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Home My WebLink AboutLAKEWOOD HILLS #3 LT 31Onsite File Lakewood Hills #3 Lot 31 #015-134-10 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax* (907) 343-7997 http://www.muni.orglonsite �Z_ - ftli_ Jepartinent On - Site Wastewater Disposal System Permit Permit Number: OSP201428 Effective Date: 10/16/2020 Work Type: SepticTank Upgrade Expiration Date: 10/16/2021 Tax Code Number: 01513410000 Site Legal Address: LAKEWOOD HILLS #3 LT 31 G:2540 Site Mailing Address: 7600 UPPER O'MALLEY RD, Anchorage Owner: KELSON NADYA TRUST Lot Size in Sq Ft: 16000 Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 3 This permit is for the construction of: 0 Disposal Field 0 Septic Tank 1771 Holding Tank 0 Privy 171 Private Well d 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 (1 8AAC72) and Drinking Water Regulations (I 8AAC80) 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 1. Once separations to surface water and wells has been established, the distance between the septic tank and absorption field shall be maximized (up to at least 5 ft if possible). Any required waivers shall be applied for with the inspection report, if required. 2. A ROW permit shall be obtained for the absorption field located partially in the Utility Easement prior to inspection report approval. am= : Date Date: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201428, Rebecca Carroll, 10/16/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201428, Rebecca Carroll, 10/16/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201428, Rebecca Carroll, 10/16/20 " Municipality of Anchorage Page / of ~-- , DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~'/.~'~.,~._~9~) PID Number: ,~m~6~ ~ ~ ~F~~ ~astewater System: ~New U Upgrade ~ ~,~~ ~. ~[~ ABSORPTION FIELD Phone: No. of Bed,s: ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION SoilRating: ~'~ GPD/Sq. Ft. Total Depth from original gr~d~: / Lot: ~/ Block: Subdivision: ~pth to pipe bottom f rom origina~ad~: Gravel depth beneath pipe Township: Range: Section: Fill added above original grade:~ ~Ft./ Gravel length: ~ /Ft. Number of lines: ]Distan~een lines: WELL: D New D Upgrade Gravel width: ~/ Ft. / I '2/~ Ft. C~ication (Private, A,B~): ~ Total Depth: Cased To: Total absorption area: Pi~e material:~/~ Driller: Date Drilled: StabcWaterLevel:F,. Installer:~~ ~¢~ Dateinstal Yield: GPM Pump Set at: Ft. Casing Height Above Ground:Ft. TAN K SEPARATION DISTANCES ~Septic D Holding B S.T.E.P, TO Septic Absorption Lift Holding 'ublio/Private ~:ctur, r: . Capacity in gallons: From Tank Field Station Tank S .... Lines ~ ~~~ Well /~¢ /~/ ~ Z~ Material: Number of Compartments: Su,f~w~r /~/~' II~' ~ ~ ~ LIFT STATI~/ ~ot /~ / /W / ~ S~z~,.ga,,o.~: Line ~ .ound~,ion 14' Z~' ~ ~ ~ ".um.o.".~"".=. Curtain _ Electrical ~.ain ~ ~O~¢ l~,~Z .~m~Mod~, ,ns.~,,onsp~r,o.m~.: Remarks: BENCH MARK Location and Description: ENGINEER'S SEAL Inspections performed by: 34E~leE~erL~d,~ 1st ~, /,~ ~"' Eagle Ri~er, Alaska ~577 2nd ~/~ Department of He d Hua rvic~s appr~all Reviewed and approved by: ' Date' / ~ / 72-013 (Rev. 9/91) MOA 25 Permit No. S~,~!930Z00 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LAKEWOOD HILLS #3, LOT 31 Legal Description: PID No..0151'5410 CO1 N.T.S. C02 99'- ~-...- 9s.~' MT C04 87.3 · 81.3'N0 WATER FOUND UTIL. E i A B FC0 24 6.5 C01 34.5 15.5 C0M 37.5 21.5 C03 54.5 33 C04 25,5 38,5 MT 34 g7.5 ~RENCH ~ 3 BDRM. FOUNDATION 100' WELL RADIUS 100' WELL RADIIUS o looo ck'h TANK SCALE f' = 40' 72-013 A (2/91) MOA 25 ENGINEER'S SEAL .. .::~-~.', '~.'~t'~'~'- ~ ~ ~" %,; 2 · ,: ,',:.~ V/ ~ '~,~' ._. 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930300 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:ALASKA CORP OF SEVENTH DAY OWNER ADDRESS:6100 g'MALLEY ROAD ANCKORAGE, AL 99516 DATE ISSUED: 8/13/93 EXPIRATION DATE: 8/13/94 PARCEL ID:01513410 LEGAL DESCRIPTION: LAKEWOOD HILLS #3 LT 31 LOT SIZE: 16000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / 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 (18AACS0). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ~'~, - ISSUED BY: / / DATE: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. AuguSt 9, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH 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 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L. Street Anchorage, AK 99519 REFERENCE: Lakewood Hills Subdivision, No. 3, Lot 31 We request you issue a permit to drill a well and install a septic system to serve the proposed 3 bedroom houSe on the referenced property. A test hole was excavated and percolation test performed on the above referenced property. The approximate location of the test hole is located on the attached site plan. Th~ property has enough area for a fu~e septic upgrade, which can be seen on the at~ched site plan. We do not anticipate any adverse effects on n~ighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact uS. ERT A SHAFER, P.E~As/gk . 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502~0650 SOILS LOG -- PERCOLATION TEST Township, Section: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19- 20- WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? P E Depth to Water..A,J~,-~,? ;, ~'~ I~onitoring? ~ Date: Gross Net Depth to Net Reading Date Time Time Water Drop ~ : ~1~ ;~ ~ ~/'~ .Y.~ , ~:SI 2 H PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN C~,E-'~ FTAND "~',~ FT COMMENTS PERFORMED BY: ~ g 5 EI~GINFgI~IN6 I "~" ~ -~ CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eanle River Looo RoadNo. 2~ T ON T~IS D ~¢ ~ ~ ~C;~,%. ACCORDANCE WITH ~.~.N~~¢UIDELIRES"IN EFFEC ATE. DATE: ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lakewood Hills Subdivision, No. 3, Lot 31 GENERAL: 1. o o The scope of this project includes the installation of a 1000 gallon septic tank and a leachfield trench to serve the proposed three bedroom residence on the referenced property. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. o The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. o Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. Page Two Lakewood Hills Subdivision, No. 3, Lot 31 August 9, 1993 o A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched ruffed- up) before gravel (sewer rock) placement. o Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. o A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page Three Lakewood Hills Subdivision, No. 3, Lot 31 August 9, 1993 MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank 9roposed for installation must be constructed by a Municipally approved septic tank manufacturer. o The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Perforated Solid Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal A permeable nontoxic silt barrier (Typar 3401 Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. Page Four Lakewood Hills Subdivision, No. 3, Lot 31 August 9, 1993 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. o The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. o The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. (907) 243-2282 FAX: (907) 243-4852 JOHF $OH DR LUNG WATER WELL DRILLING PUMP SALES AND SERVICE 38 Years Alaska Drilling CO. SEPTEMBER 14, 1993 THE BLOMFIELD COMPANY TONY BLOMFIELD 560 EAST 34TH AVE. SUITE 105 ANCHORAGE, ALASKA 99503 LAKEWOOD HILLS # 3 LT 31 KEN JOHNSON 3163 LINDEN DRIVE ANCHORAGE, ALASKA 99502 RECEIVED SEP 2 t 1993 Municipality of Anchorage Dept, Health & HUman Services VATER VELL LOG 0 FT TO 37 FT 37 FT TO 47 FT 47 FT TO 55 FT 55 FT TO 103 FT 103 FT TO 123 FT 123 FT TO 134 FT 134 FT TO 147 FT 147 FT COURSE GRAVEL & BROWN SILT SAME WITH COURSER GRAVEL ( TIGHT ) MED. GRAV & BRN SLT ( DRILLS OPEN 3~ ) FINE GRAV & BRN SILT ( OPEN HOLE 8' ) SAME WITH CLAY TEXTURE ( WEEPS H20 ) SANDY BRN CLAY SEAMS..HEAVES SLIGHTLY. DIRTY FINE GRAV & SAND.. WITH H20.. HEAVES 12 FT. CLEAN MED. & FINE GRAV & SAND..WATER BEARING., TEST BAILED ONE HOUR STATIC WATER LEVEL 75 FT. BAILED AT 15 GPM DRAWDOWN 20 FT. ( 95 FT ELEVATION ) BOTTOM STABLE LEFT 18 IN. GRAV IN CASING. TOTAL CASING 146 FT. 7 IN. KEN ,JOHNSON CWD/PI NWWA CERTIFIED 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 015-134-1~' HAA# 1. GENERAL INFORMATION Complete legal description Lot 31; lakewood Hills Subdivision ~3 Location (site address or directions) 7500 Upper O'Malley Road Property owner Mailing address Lending agency Mailing address Carrie Blomfield 7500 Upper O'Malle¥ Road, Anchorage, Day phone 274-5510 Day phone Agent Jack White Realty Day phone 563-5500 Address 3201 "c" Street..quite 2flQ~ An~hnr~g~ AW 995flr Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ ~' 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 o'f system. 4. TYPE OF WASTEWATER DISPOSAL: 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. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER 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 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 Environmental Manaqement,:nc. Phone 272-9336 Address 206 E. Firew~ l~., ~ite ~/, Anchorage, DHHS SIGNATURE ~_ Approved for 99503 Date ~/)'-~'/'~ o/ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is continued suitability. Nitrate concentration is 5.8 mg/1. EPA .mum coi~cen~ration ~s i0.0. rog/1. 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-(Y25 (F'ev 1,~1 ) Bacx MOA ¢¢21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 Health Authority Approval Checklist Leg~Descripd0n: Lot 31, Lakewood Hills Subd. ~3 P~cel I.D.: A. VqELL DATA Well ~pe private Log present (Y~ yes Total depth 147 ft. Sanitary seal (Y/I',9 yes If A, B, or C, attach ADEC letter. ADEC water system number Date completed 9/14/93 Cased to 146 ft 7 irCasing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 5/24/96 FROM WELL LOG AT INSPECTION 9/14/93 5/24/96 75 ft. 80 ft. 15 g.p.m. 6 B. SEPTIC/HOLDING TANK DATA Nitrate 5.80 Other bacteria Collected by: Chad Helgeson Tank size3000 gal Number of Compartments 2 Cleanouts (Y/N) N ~figh water alarm Y Depression (Y/N) N Pumper Rotor Rooter Date installed 9/8/93 Foundation cleanout (Y/N) Date ofPmnping. 5/28/96 C. ABSORPTION FIELD DATA Date installed 9/8/93 Length 47 ft. Soil rating ~or ft2/bdrm) 0.8 Width 2.5. ft. Gravel thickness below pipe 4 inches yes System type Deep trench 6 ft. Totaldepth 11.5 ft. Effecfiveabsorpfionarea 564 sq.ftMonitoringTubepresent(Y/N). Y Depression over field (Y/N) N Date of adequacy test 5/24/96 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test (in.); 0 in. immediatelyafter590 gal. wateradded (in.): 4 in. Fluiddepth 0 (ins.) Minutes later: 20 rain Absorption rate = 7104 _g.p.d. Peroxide treatment (past 12 months) (Y/N) N If yes, give date D. I,IFF STATION Not Applicable Date ins~/led Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Damm "Pump off' level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 118 fL. ; On adjacent lots 120 Absorption field on lot 110 ft:. ; On adjacent lots 130 Public sewer main 100+ f'c. Public sewer manhole/cleanout 100+ Sewer/septic service line 100+ Et:. Lift station Not: ApplJ_cab]_e SEPARA'HON DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Buildinglbundation 15 £t:. Propertyline 20+ t~t:. Absorption field 3 1St:. Water main/service line Surface wateffdrainage 101 fi:. Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Btdlding foundation 18 ft:. Property Line 10+ fi:Water main/service line S,fface water 104 flz. Driveway, parking/vehicle storage area 24 Curtain drain 100+ fi:. Wells on adjacent lots 101 1~ NGINLER S CERTIFICATION .:,' I certify that 1 hq~e determined thrufi/~ld inspections and review ofMunicip'a..l rec~l~Ftthe in conformance/~it~OA I~!~A gu~J~lines in effect on this date ;' ['~?/,.t,.t z/ -- -- t // ' '9,, %,'".. ..- .. m l eo 049 Date of Payment ~/g//r~7 ~' Rev. 8/95 DSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number 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 AU'T'HORITY APPROVAL FOF~ A SINGLE FAMILY DWELLING Parcel I.D. # ¢'/1~-\%~/- IR 1. GENERAL INFORI~ATION Complete regal description Location (site address or directions) Property owner Mailing address 7500 Upper O'Ma~le~ Road Th6 Blomfield Co. Day phone 562-2766 560 E. 34th Ave. Suite I05 Anchorage, AK 99503 Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NU~.IBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: XXX Individual well Community well Public water ff community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: XXX Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 tRey. 1/91) Front MOA ~21 5. STATEMENT OF INSPECTION BY.ENGINEER '17034 Eagle River Loop Road/~ Address Eagle River, Engineer's signature /×/ 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 typeofstructureindicated herein. I furtherverifythat based on the information obtained from the Municipality of Anchorage files and from my inves_tLgation and inspection, the on-site water supply and/or wastewater disposal system is in compliance wit.~b_h ~1 Municipal and State codes ordinances, and regulations in effect on the date of this ~.spbction// Name of Firm S ~~--'ff. INC- /// /Phone 2 Date .-~ 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. /~. Conditional approval for ~ bedrooms, with the following stipulations: Additional Comments ~ote, mh¢ ~¢~ ¢~ ~h%~ ~~ m¢¢~ ~t-4~ State and Municipal Codes. There are nitrates present. It is ~~that a p~iodic tcsting-bc pcrfcrmed %~-~ure ~ells is 5.98 mB/1. EPA 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 engineeFs work. 72-025 (Rev. 1/91) Back MOA /~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: lOT' $1 /_~/,<;~ H/L.L_5 ~]~Parcel I.D. A. Well Data Well type .~ I ( / A"i-~~- Log present (~N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~J/l~-/ ~/3 Driller Total depth 1~9 ( Sanitary seal (~)N) T"~-5- Date Of test Static water level Well flow Pump level1 Cased to IZ/~,' ?/f FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/,b~l~q~tank on lot Absorption field on lot / Public sewer main ~'/Y''- Sewer service line Casing height Wires properly protected (Y/N) g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank AT INSPECTION m '-r WATER SAMPLE RESULTS: Coliform 0 Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/H~4~TANK DATA Date installed ~/ Cleanouts~N) High water alarm (Y~-~ Date of pumping ~EM Tank size /0/.)O ~A C_ Compartments Foundation cleanout(~N) ~.,r Depression (Y~]) Alarm tested (Y/N) - Pumper · /CY/~ SEPARATION DISTANCES FROM SEPTIC/NG~DT~-,,,~ TANK TO: Well(s) on lot /~ ~>~ On adjacent lots /'~ ~ Foundation To property line I'J Surlace water/drainage 72-026 (3/93)* Front Absorption field ~'~ 1o1.$' Water main/service line CONTINUED ON BACK PAGE SEPARATION DISTANC~ATION TO: Well on~t~ On adjacent lots D.'~ABS;RPTION FIELD DATA Date installed ¢'/~/~..7 Soil rating (GPD/FF) C. LIFT STATION /~o~JC~. [~ESE~7~ ~ Date installed Manufacturer . Size in gallons Manhole/Access (Y/N) ~ .... ~el at Vent (Y/N) "Pump on level at ~' High water alarm level ~"~t~s tested Meets MOA electrical codes (Y/N) Surface water Length z~g' Width Total absorption area .~'~,~ Date of adequacy test ^.)Ek/ Water level in absorPtion field before test Peroxide treatment (past 12 months) (Y8 (_.~. (~ Systemtype DE£P ~kK£/,.)c_k/ ~: ,% / Gravel thinness ~ / Total depth / ~ * Cleanout present'N) ~E% ~ ~epressbn over field (Y~ ~ o Resu,s (pas~fa,I) *~ for ~ CT~ ~*~) Beer. ms ~//~ A~er test ~/A ~ O If yes, give date ~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~OO/+ To building foundation On adjacent lots P- 0 Surface water / I0 ~ On adjacent lots / OO / Property line /O To existing or abandoned system on lot ¢,Jok)E. Cutbank ~O¢.~E ~o,¢_e%E/,JF' Water main/service line Driveway, parking/vehicle storage area .¢ Curtain drain ~Jo/..JE ~,,4Uoc. O/~a E. ENGINEER'S CERTIFICATION ,cerfifythatlhavechecke_~d, verified, ~,u ........ ~4 ~gle River o EngineeCs N~gl~ H~ Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number Commercial Testing & Engineering Co. Environmental Laborstory Services LABORATORY ANALYSIS REPORT CT&E l.[ef.# 94.1247-11 Clleatt 8ample ID 131 LAKEWOOD 1 Ill ,I ,S S/D ~f3 Matrix WATER (21ientN~'trrte S & S ENrBINEERTN(i' Ordered By R. 8HAFEK project Name PWSID WOt~ Order '/6883 Printed [)ate 03/2.8/94 ¢)..'.' 12:10 ]u's, Collected r.}at¢ 03/23/94 ~./j 18:48 hfs, Rx:ccivcdI~ate 03/24/94 (.c_~ 09:30 hrs. 'l'ect'ml cal Director sTEPHEN C, 151) '.' QC Allowa[,le Ext. Ampi I'armnctcr Rcaul~:~ Qual Unit;s Med:~od l.mii[~ Bate Dare [nit --~'"'~rTa~'~'~ ................. 5,98 mg/L EPA 353,2/30(;.0 i0 03/25/94 I.LH * See 8p,;¢J. al lnstmcti, on.~ gbovc I.;A= [Jp.a,,'aih~ble ** SccS~nplel{em~k~ove, · '- i , . ' L'r=Less~um. D = 8~on~'y ~ll~ion. 5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (9071 ~61.5301 ...................... ~NVIRONMENTAL FACILITIES IN A~SKA, COLORADO, ~LORID;',, Ii .t.tNO~8, MARY~ND, NEW J~.RSEY, ONTO, UTAH. W~ST VIRGINIA