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HomeMy WebLinkAboutBLUEBERRY HILL BLK 1 LT 5Blueberry Hill Block 1 Lot 5 #050-202-23 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON -SITES AGE DISPOSALS STEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW ❑UPGRADE MAILING ADDRESS v v V — LEGAL DESCRIPTION L s� /44-' /4Z�P LOCATION 617NO. OF BEDROOMS UY DISTANCE TO: Well fir` �N� Absorption area I Dwelling PERMIT NO. aQ w�ck Manufacturer Material No. of compartments y Liq. capacity in gallons II4. V IF HOMEMADE: Inside length Width Liquid depth 0❑Z DISTANCE TO: Well Dwelling PERMIT NO. O Z < Manufacturer Material Liquid capacity in gallons ❑ w = DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. J LL Z �ZW No. of lines Length of each Ii / Total length o Iipes� (�� Trench wid inches Distance between lines E� ❑ Top of tile to finish grade f Material beneath tile ��. � J�- s -- Total effectiive absorption area LU c7 Length Length Width Depth PERMIT NO. Qa F wa Type of crib Crib diameter Crib depth Total effective absorption area y DISTANCE TO: Well Building foundation Nearest lot line J ClassA� A / r p4L Depth Driller Distance to lot line PERMIT NO. W ;t DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS j� n SOIL TEST RATINGIV INSTALLER REMARKS 0 APPROVED DATE LEGAL 72-OT3 (ReFi, 37%8) C/ 0 ��n L_ I IF *-e 13 F::- Fl r-4 0 VA ED FQ F1 C3 ET DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION r~� 825 '| STREET/ ANCHORAGE, HK. 99 1 /»u 264-4720 do C4 K L_ L_ FA VA CA V-4 I IF I -E E: L-4 EE F-* ��F-�_ Pl I IF PERMIT NO. ( 810315 APPLICANT STEPHEN G STORTZ PO BOX 4-689 99509 24] 95 G. /7--- / LOCATION SHEPHERD ROAD �1/&�LV�/u�- LEGHL L 5 B 1 BLUEBERRY HILL S/D LOT SIZE 56000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)= 275 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E> K F" IF VA= IL CA L_ EZ vA w IF v4= a w C3 K F4 41 K L_ E> E= F" IF VA= efF. THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE 15 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). ��law U I F-". E-:: C-- ES E- F:""T I C_- 'T n N K I :---" F-= ::L CA El CA 13 F4 L_��I N -'-. PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. ___ IF4 r_-1 r";2 > 11*4 ES, F:F= 0 IF I IZ:l " *=-. n FR E: F..." E: fl)l U I F-_' E-_ EN BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F* E- FR. M I IF �X F=* I FZ E: *-=. ����M E?- F= F:;-:-" ��. ���1L I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. ________________________ SIGNED:_ __ _ _ ___________ / APPLICANT STEPHEN G. STORTZ � ISSUED BY___�1_________________________DHTE_=�AAWS ------ Y4.0 MUNICIPALITY OF ANCHORAGE Department f Health and Environmenta ?rotection 825 Street, Anchorage, AK. 99501 264-4720 # # # HANDWRITTEN PERMIT # # # WELL AND/OR ON-SITE SEWER PERMIT Applicant: ST.E 1 PE/V 4'. STO'2TZ Mailing Address: ?p. BOK yC - (Qg9 Location: 51152AULp bk. Phone Number: a 4t3 - (a 95'0 Legal Description: LS- 94 / J�itlF QC20 y Ai I/ Lot Size: S'(n ®O© Type of Soil Absorption System Is: Trench: L,-_ Drainfield: _ Seepage Bed: Holding Tank: Maximum Number of Bedrooms:_ Soil Rating(sq.ft/br) ;�L-7_ 5" The Required Size of the Soil Absorption System Is: DEPTH %�, LENGTH 931 GRAVEL DEPTH (0 WIDTH 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 minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE GALLONS # # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number 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. Minimum 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. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days o -f the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * PERMIT EXPIRES DECEMBER 31, 1 9 3 1 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the esi nce is re odeled to include more that 3 bedrooms. Signed: - Issued by: 1_1L App cant Date: SWP/024(1/81) December 31, 1979 Stephen G. Stortz Post Office Box 4-689 Anchorage, Alaska 99509 Permit # 790254 Subject: Lot 5 Block 1 Blueberry Hill Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If an engineer has inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any further questions, please contact this office at 264-4720. Sincerely, C4 /n Les N. Buchholz, R.S. Senior Environmental Speci`st LNB/ljw enc: Copy of Permit -3. 'AG[ A R I-ASKA 99501 Al 1 F N 1 F H F i i N F F CT 10 N December 31, 1979 Stephen G. Stortz Post Office Box 4-689 Anchorage, Alaska 99509 Permit # 790254 Subject: Lot 5 Block 1 Blueberry Hill Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If an engineer has inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any further questions, please contact this office at 264-4720. Sincerely, C4 /n Les N. Buchholz, R.S. Senior Environmental Speci`st LNB/ljw enc: Copy of Permit rwl k.1 phs :1 C3 71 | "11.. 1 -1- "w" p:f I" K r4 C::.4, -.1 i!::::::p�� DEPARTMENT OK HEALTH AND ENVIRONMENTAL PKOTECTION 825 'L' STREET, ANCHORAGE, HK 99501 264-4720 RAI FEZ �1... 901114131 13 1`41_15 :1 -T_ E47 15 K 1"I EK I;? &K lot IQ K 4' PERMIT NO. ( 790254 ) .' APPLICANT STEPHEN G. STORTZ PO BOX 4_689 - 99509 . LOCHT[ON LEGAL L5 B1 BLUEBERRY HILL LOT SIZE 56000 SQUARE FEE'!'' TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ~FT/BR)= 275 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: a FEZ io, -r- wi= w. a ��11 T �= ���� �������� ���0F�= � THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. T E DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE THE GROUND HND THE BOTTOM OF THE EXCAVATION (IN FEET) ' THERE IS NO SET WIDTH FOR TRENCHES. - THE GRAVEL DEPTH IS THE MINIMUM DEPTH OFGRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET) Fit FEZ K0 t.j :1 Fit EH nN EE F" Ir 1 C0 0- 901 p"l lot n1v :1 G, Q! E3 F4 L, _c" P4� ` PERM,IT APPLICANT HAS THE RESPONSIBILITY TO INFORM T -IS DEPARTMENT DURING THE INSTAL49TIOWINSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBEROF RESIDENCES THAT THE WELL WILL SERVE. --- --- --- -y- lAj 0 12 it > 1: IRE CD -r x C3 0`4 13 F1 PC E��:: R";;;::! R*:��:"') ___ BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SU�JECT'TOPROSECUTION. MINIMMI.DISTANCE BETWEEN H WELL HND HNY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR P PRIVATE WELL/ OR ' 150 TO 200 FEET KOWA PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS HRE HVHILHBLE`_TO INSURE PROPER INSTALLATION. I K NET 14 FA 1 F? EE: n5 Ew EE ������ it 1. ���� ' I CERTIFY T ` 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SZTE,SEWERS ANO WELLS AS SET FORTH BY THE MUNICIPFLITY OF ANCHORAGE, ` ' ' 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] SJGNED� ___.... ..... __ .. . ~^~.,. STEPHEN .. ~^CL " . ��� ^� ' / 11 �J ^��� / � I HTE___ _�-/ _ /-� LJ�� 0 Et E GEC ECHNI CAL & DEVEL RMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL LOG 688-2280 Soils b Foundations Land Development Performed for: Name: 3 rf f1- .fX1 :!57-. 5 -roe Tp- Tel. No. Mailing Address: P, a, gox 4-65'9, AN��o.e,��E, 4A, , S9S-0? WIZZ Legal Description: dor 5, Depth (feet) 0 1 2 3 -� 4 5 6 -- - 5 P - 51,(,1 7- 8 9.! 10� 11213 11- 12- 13 -- 14 Soil Characteristics �yEPP'��Z p I 4iNE SltTY aAe4f/E4.,i-Y :5; ewD Ta /7, "q6 P45 ^Ps-/ 7- it �So�1� `ac,eFT3 4� .C�i�dEs OFFD 7V.4es+E 0 2 - 7 �0/0' A F/1C°. �g'//FST afJ/1�rri 15 5 P 45,gV---4c Y 5gwp , T,I o EsT z s �yy 1 1144E0. Z�eAlJE 7V Z>--1V-5,C, .X0-6OTTD� 0/'c t'/T Ground Water Encountered: Yes Nom If yes, what depth` Proposed Installation: Seepage Pit Drain Field_ Comments: Performed by:Date:- 7 SRR 196x r1i,er, Alaska 99577 C APUTATION SHEET SUBJECT: S VI-c—le', I !Ai L.", DATE: SHEET BY — CKD. OF C�,eriifirD Britting lkaig by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759 OWNER OF LAND ;°-� t"" %i;,' !:„ DEPTH OF WELL ADDRESS io- 0 A.,04 -7 7- �4 f , 1'- / STATIC LEVEL OF WATER FT. LEGAL DESCRIPTION 5 i3e-. / 414 F, eE &C .f RAW DOWN FT. DATE - 21�2 Ended _�_� GALS. PER HR+ PERMIT NUMBER KIND OF CASING KIND OF FORMATION: From C) to Ft. � ire (/.��t�r -- From. Ft. to Ft. From Ft. tom Ft. J-4,44 + �, s9y t �'1'� . i' From, Ft. to Ft. From l L Ft. to_j. Ft. wa' Edi From Ft. to Ft. From Ft. to (), Ft. a 4r,lee»_ From Ft. to Ft. From —Ft. to Ft. j?0 04 — From Ft. to Ft From "4 Ft. tom,: AO Ft. �&�4 4c ^From Ft. to Ft. From_ Ft. to Ft. 2 C, {; ll?i-t" From Ft. to Ft. From i:, Ft. to Ft. 4 From_ Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. _ From Ft. to—Ft. From _Ft. to Ft. —v From�F9t� From Ft. to Ft. From Ft. t yt50� From Ft. to From Ft. to Ft. Ft. From From Ft. to Ft. NO17310Nd 1d1N31'N0 t-gty ' Iia 3,- tld'Ci From Ft. to Ft. From OR:) NV 40 111iddollvm 30 Ft. to Ft. From Ft. to Ft. From Ft. to Ft. — From Ft. to Ft. From Ft. to Ft MISCL. INFORMATION: a_ DRILLER'S NAME . f f Municipality of Anchorage • '� Development Services Department -` Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us !' (907) 343-7904 fig CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-202-23 COSA# o sc-1 (02 1. GENERAL INFORMATION Expiration Date: /0 ' ( - - Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address BLUEBERRY HILL; BLOCK 1 LOT 5 21916 SHEPPARD DRIVE *EAGLE RIVER AK 99577 KELLY SMITH Day phone 240-8108 21916 SHEPPARD DRIVE *EAGLE RIVER, AK 99577 Day phone DAR WALDEN W/ KELLER WILLIAMS Day phone 865-6406 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (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 water samples. (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. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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. 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation. -GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system unde.- the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Phone 337-6179 Date _oo�op�/40 a . . ... ey A. orness, CEy 793 0 ` Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory Other By: (Rev. 11105) ON-SITE WATER AND WASTEWATER PROGRAM Original Certificate Date: - / C 5 - Municipality of Anchorage s • '� Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description:' BLUEBERRY HILL; BLOCK 1, LOT 5 Parcel ID: 050-202-23 A. WELL DATA Well type PRIVATE *CASED TO BEDROCK If A, B, or C provide PWSID# N/A Date completed 6/9/82 Sanitary seal (Y/N) YES Total depth 180 ft. Cased to *2941 ft. FROM WELL LOG Date of test 6/9/82 Static water level 105 ft. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) PITWELL in. u;E Gc.rF.?�"rF�D AT INSPECTION wises 6/20/12 t M3 A)�t? 109 Well production 6 g.p.m. 3.94 — 9 -p.m -WATER SAMPLE RESULTS: Coliform d colonies/100 ml. Nitrate Q-�g%g./L. Collected by: GEG. Ltd. Arsenic: N ug./L. Date of sample: 6/20/12 B. SEPTIC/HOLDING TANK DATA *CLEANOUT INSIDE HOUSE Tank Type/Material SEPTIC/STEEL Date installed 7/2/81 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) *NO Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 6/13/12 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA Date installed 7/2/81 Soil rating (g.p.d./ft or /bdrm 275 System type DEEP TRENCH Length 46 ft. Width 4 ft. Gravel below pipe 12 ft. Total depth *15.08 ft. Eff. absorption area 1104 ft Monitoring tube **YES Depression over field NO Date of adequacy test 6/20/12 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 71 in. Water added 600 gal. New depth 94 in. Elapsed Time: 120 min. Final fluid depth 90 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date **MT ONLY EXTENDS 130" INTO EFFECTIVE. D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons Manhole/Aocess "Pump off" level High water alarm level Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankili t station on lot *94' On adjacent lots 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line It) 1+ Building foundation 10'+ Water main_ N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *EXISTING WAIVER ON FILE WITH MOA G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSH guidelines in effect on this date. Engineers Printed Name JEFFREY A. GARNESS Date 7 � / i COSA Fee $ q 6 Date of Payment w/,42 Receipt Number C)CJ,a (Rev. 11105) Waiver Fee Date of Payment Receipt Number Y ................ hat Gn 9 A .' � (>b':. � �._._. evotwa Noe. • � �'• all 44 -� '37 ?�• .,f a •!� .�a ? N � �'e..w. [ i •'t.:y 't' � � -y y :'.,. f ri .'�' JIMMT ' .. J herebyorrdt .that 1 have soave fhe Wllew4�g dtiekkb r . ( 1 1 . Anchorage Recording PMkntl, A"&, and that ON impmo mettle eiruued thete0tt are within she Property tinea and do n ,: ;.. ;:....,• { �. overtop Or enrmid an the property tyutg ad)aant tlraraw, ih �:''"::r t', ' `: no hnpmvemmte on property kyt� ad�eaent the"tam m on the in ?' .:. .• , pro**" gvee8°n'and that fhde am noaad" tranambeian tine, oralta vtelbie eaeemom e,l said .�g•.�-••• •••.••. �,r.. prapa Datede ae inp by hewn. Daied�a{E�arRLr River, Aboks . '.. '. r.: - • a F.L., . ,_ . ::'. r thu d•of ,' 1q.Q y • ...: .. • ROl>ER'1' C. jdi{ld50N� ' SCAM iAgWerad tand 5mveyar No.10M r 7744%W vdr. AW6 99V pKa(Suit M _ ---� Municipality of Anchorage #.� Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 14 I CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION 7/-5/a3 HAA # Expiration Date: 10 -2-19 03 Complete legal description Blueberry Hili Block 1, Lot 5 Location (site address or directions 21916 Sheppard Drive, Eagle River, AK., 99577 Current Property owner(s) Pinkie Bailey Day phone 278-7575 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public 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 Department (DSD) Issues Certificates of Health Authority' Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 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. (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. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 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 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 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 KND ENGINEERING, Inc. Phone (907) 696-6111 • . • n ['1' 1i1�Pta�T. Engineer's Printed Name Kenneth M. Duffus Date 7/25/2003 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, KND can not give any estimate of how long a system will function satisfactory for current or future occupants or can KND guarantee that no unseen encroachments, deficiencies or discrepancies exist. S. DSD SIGNATURE _Itff'00' Approved for 3 bedrooms. Disapproved. .'�. OF Al �tr %%ROFESSO �_� OFr�/Oy/��� • • '•.•D,p�� J : ON-SITE WATERAND : n' WASTEWATER PROGRAM J Q •. •• ` �J:0"/ J j�"'MENT S�j�)�l Conditional approval for bedrooms, with the following stipulations: ���/))/»llltt� Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: 7 - ? s, 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 W=.ci.anch==.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Blueberry Ji(l J11, 1-5 Parcel ID: 050.202-23 A. WELL DATA Well type private If A, B. or C provide PWSID # Date completed 6/9/11982 Sanitary seal (Y/NLY _ Total depth 180 ft. Cased to 29.E ft FROM WELL LOG Date of test I„[9 / 1 9 8 Static water level 1 0 b ft. Well production 5 9 -p.m WATER SAMPLE RESULTS: Well Log (Y/N) Wires properly protected (Y/N) Y Casing height (above ground) <0" AT INSPECTION 1 0 3 ft. 3+ g.p.m. Coliform Q colonies/100 ml.Nitrate 0.517 mg./I.Other bacteria _D_colonies/100 ml. Arsenic: JU mg.A. Date of sample: 7/8/03 $s_ 7/21/03 Collected by: KND Engineering B. SEPTICIHOLDING TANK DATA Tank Type/Material ASEPTIC/STEEL Date installed 7/211981 Tank size 1250 gal. Number of Compartments2 Cleanouts (Y/N) Y Foundation cleanout (Y/N)Y.Depression over tank (Y/N)ja_High water alarm (Y/N) 11 Date of pumping_ J/22,/2Q02 Pumper J.R.'$ C. ABSORPTION FIELD DATA, Date installed 7/2/1981 Soil rating (g.p.d./ft2 or fP/bdrm)-VLft21xUm System type DEEP TRENCH Length 46M $. Width A.0 ftGravel below pipe 12.0 ft. Total depth JU ft. Eft. absorption area 1104 fie Monitoring tube y Depression over field N Date of adequacy test 512, 3/2002 Results (Pass/Fall) PASS For.3_ bedrooms Fluid depth in absorption field before testes in. Water added 450 gal. New depth PA& in. Elapsed Time: 1080 min. Final fluid depths]. in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) If yes, give date 0 D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at_ in. "Pump off" level at in.Hlgh water alarm level at in. Datum Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot 94'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer /septic service line 25'+ On adjacent lots 10 0 ' + On adjacent lots 10 0 ' + Public sewer manhole/cleanout 100'+ Holding tank 10 0 ' + SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5 ' + Absorption field 5 ' + Water main 10'+ Water service line10'+ Surface water 10 0 ' + Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10 ' + Water main 10 ' + Water Service line 10'+ Surface water 10 0 ' + Driveway. I parkingtvehicle storage 10 ' + Curtain drain 50'+ Wells on adjacent lots 10 0 ' + i F. COMMENTS E Field surcharged with 2000 gallons 24 hours prior to test. MOA G. ENGINEER'S CERTIFICATION waiver for well pit. :%'i OF 44 NI 1 certify that I have determined through field inspections and MONO „y �,.•' •'�.• ¢q �,' review of Municipal records that the above systems are in conformance with MOA HAA in effect on this date. guidelines ..� a.p • "• • Engineer's Printed Name Kenneth M. Duffus g %elk " f• Kenneth M. i uffu tQ� Date 7/25/2003 � •;"1"4'/ % CE 7716 �� JI` •. vAW HAA Fee $375.00 % ��� Waiver Fee $ Date of Payment C�� 3 Date of Payment 4i Receipt Number YSZ c Receipt Number (Rev.12AI) KND ENGINEERING, INC. 20441 PTARMIGAN BLVD. EAGLE RIVER, AK 99577-8736 (907)696-6111/FAX (907)696-8111 July 25, 2003 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: HAA — Blueberry Hill Block 1, Lot 5 Gentlemen: The owner has requested we proceed forward to obtain an HAA on the subject lot. On March 23, 2002 an adequacy test was performed on the existing system, and it was -found to be adequate._, Water samples were taken at.that.time and were found to be_._ with in the city limits for nitrates and bacteria. The owner at that time did not sell the house so no HAA was obtained. In July, 2003 we were contacted again and asked to obtain an HAA for the subject property. When new water samples were taken on July 8, 2003 the bacteria came back with 99 other bacteria with fecal. As a solution to dean the water system, the well was chlorinated on July 11, 2003. On July 21, 2003 water samples were again obtained and the bacteria was 0. If you have any questions, please contact me at 696-6111/FAX 696-8111. Respectfully submitted, XND Engineering Kenneth M. Duffus, Attachments: Survey as -built HAA blue sheet HAA brown sheet Water sample results "I 7-15-03 03:49PM FROM -CUE ENVIR MENTAL SRV r' 1 SGS Ref# 1034057001 Client Name KND Engineering Project Name/# Blueberry Hill B1, L5 Client Sample 1D Blueberry Hill B 1,15 Matrix Drinking Water 9075615301 T-366 P.02/03 F-866 All Dates rimes are Alaska Standard Time Printed Datell7me 07/15/2003 10:58 Collected Date/flme 07/08/2003 15:45 Received Daterrame 07/08/2003 16:30 Technical Director Stephrn C. de Released Sample Remarks: Allowable Prep Analysis Parameter Qualifiers Results PQL Units Method CuntainerlD Limits Date Date 1mt Waters Department Nitrate -N 0.517 0.100 mg/I. GPA 300.0 B (<-10) 07/08/03 JS Microbiology Laboratory Total Coliform 99 013"W/Fecal col/IOOml- SM19 92228 A (<=1) 6 c 07/08/03 JS Ot-24-03 12:17PM FROM-CT&E ENVIRON6ENTAL SRV 9075615301 T-475 P.01/01 F-087 r /1 ME Environmental Services Inc. fi Labonstory Division ry�0M 200 W. Porter Drive rinking Water Analysis Report for Total Coliform Bacteria •Andwrajo• AK 88618.1eofi ± F°w��02-23"REAR lNSTRIJCTAWS ONREVEE SWEBEFORE COLLECTING SAMPLE Few- AI a PUBLIC WATER SYSTEM I.D. N X 'PRIVATE WATER SYSTEM ;X -Seed Rstald ke .y�� �. �� �9, Send IRve.. o 40 W -w 3yy� ;Wf= � - +r • coo t3 Seed Rema Q Sead lareke • umm Analysis shows this Water SAMPLE to be: Satisfactory j Unsatisfactory. i t] Sample over 30 hours old, results may be unreliable D Sample too long in ttaneit: sarMle'should not be over30hours old at eiamination to indicateteliable results: Please Send. i new sample via special delivery mail. ; Date Received �• 21'�� Time RetelYtd % 0 q V ! �j 1 Aaalysla BeSan I 5' '' 1 Analytical Method: Membrane Filter Q MMO-MUO 1034448'lk ,*W ml. Result* 0-r Aack FbM Analyati 7' Joe b Fazed Date: 'Time• Client su tiffed of unsatisfactory resultsa PAoned Spoke wkk Dau: Titer. i� lFazed BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUGReralu Total Contorts F- coo Meinbrane Filter: Direct Count Coloalcul40 mi TM Verification: LTB BGB COLIFIRMOC" roe iv.Wrv.dr.Comm Fecal Coliform Confirmation Final Membrane F tr Resu /�,.,�'�/� CoufonN100 tel Reported By pate Time (U6 bra . Comments: Mamt>.r of the BGft Group (SoeiiN GinMak+do SurwiUatta) - n.i icnnNtA PLORIOA ILLINOIS. MARYLAND. MWMIGAN. MtaSOURi. NEW JERSEY, OHIO. WEST' VIRGINIA O ? 4 lu 20' SAMPLE DATE: Month . Day Year SAMPLE TYPE: Routine O Treated Water Repeat Sample (for routine sample . O Untreated Water with lab ref. no. ) C) Special Purpose ' Time Collected SAMPLE LOCATION Collected By �(.,� b r t r`f �+ c �•C 3l , t. �" , to: ems,,., tJ �c� Pkae hi.t Analysis shows this Water SAMPLE to be: Satisfactory j Unsatisfactory. i t] Sample over 30 hours old, results may be unreliable D Sample too long in ttaneit: sarMle'should not be over30hours old at eiamination to indicateteliable results: Please Send. i new sample via special delivery mail. ; Date Received �• 21'�� Time RetelYtd % 0 q V ! �j 1 Aaalysla BeSan I 5' '' 1 Analytical Method: Membrane Filter Q MMO-MUO 1034448'lk ,*W ml. Result* 0-r Aack FbM Analyati 7' Joe b Fazed Date: 'Time• Client su tiffed of unsatisfactory resultsa PAoned Spoke wkk Dau: Titer. i� lFazed BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUGReralu Total Contorts F- coo Meinbrane Filter: Direct Count Coloalcul40 mi TM Verification: LTB BGB COLIFIRMOC" roe iv.Wrv.dr.Comm Fecal Coliform Confirmation Final Membrane F tr Resu /�,.,�'�/� CoufonN100 tel Reported By pate Time (U6 bra . Comments: Mamt>.r of the BGft Group (SoeiiN GinMak+do SurwiUatta) - n.i icnnNtA PLORIOA ILLINOIS. MARYLAND. MWMIGAN. MtaSOURi. NEW JERSEY, OHIO. WEST' VIRGINIA Jul 24 03 01:19p Butler d Butler, Inc, 907-276-1584 p.2 f 06/12/2023 16:28 907-2791010 AK RZ CHAR7E'R5 PAGE 08 • `ss r�� l�r.•� .r .� �'V:s rte,` .►r-�• t • WTOYI Ck IN ' �IOr ✓f►11T $4: �t..e►r•-•/trt i�' .' j • '=.j w,T .w?N.-' mow. ''T+.:.i ,� •�.� • •'.•., • -' �. ,� •• Y•� �. �7•!i�•.:r,f�• .r ..� `F •-•'r~..,r,•�.a 't;: �Y� rl. �'T^'t- .�: , y• �-.•.••!'•ti r• s.. �5 �; .r. .'�..� �.....,• N fl ..aa� �,' .A .,4 , • j ,Y. • • •. • , ,; • •• • ' •'IVB{•/'I' ••,��" .: • .. •; •• - ..• .. � 7 tt.r:Dyrasi�• .ttw I Ib.M. ,usv..e aM so9.,.0,6 a..atb • .. • .' h� ' �� til r�'� ; w g1s P r w�. ,A✓ ' Anchor;t Recordingcf. Ataska, and that the satpmv .:' .4.-- a*" steuMod thenofl within the�pxrfy Anal and do n - , . .? . , • • oaerisp or encreaeh p on °Pe+ty tYtni adyictnt tllatttD, th ♦r'• f; •� 1 _ �. •••,,�`.� �[' no impr(wenwrltt On propftty hytn adjacent tbenr0o atTaoa or. the pttotiset In quesrtim and t there am nD joadwav Vanambcion lines or odw rttttst tamman s an "idptepim ✓r/SY�t •••••• j..�..i.. , r =Kept u indkat d tuvwn. Dated at 6,,%U Riotr, AUwks . :.., •. •: �'•� .... :• L,.„ a .: • � tbls day D[ � Fes:~ _ , • j� . 1FtODEW c 1 t aysoly �..- • SALE: �ta.�l,tt ea sand survimoR lo.18aY! - 3z &C% 7749%, Emit Rha. Ahaaka 9967 i 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 ,!� y� Telephone: Home '- ' Business Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution ;��telephone Address U (e) Real Estate Company and Agent Address Telephone 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3. 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. 4. SEWAGE DISPOSAL Onsite A, 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 72-025 (11/84) 5 ENGINEERING FIRM PROVID. . INSPECTIONS, TESTS, FILE SEARCH, I A 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. nn Name of Firm S & 6 ENGINEERING Telephone Address 17034 Eagle River Loop Road No. 204 Eag a River, Alaska 99677 3 '� Date DHEP APPROVAL , Approved for bedrooms by Date Approved K Disapproved Conditional Terms of Conditional Approval 'Wil ��i�0 0 F 41, �.�� 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 20f 2"t 72'025171/84at'.. I,AI)NICiPAItT`1 OF ANCHOP L n ENVIRONMENTAL SERVICES DIVISION MUROCFr• MUNICIPALITY OF ANCHORAGE (MOA) 19$7 1 'l HEALTH AUTHORITY APPROVAL (HAA) APR b P►�' ». CHECKLIST - FEBRUARY 1884 �'` f r 284-4720 %� C v C {}j r Legal Descriptio 1,d 5 'c.vaae-_- �y }fat A. WELL DAYA Well Classification .S. If A, B, C, D.E.C. Approved (Y/N) Jr A Well Log Present &N) Date Completed "8 Z Yield 5. q &y,)A4 + Total Depth /)SL'>` Cased to :�E L9 S + Depth of Grouting Static Water Level / 4:291 Pump Set At Casing Height Above Ground Sanitary Seal on Casing&N) Electrical Wiring in Conduit&l) Depression Around Wellhead (Y/N)' Separation Distances from Well: To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Field on Lot /0B ; On Adjoining Lots To Nearest Public Sewer Line�To Nearest Public Sewer Cleanout/Manhole WJA To Nearest Sewer Service Line on Lot Z $ /+ Water Sample Collected by Date ne Water Sample Test Results Comments * 6-mbr7% /wrTb a6iszock ,; ' Sc -G llzz' Hd)d .SkeTGN..x %u DA V✓A1%.Vz L /55v c'?P. / -/S- R& B. SEPTIC/HOLDING TANK DATA Date Installed 7-Z7,51—Size ZZ5C> No. of Compartments e— Standpipes v)N) Air -tight Caps 6N) Foundation Cleanout (Y/(CI� Depression over Tank ( Date Last Pumped /N Pumping/Maintenance Contract on File (Y/N) ; for Al/A Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well p�1'`� To Building Foundationd To Property Line lbr"f To Disposal Field G i To Water Main/Service Line ld To Stream, Pond, Lake, or Major Drainage Courser A Comments Page 1 of 2 72-026(11/84) - C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ZS Type of System Design ?F25�C'H Date Installed Length of Field Width of Field y8 n Depth of Field S Gravel Bed Thickness �Z Square Feet of Absorption Area y/C��i� Standpipes Presentd57N) Depression over Field (Y& Date of Last Adequacy Test Results of Last Adequacy Test pepoz 3 Rp Separation Distance from Absorption Field: To Water -Supply Well /�� � To Property Line Z To Building Foundation yY To Existing or Abandoned System on Lot Nl cA ; On Adjoining Lots -'?o f To Water Main/Service Line le;. .14 To Cutbank (if present) N44 To Stream/Pond/Lake/or Major Drainage Course 1h To Driveway, Parking Area, or Vehicle Storage Area lODlj Comments D. LIFT STATION Date Installed Dimensions Size in Gallons I Manhole/Access (Y/N) "Pump On" Level at Al A "Pump Off' Level al High Water Alarm Level at H Vent (Y/N) Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all M A and HAA guidelines in effect on the date of this inspection. Signsd& c„ENGINcERING Date Come Eagle RWw Loop Road No. 20MOA Eagle River.A14*0 99571 Receipt No. / y D% D Ol Date of Payment #1640 Amount: $ Z� Page 2 of 2 72-026 (11/84) Municipality P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0e,0 of � (907) 264-4111 r . AIr Anchorage TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH A HUMAN SERVICES January 15,'1986 Robert A. Shafer, P.E. S & S Engineering SRB 196-X Eagle River, Alaska 99577 Subject: Lot 5 Block 1 Blueberry Hill Subdivision Waiver Request WR86-003 Dear' Mr. Shafer: This Department hereby grants your request for a waiver of the 100 foot separation distance requirement between the well and septic tank on the subject property. This separation requirement has been waived to 94 feet. This waiver is valid for the existing septic tank only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ijw SRB.196X lasks "577 t.,0MPUTXI,-)N SHEET Eagle liver, SUBJECT: L-L— DATE: SHEET BY — CKD OF .. ....... . j, L 1, 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 ,2- 1a - 0-5' 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) V_Ay/'r-_� IM �� �= �� ►L -a lA Tom- . (f) Applicant Name �- 0� 'S'j- Telephone: Home S115"3 Business Applicant Address Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain); Lending Institution Telephone Address ' Real Estate Company and Agent-- Address+�-a-t— Telephone Zr7l_o Mail the HAA to the following address: :a I' 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA rA 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 :s t <'�C� vJ57 Address ;'sai:, �C Date L i�' Rsbarl A. Shofar+ No. 1457•E • ° ry s� �g ttn "og ad° �>Or P1T0FE 3S\`,) ge a 6. DHEP APPROVAL Approved forfh,^e� �?' bedrooms by �``"' ''a'i+"""a Date Approved Dived Connal Terms of Conditional Approval ` r } CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority 3 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) MUNICIPALIr, 7F ANCHORAGE DEFT. HEALTH & MUNICIPALITY OF ANCHOAKWMW PROTECTION HEALTH AUTHORITY APPROVAL I( CHECKLIST - FEBRUARY 19 264-4720 fL Legal Description. fS Q • I A. WELL DATA Well Classification S. F• If A, B, C, D.E.C. Approved (Y/N)'P Well Log PresenttpN)of C ?r lete (a- PO - 82 Yield EXG S 60 S, Total Depth Cased to 2 Depth of Grouting— Static Water Level C Pump Set At Casing Height Above Ground ' Sanitary Seal on CasingON) Electrical Wiring in Conduit4j%N) Depression Around Wellhead (Y/N) Separation Distances from Well: ` w vim' To Septio�IektiTig dank on Lot ; On Adjoining Lots d� To Nearest Edge of Absorption Field on Lot .;On Adjoining Lots % To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole N To Nearest Sewer Service Line on Lot 2s Water Sample Collected by � S `V-,' sJb, trJ d9!XLA—) f ; Date 12-149 -GS Water Sample Test Results 4at'►S 1, Comments cz--L- 4w GO� sKE--r, B. SEPTIC41:1069MG TANK DATA c-st2 +''+%- SAW & 2-4 watt ltv2r S!K 1�I�18(e Date Installed i - Z - 81 - Size l 7_542 No. of Compartments z Standpipes CUN) Air -tight Caps MN) Foundation Cleanout (Y 1(,V Depression over Tank (YQ ,Dale Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) P Separation Distances from Septic/Helelimg Tank: To Water -Supply Well q To Building Foundation To Property Line ► e� �'� To Disposal Field la To Water Main/Service Line I . i �- To Stream, Pond, Lake, or Major Drainage Course LA Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 2-115747 Type of System Design Date Installed ' 1-'2 - 8.1 Length of Field N � Width of Field 4 Depth of Field 5 Gravel Bed Thickness t2 Square Feet of Absorption Area t 1 ,-- 4 "�, Standpipes Present (VIN) Depression over Field (Y/Q Results of Last Adequacy Test Separation Distance from Absorption Field: Date of Last Adequacy Test • 17- - T- a -k3:5 �5A- 1 S F To Water -Supply Well 19 To Property Line To Building Foundation Lot 0 ; On Adjoining Lots To Existing or Abandoned System on To Water Main/Service Line I L::, -I To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course a'n To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons I Manhole/Access (Y/N) "Pump On" Level at .,Rump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all M A an HAA guidelines in effect on the date of this inspection. Signed I C! Date 6 Comoanw.) i.�lS[ MOA No. UD 3 Receipt No. to A a � e Q'��,.......; q 1 i Date of Payment �' C.>� .sAV- .���` Amount: $ Page 2 of 2 72-026 (11/84) 1 C>'Fl..,.........�. Qobsrt A. Shafer `u esSNo. 1457-E�'r �$, �ppR •......•••A y���q Municipality ®f Anchorage January 15, 1986 P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, '. MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Robert A. Shafer, P.E. S & S Engineering SRB 196-X Eagle River, Alaska 99577 Subject: Lot 5 Block 1 Blueberry Hill Subdivision Waiver Request WR86-003 Dear Mr. Shafer: This Department hereby grants your request for a waiver of the 100 foot separation distance requirement between the well and septic tank on the subject property. This separation requirement has been waived to 94 feet. This waiver is valid for the existing septic tank only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw 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 Januan.y G, 1986 Mun.ic i.pati-ty ob Anchon.age Vepan.tment o6 Hea.2th and Human Sen.vicez 825 L Stn.eet Anchon.age, A.2aska 99501 ATTENTION: Susan Oswatt ROBERT A. SHAFER CIVIL ENGINEER 694-2979 MUNICIPALITY OF ANCHORAQ DEPT. Of HEALTH & ENVIRONMENTAL PROTECTION RECEIVED REFERENCE: Lot 5; Btock 1; B.2ueben.ny Hitt Subdivision Request you appn.ove the attached Heatth Authok ity Appn.ovat appt i.cati.on and .issue a wa.iven to the ho4izonta.2 sepakati.on distances between the weft and the septic tank to a distance o6 94 fleet. The weft tog attached shows bedn.ock at a depth o� 26 fleet. The weft is cased to a totat depth o� 29 fleet 5 .inches .into bedn.ock and the astatic water. Levet was measuned at appn.oximatety 105 fleet 4n.om the suk. ace. The topography .in this genenat an.ea is aside hitt at appn.ox.imatety 220. The an.ea when.e the weft and on -6 ite aseptic system have been eon6tnueted is benched and the etevati.ons between the weU and on -6 ite septic is n.etati.ve.2y 4tat. The so.it,s in this an.ea ane geneAatty gravet and clay mixed (han.dpan) and .it is oun, opinion that the hotizontat 3epar.ati,on distances pn.eser.ibed by 18AAC72.201 an.e not nece6zaky in this instance. The aseptic tank is seated with watet tight eoupti.ngs and it is ouk eonetu,sion that the kisk anatysis w.itt indicate that there is no bactetiatog,icat pottution posh ibte. 14 we may be o4 6ur.then. 6er.v.iee, please contact ups. /ss A. SHAPER, P.E. SRB 196X EAGLE RIVER, ALASKA 99577