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Home My WebLink AboutBURLWOOD TERRACE BLK 23 LT 10 EpWIVS MUNICIPALITY ®F ANCHORAGE Development Services Department j' Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 007-091-18 riRrl�►1�:7_1�1►17�7:�►riP_��[�7►1 Expiration Date: tl- s ?—C) Complete legal description Burlwood Terrace B23 L10 Location (site address) 3931 Bryant Ridge Place Current property owner(s) David Schwartz & Katy Choi Mailing address Same Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer 0 Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ oZ OCA Waiver Fee $ Date of Payment jo�-�1 aoaa Date of Payment Receipt Number QoZY�O�'� Receipt Number COSA# Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify; that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE System #1 Approved for -S bedrooms System #2 Approved for bedrooms Disapproved Phone (907) 745-8200 Date "200t t ZZ OF At qkk� teven R. Pcnno_raE ':E 8149 'lr Conditional approval for bedrooms, with the following stip `lat(l p a \ J •V OFq�,�i�,/i r ON -,ITE NXI Lk m' ARTEV 4TE1 Z PROG." AM Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet ��Z�� {I•± rT. "o� E Legal Description: Burlwood Terrace B23 L10 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1961' Total depth 195* ft Cased to 160* ft 0 Sanitary seal is functioning correctly FE -1 Wires are properly protected Casing height (above ground) 13 in. Date of flow test for COSA 11512020 Static water level at beginning of test 81.6 ft. Comments *Data from 1991 Cosa inspection. B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 007-091-18 Structure served by this system 1 Well production at time of test 0.45 gpm Water storage tank volume 210 gallons Well disinfected for coliform test? ❑ Yes ❑✓ N Q Coliform bacteria is Negative Nitrate 0.200 mg/L ❑ Nitrate less than MRL (ND) Arsenic 1.000 ug/L ❑ Arsenic less than MRL (ND) Collected by Pannone Engineering Services Date of Sample 1/7/2020 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results L]Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft 7 Yes if No ft if No ft Wells on Adjacent Lots: ❑ Yes Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Ye 'f No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' ft Community Wells > 200' Animal Containment > 50' ❑✓ Yes if No ft ❑✓ Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: ❑ Yes Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS _ --�,��riyJ��rl►�.JfUfl�ri-Ts��tllo-7�ri�I�l::�iii3��'�JI1E�,Z��i'i!��"�1�`.� `I + ► �� 1 G. ENGINEER'S CERTIFICATION l certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet Well Water Advisory Certificate of On -Site Systems Approval # OSC201012 Subdivision: Burlwood Terrace, Block: 23, Lot: 10 This well's productivity was determined to be .45 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 3 -bedroom residence is .31 gallons per minute or 150 gallons per day per bedroom. Although the subject well currently exceeds this minimum requirement, the production capacity can fluctuate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. �Ma�lmg Address P O Box 196650 *Anchorage, b`laska 99519 6650 *www muni org Go m C: -0 --4 M z C- 7 > m rn r- x- 0 Cn cn 81161 0 , --A (j) M < m U) > m :z U) x (1) M > 0 r1l 2: Z La Cr Z 0M (t. m o N = 0 CO D; M F Oa --4 2: 0 r Co -n cz :iE T 0 x II x 0 z m o 15 m nC F a -r 0 a — -, rn;u o 3 0 0 CL M Z < M m 0 C, 0 :E M. 00 CD (D Ej,q 0 0 CD Cn z LoC. m G) 0 x co C) (D m < r BRYANT RIDGE PLACE 0 C) r CD a M z > N00`07'00"E 60.00 < M O a 5 10 gm°CD < CD a 0 3 N) 'D 3 0 C7 EF 0 C (D 0 3 o zy C, 0 Fn, 0 0 :Z 0 0 W 0) M M-' ti 70 < (D (D 0 ac ?5. j Q. 0 M M @ Ow, 3 U1 d CJ a I- Ul (D 0 (D 0 CL cn •ST =r 00 C/) 0 W 0 C7 0 Cn '17 CO CD (-0 0 3 s M C: '20 E; 0 (n 2, .0 00 Cn �0 (D (D co n CL 00 L 0 1 0 C) m 2:M C� a rf, a C C:) C) -9 =r,< 3 deck CL F 0 - (D 6.0 46.0 a 0 Ln CD I Story Frame House CD CD C: C) m with Basement �0 i 51 7.7 46.0 =O< Eql �W CL HT q 91=rL-n: 0) CO CD =r CL NM E0n deck 0 CD (D '0 0< 6 3 C" CD =3 D - moa :) ID m > 0 QM_ > M (D 7 co Co (n , , W 0 :3 cr) E� 0, 0 0 C: CD CD 3 0 0 20 0 0 =L Lp. 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M Lo CU (n a JOYCE ROAD (Not built) co Lo 0 n CD C— 8116J co cE N W r rr--�0� > 02 m-+cnrn (� co o�! ,. o % ccnnxmm D � r � � oZo-1 r M � � deck dk 1 , 1 -' OZ 0 6.0 46.0 p M 0 =0;U _1 II w 1 Story Frame House w o 0 -1 0 co VJ _ 46.0 m O Z = n deck lam - OMp n z n xo 0 �m0= m m o — — — — — — — — — Z o 0°' r� (- 2 0 < N O BRYANT RIDGE PLACE N _ O z CL a N00007'00"E 60.00 45-- FSm _ — N00007'00"E 60.00 -- _21 W 0 L co 0 ami zr If, f o =. 1 0 rn c- v o a� < Q x — a Q � � s a Q X, 8116J co cE N W r p > 02 CD co o�! ,. o % n Cn r - O � r � � o d 1 Z � � 8116J co W 1 02 CD co o�! ,. o ' I g v = Cn r - O r F M o d 1 r co o deck dk 1 , 1 -' 0 6.0 46.0 p w 1 Story Frame House w o with Basement VJ _ 46.0 7.7 n deck lam - n EM r� (- 2 45-- N00007'00"E 60.00 -- W 0 co 0 JOYCE ROAD (Not built) °o rn c- 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 AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1'"7~'"} - (~¢"~ - \~'~ HAA # GENERAL INFORMATION Complete legal description Lot 10; Block 23; Burlwood T~rrace Subdivision; Location (site address or directions) 3931 Bryant Rid,qe Place Property owner Mailing address Lending agency Mailing address Phyltis Goldman Day phone Eugene, Ore, on Day phone Agent Karen Largent RE/MAX PROPERTIES Day phone Address 2600 Cordova Avenue Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 257-0134 2 XX If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: 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/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 Address Engineer's signature $ & $ ENGIIIEERIN(5 17034 Eagle River Loop Road Ne. 204 Eagle River, Alaska 99577 DHHS SIGNATURE Approved for Disapproved. Conditior~al approval for Phone bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date//- 7-?/ 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. 72-4325 (Rev. 1/91) Back MOA #21 Municipality of Anchorage ~i~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,Z,~f ! O~ ~_./_r,~__K'~_ 3; ~.)v')~Jec~ .~l~arcel I.D. A. WELL DATA Well type _-~.~¢~f A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~ Date completed ~D¢~ o¢' ! }- / O- ~'l Driller ~_) ~" Total depth I ~ z.-- ' Cased to / In 0 ' " · _ Casing height ! 2 4 Sanitary seal (Y/N) FROM WELL LOG Date of test t_P ~ I Static water level ./ ~,~ --~ Well flow ~ - '7. Pump level t,) ~ Wires properly protected (Y/N) ~UNI~IPALITY OF ANCHORAGE AT INSPECTIOIF~NVIP-ONMENTAL SERVICES DIVISION g.p.m. I. ~ g.p.m. OCT ;~ 1 1991 RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ! Public sewer main Sewer sen/ice line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: ./ Nitrate ~.~l~(~'J'~m~ (~J.~'.~Other bacteria Collected by: - B. SEPTIC/HOLDING TANK DATA ~ ~ J ~'(.. -~ u,~ ~ ¢' Date installed "X Tank size (Y/N) '"',,~ Foundation cleanout (Y/N) Cleanouts High water alarm (Y/N) Date of pumpigg SEPARATION DISTANCES FROM S~TIC/HOLDING Well(s) on lot On a~tja.,.cent lots ~erwtaYt 'i~;rainage Absorption- Compartments Depression (Y/N) Alarm tested (Y/N) Pumper TANK TO: Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed X,~,_ Manufacturer gallons "~ Manhole/Access (Y/N) Size in Vent (Y/N) .'~'Pu~p on" level at , -- ~ -- ' ' r --' "Pump off" level at High water alarm level ('~~ Cycles tested .... Meets MOA electrical codes (Y/N) 'N. SEPARATION DISTANCE FROM LIFT S~TION TO: Well on lot .... On adjac'e~t lots __ Surface water --- ..~ D. ABSORPTION FIELD DATA P~[~:)l 1'(.~ ~::,~X't,~ ~ ~ Date in"~led Soil rating System type Length ',, Width Gravel thickness Total depth Total absorption~ Cleanouts present (Y/N) Depression over field~/N) __ Date of adequacy test Results (pass/fail)~ '~,.,,~ '~ for _~ Peroxide treatment (past 12 mon~h~(Y/N) __ ~ If yes, give date SEPARATION DISTANCE FROM A'~SORPTION FIELD TO: Well on lot O'l~djacent lots______ Property line TO~ i~;l:i~tfl~:datiOn -Cutbank~ To existing or abv~e~nmea~:~vr~c~i~t Surface water Driveway, parking/vehicle storage area Curtain drain ' bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in Signature Engineer's Name Date S & S ENGINEERING Eagle River, Alaska 99577 HAA Fee $ Date of Payment Receipt Number ~ effect, p~,~'Le date of this inspection. Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE for WORKorder{ 39576 Date Report ?tinted: OCT 25 91 ~ 16=00 FAX: (907) 561-5301 Client Sample ID:LiO B23 BURLWOOD TERRACE Client Name PW$ID :UA Client Acct Collected OCT 22 91 ~ 18:30 h~s, BPO # Received OCT 23 91 ~ 15:30 ~s, Req # Fr~served with :AS REQUIRED Ozde[ed By ENGINEERING :$NSENG? PO # NONE RECEIVED Completed :OCT 25 91 Send Reports to: Laborato[y Supervisor :STEPHEN C. EDE 1)S & S ENGINEERING Chemlab Ref #: 915684 Lab Smpl ID: ? Matrix: WATER Allowable Paramete~ Tested Result Units Method Limits NITRATE-N ND(O.iO) mo/1 EPA 353.2 m[O Sample ROUIINE SAMPLE COLLECTED BY: R.D,~. Remarks: I Tests Performed See Special Instructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above MA- Not Analyzed LT-Less Than, GT-G~eater Than Member of the SGS Group (Socidtd G{)n{)rale de Surveillance) DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHOKAL~e MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEClI~I~I~ONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION MAE ,9 1981 Telephone 264-4720 R E C El V E D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPE RT¥~OWNE R PROPERTY RESIDENT (If different from above) PHONE PHONE 2..UVER ~/, / MAI/lNG ADDD~SS 3. LENDING INSTITUTION PHONE MAI LING ADDRESS 4. REALTOR/AGENT~ PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6, TYPE OF RESIDENCE ~--/SING LE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [~~T~ o [] Four [] Five [] Three [] Six [] Other 7. WATER SUP~I~Y ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** [~'"'-~U B LI C UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [--I SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: If Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line NUMBER OF BEDROOMS [] THREE [] FIVE [] FOUR [] SIX [] OTHER Septic/Holding Tank Absorption Area ]Sewer Line Nearest Lot Line 5. COMMENTS [~PPROVED FOR ,~---'~BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79) GREATER ANCHdEAG:~ ';{REA BOR~GH ~ ' '" (" Department of Envfronmental quallt~/ 3500 Tudor Road, Anchorage, Alaska 99507 Date Received Tfme of ~nspectton ~.'~ Date of Inspection REQUEST FOR APPP, OV^I., OF INDIVIDUAL SEWER & WATER FACILITIES FOR 2. Pro.hetty Owner: ~~ Phone, ' "-'-'.~ ~? Z 7-.~ 7/7 3. ..... -_ .F ..... ~ · ., ~umb~r of B~drooms= e Well Data .' ' A. Type B. Depth Analysis'//- Sewage Disposal System: A. Installed /.~/_~ ~ .-- B. Installer Tank: 1. Size/~/0/~ 2. Manufacturer C. Septic D. Seepage Pit: 1. Size 2. Material . . .:.. Disposal Fteld: Total Length of Lines Distances: A. Well To: Septic Tank , Nearest Lot Line ~ Absorption Area B. Foundation to Septic T~nk C. Absorotion Area to Nearest Lot Line Absorption Area k~ ~ , Sewer Lines Request for Approval of; Individual Sewer & Water Faoil~ttes Page Two A~roval Valid for One Year From D~'te Sianed Greater Anchorage Area Borough, Department of Fnvironmenta] Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate renr~..~entation of the subiect sewer and water facilities located at: Signed Date November 9, 1972 Civilian i~iii~ary Referral Office 15S0 G~'~bell Anti, or,ge, Alaska 99501 SUBJECT: Water and sewer facilities servino Lot 10, block 23 ~urlwood Terrace. ~ ' Dear Si rs: Ti~e subject dwelling is served by a well of approved const, ruction, uhich is o , and located 34 fee~ west of the dwellinl) and 30 feet off tl~e north lot line. l'he sewage syste~, consists of a septic tank and adjoinin£~ seep~§e pit. The seepage pit is presently not operating at peak performance and must be pur.~ped periodically. The owners have contracted Issacs Pu~pin~ Service to perfor~ Chis service as needed. ' Public sewer v~as made available to C}lis lot in Septe~,ber of this year and the owners have signed to hook up to sai~ sewer by July l, 19Z2. - Therefore, this Department will give temporary approval on the sewer system until July, 1973. At that time public sewer must be serving subject dwelling. If you have any questions regarding the above, please do not hesitate to contact this Department. Sincerely, Ti~ Rumfelt Sanitarian Ir'~lA, Form~2573 ,~ Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION -~-. Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE MORTGAGOR OR SPON~R l_ PROPERTY ADDRESS SUBDIVISION NAME BLOCK ~ LOT NO. Can a~ic or oth~ a~a be made into TOTAL NUMBER:., L BASEMENT ~New installation bed~oms? LIVING UNITS BEDROOMS BATHS~ ~7.. ,.,~ /~ Yes, Bow / & / ~Yes ~ No ~ Yes ~ No WA~R'.SUPPLY BY: ' SYSTEM DESIGNED FOR ~ Public system ~ Communiw system ~ Individual .o. oy gDRMS. SEWAGE DISPOSAL BY: PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPE~OR'S SKETCH It is the opinion of ~e ~ State ~ Coun~ r ~al Department of Health that this individual water-supply system ~ is ~'Fs-ffGt~ lh~c~hs a domestic water supply for the subject property. It is the opinion of the ~ State ~ County ~ Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: C be expired to function satishctorily, and ~, Cannot be expected to function satishctorily is not likely to create an insanit~ condition TITLE . NOTE: The heal~ au~ority should complete the appropriate opinion ~ment above and affix date, signature and title in the spaces prQYided. Use of the above grid for Health Department Inspector's sketch as well as use of the hack of this form is at the option of the heal~ authori~. PARTJII.~R USE OF FHA OFFICE ~ ~ve r~iewed ~e foregoing and the peainent FHA Compli~ce Ins~ion ~e[oa, and recommend that 'the Individual water-supply system ~ considered ~ Acceptable ~ Not Acceptable ~wage dis~sal ~ considered ~ Acceptable ~ Nor Acceptable. D~l[ ~ SIGN~TURt ~'~ c.~ a~c.lr~cr DE~U~ FOR CHIEF HEALTH AUTHORITY APPROVAL FHA Form 2573 INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM Re,,. J~,b, 19se REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. [] Cesspool. Septic Tank: Distance from well, 72 feet. Material, Steel Total liquid capacity, 750 Inside length, 5 diam feet. Inside width,. '' Cesspool: Distance from: Well, Inside diameter, feet. SlCONDARY TREATMENT consists of [] Tile disposal field. ~'Seepage pits. Tile Disposal Field: Distance from: Well, Total length of tile lines,i Trench width Length of each line Type of filter material: [] Gravel. gallons. Capacity inlet compartment, feet. Liquid depth, 5 ! ' ] m: Number of compartments feet. feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, Depth, feet. Liquid capacity, gallons. Lining material gallons. Other feet. feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. feet. Number of lines, , Distance between lines, feet. inches. Total effective absorption area in bottom of trenches square feet. feet. Depth, top of tile to finish grade, inches. [] Broken stone. Other Depth of filter material beneath tile, inches. Depth of filter material over tile, inches. Number of pits I., .OuKside diameter, 81 X 8 ~fe~t. Depth,. 6__ feet. Lining material Distance· ~ . from:,. ~,Wel~', .'~. ~)5. ~,~'} feet', building foundation, 3?*5 feet; nearest lotJ.h,r~ at [] front, [~] :ide, 6 rear, 2/4 feet. iispectlon made by: ~ ~;e. [] County. [] Local Health Authority. / / _ // Date of inspection. {~ <' 'i- 30 19 (~' ~ //7-~, C/<~/~a,~A~) REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, '"' feet. Size of main, '- inches. Individual wells~,are [] are not customary in neighborhood. Give most recent~._~&.O4.~record/~f failu~re~;/~.~ ~ ,xtwells~c-~-;Ln im~ediatg~x& .~/& r-~-~ -~/~vicinity to finnish/~.~{;(. ~4 adeqtmte ~su~Dly~ (~..~¢~.'~, i. CC ~'' }~ ~f wat.~r. /7,tC~ ~ ? e C ~-b'/ Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size: 60 feet wide; 180 feet deep. Dwelling set back from front property line, 9',-~ '~ feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well fram: Building foundation ~2 feet; nearest lot line at [] front, I~l side, [] rear, ~2,~ feet, cast iron sewcr~, feet; tile sewer, feet; septic tank, 72 feet; disposal field, feet; seepage pit, , ?--$'- ~- feet; cesspool, ~ feet; other sources of possible pollution, feet. Well construction: T-lv-e of casin~s,. ~S tee 1 ;~)epth of casing, 195 feet. Diameter, 6 inches. YeWotal depth, i 95 feet_ Approximate depth to pumping level of water in well,qe i 25 feet. Approximate yield,~' 5"~ gallons per minute. qeSealed watertight to d~pth of ] ~ feet. Exterior space around casing sealed with: [] Cement grout,q¢ [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. 'k~'[~ Metal. Openings in well cover watertighO~[~v] Yes. [] No. Pump: [] Shallow well. [] Deep well. Length of drop pipe, W] 00 feet. Pump capacity, ~e~ Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No.q¢ Pump mounting watertight: [] Yes. [] No. Con nec ted w i th Type of storage: [] Pressure. [] Gravity. Capacity, .gallons. ~Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date Nov. 22 , 19 61 ~,,° Quality of water [] is [] is not satisfactory for human consumption. ~Z~ Installation ffdoes [] does not comply with approved exhibits, if any. /Inspection ~a'de by: [] State. [] County. [] Local Health Authority. Inspected by Date of inspection November ]0 19 61 gallons per minute. w Submersible Pump pitless adapter U. S. GOVERNMENT PRINTING OFFICE: 1957 O'F--427038 Indicates information furnished by property owner ADH~HSI~-6-Fi (e) This Form Must Be Filled Out Completely. INDIVIDUAL WATER SUPPLY Please Look on Reverse of Sheet for Sample Collection ALASKA DEPARTMENT OF I~.ALTH ln~ruetion~ ,~ i),~. :~ Section of Sanitation and ~n~*ineerlng Request for Bacteriological Analysis Lab No ~ ,.~ - ,,~ ,~ ~ .............. '..~..~...;~..~.~ ........... Water " '' sample collected by.~-.---~..--~~ -~.- ......... -~-~-~.--.?-..-'~..- ........ ...~...L..'~...-~......~......~. (Name of person collecting sample) (Date) (Time) Water sample collected from [] Kitchen tap; [] Bathroom tap; ~'asement tap; [] Other (list)/ '/:~ ......................... ~.~-~. :..-:. ~'~~i~ .......... ~ -~-~ ......... ~'~"~ ..... Address premise where source is located ........ .,~..~..-~... ........ ..... ............................ lVlatl report to (MtsO*. ................................................. (Name) (Box ~qo. or street a~ldress) (City) Please place an "X' in the box before lte.,~ich best describe your water supply: SOURCE: Well ~ [] Dug, [] Driven, [~rilled, [] Bored [] Spring, [] Cistern, [] Other (list) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond .................................................................................................................. DUO WELL OR CISTERN CONSTRUCTION: Walls ~ [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block Top ~ [] Wood, [] Concrete, ~] Metal, [] Open Top LOCATION: [] In basement, [] Basement offset, [] Under l~ouse, ~'~ yard Other ..................................................................................................................................................................................... DISTANCE TO: Building sewer or other drainage pipe.. ~....~?.....feet,~- -- Septic tank ..~.:...~.. ..... feet, Tile field .............. feet, Seepage pit ~.'..~.....~'...feet, Cesspool .............. feet, Privy ..............feet. Other possible source~ of contamination .(.list) ............................................................................................................................................. MATERIAL: Building sewer ~ ~'"Cast__~,~ ~ .~lrq~' [] Wo~l~ [] Tile, [] Fibre pipe, [] Asbestos cement Joint material -- Type ...... ~_,_~'~_..~ ............................................................................................................ GENERAL INFORMATION: Does water become muddy or discolored? [] yes, [] no When? ................................................................................................................................................... Diameter of well .............. ~. ................................... depth ......... ~.....~.....~.....~ ............................ feet Well casing materlal....~:~._~~. ........... diameter ..... .~:..~.~. ...... depth...~/...~;.....~..'~.--.....~. ........ Length of drop pipe ............ ~.....~..~.. ................................................................................................. Water depth from bottom ................................. .~.....~-.. ................................................................. fe~'~ Pump location: ~Ih' 'well, [] Offset In basement, [] In basement [] In utility room, [] On top of well [] Other (list) ........................................................................................................ PUI~POSE OF EXAMINATION: Illness ~uspected? [] yes, [] no New source of supply? ~3~'~, [] no Repair~ ~o existing ~ystem? [] yes, ,~] no Remarks: ......................................................................................................................................................................................................... PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN L~NES OR OTHER SOURCES OF POLLUTION AND DISTANCES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FA~.ILITIES, SAMPLES MUST BE sUBMITTED IN CONTAINERS PR. 10~D BY THE ALASI~A~ DEPARTMENT OF HEALTH