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HomeMy WebLinkAboutSOUTHPARK #2 BLK 3 LT 30 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ( ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [~NEW MAI LING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF ~[DROOMS Well Absorption area ~ <Z Manufacturer ~ ~E~ M at er~,r~E ~. No. of co~artments ~ ~ Liq. capacity in gallons Inside length Width Liquid depth J, '~ ~O IF HOME'DE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation Nearest lot linc PERMIT NO. ~ ~ ~ No. of lines Length of cach line Total length of lines Trench width Distance between lines ~ ~ ~ inches ~ Top of tile to finish grade Material beneath tile Total effective absorption area ~ inches Length Width ~j , Depth ~,~, PERMTNO, ~ Type of crib Crib diamete~ Crib depth m~{U -- Building ,iu.~i~n Nearest lot line ~ ~ DISTANCE TO: ~ Class Depth Driger Distance to lot line PERMIT NO. m Building foundation Sewer line Septic tank J Absorption area(s) ~ DISTANCE TO: OTHER SOIL TEST RATING ~L; ,~ ~' , ~ ' '. ~ t .' ,' PERM ~T NO: DATE ISSUED: 'DEPA~TMENT OF HEALTH AND 825 L STREET:, ANCHORAGE, 264-'4720 84¢)7,3,: 09/05/84 APPLICANT: ADDRESS: CONTACT PHONE: STEVE SCHRECK SRA BOX 4029 ANCHORAGE~ AK 545-5451 995()7 LEGAL DEGCRIP: SUBDIVISION: SOUTH F'K ~2 LOT: 30 SECTION: 3 TOWNSHIP: :[~N RANGE: 3W LOT SIZE: 35000 (SQ.F'T. OR ACRES) ~PX BEDROOMS: 4. BLOCI .. 3 GRAVEL LENGTH (FT.) ~,~,,V~L '¢OLUM~ (CU.YBC.> TANK SIZE (GAL. S~ SOIL RATIN6 (SQ.FT./BR) L. isted below4 ar.e the options available '~o you in designin£] your septic system. Choose 'Lhe option tha~ best Fits yoLtr site~ DEFTH TO FIPE BOTTOM (FT.) OTAL..~E,'TI..] (FT.) GRAVEL WIDT~ (FT.) ~ TANK MUST HAVE AT LEAST TWO COMF'ARTMENTS .................................................................................. I certify that: 1. I am £amiliar with the ~equipmmmnts fop on-site se~*;ers and wells as set ~orth by the Municipality of AnchoPage (MOA) and the'State oF Alaska. I will install the system in accordance with all MOA codes and and in compliance with the design cPitePia of this per'.mi'~. 3. I will adhePe 'Lo all MOA and State o~' Alaska pequipements fop the s~t back distances from any existin~ well,, .w=,~t=w=~e, disposal, system oP public sewerage system on this or any adjace~nt ~r nearby 4. I und[~rstand that this pepmit is valid ¢op a maximum o~ 4 bedpooms and any enlargemen'L v,d. I1 reqg~ire an additional per,Lt. ~F A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES~ THEN (t) AN ELECTRICAL PERMIT AND IN~FI_b¥]ON~ ,z~. ' MUST BE OBTAINED; (2) As-'BUILTS WILL NoT BE APF'ROVED WITFIOUT Alii ELECTRICAl_ INSPEC]'ION REFORF, AND (.3) THE ELECTRICAL WOR~ MUST BE/DGNE BY A LICENSED ELECTRICIAN. APPLICANT.: ~ ~ZC~: DEPARTMENT OF HEALTH AND ENVIRONMENTAL FROTECTION~--! 825 L STREET.~ ANCHORAGE, AK 99501 264-4720 PERMIT NO: 84(.)68.-~ DATE ISSUED: 08/09/84 APPLICANT: ADDRESS: CONTACT PHONE: SCHRECK CO BUILDERS SRA 4029Q ANCHORAGE, AK 99505 345-5415 L.EGAL DESCRIF': LOT SIZE: MAX BEDROOMS: SOBDIVISION: SOUTH PARK ADD~ LOT: 30 SECTION: 3 TOWNSHIP: 11 RANGE: 3W 35000 (SO.FT. OR ACRES) 4 BLOCI<: Listed below are the options available to you i.n designing your septic system. Choose the option that best Fits your site. -- DEPTH TO P~IPE BOTTOM (F'T.? 4.0 GRAVEL DEF'TH (FT.) ~ 3.5 TOTAL DEPTH (FT.)' / '7.5 GRAVEL WIDTH (FT.). / ~ .~' ) 5.0 GRAVEL VOLUME (CO. YDS. ) / / / k,-P/,,~C~2 'V 70.0 130.3 1 50.A ** 1~25".0 ** TANK SIZE (GALS) [/ ~50.0 ** - SOIL RATING (SQ. FT. /BR)~ ~07 407 Forth by the Municipality of Anchor, age'(M~A) and t~-~S~e o~ Aiasl<a. . 2. I will install the system in accordance with all MOA codes and.rmgulations..~ and in compliance with the design criteria of this permit. :5. I will adhere to all MI]A and State of Alaska requirements ~o~ the stat back distances From any exipting weli, wastewater disposal system or public sewerage system on this or any adjacent or' nearby lot. 4. I understand that this permi{ is valid FoP'a maximu, m of 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES.~ THEN (1) AN ELECTRICAL PERMIT AND INSPECTION rqUST BE GBTAINED;, (2) AS-BUILTS W.ILL NOT BE APF'ROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. .: 1 GNED APPLICANT: I o,:IJED BY MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST DATE PERFORMED: ,/~/Or~'/ Z~ /'q~ LEGAL DESCRIPTION: 11 12 13~ , 14- 15- 16- 17- 18- 20- SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop COMMENTS PERFORMED BY: PERCOLATION RATE '~' ~ ,(minutes/inch) TESTRUN BETWEEN ~'~' FTAND ~)/~--- FT DATE: 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 P?rY~ 3 4 5 6 7 8 9 10 11 12 13- 14- COMMENTS SLOPE WAS GROUND WATER SL ENCOUNTERED? /I/Z~) O IF YES, AT WHAT DEPTH7 SITE PLAN ~/~ P Gross Net D~pth to Net Reading Date Time Time Water D~op ,~ t&o ,,~) .'00 I, 35 I q' ~ /~ :.ye) Zo . ~& , fi? ~o /~ :~1 I,~ CERTIFIED BY: 72-008 (6/77) 6788O ..�r� Municipality of Anchorag '� A` On-Site Water and Wastewater Program i7l'�. 21 1018 A F E T Y (907) 343-7904 kY1` �1 Certificate of On-Site Systems App ' I Parcel I.D. 020-502-28 Expiration Date: Y 1. GENERAL INFORMATION: Complete legal description Southpark#2; Block 3, Lot 30 Location (site address) 15751 Stanwood Circle*Anchorage,AK 99516 Current Property owner(s) Kurt&April Andreason Day phone 907-331-9850 Mailing address 15751 Standwood Circle*Anchorage,AK 99516 Real Estate Agent Brandy Pennington Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ® Public Sewer ❑ WaiverNariance request for: Distance: l � Received by: %I Date: 31iZ3fre COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment ala I,11 Date of Payment Receipt Number Cn /��G Receipt Number COSA# 05C,1 a 1061 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 procedaresoutlined 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 (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: 3 1 Z it 8 � In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o QF C %% in accordance with the guidelines and regulations established by the Municipality of Anchorage and .� •.-••.-- •., cc��� industry practices. The reported results describe the condition of the system/s on the date/s of the Q' P,- j ' v �Oh evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • ►. encroachments may exist that were not identified during the evaluation. The operational life of all wells 4 9 H )'\ '•37 VD and septic systems depend upon a variety of variables, including but not limited to, soil conditions, D groundwater levels (that may fluctuate during the year), quality of construction (materials and 2 workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and /14)130 ..1.. Q are outside the control of GEG. Satisfactory test results do not guarantee future performance of the / -y Go ness;' 0 system/s; therefore, GEG makes no warranty (express or implied)regarding the future performance of 14)CCE—79 3 Q� the well or septic system. GEG makes no representation whether an alternative well or septic system s 11c�Q can be installed on the property in the event either of the current systems fail to perform adequately in 04 3•!..f .(.9./�°o: the future. The content of this report is for the sole benefit of the person/party that retained GEG to ��eaprofe•sstooco>' • perform the evaluation. Reliance upon the information provided in this report by any other person or 4� � party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE ySystem #1 Approved for 11 bedrooms System #2 Approved for bedrooms OF ,e.vv Disapproved �U T Conditional approval for bedrooms, with the follow sti qi hsE INA AND WASTFWATFR ;� PROGRAM 2 3 rl BYE 7 Original Certificate Date. 3 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 blue sheet 10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: Southpark #2; Block 3, Lot 30 Parcel ID: 020-502-28 A. WELL DATA PUBLIC Well type If A, B, or C provide PWSID# Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height (abo - 'round) in. FROM WELL LOG AT I CTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RES : Coliform colonies/100 ml. Nitrate mg./L. Collected by: enic: ug./L. Date of sample: B. SEPTIC/HOLDING TANK DATA *Pre—tank and post—tank double cleanouts. Tank Type/Material Septic/Steel Date installed 7/29-31/2015 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Yes Foundation cleanout (Y/N) *No Depression over tank (Y/N) No High water alarm (Y/N) N/A J Date of pumping f 1 j Pumper 4 l4 G SLr(di C e S C. ABSORPTION FIELD DATABelow Existing Grade Date installed 7/29-31/2015 Soil rating ..p.d./ for ft2/bdrm) 0.5 System type Bed Length 50 ft. Width 24 ft. Gravel below pipe 0.7 ft. Total depth *5+ ft. Eff. absorption area 1200 ft' Monitoring tube Yes Depression over field No Date of adequacy test 3/15/2018 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 746 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) None Known If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit r-•. rements? E. SEPARATION DISTANCES _ SEPARATION DISTANCES FROM WELL ON LOT TO: PUBLIC Septic tank/lift station on lot on adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic servic- ' e Holding tank Animal .• .inment areas Manure/animal excrete storage areas 'ARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 1 00'+ Wells on adjacent lots 100'+ PVT & 200'+ PUBLIC SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain None Known Wells on adjacent lots 100'+ PVT & 200'+ PUBLIC F. COMMENTS ooOppO G. ENGINEER'S CERTIFICATION o OF 1.'4 ' I certify that I have determined through field inspections and 0 � ; 41', I - 0 review of Municipal records that the above systems are in & 'i VA conformance with MOA COSA guidelines in effect on this date. i 'N, A. Gar ess.: Engineer's Printed Name JEFFREY A. GARNESS �O�, C oop� �4st� ....,3 ZIP$.. � p0 Date 3i21/43 0 .-e 0o 4\\�a�'rofessioco�o 0 \‘O000�� #AECC884 (Rev. 11/05) _.. ;•••.•• �....�'�A� -- -- -- — 11 O'' // -------� No SP/PA �� F. �q�l — ` O ���. 9 !'r b STAIR: sg I L 36'•98 (R2 ��. 6\) * . 4 9 TH % ' //`` a :' cecv-- ,� R5 /h1-- 4J �j �/ ..,...-Z r .c.- ��,, J / 1 < OFP . i . � ,f / . DECK 71. '.MICHAEL.4.HCRNE c /� . 00 L5-5 18 ��, �j • DETAIL .:YOT TO SCALE. L OT 2,ci �b �,r,6': i j SEE S�lAl( s tij \ o 0� ,,,,.;\, .,..;* v SII2RY O 1 1 1x� sy?' <26,� .i��1\\\i% ::r'Pr'V (iii I ,� Fo `�; HOOF tc o L4,1.17; ',.•.f._,/: : LOT 3 1 \ • i ,` $ PAVER / N 2 J. W N-2 - SEVER ?,9Tr0 O 1 \ CLEAt`10Ui (lYr`YCAL' 01 CREEPNOUSE ` 1G• T& E EASEMENT j V "Z\ t t M LOT 30 1c -- 4 ' � yV/' rn ` frw f0' . -- -__ .1 N 89'50'14" W 219.80' — _ -� NOTES: -1 1) BEARINGS AND DISTANCES ARE RECOORI:PER PLAT NO.83-213 UNLESS OTHERWISE NOTED. 2) THE RECOVERED MONUMENTS WITHIN TI-i15 SUBD:VISION WERE USED TO CONTROL THIS SURVEY. ?REPAR£D FOR: Nci.: , rGlacier City Realty '%, 74 Hightower Road Farpolnt Land Services, LLC 3;rdr;ood,A}:9958 f ' SURVEYING, MAPPING, LAND PLANNING, GIS i f SURVEY CERTIFICATION:FARPOINT has conducted a 1 1 3 I E. 7Gth Ave., 5urte 101 Anchorage, Alaska 995 18 .,physical survey of this property as shown on this ,..•1/4, rarpo.ntAK.com (907) 522-7770 survey@farpoir:tak.com raying and that the improvements situated thereon are within the property lines. .5 SSUf:. OF: -XCLUSION NOTES:)t!S the owners respons.biI,ry:o Jew Septic System, Lot 30, Block 3, South Park Subdivision determine the existence of any easements, covenants,or restrictions which do not appear on Jo. 2, Plat No. 83-213, Anchora;e , Alaska +,e recorded subdivision plat.NOTE:Undernc 01.5 I ..n A t ^rrtt,r. Ctir 5tanCES should any data hereon be used'Cr' ,s!$ ' A r " Jnr r A.�_ .e w . .�.•, ('.f'e Ctlnstr SCtior or for the establishing of property 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. # f'h.q("~ - C'~Z~ -LI .z) HAA# ~¢'~ ¢~ L i O¢~ ¢'c~ GENERAL INFORMATION Complete legal description Location (site address or directions) ~vv4/f0£,5 r~ e'., Ah'. Propertyowner ~'¢/ /..z.,, /~ ./vl ,F. ?'-/-/o /v~A.~ Dayphone Mailingaddress /,5~z.5/ 57',5/VV~'Ooz9 ¢/£¢z.~-...A,.Vc/f¢~'~c', ,~ Lending agency ~ Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: /"/ I' 3. TYPE OF WATER SUPPLY: Individual well Community well Public water ' r)¢' NOTE: · If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL:' Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~)25(Rev. 1/91) Front MOA~Y21 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 watb~r supply and/or wastewater disposal system is in compliance ~vith all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ AA/C. Phone Engineer's signature ~e~'~l ~ ' Date~ DHHS SIGNATURE /~' Approved for Disapproved. Conditional approval for bedrooms. 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:/OT $o/ ~/,/'¢ ,_'3 A. Well Data /V'/.A, Wail type Log present (WN) Total depth Sanitary seal (Y/N) Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main FROM WELL LOG g.p.m. AT INSPECTION g.p.m, r-r'l ; On adjacent lots m z~ ~> ~ © ; On adjacent lots Public sewer manhote/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed /O/z/5 / ~/' Tank size /,~..~O Compartments Cleanouts (Y/N) y,~ 5 Foundation cleanout (Y/N) ~"~:'.5 .Depression (Y/N) High water alarm (Y/N) ~O Alarm tested (Y/N) Date of pumping OS/Z~/~/~ Pumper ~¢ /~'O~£ /JO SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~///&, On adjacent lots /V//~ Foundation 2 3' To property line / ~ ,-~ / Absorption field / ;2 ~ ~ Water main/service line 2/0 ~ Surface water/drainage ,~/00 ~ CONTINUED ON BACK PAGE 72-026 (3/93)* Front Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /0/?~/~' Length ¢'/~. F 7' Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width ~)~2 ¢'7'z Cleanout present (Y/N) ~ ,5/$/ / ~ Results (pass/fail) Soil rating (GPD/Ft2) ~)' '-~ System type /:: 7' Gravel thickness Total depth Depression over field (Y/N) fl,4 ~.5' for /7' Bedrooms After test (7.). ~'/¢ 7' If yes, give date /V/A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots ~ /O ~ Surface water ~/00 i Curtain drain /~/A /2-6 ' On adjacent lots /V,,~ Property line To existing or abandoned system on lot Cutbank /k/J.,~ Water main/service line Driveway, parking/vehicle storage area / E. ENGINEER'S CERTIFICATION I certify that I have chq,cked, ~verified, or conformed to all MOA and HAA Engineer's NJ .~ '--~(~"'~"-~ HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ,E~-~,~e .~',~,¢~-cY.._ Telephone: Home Business '~ ~- 5-.~',~,~'.~' (c) Applicant is (check one): Lending Institution []; Owner/builder,,~Buyer E]; Other [] (explain); (d) Lending Institution ,Z Address ~-'~,' (e) Real Estate Company and Agent Telephone Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well [] Community ~;~ Public [] / Note: If corn munity well system, must have written conf rmat on from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [~ Public [] Community [] Holding Tank [] / Note: If com munity well system, must have written confirmation from the State Department of attesting to the legality and status. Page 1 of 2 Environmental Conservation 72 025 n 1/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATIOI~ As cert f ed by my sea att xed hereto and as of the vahdatlon date shown below I verify that my investigation of th Authority Approval shows thst 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 fu~her 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 ~n compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection, Name of Firm ~ ~ ~ ~ Telephone ,5--~ / 3~ ~o Address /~o ~, ~.~ ~ ~ '~ ~~ ~ ~ ¥~ / Date ~ '- ( ~ ~ ~ Engineer's Seal DHEP APPROVAL,~,~;__ ~,~L~ b~ Approved for ~ ~ bedrooms ~ Disapproved Conditional Approved Terms of Conditional Approval Date 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 [ending 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 /VlUNICIPALIT~ OF ANCHORAGE ~-'~t'~, DE'PT OF HEALTH & .... ~cNTAL PROTECT~O~ MUNICIPALITY OF ANOHOHAGE {MOA) HEALTH AUTHORITY APPROVAL (HAA) ~U N o ~ 40OC CHECKLIST - FEBRUARY 1984 Legal Description: ~ p~ ~4~ ~ Z WELL DATA Well Classification ~,/*~,'~ "'~ "? If A, B, C. D.E.C. Approved 'Y~) Werl Log Present (Y/N) ~ Date Complete~ "- Yield Total Depth Cased to Static Water Level ~- Casing Height Above Ground ~ Electrical Wiring in Conduit (Y/N) ~ Separation Distances from Well: To Septic/Holding Tank on Lot :~'~ '~F To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ,4/'.4- Cleanout/Manhole .4'/¢ Water Sample Collected by Water Sample Test Results ~ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ;~-oo-F ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date ~ Comments B. SEPTIC/HOLDING TANK DATA Datelnstalled JO/I,.S,/'~r Size I~"~'~0 -No. of Compartments Standpipes~N) Air-tight Caps'4) Foundation Cleanout ~.1) Tank (Y/f.~ Date Last Pumped I~/~ Depression over Pumping/Maintenance Contract on File (Y/N) lq, .A ; for v Holding Tank High-Water Alarm (Y/N) IV'¢~ Temporary Holding Tank Permit (Y/N) Separation Distances from Sel~tic/Holding Tankl To Water-Supply Well ~2--o 0 ~- To Building Foundation 3-¢., S To Property Line 1 "~ '~- (~1~,'~-k ~-~'} To Disposal Field { [ '~-' To Water Main/Service Line ] r~t''F To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~ 4- 6 Date Installed ~ / I~'-/ ~"~' Width of Field 2. I Square Feet of Absorption Area ~:' ~' ~'~ Depression over Field (Y/~). Results of Last Adequacy Test /"¢ ^ Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation t ~ (~ t Lot ~l' ,/N To Water Main/Service Line To Stream/PondlLake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area r'~ ~/,b. Type of System Design Length of Field 'Z~ ~ Depth of Field ~.. , ~ Gravel Bed Thickness ,5 ,1 Standpipes Present ~*~N) Date of Last Adequacy Test To Property Line '~'~ ' %' * To Existing or Abandoned System on ; On Adjoining Lots 3 o I+ To Cutbank (if present) I'¢ A. Comments D. LIFT STATION Date I n st alle d'~'"~"~ Dimensions Size in Gal,l, ons -~"~.~ ~ Manhole/Access(Y/N)~ ~:gsthedWfa~:r Ala~rm L(ve, at _J Pu~uring Adequacy T~':~<~VVent (Y/N) ~est. Meets MOA Electrical Codes (Y/N) Comments ~ ** 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. Signed ~,¢.'~'L ~ ~ Date ~'~ Company Receipt NO. Date of Payment Amount: $ MOA No. Page 2 of 2 72-026 (11/84) Engineer's Seal DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 RILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom it May Concern: ~ P~ According to records on file in this office the Water System is in compliance with the State Drinking Water Regulations Sincerely,