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HomeMy WebLinkAboutSTUCKAGAIN HEIGHTS BLK 1 LT 1tuckagain Heights Block 1 Lot 1 #041-021-13 l / MUNICIPALITY OF ANCHORAGE DEPA50TMENT OF HEALTH AND HUMAN SERVI>— S ` Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name (7 C7�CaNNLL DISTANCES TO FROM SEPTIC TANK ABSORPTION FIELD WELL Address _ g'� �A�S}}� � l ✓ �' Phone(s) Permit No. No. of Bedroo, 337-� g�7_111� WELL I /0 n `a B LOT LINE > "10 �I, a O „�--• LEGAL DESCRIPTION - 17 o Lot Block Subdivision STLICXAGAIN WAF16MTUFOUNDATION cjC+ - Township. Range, Section W `) a ^ S (^- (G� AS -BUILT DIAGRAM driveway, water bodies, (Show location of well. etc.) septic system, p yproperty lines, foundation, TANKS SEPTIC ❑ HOLDING Manufacturer Capacity in gallons Vacs L material sn 9T'IF— No. of Compartments TYPE OF SYSTEM TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom from original grade S.5 FT Total depth from original grade 0_ FT Fill added above original grade FT Gravel depth beneath pipe FT CA 3 Gravel length R-� FT Gravel width ® / FT Total absorption area IAC SO FT Distance between lines / /Q A�u �9Ci57`. FT � ID o 40 0 if Number of hoes Soil rating �B ® SOFT Plpematerial 30;3 Installer //J/ S' vtaa Dale Installed // WELLS ❑ PRIVATE [IOTHER fldentifv) Classification (A,B,C) Total Depth FT Cased to FT Q Installer Date Installed: _4+ REMARKS: !$ '�//may flr(��.OT-tiyyhh y Scale: Inspections Performed by: ENGINEER S SEAL it ............ �� o. 9 -225 -F.'s JUNi 25 ,1971. Date J. inspection was performed according to all r �� -.y cedify that this Municipal and State guideli in effect on this dale: Health Department Approvah Date: , `013 (3/85) ^ / �k 0PA 1 C� 1 dt�i,L- I C-) PA C `DEPARTMENTl�� HEALTH AND ENVIRONMENTAL`7^ROTECTION ET ANCMORAGE AK �9501 825 L STRE / , 264-4720 �T E.- EM". FEE- 'b"o�� P�RMIT NO: 860214 UPGRADE DATE ISGUED: 07/()3/86 APPLTCAN T: CHUCK n'COMNELL AODRESS: C/n T(]BBFN SPURKLAND ANCHDRAGE, AK 99503 CONTACT FHONE: 279-3916 / LEGAL DES�RIP: ` JVI�ION:���T ���' 1�� �`� � BLOCK:``1 � ��'"� �..'�/�~^^°~,��r-.�� r 8EC1I13N: 6 TOWNSHIP: 'i2N RANGEi! 7W` LOT SIZE; 2A (88.FT. OR ACRES) I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria ofhis permit. 3. I will adhere to all MOA and State of Alaska i,equiremenis f'(--jr the set hack distances from any existing well, wastewater disposal system or, public `sewermage system on this, or any adjacent nr nearby lot. IF A LTFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES; THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; <2> Hq-DUILTS uILL NOT BE APPROVEQ WITHOUT AN �LECTRICAL INSPECTION REPORT; AND (3) THE ELECT�ICAL ONE � LICEmSED ELECTRICIAN" SIGNED /1 DATE: APPLICANT: C ISSUED BY /�� ^ DATE-,- W-0c ATE; mf ` t-l�� 4�`/` m-��^-//�«��' v '�/ met/ 7 ct r M oe� WiE L.L, I..dl l , BK 1, STuc,1 AFtAiM 4A1614TS C40ck. o'e©NNat_L E N2225 -E•• 25, 1911 jun c SOILS LOG MUNICIPALITY OF ANCHORAGE EI DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: CHUUL OIGONKIEL DATE PERFORMED: LEGAL DESCRIPTION: LOT L B V i7 STUGIL AIN 4F=l6AT5: SEC_--%la.ri I�.eGVy I -- SLOPE DTH EP 00e4aNIcs I �l-TTS 2 D' 3 ` 4- 7 7 D• 8 .... 1 9- 10 10 ..k- 11 12 13- 14- 15- 16 3141516 m •: D'7t = 4t 17 . 18 '1- P 4�d��4 19aL 20 GlMD L G 2A V E L,. 1099 �NS� TrufC14 i.ta� .5; %/J O ;4 ## - 'wase we� :51 LT,/ s,4u b fAt S M WAS GROUND WATER ENCOUNTERED? �t O 44 tl O�� IF YES, AT WHAT DEPTH? C �'C o L g;da •' � �. 2225-E .lL .. VE 25, ,4971 .N COMMENTS KDKL lewev NO LA.)-O- .,r PERFORMED BY: 72-008 (6/79) u4c� Reading Date Gross Time Net - Time Depth to Water Net Drop PERCOLATION RATE/ NQ V;.SLJAL (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFIED BY: / DATE: MUNICIPALITY OF ANCHORAGE Heaand Environmental Prote — n Fourth Floor West 825 L Street Anchorage, Alaska 99501 279-2511, x 224, 225 Ii�ISPEf'TIG ! REPORT ON-SITE SEWAGE DISPOSAL SYSTEM oV < c.J p��1or �• ----.� PE-IONE__�J .j:N 8Ll NAME________41.._ca�-r`-"--____ MAILING ADDRESS _-.___--_ -_ - LEG A DESCRIPT ION ___-L.�_f -✓= G- V� `�S_�.---_. LOC ATION.��t�6' - --_ L_ SEPTIC TANK: DISTANCE..111 NUMBER OF FROM WELL _��l'_ MANUFACTURER RIAL __ � �g1 COMPARTMENTS_. _ _ s INSIDE LENGTH -__. _ INSIDE WIDTH_ -___ LIQUID DEPTH __ LIQUID CAPACITY �b�GALLONS. TILE DRAIN FIELD: I It TOTAL LENGTH � DISTANCE FROM WELL t q0_�.__FOUNDATION._ l (30-f'_NEAREST LOT LINE._"'-(�> ____ LINE L4 # of Lines ____- DISTANCE BETWEEN LINES _ wi-!=—TRENCH WIDTFli ' IN. TOTAL EFFECTIVE ABSORPTION A14EA —.- .� _ -_._ SQ. FT. LENGTH OF EACH LINE— ( UEPTEI OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE 3'y -_MATERIAL BENEAEH TILE ----IN. ABOVE TILE _ Z _IN. SEEPAGE PIT: DIAMETER --- OR WIDTH ___, LENGTH._, DEPTH Log Crib —Rings ---Crib Size: DIAMETER___UEPTH_— DISTANCE FROM: WELL _ -' - ---- - - TOTAL EFFECTIVE BUILDING FOUNDATION__, NEAREST LOT LINE.__.. ABSORPTION AREA (WALL AREA) _-SQ. FT. Well_N° yak Class: ✓�'- - Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: —wl�de # of Bedrooms: " Installer: C��ucl s gt�cr�o� Remarks: _mss' I I0o 0 U A T E �q��7 APPROVED I 1 � N wf ;_. 114 - - �I 0 U A T E �q��7 APPROVED t /'M -W DRILLING, INC "�-;-" DRILLING LOG Well Owner ewa i' G0Y k; i::i t1C �i oil Location (address of: Township, Range, Section, if known; or distance main i,aL l Bi,_or,J.c i. `�L'ur_lc�rai•ri. V t� of Well i. Size of casing C' Depth of hole 1831 feet Cased to i.ul - feet Static water level ft. (apQye) (below) land surface. Finish of well (check one) open end Screen ( ); Perforated Describe screen or perforation Well pumping test at gallons per (iYonTf (minute) for hours with OOL' ft. of drawdown from static level. Date of completion 19/ 217 / WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO 2 C asiri; stickup L TO r, _ Organics b' TO l.t) Silty' gravel. 10 TO 21 Louse gravel. 21. TO 4 Silty gravel. 43 TO 56 Loose 1;r<vel 56y Sandy S,ravel 66 TO 80 Loose gravel 80 TO --A 5 Silty gravel. cobbl.y y5 TO 1.01.5 - i 008e sandy P, -r vel cobbl Y. boLddey 120==12.1., 11.5 1501 TO C`' y? :ravel «arCir+pan '�`l� dq 1.50 TO 140 52:.xtdy PY'ti.ye wnt'Pi^ 2—TO— _ ISodJrock TO To 2 — STATE r-1 LJ I°A I Aa_ I F=° f=1 I— I -I- "T CA F= 1=1 to CV CA F` 1=1 Awe E= j . )n PMS ° _ DEPARTMENT _ L HEALHADENVIRONMENTAL, V IONME TAL, OTECT I ON r_­'STREET,ANCHORAGE, A 79-2=11 nous t 4 F= A-- lL_ F=A r4 C> cy r-.1— ci I T E- F= NJ EEC_.L_)-, AJA PERMIT NO. ( 7 616 ) APPLICANT TOM STEWART BASHER DR 333-8684 LOCATION BASHER DR LEGAL L•]- Bi STUCKA3AIN SUBD LOT =SIZE 84000 SQUARE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOM. = = SOIL RATING (SQ FT/BR)= 100 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: CaE:&TA--1= E3 O_E:rAA31FA-1= __ " C3F_FlvWE=L_ E>E:F•TE-1= A-4 THE LENGTH DIMEt'SION IS THE LENGTH (IN FEET) OF THE TRENCH OR GRAINFIELD. THE DEPTH OF A TRENCH OR FIT Its THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL_ DEPTH IS THE MINIMUM DEPTH OF GRAVEL. BETWEEN THE OUTFALL FIFE AND THE BOTTOM i iF THE EXCAVATION 0N N FEET ). F;ZE C=91-_1 I F: E: C -e Eo F=" T I Ate- T 1=11 1 I<: 00 I , _° F = 1. CA A CA C3 Fl B_: W_ CA ?A * Fl F-°F-1CoE_- FlA_@Ew F=•A_FArAT CAF°T I �J1-1------- _— A PACKAGE PLANT MAY BE INSTALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE FOLLOWING CONDITIONS: 1. EITHER A CLASS I. OR 11 NSF APPROVED PLANT MAY BE INSTALLED. 2. A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL --- AB-+ORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION.` -----_— T t4 CA rn ; :. I F°-.1=. F=' F= r. T I A_® i°,# :=• F=1 F° E". F=' F=1= a 1_.1 I F" F= E> — — — BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL.. BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC: WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAIL..ABLE TO INSURE PROPER INSTAL.L.ATION. F=•E:F°rl I T F= A eF'I F:F=i_ E>E=CTF =PlE:EwF° = nL1 AL•9 w- - I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL. INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDF_.NCE ISAAEMODELED TCS INCLUDE MORE THAN 3 BEDROOMS. SIGNED I CANT r. 1 ISSUED B'r_J� -•--- ----------DATE---------------- V-;. 0 4 "One test is worth a thousand opinions" 2204 Cleveland Anchorage, Alaska 99503 Performed For Tom Stewart Date Performed 7/16/77 Lenal nescrintion: Lot 1 Block 1 Subdivision Stuckagain Heights This Form Renorts Soils Loq yes Percolation Test_ nenth Feet Soil Characteristics 2 — 0 6— Sandy Gravel 8- 10- 12- 14- 16- 18- 20— Bottom - 10-12--- 14-16-18- 20— Bottom of Test Hole Was CZround Water Encountered? No If Yes, At what Depth? �Readinq Date Grnss Time Net Time Depth to H2O Net Drop L — Percolation Rate Minute Prnnosed Installation: Seenaae Pit Drain Field Deoth of Inlet__ Depth 7o 6Bottom Of Pit Or Trench _ rnMVFNTS: 100 Sg Ft drainage area reguired_per bedroom from _1 to -12 feet. Test Performed By___ David Paul Data Certified BS__✓{ ? t Oate �2- Municipality of Anchorage op*�� Development Services Department Building Safety Division On -Site Water and Wastewater Program 5. L f Y 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. !7�(r'- 0, /L 3 COSA # b�Cta l�2.� Expiration Date: / q - !Z 1. GENERAL INFORMATION Complete legal description 5 �-u &14, a 9 ar� Location (site address) 9 4s S f f� or -S, k cc Ouly v r Current Property owners) 0Zunn�l� Day phone � Mailing address Q ear S 1 >5u4 4,rr OV Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address - Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: S 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Weil ❑ Community On-site ❑ Public Water System ❑ 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 ofFirm _N_(iAae/tj/4A-erid.,-f - Phone 315_,V3 517 Address _ 14 & (a Id u rerR., ✓'f -v e. Engineer's Printed Name MI h c /\( Date r z— � OF Al 9i� xr4Ig MICHAEL N. ANDERSON :'A- 5. DSD SIGNATURE d s • ry C 94 9 2��'o l/ Approved for � bedrooms. • .. • q�'�p Disapproved: %Q28TE`SO Conditional approval for bedrooms, with the following stipulations: Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory By: Original Certificate Date: 2 (Rev. M5) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: 5 'stn Ttu q 941✓ ley ns%144 � 11 (� I Parcel ID: A. WELL DATA Well type vaiG If A, B, or C provide PWSID # Well Log (Y/N) Ye' 5 Date completed 42 7i Sanitary seal (Y/N)Wires properly protected (YM) Y Total depth �� ft. Cased to,[ -ft. Casing height (above ground) _f n. FROM WELL LOG AT INSPECTION Date of test ' -L 1.74 zL' / Z Static water level f S S ft. Well production g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate Arsenic: ug/L date of sample: B. SEPTIC/HOLDING TANK DATA,, --Mae? ` g.p.m. Collected by: � 3 ✓t9rna/ Cootae cud taw M r ya//on5. C^ *Ld. Tank Type/Mater'al?-) Ft h'rr q to 5 4 '- .1r•P t'L Tank size0VV 5d gal. Number of Compartments � Date installed 0 Cleanouts (Y/N) Foundation cleanout (Y/N) � Depression over tank (Y/N)±L_ High water alarm (YIN) Date of pumping Pumper X., tj� 14 xn (cc t(u P 40c�, C. ABSORPTION FIELD DATA,/r//�� Z� 4-roD5 Vor 11rovel Date installed _ Soil rating (g.p.d./ft2 ft2/bdrm) System type A'ee P Length y2 �d 2S� ft. Width '30 ft. Gravel below pipe _ft. r Total depth ?. 5 ft.0� Eff. absorption area > 3Gft2 Monitoring tube Y Depression over field 44 Date of adequacy test Z Z R sults (Pass/Fail) na �i �i For SL bedroom 1? i 0 b ca pr7-f /�Ir it Fluid depth in absorption field before test m. Water added_ gal. New depth_ in. f 2�' o" Elapsed Time:��min. Final fluid depth —in . Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) u ✓I GU n awn if yes, give date D. LIFT STATION Date installed "Pump on" level at —in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off" level tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septictank/lift station on lot /,00 -A Absorption field on lot ! VC) Public sewer main )Y Sewer/septic service line SD /f Z Animal containment areas Manhole/Access water alarm level at in. Meets alarm & circuit requirements? On adjacent lots /C* i < On adjacent lots / VO /)c Public sewer manhole/cleanout Holding tank )t! fu. Manure/animal excrete storage areas d� lr90� SEPARATION DISTANCES FROM SEPTIC/IdOlt:V4B TANK ON LOT TO: Building foundation Sy r� Water main Wells on adjacent lots 10`0 r Property line 20 ;_' Absorption field /O Water service line 60 rf Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line "z- 0 '-f Building foundation 'S 0 l �- Water main Water Service line 5 d 4 - Curtain drain NM r'G %+ WvI F. COMMENTS G. ENGINEER'S CERTIFICATION too t/ 50i¢— Surface water / V V 14- Driveway, parking/vehicle storage /O i lf- Wells on adjacent lots / v o '/ I certify that t 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. Engineer's Printed Name Ciyl K rwiy d elf 40, Date ZA-Z 2' COSA Fee $ G9 � q Date of Payment / ?i Receipt Number 140b,5 / b, (Rev. 4/10) Waiver Fee $ 0�'1.� �•�. nIA .4 �'•,�r i *' 49twee v 79/6�<�� Date of Payment Receipt Number N O M - 9•s�' •'AS-L�IIl.T' hereby certify that I have surveyed the following described property: LOT j 73wCt� ( 5s1>C 411 4C—Ilj Ei''(5 and that no encrtaackrnents exist except as indicated. :xclusion Note: ®� �M V'AV4 t is the responsibility of the owner to detannine the existence of ,••••••, �'Q �$ any on plat. w ovenants, or restrictions which do not appear on the recorded subdivision plat. � yah°.•' • � ®� haler no circutstances should any data hereon be used for construction or for y it ; •• � * $ stablishing boundary or €ence Tires.00— ••• � p � Fated at Anchorage, Alaska, this 1% day oE��yt. y , 9[��j pa •y' 0. sew o alMAMT EMDO ELS & ASSOCIATES ®� j •• LS -2233 C ��0 0 `�`0 @b '•••....••'�S`�cv .27(1 Rri arcx:od Street ..,t n ,. , i .—.. �p�I7(Eccinnal . E -...r._ h t7 WPM FJS6£ 'DECx � • • ..... .... . o' .. _ . � l+'.'Gil-.)�• .. ...... b � '��� ., ... P .. _. ..... "" --.... Cf6liT• Ptah ' aRAV6'L •'AS-L�IIl.T' hereby certify that I have surveyed the following described property: LOT j 73wCt� ( 5s1>C 411 4C—Ilj Ei''(5 and that no encrtaackrnents exist except as indicated. :xclusion Note: ®� �M V'AV4 t is the responsibility of the owner to detannine the existence of ,••••••, �'Q �$ any on plat. w ovenants, or restrictions which do not appear on the recorded subdivision plat. � yah°.•' • � ®� haler no circutstances should any data hereon be used for construction or for y it ; •• � * $ stablishing boundary or €ence Tires.00— ••• � p � Fated at Anchorage, Alaska, this 1% day oE��yt. y , 9[��j pa •y' 0. sew o alMAMT EMDO ELS & ASSOCIATES ®� j •• LS -2233 C ��0 0 `�`0 @b '•••....••'�S`�cv .27(1 Rri arcx:od Street ..,t n ,. , i .—.. �p�I7(Eccinnal SCS Ref.# 1120314001 Client Name Mike N. Anderson, P.E. Project Name/# 9851 Basher Client Sample ID 9851 Basher Matrix Drinking Water Printed Date/Time 02/07/2012 15:07 CollectedDate/Time 01/31/2012 13:00 ReceivedDate/Time 01/31/2012 13:40 Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date ]nit Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 02/01/12 02/02/12 SCL Waters Department Total Nitrate/Nitrite-N 3.10 0.100 mg/L SM20 450ONO3-F B (QO) 02/06/12 CMA Microbiology Laboratory E. Coli Negative 1 100mL SM21 9223B A 01/31/12 DLC Total Coliform Negative 1 I00mL SM21 92238 A 01/31/12 DLC (a) Legal Description (include lot, block, subdivision, section,. township, range) ► oT(, iC/, sT0c-KAP AIN !f1Zl6#7_S SSC- to % IAN, ya a- 0 / Location (address or directions) &A -e - (b) Applicant Name 4,1y 6�1,249HK�IlTelephone: Home Business Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address - (e) Real Estate Company and Agent Address _ Telephone (f) Mail the HAA to the following address: Telephone r ; i2. TYPE OF RESIDENCE Single -Family llG Multi -Family ❑ Other - Number of Bedrooms 3, WATER SUPPLY Individual Well Community ElPublic 13Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. `4:; SEWAGE DISPOSAL OnsitePublic ❑ 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. ,.,Page 1 of 2 _ - - 72-025(11/84) u k ' ¢`As cerhfled by myseal affixed hereto"and as of the validation date shown below, I verify that my investigation of `AuthorityApprovalshowsthattheon-sitewatersupplyand/orwastewaterdisposalsystem issafe, functional anda for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtat� from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/Zi, wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Firm LC Telephone Name of — Address �� "O� Date l �b OF AZ qt t *; 49TH .. �f.�AA ..... W .,... 2225-E € 25, 1971 •� Engineer's Seal 1 r 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 lending 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 ' ° 72-025(11/84) 6.' DHEP APPROVAL / y�- / ' Approved for � bedrooms by / Date Approved—_�---- Disapproved Conditional Terms of Conditional Approval n K s _ .- 04 n�e 1 r 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 lending 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 ' ° 72-025(11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: L�O T l 73K I -SrV e–VAGAI Ute) -r.Q , Sac 6 f ri.2N� a au/ A. WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) y / Well Log Presentt�(Y/N))Date Completed Yield Zgew, ����✓ Total Depth —1901(Aft. Cased to /A( � Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground ( ie Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) ;K Depression Around Wellhead (Y/N) N Separation Distances from Well: Q �s To Septic/Holding Tank on Lot 108 On Adjoining Lots / 100 To Nearest Edge of Absorption Field on Lot i b+f On Adjoining Lots 10D To Nearest Public Sewer LineN 0�`i C To Nearest Public Sewer Cleanout/Manhole N O N1 15s To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date A " Urrq-� Date Installed 71l & Size 1066t404) No. of Compartments Standpipes (Y/N) —__ Air -tight Caps (Y/N) Foundation Cleanout (Y/N) / Depression over Tank (Y/N) {� Date Last Pumped E bi/ XVA'/' okf'> Pumping/Maintenance Contract on File (Y/N) Q for tyles Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) t41A Separation Distances from Septic/Holding Tank: To Water -Supply Well M Fi �//ay Aid-stTJ o Building Foundation 8 To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /0-0 L Type of System Design 2�,�A, e / Date Installed 1�1//�% Length of Field a b 92 /�/ W i Width of Field a© Depth of Field �/f� �� 6i� /-2 ✓ Gravel Bed Thickness % °� F�! ✓Ji3✓> Square Feet of Absorption Area 336 F Rte' S �� Standpipes Present (Y/N) Y Depression over Field (Y/N) /" Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption /Field: To Water -Supply Well / 0 7 To Property Line To Building Foundation '7''/ To Existing or Abandoned System on Lot /a On Adjoining Lots % /C+ -y To Water Main/Service Line To Cutbank (if present) NOaIE- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons — "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access(Y/N) 'Pump Off' Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verifie or conformed to all OA and HAA guidelines in effect on the date of this inspection. Signed s Date Company MOA No. Receipt No. Date of Pay Amount: $ Page 2 of 2 72-026 (11,84) 1 t. �*°49711 %- vii �l N . 222.5-E: 6jd r, NC 7., 1911 Engineer's Seal 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 5/22/6' 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) l.a?_ J. 13 lack 1 Sfucl2w •r'rn Ff£r Location (address or directions) 985-1 basher Ra( (b) Applicant Name Charltl 0'4111441/ Telephone: Home 33 7 -6Y6'Z Business 27y—OS'36 Applicant Address 9&,i 1 i3a4ker R.l AAr-horcege (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder N; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Naf 11 Sae IF oJr- /4(arkot Telephone 276 —( 13 2 Address 3Ol w. m& 'µtr#) Amchor4qt 99av3 (e) Real Estate Company and Agent N. A Address Telephone (f) Mail the HAA to the following address: yoia for /!tckete 2. TYPE OF RESIDENCE Single -Family IA Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well R Community ❑ Public ❑ Note: It community well system, must havewritten confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ® 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. Page 1 of 2 72-025 (11,84) 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 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 Firm ",r Aicaf S,*rAeV Telephone Address IHS30 Echo -Sf Ar►_ charoVe. Ah 995V' Date /2L /84 Engineer's Seal 6. DHEP APPROVAL i/ 3 Approved for bedrooms by O a Date�� Approve Disapproved Conditional Terms of Conditional Approval C 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 lending 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 72-025 (111841 MUNICIPALITY OF ANCHORAGE"'NICIPALITY OF ANCHORAGE DEPT. OF : �_) DEPT. OF HEALTH & ION MUNICIPALITY OF ANCHORAGE (M&yIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) MAY 231986 1986 CHECKLIST - FEBRUARY 1984 [ [ [ 264-4720 V R E C E I V E D Legal Description: Y�®� $�ccLr a�n h 513 A. WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) N41• �,� �m YheuSure Well Log Present (Y/N) Y Date Completed 9 7 Yield? Total Depth 1 BS r Cased to f B t Depth of Grouting Nr A+ Static Water Level I Ni Pump Set At Un k n Casing Height Above Ground 19 Sanitary Seal on Casing (Y/N) r Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) 9 Separation Distances from Well To Septic/Holding Tank on Lot 109' 1v 94,9471P6' ; On Adjoining Lots '7 IW To Nearest Edge of Absorption Field on Lot If2 On Adjoining Lots > tCrar To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole n(• F} • To Nearest Sewer Service Line on Lot /l Water Sample Collected by FM /�D�ate �/2.a l �� Water Sample Test Results 56&f J6C�Qr� —Ile CO�tOw+�a cI• Qikd 1POLCAINAlft Comments B. SEPTIC/HOLDING TANK DATA Date Installed 9/9 / 7 7 Size 1000 No. of Compartments 2 Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped io 145Fd of Pumping/Maintenance Contract on File (Y/N) N A for A, Holding - Holding Tank High -Water Alarm (Y/N) N.A Temporary Holding Tank Permit (Y/N) N.A . Separation Distances from Septic/Holding Tank: To Water -Supply Well /09` To Building Foundation To Property Line I < To Water Main/Service Line Course > too Comments Page 1 of 2 72-026(11/84) To Disposal Field e.0.'s To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 10 )/3drm Type of System Design ­ r"AC4 Date Installed 8 /9 7 7 Length of Field Y al Width of Field 36° Depth of Field _ 3 112- iyGravel GravelBed Thickness q19 Square Feet of Absorption Area Standpipes Present (Y/N) Y Depression over Field (Y/N) N Date of Last Adequacy Test Results of Last Adequacy Test Ad,auct Fe r 3 bec�ra c2A1! Separation Distance from Absorption Field: To Water -Supply Well f l2 r To Property Line 7� To Building Foundation To Existing or Abandoned System on Lot IN, k • ; On Adjoining Lots 7 3c I To Water Main/Service Line N'A' To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course - (CSG To Driveway, Parking Area, or Vehicle Storage Area 30, Comments D. LIFT STATION N,A, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments — Dimensions Manhole/Access (Y/N) "Pump Off' Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** 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 Date Company Receipt No. — Date of Payment Amount: $ Page 2 of 2 72-02 (11/84) MOA No. Engineer's Seal