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Home My WebLink AboutSPRING BROOK VISTA #1 BLK 2 LT 5WWI #050-091-16 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 OSp_ SEPTIC ABSORPTION WELL Address \\ FROM TANK FIELD �ji'7fJ0 ..W • t r�r� 419111 Phone(s) Permit No. No. of Bedrn WELL WELL ? I A' 1'ct—"I 1� eli LOT LINE LEGAL DESCRIPTION , t•� 1 Lot / Block Subdivision Township, Range, Section 1 ,\ AS -BUILT DIAGRAM (Showlocation of well, septic system, property lines, foundation.. driveway, water bodies, etc.) TANKS SEPTIC/1— I ❑ HOLDING t ( G 111 11 Manulacturer Capacity in gallons/ I All 1 ` D I lie1 Material No. of Compartments w✓ TYPE OF SYSTEM ❑ TRENCH B DFW DRAIN ❑ OTHER r r ` Depth to pipe bottom from Total tlepth fromorig al grade • original gradeFT 0115 7 FT Fill added abolve original grade Gravel depth beneath pipe <> FT LO, 5 FT Gravel length Gravel width �O FT FT Total absorption area Distance between lines M nC,0SQ FT (O FT 'r Number of lines Soil rating Pipe material I \611 SQ FT O --5 R. Installer Date Installed WELLS 0 ❑ PRIVATE �THER (Identity) Classification (A,B,C) Total DepthCased to FT FT Installer Date stalled: ' REMARKS: q+ Scale: , , ENGINEER'S SEAL •�, c 1�(� GL}(�7r firs Inspections Performed by: .e� a 'it, %34't' irr'� 1"✓V ✓`'- �t�" \✓ • l`�T7p,_G_i. �•�?'� •sa°aoap 1tt+��{4W(. Y"\ '. Date: 1 1"� TJ l (;�,�`` ,� °°oory ep t . ` _ ; SYi �j ` • c.onve,rlt e tl°see.•e S & S ENGINEERING _— ,�:.�gloRive't-�,e� Qnzii�_ -_ —_ liifyIh this inspection wasperlorinedaccordingtoall e� � w..•^••^••°°°'9 I ff I� g W , I, �efOf�hfVgg 7 A. ShaCae Municipal and�tilN%i�elM($�ih L s d�l� �� ,�, ;�,R�� •:? Health Department Approval: �� --- Date: !L / �- qq pROFE'3s�o�, 72-013 (3/85) MUNIClPALITY OF ANCHORAGE Department o{ He�1th & Human Services 825 | Street, Anchorage� Alaska 99501 343 ON - SITE SEWEH PERMIT PermitNumber: 890247 Upgrade ��/u /��z / ' Date Issued: 10/25/89 Engineer Uesigned Owner Name: NA[HAN A" HURLBURT Owner Address: 12308 W, PRINCE OF PEACE EAGLE RIVER, AK 99577 Day Phone: 276�1319 Parcel ld: 050-091~16 Lot Legal: Subdivision: VIGlA #1 Lc)t: 5 1.1lc ck: 2 Section: 1 Township: 14N Range: 1W Lot Size 19470 (sq,ft, or acres) Max Bedrooms: This Permit: 3 7otal Capacity: 3 SEPTIC TANK: Minimum toLal septic tank capacity: 1�000 g�llons" Each septic tank must have at least 2 comparLments. Depth to top o� septic tank(s> < 4.0 �eet requires insulation over tank(s). INSTALL PER ENGINEERS ATTACHED APPROVED DESIGN^ NOTIFY DHHS PRIOR TO EACH INSPECTION. LIFT GTATION PUMP AND WIRING TO BE INSTALLED TD CODE, VERIFY EXISTING SEPTIC TANK/S INTEGRITY, EXCAVTION MUST BE OPENED AND CLOSED ON THE SAME DAY OR ELSE COVERED AND HEATED IF LEFT OPEN FOR MORE THAN ONE DAY" THIS I:,;, EXPIRES ON 12/31/89^ I CERTIFY THAT: 1. J. with the requirements for oniite sewers and wells as seL �orth by the Municipa1ity of Anchorage (MOA) and the State oAlaska. 2^ I wi1l instalystem in accordance with all MOA codes and regul�Lions, and in compliance wi1.h the design criteria o< this permit. 3, I will adhere to al1 MOA and State o� Alaska requirements �or the set back distances from any existing wel1, wasiewater disposal system or public sewerage system on t�)is or any adjacent or nearby lot. 4, I understand that this permit is valid for a maximum oI 3 bedrooms" I a1so understand that the capacity of the total system is 3 bedrooms and any enlargement will require an additionai permit, Signed: UATE: ��~--^-~ A'-�- �» �h lssued By: DATE: ^--~��~~-~ u Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ogp�`� �'•. Asa .,-.� PERFORMED FOR: DATE PERFORMED:.. LEGAL DESCRIPTION: � % Toyynship, Range, Section: II r G SLOPE SITE PLAN 1 2 ,10 3• / 0 4 r r� 5" O• C> 6 f• r 7 F 8 h or 9 • Y- ��p 0 10- 11 0 11 45 12 A 13 14- 15- 16- 17 4151617 81920 18- 19- 20 COMMENTS , CA11151 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S�r Depth to Water Alto(– Monitoring? INEERING —�� S \ 24 L D P E --' Date: Ito -k!5 -'a tl Reading Date Gross Time Net Time Depth to Water Net Drop ur ('lJ 'rJ PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER LAP, TEST RUN BETWEEN FT D 2— FT 17034 Eagle [liver Loopy React IVL• 2 PERFORMED BY: Alaska 995 Ewe-E_-"-'�,, �P / ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDECI ES 1 72-008 (Rev. 4/85) CERTIFY THAT THIS 'EST WAS.PERFORMED IN ON THIS DATE. DATE: a �! I I f `;\�\ �/ : l i� i"Y • i'1 Y l 4. � i �/ 1 \ i"'� Li L. -%'Y i\ �. �'1 eJ 6s . \ ✓ : : �li� ;r' Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 _ INSPECTION REPORT Off] -SITE SEWAGE DISPOSAL SYSTEM .NAME 'rnf;N j f: i (f M_ AILING ADDRESS PHONE -L `% l3 LOCATION LEGAL DESCRIPTION L c r 5 I c,< Z_ ✓I^.2i ,e;: �� SEPTIC TANK: U LAr k7611o`l DISTANCE NUMBER OF _ FROM WELL MANUFACTURER Sn�c ie�I- MATERIAL COMPARTMENTS `=- 1250 INSIDE LENGTH INSIDE WIDTH _LIQUID DEPTH LIQUID CAPACITY_____GALLONS. SEEPAGE PIT: NUMBER OF PITS DIAMETER. _10 OR WIDTH �4 LENGTH �I DEPTH LINING MATERIAL Concrete CRIB SIZE: DIAMETER DEPTH � DISTANCE FROM: WELL. TOTAL EFFECTIVE_ l,— BUILDING FOUNDATION_!` , NEAREST LOT LINE -"Z ABSORPTION AREA (WALL AREA) Sy SQ. FT, ADDITIONAL ABSORPTION WELL,: C�ti;,ku�„fir TYPE BUILDING FOUNDATION CESSPOOL APPROVED DISTANCES: INSTALLED BY: PIPE MATERIAL: '.Uy SLOPE: aY t.L[A R Y,S; CONSTRUCTION NEAREST LOT LINE NEAREST SEWER LINE OTHER SOURCES DISAPPROVED REMA DEPTH SEPTIC TANK_ DIAGRAM OF SYSTEM. DISTANCE FROM: SEEPAGE SYSTEM _. GRE. 'ER ANCHORAGE AREA BOf 9GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 SEEPAGE PIT: NUMBER OF PITS I DIAMETER _! ` OR WIDTH—Li LENGTH_L) DEPTH LINING MATERIAL Vi — _ CRIB SIZE: DIAMETER DEPTH �� _ DISTANCE FROM: WELL 1 TOTAL EFFECTIVE BUILDING FOUNDATION NEAREST LOT LINE_' ABSORPTION AREA (WALL AREA) f� �' SQ. FT. ADDITIONAL ABSORPTION WELL: �o bLiLil ii r �/ TYPE BUILDING FOUNDATION CESSPOOL APPROVED DISTANCES: INSTALLED BY: PIPE MATERIAL: LOT SLOPE: REMARKS: Form No. EQ -031 _CONSTRUCTION NEAREST LOT LINE_ , OTHER SOURCES DISAPPROVED DEPTH NEAREST SEPTIC SEWER LINE -,TANK_ REMAR DIAGRAM OF SYSTEM DISTANCE FROM: SEEPAGE SYSTEM _. INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ,1rviFiN Iui � b ir;r _ MAILING ADDRESS 'k ` %- I%01< �iYLeL r _ PHONE LOCATION LEGAL DESCRIPTION C'r �' 1/01�0 SEPTIC TANK: ULj*` 1 DISTANCE (( NUMBER OF FROM WELL ___ MANUFACTURER —MATERIAL— _COM NTS Z- _ INSIDE LENGTH INSIDE WIDTH _LIQUID DEPTH_ LIQUID CAPACITY(�(J'60GALLONS. SEEPAGE PIT: NUMBER OF PITS I DIAMETER _! ` OR WIDTH—Li LENGTH_L) DEPTH LINING MATERIAL Vi — _ CRIB SIZE: DIAMETER DEPTH �� _ DISTANCE FROM: WELL 1 TOTAL EFFECTIVE BUILDING FOUNDATION NEAREST LOT LINE_' ABSORPTION AREA (WALL AREA) f� �' SQ. FT. ADDITIONAL ABSORPTION WELL: �o bLiLil ii r �/ TYPE BUILDING FOUNDATION CESSPOOL APPROVED DISTANCES: INSTALLED BY: PIPE MATERIAL: LOT SLOPE: REMARKS: Form No. EQ -031 _CONSTRUCTION NEAREST LOT LINE_ , OTHER SOURCES DISAPPROVED DEPTH NEAREST SEPTIC SEWER LINE -,TANK_ REMAR DIAGRAM OF SYSTEM DISTANCE FROM: SEEPAGE SYSTEM _. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO 3330 "C" STREET ANCHORAGE, ALASKA 99503 L � TELEPHONE 274-4561 S� SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT f��x-`r ACG7� �"6{r - ro �j NAME OF APPLICANT "'�t' — C-� MAILING ADDRESS PHONE INSTALLATION LOCATION LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK Gam_ SEEPAGE PIT G./ DRAIN FIELD OTHER TYPF. AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH TO i BE INSTALLED BY SOIL TEST RESULTS NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM FOUNDATION TO SEPTIC TANf( S / FOUNDATION TO SEEPAGE PIT DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK , SEEPAGE PIT DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK LN P SEEPAGE PIT DRAIN FIELD ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD SEPTIC TANK, .L, SEEPAGE PIT DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT �F SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMQj/,�$�E� CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH }ZEGVLATIONS REGARDING INSTALLATION (A g ic - G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 26-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. / --> 7 DATF_ -L--( �-7 1�� APPLICANT'S SIGNATURE �r '"I�l �'✓ `� -'- �` _ FORM NO. EQ -016 0 & E EIV I NEERI NC & DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 333-5240 Russell Oyster Earl Ellis 694-2774 333-5240 Civil Engineering Surveying Soils Et Foundations Land Development SOIL. LOG Performed for: Name: !\W 5UKy� Tel. No. 7 Mailing Address: `tx �� V,f,� �dL�v£Jz Legal Description:sc Depth (feet) Soil Characteristics 0 _ 2 3 4 7 _ 7 9 i�>V� C i fvLYr� t 10 2, i G� 11 12 Ground Water Encountered: Yes__ No ✓ If yes, what depth_ Proposed Installation: Seepage Pit Drain Field Comments:_ 7.z_ Performed by: ��ia,.,g �� Date: 1 ? _ Municipality of Anchorage Development Services Department \\ ~ Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.orglonsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. COSA # L10 Expiration Date: / , ? 1. GENERAL INFORMATION Complete legal description Lot 5; Block 2; Spring Brook Vista #1 Location (site address) 12308 W. Prince of Peace Dr. Eagle River, AK 99577 Current Property owner(s) Mike 6 Nancy Cox Day phone Mailing address Lending agency Day phone Mailing address Real Estate Agent Katherine Dehoop / Exit Realty Day phone 230.8522 Mailing Address 243 E. Slh Ave. Ste. 202 Unloss otherwise• requosted, COSA will be held by DSO for pickup. :vt.: Y=.1:.': 2..NUMBEk& BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site ❑� Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System 0 Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 s 3 s engineering Phone s9a 2s�e Address 15861 S. Birchwood Loop Chugiak, AK 99567 Engineer's Printed Name Robert A. Shafer Date 5. DSD SIGNATURE 3 Approved for bedrooms. ' Disapproved. Conditional approval for bedrooms, with the following stipulations: Ila /0 Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory� Other i By: ;C V (R«. I IM) Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907)343-7904 CERTIFICATE �7�OF ON-SITE SYSTEMS APPROVAL CHECKLIST ILegal Description: VT Sj D. LIFT STATION Date installed I( (7 Size in gallons U -SO Manhole/Acces�l) _ to V1 ry 'Pump on' levet at � in. "Pump off level at in. High water alarm level at in. Datum TOF O F Pjgri f ac Cycles tested �J Meets alarm & circuit requirements? � E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO. (,43rj-T C Septic tank/lift Absorption field on lot Public sewer main Sewer /septic service On adjacent lots On adjacent Holding tank manhole/cleanout Anima nment areas Manure/animal excrete storage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation S -f Property line 5 4- r Absorption field S ! / Water main /17 Water service line /0 A Surface water r Wells on adjacent lots o2W 4 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ! r ! Property line /0 f Building foundation /D f Water main �� A r ) / Water Service line D f Surface water /� "F Driveway. parking/vehicle storage /04 Curtain drain ,ytx9t Kuac'K1 Wells on adjacent lots ,12!�o _ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined review of Municipal records h� conformance with MOA COSAIgL Engineer's Printed Date r � COSA Fee $ 0 Date of Payment Receipt Number (Rev. 11/05) field inspections and Waiver Fee $ Date of Payment Receipt Number 9:::.•«•per �' ie• . j• �5;role: 1 � R /10 I AS -BUILT I hereby certify that I have surveyed the following described 17 ,t PUS.. M'�7 A_iv��U�• E2 SW 4. Se•.e.n /LT I_q_N� R zw� s/yt Anchora,:c Recording Precinct. Alaska, and that the in, ovemerls situated thereon are within the property e! linand do not overlap or encroach on the property lying adjacent tacreto, that ❑o improvements on prop- erty erty lyin, adjm•ent thereto encroach on the premises to quesuon 2nd that there are no roadways, transmission hmcs or mhcr vit;:b'.^ casements on said property except as indicated hereon. Dated at Eagle River, Alaska this_ LS -._day of �I i 19. e ROBERT C. JOHNSON Way E7— SCALE: Registered Land Surveyor No. 880 -LS 1•_30Pox 455, Evcle River, Alaska , Phone 694-2.517 11/20/2008 10:57 JRs Pumping PO Dox 773413 Eagle River, AK 99377 (90-)694-6454 9073449821 Billing Information S 8 S Engineering 15861 South Birchwood Loop JRS SEPTIC Job Description: 12509 P.O. Number: Chuglak, AK 99567 Terms: Net 30 (907) 694.2979 Salesrep: Kadia Map Book: Job Site Information Cross StreeW Yoshi Job Comments: 12308 W Prince of Peace Dr Eagle River, AK 99577 (907) 694-2979 Additional Location Comments Septic @ Back of Home Tank w/ US Service Type Septic Service 126K uto wenn rlwy PAGE 01 Service Agreement Number: 027772 Order pale: 17 -Nov -2008 Service Date: 20 -Nov -2008 12:0 Technician: Mike Tax %: 0 Job Type: Repeal Map Grid: 85. . Last Sery 0062012003' 12505 Tank - WUS Cked 6 Pumped Tank 8 Lift Station Go pipe Q back of home bent over L's good -B/F -2 -X's Diagram: S: IDiaaroms\27772 bmo lA,l e T.k C. Qty Price Each Tax? 1 $165.00 No Gallons Planned: 1250 Gal Actual: Hose Length: 1.5 Double Tank: O Pump System: Baffles Inlet: O Baffles Outlet: ❑ Extension Actual $165.00 NonTaxable Total Taxable Total Tax Total Grand Total Estimated Charges: $165.00 $0.00 $0.00 11165.00 Actual Charges. Customer agrees to the terms and conditions shown. THIS IS A BINDING AGREEMENT. Signay9sVIfilsofCusto er RepresernatIve Date cep d by J umping Date Accepted For your adds omenle we accept: American Express, Dleover, Visa and Water Card payments over the phone. Atter 30 Days account wig be turned over to COLLECTIONS. S30.00 For NSF Checks Returned. J.�K n'liw.► MdffiicipelitybfAfidhofligtY gevelopriient Senfiees bdpartmbint Building Safety Division _ Onsite Water & Wastewater Program 4700 South Bragaw St.. - P.O. Box 196650 Anchorage, AK 89519 6650 www.ai.anchorage.gk.us CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 6 —iq 1 &V HAA# 06C004 1. GENERAL INFORMATION Expiration Date: T — 7o. — O S Complete legal description SPRING BROOK VISTA SUBDIVISION #1: LOT 5. BLOCK 2. Location (site address or directions) 12308 W. PRINCE OF PEACE DRIVE * EAGLE RIVER, AK 99577 Current Property owner(s) WILLIAM do JEAN BROWN Day phone 696-7071 Mailing address c/o KERI BAILEY w/ PRUDENTIAL VISTA Lending agency L Day phone Mailing address Real Estate Agent KERI BAILEY w/ PRUDENTIAL VISTA Day phone 689-6487 . Mailing address 16635 CENTERFIELD DRIVE • EAGLE RIVER, AK 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-sfte i♦ Individual Water Storage ❑ I Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System it Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certffed by my seal affixed hereto and as of the validation date shown below, 1 verify that my Investigation, based on procedures ouGined In the Health Authority Approval Guidelines for this application, shows that the onsite wafersupply and/or wastewater disposal system Is(ars) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. 1 further verify that based on the Information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the onsite 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 Finn GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engheering analysis of the system In accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 He of all wells and septic systems depend on the kcal soils condition, groundwater levels that may fluctuate during the year, and the wafer usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee futura performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ud. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any otherperson or party Is not authorized, nor will K confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Phone 337-6179 Date f Z Z9I I Conditional approval for bedrooms, with the following stipulations: Jej ON-SITE �g � �ennTGR nNn WASTEWATER 0. PPA(ZRAM Attachments: HAA Checklist �� Maintenance Agreements J'J��X ••� 5'; Septic System Advisory Supplemental Engineer's Report mm", Well Flow Advisory Other By, + Original Certificate Date: _ y J 0 taw. lamp k Municipality of Anchorage •roE °�. • Development Services Department Building Safety Division ` On-Site Water & Wastewater Program s w 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 g a www.ci.anchorage.ak.us (907)343-7904 q V HEALTH AUTHORITY APPROVAL CHECKLIST ry`. Legal Description: SPRING BROOK VISTA S/D tit; LOT 5. BLOCK 2, Parcel ID: '050-091-16 b PUBLIC WATER A. WELL DATA Well type If A, B, or C provide PWSID# Well Log (Y/N) r bate completed Sanitary seal / lres properly protected (Y!N) Tot Cased to ft. Casing height (above ground) in. l I FROM WELL LOG AT INSPECTION Date of test M Static water level ft. ft• Well production g.p.m. g.p.m. E ` WATER SAMPLE RESULTS: Coliform colonies1100 ml. �Dateof mg./L, once 100 ml mple: Collected by: B. SEPTIC/HOLDING TANK DATA i 3 y Tank Type/Material STEEL/S.T.E.P. Date installed 11/17-19/89 n t Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (Y/N) YES , c J Date of pumping 12/17/2004 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA *MTl/MT2 s Date installed 11/17-19/69 Soli rating (g.p.d./ftzor d� 197 System type BED Length 50 ft, Width 18 ft. Gravel below pipe 0.5 Total depth'3.63-3.e3ft. Eft. absorption area 900 ft' Monitoring tube YES Depression over field NO { Date of adequacy test 12/14/2004 Results (Pass/Fail) PASS For 3 bedrooms **DRY/ **6.5/ Fluid depth In absorption field before test 10.5 in. Water added 525 gal. New depth 1?•b5in. 4 **DRY/ M i Elapsed Time: 1197 min. Final fluid depth 10.5 in. Absorption rate >= 450+ g p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - **SEE ATTACHED DRAWING FOR MT ELEVATIONS IN DRAINFIELD. s I r Date installed 11/17-19/8 Size in gallons 1250 Manhole/Access(YIN) YES "Pump on" level at41 in. "Pump off" level at 41 in. High water alarm level at 45 in. Datum BOTTOM OF TANK Cycles tested 3 Meets alarm & circuit requirements? YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on tot Public sewer main PUBLIC WATER On adjacent M Public sewer manhole/cleanout line Holding tank SEPARATION 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 100'+ Wells on adjacent lots 200'+ 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 200'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date HAA Fee $ -OD Date of Payment 3 `s Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number 12/28/2004 14:08 FAX LIFT Wl IATION \""Do a111 N I 1 1 LOT 4 i 1 I Irt N i NO CORNERS SET THIS DATE I SCALE: V • 30' I HEREBY CFATiFY THAT I HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THC FOLLOWING i DESCRIBED PROPERTY. LOT S. BLOCK 1, SPRING BROOK VISTA SUS., IU S W AND ROINGDTEDT THEINFORMATION HSREONIS PORTHS USSOF LENDING INSTIILTIONSSPECIFI".ALLYTOSHOWAWCONEUCTS BETWEEN CREONA(A THE IMPAVEMINGE THE IMP ARE WITH WWTING ST LCTUEt,, AND PUTTED LOT LINES OR MEMEM'S ANO IS NOT TD Eli USED FOR POSITIONING ADDITIONAL Ln STRUCTURES OR FENCCLINCS. ( OTHER THAN NOTED. EASEMENTS OF RECORD. OTHER THANTHOSE SHOWN ON THE RECORDED PUT, ARE NOTSHOWN HERE01l / Ln DAY OF DECEMBER 2004-1 NOTE IO HOLT LATJD SURVEYING 7EEB ORLOCAYFENCELTURES. ORLOCATfi STRUCTURES. I - C3 m a m �I �l II{{rr I' R T 49TH SHANLT A. MOLT. s0 4i LS -W914 n � LOT S N ET n j 1 git,1'i is 10 Ai1AO fP <�CK 00 N� wir 5.64"g=;'SD"E54.82' I 3' I //1 OfuYEL DRIv6wnr AS 1 AP•.LT c 0 In z W� 11002/002 i I 1 1 LOT 4 i 1 I I I I AS-e1mT SURVEY i NO CORNERS SET THIS DATE I SCALE: V • 30' I HEREBY CFATiFY THAT I HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THC FOLLOWING i DESCRIBED PROPERTY. LOT S. BLOCK 1, SPRING BROOK VISTA SUS., I I UNIT NO. 1 AND ROINGDTEDT THEINFORMATION HSREONIS PORTHS USSOF LENDING INSTIILTIONSSPECIFI".ALLYTOSHOWAWCONEUCTS BETWEEN CREONA(A THE IMPAVEMINGE THE IMP ARE WITH WWTING ST LCTUEt,, AND PUTTED LOT LINES OR MEMEM'S ANO IS NOT TD Eli USED FOR POSITIONING ADDITIONAL S ENCROACHMENTS NO VISIBLE fNCROACHMENi9 PROPERTY LINES AN NO VISIBLE STRUCTURES OR FENCCLINCS. ( OTHER THAN NOTED. EASEMENTS OF RECORD. OTHER THANTHOSE SHOWN ON THE RECORDED PUT, ARE NOTSHOWN HERE01l OATLD AT ANCHOAAGE, ALASKA THIS 16TH_ ' WN ARE LOCATED IIPFRO%IIMTEC'r aND ARe NOT EF USEo'IO DETERMINE FROFeRTY UNFS DAY OF DECEMBER 2004-1 NOTE IO HOLT LATJD SURVEYING 7EEB ORLOCAYFENCELTURES. ORLOCATfi STRUCTURES. I - TEL 746.6611 '. FS 37-6 167. .8�7 r i 03.59 11.05 N1-rI S1-6ajv ,c 4,g" oC EFFrrnJ. M -r L s i%crI ld+ (1 n OF �LTwE rt)? L M" 2L, PAe-rfnu,< PcLJG6rp/"G✓laKro if '$ 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. # S-� ° 67 / -' 6 HAA # by n")1.:C')'3 _ 1. GENERAL INFORMATION Complete legal description Lot 5; Beock 2; Spting Bnook Vista =1 Location (site address or directions) 12308 W. Pkince of Peace Eaate Riven.. AK Property owner Debi Otzenak Day phone 563-7888 Mailing address —P.O. Box 771708 EaQ2e R.r_ven, AK 99577 Lending agency Day phone Mailing address— _ Agent Lynn SwanAon/ Jack Wh.i,o. Co- Day phone 694-5500 _ Address _ Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water X" 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 xxx 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. 1191) Front MOA 021 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 f=irm e _S& S ENGINEERINGCC G Phone_ fy'a-�� 17034 Eagle River Loop Road No. 204 Address Eaole /70 Engineer's signature XAt✓'' Date 5f / 7 l FA a Gj�� ROBERT "C. COWAN,' CE • 8801 6. ®HHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 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. rtaram...+v+) a. H_Arr. MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage AUG ® 8 199 DEPARTMENT OF HEALTH & HUMAN SERVICES 1 Environmental Services Division R E C E I V 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: 4o7- ��, see, 4ti6 Parcel I.D.: A. WELL DATA Well typePUhF.zc wArO e If A, B, or C, attach ADEC letter. ADEC water system number lv, A . Log present (Y/N Total depth Sani al-('f/I Date of test Static water level Well production Date completed 161, ,4, Cased_to._---= Casing height (above ground) Wires properly protected (Y/N)-- --___ FROM WELL LOG AT INSPECTION WATER SAMPLE RESULTS: Coliform B,,-3LG/iIOLDINGTANK DATA Nitrate Collected by: Other bacteria Date installed,//-/ 7 Tank size /zS 6 -Number of Compartments Clean outs ON) Y-fS Foundation cleanout /N) YY� Depression (Y/ei✓y High water alarm ON) YZ�-S Date of Pumping M -Pumper C. ABSORPTION FIELD DATA Date installed 11.17_k9 Length S0 Width _ Soil rating (g.p.d./ftz or /bdr`r�p /9 System type '/' Gravel thickness below pipe _Total depth Effective absorption area _ DO ✓ Monitoring Tube present &N) Y, S Depression over field (Y ,-&10 Date of adequacy test 8' -7 - 9z Results�s��ail) /Wf For _ ' bedrooms Fluid depth in absorption field before test (in.); Immediately afterc�7 gal. water added (in.): O Fluid depth (ins) Minutes later: Absorption rate =_!S U g.p.d. Peroxide treatment (past 12 months) (Y/O o ✓ Noy ✓ If yes, give date %l� /-4 72-026 (Rev. 3/96)* D. LIFT STATION 0 Date installed 11-17-4f i Manhole/Access (A) YDS Size in gallons Pump on level at "Pump off" level at* / O High water alarm level at* D 7y *Datum Iola o,,' - Cycles �Cycles tested � �n/GGuO�J S��r'T.fG 7fin/.� E. SEPARATION DISTANCES SEP R DISTANCES FROM WELL ON LOT TO:/— Septic/holding tank on lot On adjacent-lotsf Absorption field on lot � Qn_adjacent lots Public sewer mai ry Public sewer manhole/cl`66Mout— Sewer /septic service line Lift station -- SEPARATION DISTANCES FROM ,8EPT b/HOLDING TANK ON LOT TO: Foundation f Property line S- t Absorption field Water main/service line Surface water/drainage /00 Wells on adjacent lots -r?- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Building foundation �� Water main/service line Surface water /0c Driveway, parking/vehicle storage area , Curtain drain No.v-f Wells on adjacent lots C 0 F. ENGINEER'S CERTIFICATION t certify that i have determined thru field inspections and review of Municipal recap tems are in conformance with A 4-A 7/�V ines in effect on this date. �`` .•'' •• - Signature Engineer's Name ROBERT C. COWAN Date r6(7 �� 'iJ, CE -8801° �r HAA Fee $ tD Date of Payment lrl z -• \ Receipt Number 1) 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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 1. D. # C) , - LIS \ - \ln HAA If 1. GENERAL INFORMATION Loi 5; BEocfz 2; Snning Bnuofz Visa 01 Complete legal description Location (site address or directions) 12308 Wu t Pkinee o) Peace Dki-ve Property owne�hnti's & HOU Sama.�e Day phone Mailing address 1357 Dex.ten. Bnoorn decd, Cotonado 80020 Lending agency Day phone Mailing address Agent Day phone 279-7611 Address 501 (llohxNoit;thpAyi I,igh A 8Pvd Anchnxap -, Ah aa�n3 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 y 3. TYPE OF WATER SUPPLY: Individual well Community well XX Public water 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 XX 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) Font MOA N21 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 furtherverify 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 Phone Address 17034 E3Ule River Loop Road No. 204 aa> is River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE —L1— Approved for Disapproved. Conditional approval for Additional Comments bedrooms. Date .n '�w,•A'' o� h�ia� . yi rc� . FtUG€', dSH FER, P.E cg o�NP� bedrooms, with the following stipulations: By: — Date / -�- - % 7 - y / 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 orderto 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. 1191) Back MOA 421 Municipality of Anchorage Department of Health & Human Services 1 �HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �Z ��a� �°O�'arcel I.D. 0'-0 — b 9 A. WELL DATA Well type MLD lk'SIf A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level Date completed Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Driller Casing height Wires properly protected (Y/N) b AT INSPECTION a o eo ILJ Z eri g.p.m. — g•p• ; C. LIFT STATION Date installed g'CA Manufacturer &h�Li 1 �Lkr11� Size in gallons Manhole/Accesses/N) Vent/N) "Pump on" level at q X11 "Pump off' level at 3�t High water alarm level Cycles tested Meets MOA electrical codes&N) V SEPARATION DISTANCE FROM LIFT STATION TO: 11 Well on lot von 0rOnadjacent lots 11-gk D. ABSORPTION FIELD DATA Surface water I cc -D \ +- Date installed �� l'l �S�l Soil rating.. Ell �l�f� System type�oyr�l��h T3E:D Length 5b, Width �� G ravel thickness CaS Total depth q- D Total absorption area n Cleanouts present ( N) V Depression over field (Yo Ll Date of adequacy test 12- —1 -?-- Results Jgjjs'fail) FA -5S for TN C3> bedrooms Peroxide treatment (Past 12 months) (Y& gAio yinJ If yes, give date "J SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot Zo c-,, � A— On adjacent lots � IAk- Property line To building foundation - lcA To existing or abandoned system on lot 1 S 1 On adjacent lots !22 t Cutbank a Ilk Water main/service line lfl �4— Surface water 1 ob t-- Driveway, parking/vehicle storage area Curtain drain n1 ft�, E. ENGINEER'S CERTIFICATION 2v � I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effecct9q,( Q, to of this inspection. 6na f 1 �' a° L fi p •a �e y9°#' 5 A S ENGINEERING Signature 17034 r;agle River Loo} Road No.9n4 t9 u Y s :i •° $a � `.agle Diver, Alaska 995 '' u Engineer's Name ® ° ° °' ° • ° °� ®aaa si n eae°e0e ae Date �2 r `� — 1 D� 7n , ` iAFER, FS a �' �N F> HAA Fee $ 170 Waiver Fee: $ Date of Payment -LZ •-1.3 W Date of Payment Receipt Number ��x i (�G%�fC��— Receipt Number 72-026 (Rev. 3/91) Back MOA 21 ��.} �n illi r...v A.n - .-•..•• MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services s DIVISION OF ENVIRONMENTAL SERVICES �} 343-4744 CERTIFICATE 01= INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # --®9 ) - < (-'o HAA # 0 C�S-3L� 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LUT 5; BLOCK 2; SPRING BROOK VISTA H Location (address or directions) 12308 Wi?bt P&inee o4 Peace (b) Property owner Mailing Address M. ffunebun.t ,12308 W. Pntince 0 Telephone: (home) —_Business (c) Lending Institution _ NogTNl AND MORTGAGE Telephone Mailing Address FAGI F RIVER, ALASKA (d) Real Estate Company and Agent RF/MAX r7F Fngo R,ruon ATTU• ROR WAMROIT Address # Telephone (e) Mail the HAA to the following address: (or check hereU if hold for pick up.) List contact person and day phone number below: S & S ENGINEEKINk' I ;En34 EALe River Loop Road No. 204 Eagle River, Alaska V9577- 2. TYPE OF RESIDENCE Single -Family EXX Number of bedrooms 3 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 i On-siteA 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 verifythat my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of FirrrS & S ENGINEERING Telephone ? 17034 Eagle River Loop Road No. 204 Address Eagle River, Alaska 99577 Date 6. DHHS APPROVAL Approved forbedrooms by Date Approved )r Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval 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 orderto 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 forerrors oromissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 fvi4t;[CIPALITY OF ANCHORAGE (MOA) •Health Authority Approval (HAA) _ CHECKLIST - FEBRUARY 1984 j 343-4744 Legal Description: A. WELL DATA a4��j l Well Classification — J �� `� If A, B, C, D.E.G. Approved (Y/N) Well Log Present (Y/N) Date Completed Yield — Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: ( To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Field on Lot t" _ ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole — To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results l Comments B. SEPTIC/HOLDING TANK DATA Date Installed f\' l'� Size _��?�.No. of Compartments Standpipes CYN) V —Air -tight Caps&5%) --4Foundation Cleanout:4'WN) _ - Depression over Tank (Y/G LJ 7�e Last Pumped Pumping/Maintenance Contact on File (Y/N) ; for - Holding Tank High -Water Alarm (Y/N) d Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: I To Water -Supply Well '4" To Property Line � d t -4 To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Cou Comments �i1 ri �/�"►^ ��,� To Building Foundation To Disposal Field l _�_ 72-026 (Rev. 7/88) Front Page 1 of 2 t.A, C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed Length of Field' Width of Field Depth of Field Gravel Bed Thickness 5 Square Feet of Absortion Area Statndpipes PresentOM) Depression over Field (Y�p r Date of Last Adequacy Test f`J Results of Last Adequacy TestIJ�� S� N sr-K-� SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well % o t To Property Line S ) 1 To Building Foundation ( Gl To Existing or Abandoned System on Lot 15 ; On Adjoining Lots 2� t-4- To Water Main/Service Line 1 �� To Cutback (if present) t� To Stream, Pond, Lake, or Major Drainage Course � �o To Driveway, Parking Area, or Vehicle Storage Area Z� ( Comments D. LIFT STATION Date Installed - 11 _ Ems`) Dimensions�'nL�ib-�aL Size in Gallons `�� I �� Manhole/Accessk N) �� 7 "Pump On" Level at `t'"� "Pump Off' Level at �`al N High Water Alarm Level at VentON) % Tested for7 1 �Z Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(09N) 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 inspection. Signed s & S ENGINEERING 17034 Eagle River Loop Road Ne, 204 Company nsita 99577 Date MOA No. ��117 4 Receipt No. Date of Payment (�% Amount: $ 120, y Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 §his �•aaea. e oe e �X) UNICIPALITY OF ANCHORAGE J�� j PAR M T OF HEALTH & ENVIRONMENTAL PRCITECTMYVPgLI1Y OF ANCHORAGE [ t` 825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION (I 1/f Ij ENVIRONMENTAL ENGINEERING DIVISION y / Telephone 264-4720 SEF 2 9 1978 V STA E LOCATION REQ FOR APPROVAL OF INDIVIDUAL WATER AND SEW f IV/ rS% EV DIRECTIONS: Complete all parts onpage -1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTYOWNER NUMBER OF BEDROOMS IrSINGLE FAMILY ❑ One ❑ Four ❑ Other MAILING ADDRESS A-7 -A0 a 70 RA oee*C L'' OA Lf -#45-4-6- f VZ -7A 4? 7 PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE ❑ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled MAILINGADDRESS- - 3. LENDING INSTITUTION PHONE depth (attach log if available.) JA 41 MAILING ADDRESS 3 G-:67- c�- - C. /,/- '--" a ,��-� r _ 4. REALTOR/AGENT PHONE - MAILING ADDRESS 5. LEGAL DESCRIPTION STA E LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS IrSINGLE FAMILY ❑ One ❑ Four ❑ Other C�fwo ❑ Five ❑ - MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY ❑ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM **If INDIVIDUAL/ON-SITE** individual/on-site, give installation date If ri�Cr/ If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE E] PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED_ 9 .. `j INSTALLER ❑Septic Tan or ❑ Holding Tank Size: Df Q0 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER g�, srffC 1 TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS e -APPROVED _,:3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78)