The URL can be used to link to this page

Home My WebLink AboutBRUIN PARK BLK 4 LT 18 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES __ ~ O"/C~ 1'4 0 L.B ~l~l ~0 SEPTIC ABSORPTION Address WELL -.~ TANK FIELD Phone(s, I Perm,t No. I,o. of Bedrooms WELL 4,5 I ?... LEGAL DESCRIPTION LOT LINE I 0 Lot 1 BIoc~ I Subdiv,slon AS-BUILT DIAGRAM (Show Iocahon of well, septic system, property hnes, Ioundabon, TANKS N Manulacturer Capacdy m gallons i ' I '~'at'~ri~l ' No. of Compartments I ,I TYPE OF SYSTEM I ~ j ~ Depth to p~pe bottom ~rom Total Oepth ~rom original §raOe / Fill added above original grade Gravel depth beneath p~pe Jg)} Gravel length Gravel w~dth FT FT! _ ~:~ s~o,I SOFT ~ FT k ! Number of hoes J rating Pipe material ~' Installer Date Installed WELLS - · ~ PRIVATE [] OTHER fldentifv) Classification (A,B,C) Total Depth I Cased to ~'nstallel Date Installed: REMARKS: Scale: id= ~0 I I ~ ~ certily that this inspection was pedormed according to alt Municipal and State guide~es in effect on this date: I~)~ t'2/ / ~ t~) , Health Department Approval: . _ _ ~ Date: 72-013 (3/85) ~:::l!i;l::;~ ' :iiii; !)lES ~; E')N D/;'., TiED ~:..':/11.8 I':::;"O ,, 'TH~ t:)E:I~- -~~~-' 11.5 l:::'E}O"f' "'"~'"" ' ~c¢.J. F'!EI::;.'.!"I;t: '~'c: i"Lr', ra :5 ~:....b..),,,(..)L.l ...,., , ~ r..[ . f:::'liii: ,, ""' ' '.:: 'I ...... , ...,.~. ........ ,,,r c.,.- , ,' ...... .... ~.:~ ..... F:: ¢.':}t"t Z L. Y' ;' ...... :'<,,,, >'.,. ~., r'; ' ,.:;.u.L,¢:. '= W' ''/l...,~.t... Iii!:,, t 1..I ,. DN :t.;';.2/7.!; :t./'.:;W':, , 203 W. 15th AVE "C" SUITE 203 ANCHORAGE. ALASKA 99501 TELEPHONE: (907) 279-3916 Oo~ ~ c s~.~?~l~~ ~ Tobben Spurkland P.E. l~oB F40L.'~ IF_ N ~,Z t ST/ri ~ 1.5 - 8~ Tobben Spurkland P.E. 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) ' LEGAL DESCRIPTION: ~_~'L-- t~ ,'~ ~,~._q-"~¢O Ir1 'Pc~,~,l, rT°wnship, Range, Section: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 SLOPE WAS GROUND WATER ENCOUNTERED? NC) SITE PLAN I IF YES, AT WHAT DEPTH? Depth to Waler Alter Monitoring? ,~ 0 S E Reading Date ' Gross Net Depth to Net Time Time Water Drop 2O PERCOLATION RATE t--~ (minutes/inch) PERC HOLE DIAMETER TEST RUN %TWEEN ~ FT A~D ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC* ON THIS DATE. DATE: ..~~ 72-008 (Rev. 4/85) [ 1�11UMCPAU Y OF ANCHORAGE �. t 64r Development Services Department `�- �z Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 016 101 20 Certificate of On -Site Systems Approval � i a�� Expiration Date: � N tt i. FJ 1. GENERAL INFORMATION Complete legal description BRUIN PARK B4 L18 Location (site address) 11220 POLAR DR Current property owner(s) BUSS Mailing address - - Day phone _ Real estate agent Day phone 2. TYPE OF DWELLING: [71 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex)jr 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: s0(v2u51-() TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic ED Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: N O N E Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee Date of Payment Receipt Number COSA# 50 (cov) b - 19 gs /d 0A a Ba 15 2 b 0Sc)o190 + q, s0(v2u51-() Wai er Fee $ 2z1.?o2o Date of Payment t�602�D Receipt Number 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. Name of Firm C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 8/28/2020 OF A/-,,49 TH Ss� 6. DSD SIGNATURE • `� -- -System #9 -Approved for --3 bedrooms.___ _... _ . __ ..._ __ ...- . - - -_� '" - - - _-- _�_.�....._ .... >+HARLES G BALZARIt�f System #2 Approved for bedrooms �� 9F� CE-13854AMW .••��i Disapprovedop • .... • P�F��. �l ROFESS\ �. Conditional approval for bedrooms, with the following stipulations: A Y ON-SITE WATER AND XA1AQT1:!'W!ATE=R Z,1 J PROGRAM �y: 1 v, " Original Certificate Date: Q- 2 s-Zo 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 • Legal Description: BRUIN PARK BLOCK 4 LOT 18 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Parcel ID: 016 101 20 Structure served by this system 1 A. WELL DATA Adequacy test date 8/17/20 OR Well log is filed with Onsite (or attached) Well production at time of test +5.3 gpm Date drilled 1961 Water storage tank volume NA gallons Total depth 107 ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to 107 ft ❑Q Coliform bacteria is Negative FE -1 Sanitary seal is functioning correctly Nitrate mg/L ❑■ Nitrate less than MRL (ND) FE -1 Wires are properly protected Arsenic 5.37 ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) +12 in. Collected by C.Balzarini Date of flow test for COSA 8/17/20 Date of Sample 8/19/20 Static water level at beginning of test 52 ft. Comments WELL CASING EXTENDED 12" ABOVE VAULT FLOOR. DRAIN TESTED AND FUNCTIONAL. B. TANK DATA Age of tank(s) 't1NK years Tank type/material cONC Measured operating fluid level in septic tank 40.5 FN Standpipes/foundation cleanout per record drawing Date of pumping 9/16/20 D. ABSORPTION FIELD DATA BED C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: CONCRETE SEPTIC TANK OF UNKNOWN INSTALLATION DATE Which system tested (date installed) 1990 Adequacy test date 8/17/20 0 ALL standpipes present per record drawing Results D Pass For 3 bedrooms Total measured depth from grade 7 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 6 ft (min) Water added 450 gal ❑ N/A — pressurized field 3 New depth in 0 Monitor tubes go to bottom of effective. If not, state <1440 depth into effective Elapsed time min Q Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NO date of test) Gallons introduced NA gallons If yes, enter date NA Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) ❑ Yes Septic Tank/Lift Station on Lot > 100' 65 Surface Water > 100' Community Sewer Manhole/Cleanout > 100' F1 Yes if No ft Yes if No ft Neighboring Tank > 100' [L—] Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' Community Wells > 200'aQ Yes if No ft Animal Containment > 50' 0 Yes if No ft [L-1 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' El Yes if No ft � 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: Private Wells > 100' 0 Yes if No Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' Q Yes if No ft Community Wells > 200'aQ Yes if No ft Water Service Line > 10' F4� 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' Q Yes if No ft Private Wells > 100' 0 Yes if No Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' Yes if No Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS PREVIOUS COSAS INDICATE TANK WAS INSTALLED PRE 1970, IN 1964. WELL TO TANK SEPARATION DISTANCE AT THAT TIME WAS 50'. SEPARATION DISTANCE HAS HISTORY OF HEALTH AUTHORITY APPROVAL G. ENGINEER'S CERTIFICATION l certify that / 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. 9/15/20 COSA Checklist yellow sheet 00 OF A�q <<i *'•STM*err �• ... .. C HARLES G BALZARII� CE-13854Aaw Ili\F�PROFESSIONP .� ft M ANCHORAGE RECORDING DISTRICT, ALASKA / ASBUILT OF: / BRUIN PARK SUBDIVISION �O, LOT 18 BLOCK 4 PLAT P -222B _ _ _ SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no encluoachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. IEXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 20-059 17, 2020 1 1"=30' JLS I SW2633 1 200173 ��. OF � -%X, 1 49TH co * ... A. .JOHN L. SCHULLER o �Ia' Y LS-10408 a(P keo, • . , �' !'7 •.2..x"3 �a� 10 � ai \O� fessiono\ —'®� �,riD SUR LSD Ua. o qtr'' 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax CM ENGINEERING SE I S Ph: 907-8545558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Bed System in Parking area at Bruin Park Block 4 Lot 18 Dear Reviewer, The existing bed system is located partially under an area which may be used for vehicle parking or limited driving. Due to the depth of earth cover over the bed and the materials of construction, we have found that the system is protected structurally and from freezing concerns. We request that the COSA be approved and that the drainfield area be considered suitable for vehicle turning, parking, or storage. It is recommended that heavy equipment and large motorhomes not be parked directly over the drainfield, but damage is unlikely to occur from passenger vehicles or light trailers. Calculations detailing the structural demands on the drainfield piping are attached. Sincerely, Charles Balzarini, PE 9/25/20 vjwh'iwa-1,13,91"PA 'CHARLES G BALZARINi 9Fc CE13854.�` ��t PROFESSIO��'4"w Determine if drainfield distribution pipe in driveway is acceptable Use Plastic Pipe Design Manual by Vylon Pipe http://www.primeconduit.com/Brochures/Vvlon/Plastic Pipe Design Manual.pdf A Calculate pipe load B Calculate deflection C Check buckling D Check crushing A Pipe Loading Py=DL+LL DL= yXH Y= 150 pcf soil weight H= 6 ft burial depth DL= 6.25 psi LL= 1.39 psi based on Table 1, H2O Truck Py= 7.64 psi B Pipe Deflection deflection= DI*K*Py*100 (.149*PS)+(.061*E') D1= 1 Lag Factor taken as 1. K= 0.1 Bedding cctaken as 0.1 Py= 7.64 Prism load PS= 46 Pipe stiffness F/Y E'= 200 Soil modulus for loose, coarse grained soil (conservative for sewer 1 deflection= 4.009657 deflection limit of 5% C Pipe Buckling Pb= 1.15* sgrt(Pcr*E') confined pipe buckling Pcr= 0.447*PS/(1-V*V) unconfined pipe buckling V= 0.38 poissons ratio for pvc pipe Pcr= 25.64516 psi Pb= 82.35985 psi F.S. 10.78009 factor of safety D Pipe Crushing comp stress T/A allowable compressive stress T= Py*D/2 wall thrust (psi) D= 4.5 OD of pipe T= 17.19 Ib/inch A= D/dr Area of Pipe Wall (in*in/in) dr 35 (for 3034 sewer pipe) A= 0.128571 in/in 133.7 psi F.S. 17.5 factor of safety Conclusion: Deflection controls, but is within 5% limit. So pipe is ok structurally MMA"'I'ON r'-J� ..... TW .. r 'CHARLES O BALZARINr / CE13854 ww`� ' r?,08OFESSi60—. ' 9/25j2020 L i Height of Highway' Cover H2O (ft) (lb./in-) 1 12.50 2 5.56 3 4.17 4 2.78 5 1.74 6 1.39 7 1.22 8 0.69 10 N.S. 12 N.S. 14 N.S. 16 N.S. 18 N.S. 20 N.S. 22 N.S. 24 N.S. 26 N -S. 28 N.S. 30 N.S. 35 N.S. 40 N.S. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property ownel~ Mailing address I J ?.. 2.0 Lending agency ('~,'/~ - Mailing address .-.~. ,,, ,~/0,.¢..~ Day phone p,,, P,. ,, Jt4/o..r...-hL¢,¢...~c '~.,¢-...L.~H~I,j Dayphone Agent Address Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 {Rev 1191) 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. NameofFirm-/~'b~.~ ~Uy~,.~.~ '~. Phone (2~TE/-~/jo Address ~ ~ l¢~ Engineer's signature '~~ Date ~ ~/~ ~ DHHS SIGNATURE Approved for ~'~-~.~,) bedrooms. Disapproved. Conditional apprOval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA#21 ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~¥~J I't4 '~ Parcel I.D. O / ~ -- le l- 2..0 A. WELL DATA Well type ~ Log present (Y/N) y Total depth ! 0"~ Sanitary seal (Y/N) y If A, B, or C, attach ADEC letter. Date completed Casedto I ? FROM WELL LOG Date of test ~"/2-~/~ / Static water level ~ ~ Well flow ! D Pump level ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot J Public sewer main [%///"'~ Sewer service line Casing height Wires properly protected (Y/N) g.p.m. ADEC water system number '~f~/[~/ Driller AT INSPECTION J~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank g.p.m. ~ ~./u-o WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ////~/4 Other bacteria B. SEPTIC/HOLDING TANK DATA Date insta,ed >/q 70 Cleanouts (Y/N) (~ ~ Tank size / ~"~--P Compartments Foundation cteanout (Y/N) J~ Depression (Y/N) /~/A... Alarm tested (Y/N) High water alarm (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ ~ On adjacent lots To property line J~ 'j' -- Absorption field Surface water/drainage I'"'/ /'1~ Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manhole/Access (Y/N) "Pump off" level at 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 c[ Length ..~ Width Total absorption area Depression over field (Y/N) Resu Its (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating Gravel thickness r-,/ Cleanouts present (Y/N) Date of adequacy test for If yes, give date System type Total depth bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots '~ 1¢--~ Property line [0 To existing or abandoned system on lot ,~ ~ Cutbank I~ ~ u..~. Water main/service line '~ ,,~ ~"'- Driveway, parking/vehicle storage area ~ ~ D E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guide!ines in effect on the date of this inspection. Signature~ Engineer's Name i Date Ab,,~ t ~:~L ~1~____~ ~ ~ I HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS RESULTS fox INVOICE 8 53140 Chemlab Re£.$ 92.1733 Sample 8 1 Matxix: WATER FAX: (907) 561-5301 Client Sample I9 : LIB/B4 BRUIN FWSID : UA Collected : ~ Received : APR 2~ 92 @ 12:15 P~ese~ved with : AS REOUIRED Client Name :TOBBEN SPURKLAND, P,E, Client Acct :TOBBENS l~s, BPO~ ; POW ;NONE RECEIVED hrs. Req~ : Ordered By :TOBBEN Analysis Completed ; APR 27 92 Send Reports to: Laboratory Supemviso~ : STEPHEN C, EDE lJTOBBEN SPURKLAND, P,E. Parameter Results Units Method Allowable Limits NITRATE-N ND(O.iO) mu/1 EPA 353.2 10 RECEIVED Municipality ot Anchorag. e Dept. Health & Human Serv,ces Sample ROUTINE SAMPLE COLLECTED BY: UA, NO TAG FOR THIS SAMPLE, 1 Tests Performed ' See Special Instructions Above U~,,Unava~lable ND- None Detected *' See Sampl~ Remarks Above NA- Not Analyzed LT-Leas Than, GT-Gzeate~ Than Member of the SGS Group (Soci~t~ G(~n~rale de Surveillance) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~"~\~r'~ - \["'~\ - ~'.'~,(-~) HAA # ,.L_, ~%~ ~J~"'~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~O~, Mailing Address Telephone · (home) ~t ~,~. Business. ~H9 - ~'~ ?... (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here[], if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family/~ 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 th legality and status. 4. SEWAGE DISPOSAL On-site/~ 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is 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. NameofFirm -"~-~ ,.-..~p~.,,-.~l~/.~,~ Telephone ,,¢--~- 5"C:)~3'" Address ~ ~.g~/ L,)~/ ~) I tg.~ ~ AI L3 Date Engineer's Seal 6. DHHS APPROVAL Approved for ..~-F. bedrooms by Approved "~L Disapproved Terms of Conditional Approval Conditional Date "f-'1,~JI i ['J t The Municipality of Anchorage Department of H~alth and Human Services (DHHS) issues Health AuthorityApproval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 A. WELL DATA Well Classification Legal Description: LOT' Well Log Present (Y/N) Total Depth ~O'] Cased to Static Water Level E,....~ Casing Height Above Ground If A, B, C, D.E.C. Approved (Y/N) Date Completed Depth of Grouting ! Yield ~ ir,.I PArP-E. Pump Set At Sanitary Seal on Casing (Y/N) ~' Depression Around Wellhead (Y/N) ; On Adjoining Lots > ! ~0 ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Electrical Wiring in Conduit (Y/N) (,. SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ~.---~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by 1-"~, .~ Water Sample Test Results Comments JO e.,~, B. SEPTIC/HOLDING TANK DATA Date Installed.~ t~70 Size Standpipes (Y/N) ~/~ ~- Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line t,~iO~ '~No. of Compartments 0 ~ ~.L Air-tight Caps (Y/N) y Foundation Cleanout /'~ Date Last Pumped ,~' J~/A'~ ; for Temporary Holding Tank Permit To Building Foundation To Disposal Field To Stream, Pond, Lake or Major Drainage Course Comments '"~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area ~, Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well /,~-~ '~ To Building Foundation c~O ~ Lot ..~ C) To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots" To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ~'~~o~~4,' Company ~,t~. '~, ~ , ~ .... ~ .... MOA No. c,~ %~7 { } ~{}~'~.~ Receipt No. , Receipt No. Date of Payment Amount: $ 72~026 (Rev. 7/88) Back Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT ~¥ SAMPLE for Work Order t 27214 Date Repo~t Printed: SEP 15 90 ~ 17:36 Client Sample ID:L18 ,4 BRUIN PARK PW$ID :UA Collected SEP 13 90 ~ 13:15 hts. Received SEP 13 90 ~ 13:30 hts. Preserved with :AS REQUIRED Client Name : TO, BEN SPURKLAND. P.E. Client Acct: TO,BENS P.O.~ NONE Req ! Ordered By : Analysis Completed :SEP 14 90 Send Reports to: Laboratory Supervisor :~T~PIIEN C. EDE 1)TO,BEll SP~IILAItD. P.E. Released,y: .~~ ~'..~ 2) Special Instruct: Chemlab Re£ S: 903622 Lab Smpl ID: 1 Matrix: WATER Allowable Pazamete~ Tested Result Units Method Limits NITRATE-N ND(O.IO) mg/1 EPA ~53.2 10 Sample ROUTINE SAIIPLE. Remarks: SABLE COLLECTED B~ T.S. 1 Tests Performed ' See Special Instructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above NA- Not Analyzed LT-Less Than, §T-Gzeeter Then TOBBI BPUJ & D P.IR. 6751 W Dtmond Anchorage Alaska 99502-3904 (907) 240-5095 RESIDENTIAL WELL INSPECTION LEGAL: Lot 18, Block 4, LOCATION: 11220 Polar Drive OWNER: Bob Holben WELL CLASS: INSTALLATION REQUIREI'IENTS I'IET: WELL LOG AVAILABLE: WELl. YIELD FROH WELL LOO: PUMP YIELD FROM TEST: DATE OF INSPECTION: Bruin Park Single Family Residential Well Yes Yes I0 gal. per minute 3+ gal. per minute 9/13/90 TEST PROCEDURE: This well was installed in 1961, Well is in concrete pit next to building. Pit is six feet deep and filled with insulation. A 4-inch drain is day-lighted from the pit bottom to a sidehill, The waterline comes up through the center of the well cap and leads to the house. As a result the well cap can not be removed without dropping the pump. Five gallons of water was discharged into the pit. All water drained away to the side hill, The well was pumped for four hours at a rate of three gallons per minute, A total of 720 gallons were delivered. TEST FOR E.COLI AND TOTAL NITROGEN: for' E.Coli and nitrates on September ! 4, 1 990. Detected) for Nitrates. A sample of water taken from the well was tested Test results showed no E., Ocli And ND (Non E,Coli allowable O, Max, allowable total nitrates lO.O mg./1, TEST RESULTS: This well meets the requirement of the Municipality of Anchorage, THIS WELL WILL PRODUCE tIORE THAN ;5 GALLONS PER MINUTE FOR rlORE THAN FOUR HOURS. Tl~e Murdcipal r'equirement for' well flow is 150 gallons of water per'- bedroom per- day, TI-ds well exceeds this requirement. The assessment of the condition of the welt applies only to the conditions as they were on the day the well was tested. The flow rate may change due to subsurface conditions that can not be observed from the surface, or from changes in the land use or other' factors that may impact the aquifer feeding the wetl, GREATER ANCHORAGE AREA BOROUGH Department of Envfronment~l Qu, lftv 3500 Tudor Road, Anchorage, Alaska 99507 279-8686 Date Received , ~~~. Time of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Aoproval Requested By: ~-6~/'c~.x~' / 3. Legal Description: ,~g~//,, ~d.~ ~~/~/~ d/Z ... 5. Type of Facility ~o be ~nspec~ed~ ~/~~ ~~/~ . Number of ]3edrooms: ,. ~~~~~ 6. Well Data: C. Constructi on /~/ 7. Sewage Disoosa~l ~System.~ A. Installed .~ ~; C. Septic Tank: 1. Size B. Depth //~_27" D. Bacterial Analysis 8. Installer 2. Manufacturer D. Seepage Pit: 1. Size 2. Material E. Disposal Field: Total Length of Lines 8. Distances: A. Well To~ Septic Tank , Absorption Area , Sewer Lines . Nearest Lot Line , Other Contamination Foundation to Septic Tank Absorption Area C. Absorption Area to Nearest Lot Line . Request for Approval of Pege Two Sewer & Water Paotlit ~ g. Comments ?S Approval Valtd for One Year From Date Signed G~eater Anchorage Area Borouqh, Department of Environ~.ental Quality DIAGRAM OF SYSTEM I certify that ~he ~nformaMon contained tn th~s ~e~est for approval to be a true and accurate representation of the sub~ec~' sewer and w~er