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Home My WebLink AboutBRUIN PARK BLK 4 LT 3Onsite File :,. Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211144 PID Number: 016-102-06 Dwelling: M Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name John Atchison ABSORPTION FIELD ❑ Dee P Trench F] Wide Trench El Bed El Mound' Site Address 11011 Forest Drive El Other Phone rNumber of Bedrooms Soil Rating depth from original grade GPD/SF JTotal Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot Bruin Park 4 3 Ft. Ft. Fill added above original grade Gravel length Township Range Section Ft, Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption j Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station I Tank I Line Ftz Ft. Well 100'+ 100'+ NA NA 25'+ TANK ❑p Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1500 Gal. Surface Water 100'+ 1001+ NA I NA I Material Number of compartments I Lot Line 10'+ 10'+ i NA NA NA HDPE 2 Foundation 10'+ I 101+ I NA NA LIFT STATION Manufacturer Capacity i Remarks Gal. Alarm location Electrical installed by 1. Installer PIPE MATERIAL House to tank Tank to3034 AUC drainfield Dean Construction & Development Drainfield CO/MT Inspector Pannone Engineering BENCH MARK (Assumed elevation) 100.0 ft Inspection ist 06/01/21 06/02/21 Location and description 3'd 2nd 4th Rear Door Sill Garage ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional A pproval: Date SOF A� _ ' ... .. .. .... Septic Syste S •! ven �Pannone +'E 814 Approved Date g Note: this approvel does ninclude well permit requirements. roe„ n�tno�a o� ��vmic�'i0�m--'D 0o""=cl) W I-1OK-l-�vc7m -0 -{ M 0 Z :r O O r xc N� r O Z GZ7 0 rriO 0 n-iAPZ'o (n m mD off' o � Z q w -ax m D -02 r_ C1 (� c m Ln� f--1 O o J -G G7 �!aO Z m m X m N v ,o 0 n O D m -n Z r– �nlm —i C ---I Z (n1c: � CA O U) to N 9c"'j-p" — m O DO 00 Ln — O D 0('400�0 (s Lo -I o D v a7 O W O -P O W M m cn � � rn W Ci TCo 9) W Ut N V (n co 00 W Cn -P W (O —i C ---I Z (n1c: � CA rn U) to N cn rn N � — m rno z Ln — O D (s Lo -I o (D D cn O M m Ci m c/) r m 0 CD rn � �o� c) � (n O m �z O ox � zo N U1 mCn DD \ m CA\ Z<%o \\> \ cp �v�0 H o �9i\•� m DC7D m ` + rn +`l D z) \ z I Lr) mm Ln rn X z x x z. O D 5415.pdr, C� @ = SS o M 1 Dpi NOTES: -11� PANNONE ENG SVC LLC (C.1. '1088) �e��e\�� REVISIONS RECORD DRAWINGS P.O. BOX 1807 PALMER, AK 99645 PHONE (907) 745-8200 FAX (907) 745-8201 BRUIN PARK, BLOCK 4, LOT 3 DRAWN LJC JOHN & RITA ATCHISON / steven..R. Pan .n.6i * SITE: 11011 FOREST DRIVE PPj+tg.- CE 8149 SITE PLAN ANCHORAGE, AK 99516 (�lioi+a�°� 03/03/2022 SCALE 1" = 50' I.D. NO 016-102-06 'ERMIT NO. OSP211144 HEET 2OF2 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,org/onsite 4n -Site Wastewater Disposal System Permit Permit Number: OSP211144 Work Type: SepticTank Upgrade Tax Code Number: 01610206000 Site Legal Address: BRUIN PARK BLK 4 LT 3 G:2633 Site Mailing Address: 11011 FOREST DR, Anchorage Owner: ATCHISON RITA A & JOHN N Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date l'1 1 Department Lot Size in Sq Ft: Total Bedrooms: 5/18/2021 5/18/2022 20000 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 (18AAC72) and Drinking Water Regulations (18AAC80) 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 f Received By: Date: %� f Issued By: Date: 5 0��|8 Q�80A�*��8�� 0 B~�~�� Q6=*��8��`H�� 0��0��Uv�8q�,��~��~@ 8 � q��U- ��'�'�q�'��Y��O�u�� Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Poroe|iD. 016'102-06 propertynvvner(s) John & Rita Atchison Day phone Mailing address Site address 11011 Forest Drive Legal description (Sub'U,Block & Lot) Bruin Park Block 4Lot 3 Legal description FTovvnship.Range &Section) Lot Size 20000 q. Ft. Number ofBedrooms 5 APPLICATION |SFOR: APPLICATION I3AN: TYPE OFDWELLING: (Zall that apply) Absorption Field F� |nhja| El8ing|e Family (SF) FX1 Septic Tank NUpgnade -- k��nAD0 N' -- El Duplex (0) Holding Tank | | Renewal 0' ' -- Multiple Dwellings F] Privy El - (SF and/or D\ - PrivateVVe|| F] Water Storage El THIS APPLICATION INCLUDES AVARIANCE /WAIVER REQUEST FOR: Distance:_______ I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 5 Waiver Fees: Date of Payment:. /;� o2 Date of Payment: Receipt Number: 17 0 SID 6 Receipt Number: PermitNo. 0 Sip �)J/ NY Waiver No. Permit AnP-�'- :'�c ; Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211144, Rebecca Carroll, 05/18/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211144, Rebecca Carroll, 05/18/21 Municipality of Anchorage Page 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: ~XAj~:~tl ¢[ ~ PID Number: c:~(.~,L~..~'Z-,¢(~ Name:Wastewater System: [] New [] Upgrade ~e~ ~,y. ~ ~A¢~, ~~ ABSORPTION FIELD No. of Bedrooms: Phone:~_ ~ ~ ~ ~ Deep Trench ~ Shallow Trench ed ~ Mound ~ Other LEGAL DESCRIPTION So,,.at~.: ~ GPD/Sq. Ft. Total Depth from original grad~ L~ ~ ~~BIock: ~~p~S~bdi~: Depthto pipebottom from orig~g~r~Ft. Gravel depth beneath pipe ~~ a~ S Fill added above original grade: Gravel length: WELL: ~ New ~ Upgrade Gravel~: ~1 NuT, of lines: Distance bet~n lines: Ft. Ft. C~~~e~ A.B,C): Total Depth: Cased To: Total absorption area: Pi~e materiah ~ Driller:' Date Drilled: Static Water Level: Installer: Ft. [~~~ ~~ Date installed: Yield: GPM IPump Set at: Ft. ICasing HeightAb°veGr°und:Ft. TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private M~f~c~ur~r: ~ ~ Capacity~allons: From Tank Field Station Tank Sewer Lines /~.~ ~ ~~ t~ ~ Well ~, ~1 ~ ~ ~,~ Ma~~ Number o~partments: S~rf~ce ~ ~ ~ ~ ~ LIFT STATION Water , Lot Size in gallo~ Line ~ [~1~, / / f Foundation ~1 ~~ / / ~ "Pump on" level at: I"~.m. o,," ,~~~'~rm a': CurtainDrain ~"~/ ~~ ~ Pump Make & M°del I Electrical Inspecti°ns perf°rmed bY: Remarks: BENCH MARK I Assumed Elevation: ~ ' ENGINEER'S SEAL S & S ENGINEERING 5~'A-; ~f,?'7 ~:~ Inspections performed by: 17~4 ~-=~- ~!.'~er L~ ~d N~: 1st ~ ~'~ ) ~ ~~;;'~:;~ Department of Hea~ and Human Services approval ~,;.%,, ~ Reviewed and approved by: ate: ~--2 ~'¢/ ~ r '''' ' '' ' 72-013 (1/91)MOA 25 Permit No. Page ~" of ~" 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 Legal Description: PID No.: 72-013 A (2/91) MOA 25 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 WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910185 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:BARDARSON BLAINE OWNER ADDRESS:PO BOX 689 SEWARD AK 99664 DATE ISSUED: 7/08/91 EXPIRATION DATE: 7/08/92 PARCEL ID:01610206 LEGAL DESCRIPTION: BRUIN PARK BLK 4 LT SEC 20, T12N, R3W, SM 3 LOT SIZE: 20000 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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 (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: INSTALL 2' SAND FILTER, RATED AT 0.7~GPD/SF, BELOW BED. ISSUED BY:__ DATE: ROBERT SHAFER, P.E. ROGER SHAFER July I, 1991 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 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 3; Block 4; Bruin Park Subdivision; Request you issue a permit to upgrade the septic system on the referenced property per our d~sign dated June 26, 1991. An adequacy t~st was performed on the existing system on May 30, 1991. The absorption capacity of the existing syst~ is inadequate for the existing 5 bedroom house. Two test holes were excavated in the area of the proposed upgrade. There is an upper layer of GW soils with a percolation rate less than I min/inch. These are to be the receiving soils. The lower layer of soils have a higher sand content with a percolation rate of 4 min./inch. Due to the lower layer of soil above the groundwater level there should be no need for the addition of a sand filter within the absorption bed. We foresee no negative impact on the development of the adjacent properties by the installation of the proposed upgrade. If you have any questions or require additional information for your review, please contact us. PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGA, DESCR,.TION: b'~ ¢~4- 10 11 12 13 14 15 16 17 18 19 2O DATE PERI~ Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E Depth to Water Alte_.~_.r Monitoring? ~l-'~'~y Date: SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop .z. - _ A:"~o~ ~,o~,~ *? ?/~ ~'/~ PERCOLATION RATE ~" ~..~.b_ (minutes/inch) PERC HOLE DIAMETER ~ ~t' .,e"=- TEST RUN BETWEEN ~ ~,"~'t- AND PERFORMED BY: ~[4G[~,~NG I / /~ ~ ~RTIFY THAT THIS TEST WAS PERFORMED IN S&5"-'"";%";" 72 008 (Rev 4~85 a~le Bl~r~ AI~,,I~:~ ~'~¢-, ' _ . -. ..... Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE LEGAL DESC.,PT,ON: 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O 4 d~.Otl~ '~¢_..~Township, Range, Section: SLOPE 'ER h O WAS GROUND WATER ENCOUNTERED? SITE PLAN S L IF YES, AT WHAT O DEPTH? p E Depth to Water~Ute~ / Monitoring? _~ ~'~' Date' I Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~"1 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ AND ~ FT COMMENTS /' / gie J~iver, Alask~ 9¢57;~' ' "*~'~"" PERFORMED IN PERFORMED ~. ....... I / ~_- .~'~_/'"'"~-~ CERTIFY THAT THIS TEST WAS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELII~ IN ¢CT ON THIS DATE. DATE: 72-008 (Rev, 4/85) C~""ATER ANCHORAGE AREA BORO'"~H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 ~T? 6~1 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SEPTIC TANK: MAILING /j ADDRESS -'I (~ LEGAL DESCRIPTION DISTANCE FROM WELL LIQUID CAPACITY i~-OC) GALLONS. MATERIAL~C_J~::~(~ (~{C~-. NUMBER OF COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH.~ SEEPAGE SYSTEM: SEEPAGE PiT: / NUMBER OF PITS / OUTSIDE DIAMETER OR WIDTH i~ i L,N,NG MATER,AL k%~ (~-"4'r, S 'X r,,,,S') . D.STANCE FROM WELL //~" NEAREST LOT LINE TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LENGTH "~ i / BUILDING FOUNDATION L/)"'~8~_~-, O sq. FT. TILE DRAIN FIELD: ~¢'CkT-A L LENGTH DISTANCE FROM WELL ,,'~ , FOUNDATION'~ NEAREST LOT LINE / ,OFLINES NUMBER OF LINES /DISTANCE BETWEEN LINES~ TRENCH WI~ DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. TOTAL EFFECTIVE IN. ABOVE TILE WELL: TYPE DJ~'~,/ DEPTH J'~' ' DISTANCE FROM " , , BUILDING FOUNDATION ~::~-~ WATER SAMPLE ~ LOT LINE j q / NEAREST SEPTIC t SEEPAGE J SEWER LINE~ , TANK ~ , SYSTEM ii ~ , CESSPOOL NEAREST OTHER , SOURCES DIAGRAM OF SYSTEM DATE APPROVED HEALTH AUTHORITY ~,~a"-""-~ GREATE], ANCHORAGE AREA HEALTH DEPARTMENT Anchorage, Alaska 99501 DROUGH 279-2511 Case No. SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT APPLICATION TO INSTALL: SEPTIC TANK SEEPAGE PIT ~ , DRAIN FIELD , OTHER TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH :~L~ TO BE INSTALLED BY PERCOLATION TEST RESULTS ~-C.,C/'- ANTICIPATED DATE OF COMPLETI BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS DISTANCES: ~/e// ~,~//'b ~/0¢¢~ ~ t4 PERMIT TO INSTALL A '~~ .fi'~>~ t~ As DESCR,~ED BELOW. S, ZE OF UN,T TO. BE SERVED ~-~, :~ ?~/< · SEPTIC TANK SIZE /~-~¢~ .TYPE ¢-¢ ~<-~o.¢1 SEEPACE AREA TYPE DIAGRAM OF SYSTEM Authority I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. ~~ ~/,~/ k//)~dF4/~O/7 ~fi'P' DATE ~~ ~ /¢// (~ APPUCANTSSIGNATURE ~¢ ~~~ gray fine sand (SP) with dense seams -7 m 4--- 6--- 8--- 10--- 12--- gray gravelly sand (GW) grading to (SW) Location Sketch Was Ground Water Encounter, ed? no .... ~',,',' dt Depth Reading D a't e Net Drop ;~.,,~ X Drain Field " COM~'!ENTS: .... --~ - - 140 S uare ~~~na~e area is re~,,~ Tes't' Pemfo~med Data Certified By: National Testin Ser '_ , Date: .... . ~,~~es Inc. Perfommed For Don Hoffman L~' ~ 1 ' "~" '-~-"~ .... ~ bc:~<~,~'ot~?,r ,. ~,~ ~,, · ~ ........ ~-'~ ~)ate Performed 5/26/71 ............. t,~.,¢ ~ ~. ~ s '.t .m Bruin Park ...... ~ Th.i.s ~crm Reports a: oo.~ ~ L<'~,~ ~ Depth ......... ~'erc:ozat ton Tes't uni pality of nch ra ¢ Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 September 5, 1989 Mr. Peter R. Michael 11021 Forest Dr. Anchorage, AK 99516 Subject: Waivers to Well and Septic on Lot 3 Blk. 4 Bruin Park. Dear Mr. Michael: This letter is to inform you that the waivers of separation from the -~ell and septic to the subject lot have been reinstated. Per the findings of Land Use Zoning Enforcement case #.89-0386, the dwelling located on the subject lot was a 'single family unit after the Area-Wide Rezoning of 1974. An order has been issued to the property owner to restore the dwelling back to it's single family status within thirty days. If you have any questions please contact Dan Bolles at .343-4744. Sincerely, j /~ J~n W. Smfth, P.E. P~ogram Manager, On-site Services, DHHS db/90 "Kids Are Our Future" unicipahtYof nchor ¢ P.O. B,.,X 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES June 30, 1986 Jean Bordaison P.O. Box 689 Seward, Alaska 99664 Subject: Lot 3 BLock 4 Bruin Park Subdivision Waiver Request, WR86-058 Dear Ms. Bordaison: Any waiver of the 100 foot separation distance requirement between a septic tank and well granted by this department is considered valid indefinitely. In your specific case, your neighbor has located his septic tank 93 feet of your well. This waiver, if granted, would be attached permanently to our records of the septic system serving your property. This waiver would be honored indefinitely in future Health Authority Approvals for your property. Waivers to separation distance requirements are not granted unless there is sgfficient evidence to demonstrate that a lesser separation (93 feet vs. 100 feet)., is warranted. In this case, an engineering report demonstrated that site conditions were such that the potential for contamination resulting from this waiver is very low. This letter, along with the technical information about soils and hydrogeological conditions supporting the waiver will be permanently attached to the records for your septic system. This waiver, if granted, will not affect your ability to obtain Health Authority Approval for your property. Sincerely, · Morr±s Civil Engineer On-site Services SSM/ljw unicipali of Anchorage P.O. BO 96650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES June 16, 1986 Jean Bordaison P.O. Box 689 Seward, Alaska 99664 Subject: Lot 3 Block 4 Bruin Park Subdivision Waiver Request, WR85-058 Dear Ms. Bordaison: Tim Taylor, owner of Lot 4 Block 4, the lot to the northeast of your property (the subject lot) has requested a waiver of the 100 foot separation distance required between the septic tank on his property and your well. Mr. Taylor has been required by this department to move and replace his existing septic tank. He has moved his tank to a location 93 feet from your wmll. Mr. Taylor has submitted an engineering report describing soils and ground- water conditions in the area of the septic tank. This report was prepared by Ted Moore, a registered civil engineer. This report showed that site conditions were such that the potential for well contamination was very low and that a waiver of the required separation between a well and septic tank was warranted in this case. This department is required to notify adjacent property owners when a waiver, requested by another individual, will affect them. This department is prepared to grant this waiver based on the engineer's report. If you have an objection to the approval of this waiver please notify this department in writing before June 23, 1986. If an objection is not received before this date it will be assumed that you do not object to the issuance of this waiver. Please call this office at 264-4720, if you have questions regarding this matter. Sincerely, Stephen S. Morris Civil Engineer On-site Services Parcel I.D, # ~c~ {(3 _ ~ C'~-'~'- ~(")~o 1. GENERAL INFORMATION Complete legal description 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 Lot 3; Block 4; Bruin Park S~bdivision; Location (site address or directions) 11011 Forest Driv~ Property owner Mailing address Lending agency Mailing address Agent o~_n T~ompx_on Blain~ & J~an Bardarson .. Day phone 1-224-3140 p. 0. Box 689 Sward: Alaska 99664 Day phone Day phone 279-7611 Address 501 W~t Northern Light~ Blvd., Anchorage, Alaska 99503 ~.~ ~.... . , - -~ ~ .!~",' ,,~ 2. NUMBER OF BEDROOMS: 5 ~ ;~ ?~* ~ ~,: . 3. TYPE OF WATER SUPPLY: ' Public water NOTE: If 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 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 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 .s~pply and/or wastewater disposal system is safe, functional and adequate for the nu tuber of bedrooms and type of structure indicated herein. I further verify that based on the information obtained fro m 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, or(:inances, and regulations in effect on the date of this inspection. Name of Firm s & $ ENGINEERING Phone I~U,~4 F. agie k~ver Loop ~oa~i J~o. 204 Address Eagle River, Alaska 99577 Engineer, s signature Date- ~- / ~'-"~ { ................. ,~ ,~ ~,'~'~,.~. .: . 6..: DHHS :' SIGNATURE-,. ........ ' : ~:~'~ 'Approved for "" -. Dis ved. ·., .... ~,~ -. -~ ........... ., ...... .~_q -?Condit?nal approval for · ... : , . , .......... 4~ ...... ~ ~.~ ---- ~ .,',,,~¥' . . Additional comments bedrooms. bedrooms, with the following stipulations: 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 engineers work. 72-025 (Rev. 1/91) Back MOA/C21 Legal Description: A. WELL DATA Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Well type '~.~ ~jjC~... Log present (Y/~ $ Total depth i ~ Sanitary seal ~'N) If A, B, or C, attach ADEC letter. ADEC water system number ~ Date completed "~ [~l Driller i~.~,.,l~ed t° ~.¥¢::>1 j~ Casing height ~ Wires properly protected (3[;ZN) ~ Date of test Static water level Welt flow Pump level FROM WELL LOG g.p.m. SEPARATION DISTANCES FROM WELL TO: t Septic/holding tank on lot /'~'~ Absorption field on lot I~::~ ~' Public sewer main t,J /~ Public sewer service line ~/~ ;On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ ~,~1,~o. ,~ Nitrate Date of sample: ~__~-- I '33 - ' ~"~- Other bacteria Collected by: ~ ~ ~ ~------~-----3~ B. SEPTIC/HOLDING TANK DATA Cleanouts (~) High water alarm (Y/N) Date of pumping I"J~V~ Tank size ~ '~'~:~:~ Compartments ~ Foun~dat!on cleanout~::~N) "~ Depress on (Y/~ r~ /.,~ Alarm tested (Y/N) '----- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~..~c~ On adjacent lots \ (-~-~ To property line I ~-~ l.~ Absorption field ~ Surface water/drainage \ ~ 1~ Foundation Water main/service line 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length ~ Width TOtal absorption area Depression over field (Yd~ Results (pass/fail) Peroxide treatment (past 12 months) (Y/~:~. Soil rating ~), 1~ ~?/~/~' System type I Gravel thickness ~. Total depth Cleanouts present~) ~/ Date of adequacy test I~~ for ~-~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I ~C~l~~ On adjacent lots [ c:~ ~ 1.,~ Property line To building foundation ~'-d::='l To existing or abandoned system on lot On adjacent lots ~'~c::='~ '~ Cutbank F,~c:>~,~, Water main/service line Surface water ~ ~ ! '~ Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,, o.l~.t~,e,~ate of this inspection. S & $ ENGINEERING ~-~Y',~' '~': -' ' .... , '? ".-~' ~.? ~;:;,,~ ';..~ . ~-r'' "?~" 'h..'' ~' "'~ Signature 17034 Eagle R~ L~ Road NO. ~ Eagle River, Alaska 995~ Engineer's Name Date ~ ~ J ~ HAA Fee $ J~O. ~ Waiver Fee: $ Date of Payment /~ ~ [ Date of Payment Receipt Number ~.~ ~ Z ~ ~ ~ Receipt Number 72-026 (Rev. 3/91) Back MOA 21 .e~.~ ~ .... - ~UNICIPALITY OF ANCHORAGE ./~e~.'~ DEPARTMEN'~ ;f HEALTH AND ENVI~ONMENTA PROTECTIO~ , ~,~ilL-- . 825 L Street, Anchoraa.. Alaska 99501 / ~- . 264-4720 ~'- Date Received: Nove~.mber 3, 1977 / ~1: Time ~,'D~m 92: Time ~ 93: Time , t,A~ .... 2. Property Owner: Mailing Address: Jerry Renner % Russ Schmeider 276-8145 Phone: 3. Legal Description: Lot 3 Block 4 Bruin Park Subdivision 4: Single Family Residence: (~ Multiple Family Residence: ( ) Number of Bedrooms: Number of Bedrooms: Se Well System: Individual Well ~ } Permit $ Depth of Well Construction ~ ~-'~[~.. Community/Public System ( ) Bacterial Analysis . .. 6. Sewage Disposal System: On-site System (~ Public Utility ( ) Septic Tank Size I.~OO ..... Manufacturer ~~- ~.~ '~ Absorption Area ~ ~. Soils Rate' ~0 Materla 7. Distances: Well to Septic Tank .~'-~ 'to Absorption Area to Sewer Line ......... Nearest Lot .line t ' Absorption Area - % to Nearest Lot Line ,, $,."~, '~, k. JNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchora,~e, Alaska 99501 ~ 279-2511, ext. 224, 225 " REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES ..'1. ' 'Type of Inspection: ' VA FHA CONV 2, Property Owner: Jerry Rennet Mailing Address: ':3.' Name of Buyer: Jerry M. & Cheryl A. Harman Day Phone: Mailing Address: 4. Name of Lending. Institution: Alaska Nationai Bank Mailing Address.Pouch 7-010, Htg)Loan, Anchorage 5. Name of Realtor or Agent: Russ Schmeider Mailing Address: 521 East 45th, Anchorage 6. Legal Description: L3, Blk 4, Bruin Park SRA Box 395W, Anchorage AK 9950~ay Phone: #344-0731 99510 Phone: 278-4581 Phone: 2'76-8145 Location: NHN Forest Drive Type'of Facility to be Inspected: single family dwel 1 lng Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well. Sewage Disposal System Type of System: Public Utility If Individual, date of installation No. Bdrms. 4 Individual X Individual (on-site) X PLEASE CONTACT RUSS SCHMEIDER, ALASKA BROKERS REALTY, FOR ENTRANCE TO THE HOUSE. 72-003(3/76) page TWo Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description' -Lot 3 Block 4 Bruin Park Subdivision Comment s: Affadavit Attached: -~ (~) APProved:' Date: Disapproved: Date: Letter Attached Department Worksheet: