E...I...EEE it.la ,.'5 FT. ERCH) :+::+: TFtNk: MUST .HI:~',,,'E FIT LE!::i:E;T 'T'!41])C:EH"1F:'RF;:'TMENTS 'J: CIEF;:T I F"r' TH!::IT · 'J..! Ri"! FRi"!I'L.!F:ID: HITH THE Fi:E[;:!UZF;]'.I!EHEi",FI"L:i; FCff"~: OF,I":':E;tTIE SE.I-,.IEI':~:S'; RI",Ii]' .HELI_S FI!E; SEq" F: DD"I'H E',Y TI-iE t',ii I~.J T f": i PFII T TY 0t:: , ,! ,t .......... f ..~ ... ,:: I"!OR ::, Fthl[:, 'I'HE E;TRTE ElF FJL. RSI<R. ;2:. T 1411_!. ih!:E;TI::!LL. Ti-.iE :, .:,,E.i'i it",1 F:n"'F:r"iF?!":,FIi'.,IF:F i4ZTH RLL HOR CE~E:,ES Rhl[:, !:N:E;13LILRTIFIhlS., RNE:, ..T.i'.,i (]Ed"iF'L. ZRi'.,iC:E i,!:i'T'.-! TF..iE DESIGI"4 E:i:;;:ZTEI-~:IFi OF .THIS PEF.:MZT. ..i:. i HiL. i_ RE:,HERE: "t"E* i::IL.L .,t-t:::. F:lhi[:, :FSTFiT[:L" EiF: FIL..RSJ;I<:R i~:EQUIF'4:Et"IENTS F:'EIF.: THE SET E:RCI< [:' i ?i"Fti"4CES FF:-" - l'i "" ~ ~::';:.:' ,"r',,x ..... T'~TiI"iEi i.,.iEi_! .....i,.iI::!STEH. RTEFt D.T. SF:'E~E:iF:iL S"r'L:'~;TEM OR F'UE',L~E; ', ....................... T t...II"4DEF~'.STRN[:, "i"FiI::I"i" 'T'HIS F:,i-u'r~?M'rT 'r'E; ',/f=tLID t::'i'R R i','IF:IXII',I_H FqF 2 E',E[;,F.:[]FH'"I'.E, RhiY ENLIqRGEi"iEi'.,F!" H i I. _ I;i:E(;:¢..I ! F;:E FiN FIE:,D I TI OI'-,tI:::!L F'EF4:I"! ! T. iF F! ............... 'r~T ST!:ri'!"ION 'r,::; tI'.,!:.STF:!!_LE[:, IN F:If.4 FIF~:EFI .... ',.,'FF,?ED ~:Y:, HOR E:LilLE:,IN[~i... C:O[:,ES., THEhi ,:;..1..::, FiF,! EL..EIZ:Ti:;~:iE:I::I!_ F'EF;:HiT FII'.,iD iI'.,!SPECTIEd'.,i HI...IST E:E OE:TRINED.: <:2') RS-E:UZLTS i.,.IILL. NOT E',E !::!PF:'[;i:C'I',,,'E[:, !-,.lt".f'HOI...IT F:ii'.,I EELEC:TRiE:F!L INSPEE:TiON F~:E:F'OF~:T.~ FIf.,,I[:, "':J" THE SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4~ 7 8 ~0 ~2 14 2O COMMENTS DATE PERFORMED: SLOPE SITE ENCOUNTERED? 0 P E IF YES, AT WHAT DEPTH? GrossNet Depth to Net Reading Date Time Time WaterDrop Z ', 3;~o ~o ',/~ '/'z Z" ~ ,, ~;w /,, ', /??~,'Y~'" 6' ,, '/,, /, , /¢ '/~, //~. ' PERCOLATION RATE TEST RUN BETWEEN /F (minutes/inch) ~ FT AND ~ FT DO(; Co, dba , P. O. BOX 272, CHUGIAK, ALAsKA 99567 · TELEPHONE 688-2759 OWNER OF LAND DEPTH OF WELL :,i. <~: G ADDRESS /; ,' ) ?'¢:"y LEGAL DESCRIPTION <'. DATE- Started ~t,/ ff:'~' _ pERMIT NUMBER STATIC LEVEL OF WATER FT. _'~ C, ~AW DOWN FT. GALS. PER HR KIND OF CASING (];~ ~''~ ' KIND OF FORMATION: From ~) Ft. to '~' _Ft. From ,4[ Ft. to / f'~ Ft. From Ft. to Ft. From / :'~?' Ft to. ~ ) ? Ft. From.. Ft. to.. _Ft From ~ Ft. to: /'?::, Ft. From.../,-~ Ft. to - ,'u'Ft. From, ,~!- Ft. to_ / :'/ Ft. From_LC~ -/ _Ft. to ,~? ~'--Ft~. . From . Ft. to Ft. From Ft. to___Ft. From_ _ Ft. to___Ft. From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From ~O NF kl~dT:,f_© F~.k-~,IC HOP, AO E F, Di?T OF HEALTH & ./ :~ '::,&' d,'.. From ENv~k~.~t.~[~Z,".b ~oTECTIO~ --- Y ':~h',. j "(} (' ,";>F' From FromLZ~__Ft. '.'~7, ' ' --., ~ to~:' ~: ~.L-Ft .... /?,-- ~::-~ -;, c., ~ ~__. From____ Ftiini~'~:' Ftt° ' ~-'~:: : Ft '. ' From Ft. to _Ft. From From _Ft. to_ Ft. From... From__ Ft. to Ft. From From , Ft. to Et Frmn ___Ft. tommy_ Ft.,~g84 Ft. to____Ft._ _.Ft. t~lV ED _Ft. to Ft Ft. to Ft Ft. to Ft. Ft. to Ft. Ft. to .Ft, 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 1,/; B.~ock 9; Lak~.~z'.dge. Terrace Location (site address or directions) I9108 Fish Hatch~.ry Road, Eagle. Rvier, AK. 99577 Property owner Mailing address Lending agency Mailing address Ed Wa!tars Day phone &9~-2974 P_O_ ~ov. 777~5~, ~.g~e_ R;ver, aK 99577 Day phone Agent pn,,~ ~l~¢.?2a./On. ~f.~Ka~,~J¢ l?¢.r~.~ F.~;~,~.¢¢ Day phone Address 13135 01d Gl6nn, Eagle. R~ve.r, AK 99577 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 TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. X 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. 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 Address EngineeYs signature 6./~S SIGNATURE Approved for Disapproved. . Conditional approval for 17034 Eagle Ri.vet Loop Road _N_o_',_ ~0~.' *~sgte River, Alaska bedrooms. Phone 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 ~21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:~'~ ~¢--~:~ ~--~-V.~.~.~)L~ . Parcel I.D. A, WELL DATA Well type [;;~--~,~'r'~..- If A, B, or C, attach ADEC letter. ADEC water system number Log present t~/N) ~ Total depth '7.. c>c:> ~ Sanitary seal (~N) Date completed Cased to '~C)~ Wires properly protected ~/N) Driller ~-~ ~-~-, Casing height t '7~ FROM WELL LOG Date of test Static water level ~'~ Well flow Pump level AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~l Sewer service line 'Z.~' ~' WATER SAMPLE RESULTS: Coliform d:~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate ~ [~ MUNICIPALITY OF ANCHORAGE FNVIRONMENTAL SERVICES DIVISION 2 1991 RECEIVED Other bacteria .,~ Date of sample: ~,~ -' ~ -~ \ / .~ c~ -'~.~ct, t Collected by: ~ ~ ~ ~ ~ ~ ~ 17034 Eagle River Loop Road No, 2~ B. SEPTIC/HOLDING TANK DATA ~e. ~~ Eagle River, A~aska 99577 Date installed ~ Tank size ~ Compartments Cleanouts ~YN) ~ High water alarm (Y/~ Date of pumping Foundation cleanout t(~/N) ~ Depression (Y~[~ ~ Alarm tested (Y/N) ~ct~, Pumper ._-'~"~ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot t ~,c> ~' On adjacent lots ~ c>¢ ~4- Foundation To property line [c~ er ' Absorption field ~ ~ ~ Water main/service line Surface water/drainage [ o~ ~ 72-026 (Rev. 7/91) Front ' CONTINUED :ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) Manufacturer Manhole/Access (Y/N) "Pump on" level at .--~----'q~ump off" level at High water alarm level .¢~ Cycles tested Meets MOA electrical codes (~~ ST^T.O, WeiCon lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~ ~ Length [¢"D~ Width Total absorption area Depression over field (Y/~J~ Results4~fail) Peroxide treatment (past 12 months) (Y~ Soil rating "/.-~.~ L~ ~P/~¢-/ Gravel thickness Cleanouts present ~/N) Date of adequacy test for ('"~'~ ~/'~J¢--- /g-~'~/'~ If yes, give date System type ~"~ Total depth bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot !z2c~ To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~. ~ ~'~ Property line ¢~r1~\ 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, or conformed to all MOA and HAA guidelines in eff_.,~_t,~ltCd'~.¢,of this inspection. Signature ~ 7eA4 ~*al~ Ri,vet I_ooa [Oa~ ~O, ~ Engineer's Name ,, HAA Fee $ //~') Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number ROBERT SHAFER, P,E. ROGER SHAFER, P.E. November 7, 1991 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTR AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Ed Walters P. O. Box 771456 Eagle River, Alaska 99577-1456 REFERENCE: Lot 14; Block 9; Lakeridge Terrace Subdivision Dear Mr. Walters, At your request a flow test was performed on the well serving the referenced property on November 1, 1991. The static water level was measured in the well at 47 ft. below the top of the well casing. A meter was connected prior to the holding tank and the flow turned on full. After fifty-five minutes the water level was drawn down to the pump (188'). The pump was then shut off and the water level was allowed to recover for approximately twenty minutes. At that time the pump was turned on again and the water level drawn back down to the pump while the water quantity was metered. This process was repeated 4 times with consistent results. From this test we have found the well to currently produce approximately 68 gallons per hour (GPH). This flow rate is not guaranteed to remain constant, subsequent variations can occur. If we may be of further service, please contact us. Sincerely, ROGER J. SHAFER, P.E. RLS/gm 17034 EAGLE RIVER LOOP. SUITE 204. EAGLE RIVER, ALASKA 99577 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE ior WORKorder~ 39527 Date Report Printed: OCT 23 91 ~ 14:53 FAX: (907) 561-5301 Client Sample ID:L14 E9 LAKSRIDGE TERRACE PWSID :UA Collected OCT 21 91 ~ 16:40 h~e. Received OCT 22 91 ~ 13:45 hrs. Preserved with :AS REQUIRED Client Name :S & $ ENGINEERING Client Acct :SNSENGP BPO # PO ~ NONE RECEIVED Req # Ordered By :R. S~AFRR Analysis Completed :OCT 23 91 Send Reports to: Laboratory Supervi~or~TE~NEN C. ENE lis & S ENGINEERING Reloaoed By :~~.~--"/ 2) Chemlab Re£ ~: 915657 Lab Smpl ID: 3 Matrix: WATER Allowable Parameter Tested Result Units Method Ltmlt8 NITRATE-N ND(O.IO) mR/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED Remarks: Tests Performed ' See Special Instructions Above UA=Unavailable None Detected '* See Sample Remarks Above Not Analyzed LT=Less Than, GT-Greater Than S-~ Member of the SGS Group (Soci6t~ G~n~rale de Surveillance) ~FdNICIPALITY OF ANCHORAGE DIVISION OF ENVIRObR4ENTAL HEALTH DEPARTMENT OF w~.ALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY A]?PROVAL CERTIFICATE 1. General Information Application Date /~'~/~ ~"~/~. ~ (a) Legal,De.scr. iption (include lop, bloc~, subdiv~yfision, section, township, range) Location (address or directions) 6 5x (b) Applicants Name ~ ~ Telephone- Home Business Applicants Address ~ ~a,/_~ ~75g//~(?~ f/fq~j _~/~°~-~/~ ~ ~<[ ~/~/~ (c) Applic~ant_fls (check one) Lending Institution ~-~ ; Owmer/builder.~.; Buyer ~--~ ; Other ~--~ (explain); ' (d) Lending Institution ,~cO ~ Telephone Address (e) Real Estate Co. & Agent Addres's Telephone .AA to the ollowing aress: Type of Residence Single-Family? Multi-Family ~--~ Number of Bedrooms Other (describe) Water Supply Individual WelL~ Community ~-~ Public ~-] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposal 0nsite ~ Public ~-~ Community ~ Holding Tank ~--~ Note: If community well system, must have w-citten confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providing Inspections~ Tests, File Search~ Data and Information o 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 regula- tions in effect on the date of this inspection. Name of Firm Address .,,. ~,.,~,. ~ r,~':~ 'f2577 Date DHEP Approval Approved fo bedrooms Approved~X~ Disapproved (ENGINEER SEAL) Telephone Conditional Terms of Conditional Approval CAUTION THE ~<0NICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES ~ND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE. REQUIRE- MENTS. 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. RR4/ej/D18 [Page 2 of 2] (DHEP SEAL) 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ae Well Classificat~ ..~/~/~ Total Depth ~'~ ! Cased to If A, B, o~ C, D.E..C. Approved(Y/N) ~ / Date Completed ~/~ Yield ~z~_~/_3~ ~-O' Depth of Grouting ~ // Static Water Level ~_~O Pump Set At Casing Height Above Grcund ~- ~ t' Electrical Wiring in Conduit:Y.~) Separation DiStances from Well: Sanitary Seal on Casing~/~) Depression Around Wellhead (~ To SepticpS~i~ Tank on Lot //~O ~ 7A ; On Adjoining Lots /OO t~ To Nearest Edge of Absorption Field on Lot//~O t~ · ; On Adjoining Lots lOO '~& To Nearest Public sewer Line ~J /~ To Nearest Public Sewer Cleancut/Manhole /g/m To Nearest Sewer Service Line on LOt 30 ~ Water Sample Collected By ~ .~ ~//~_3'1~; Date /6).~//~ ~ Wate~ Sample Test Results ~--~ -/f .C~C~O~ ~ Cc~'~-ents w%30 ~/~ Be SEPT IC/H~bB{4~TANK DATA Date Install~d F/~ ~ Size /~O No. of Cc~partr~ents ~ Standpipes :~/~) / . Air-tight Caps~ ~/N7 Foundat ion C leanout:_~ Depression ~ver Tank (~) Date ~s~d _ ~ ~ ~ ~ ~ P~ing~intenan~ ~n~a~ on File, t~/~ ; for -- ~/~' Holding Ta~ High-Wate~ ~a~ (Y~ Te~rary Holdi~ Tank Pe~t (Y~, ~p~ation Distance ~ ~ptic~olding Tank: . To Water-Supply ~11 /~ ( ~ To ~ilding F~ndation ~ ' To ~o~rty ni~ /~ '~ To Die.esl Field /O ' To ~ter ~/~rvi~ Li~ ~ '~ To S~e~, Pond, ~ke, ~ ~jor ~aina~ Co~ ~ ~ ~ ~ Comments A~ O ~ ~ [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Installed ~/~ 9z Date Width of Field ~f)" '/ i9.54 Zdp ~,/ - Type of System Desigh ~ngth of Field Gravel Bed Thickness . Square Feet of Absorption Ar. es ~O ~ Standpipes Presen't (~) Depression over Field ~ Date of Last Adequacy Test Results of Last Adequacy Test ~ Separation Distance from Absorption Field: To Water-Supply Well /~ ¢ ~- To P~operty Line /O To Building Foundation ~- ' To Existing or Abandoned System cn Lot /~ ~) ~-~ ; On Adjoining Lots ~O ~ 7/~' TO Water {Wa-in%/Service Line ~--0 ~ To Cutbank ( if present) ~ TO Stream/Pond/Lake/or Majo~ Drainage Course ~3L9 ~ To D~iveway, Parking Area, Or Vehicle Storage Area ¢~) ' -~ Con,rents ~ ~ ~ ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dime ns ions Manhole/Access (Y/N) Off" Level at Vent (Y~) Pumping Cycles during Adequacy Test. ~eets MOA Counts ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, o~' conformed to all MOA HAA Guidelines in effect on the date of this inspection. Company KB1/d5/s [Pa~ 2 o~ 2] Date ./__./_~ MOA No. 2-15-84