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Home My WebLink AboutT15N R1W SEC 9 LT 65 N2 Municipality of Anchorage Page i of ,~ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~ ~ ~ ~ O '3 ~,'~ PID Number: Name:Wastewater System: [] New ¢3(Upgrade A~..,,: ABSORPTION FIELD Phone: I No. of B~oom~:~ ~Beep Trench B Shallow Trench B Bed Q Mound B Other Total Depth from original grade, LEGAL DESCRIPTION so...~.~:/.~ Lo · Block: Subdlv~ion: Depth to pipe bottom from originsl grade: Gravel depth beneath pipe Township:~ ~ ~I[ Ra~: ~ ~Il Section: ~ Fgl added above original grade:¢ Ft. Gravel length: '~ ~ Ft Number ofjlines: lB'stance between hnes WELL: U New ~ Upgrade Gravel width: Ft Classification (Private, A,B,C): Total Depth: Ft. Cased TO: Fb Total absorption area',~ ~ SQ. Ft, Pipe/% ~materlah/~ ~, ~ '~O '~ SEPARATION DISTANCES ¢Septic ~ Holding U S.T,E.P To Septic Absorption Ldt Hold{rig ~ubhc/Prlvate Manufacturer' Capacdy From Tank Field Station Tank Sewer Lines ~ N ~ l~ ~ Matertak Number of Compartments~ su~.o~ LIFT STATION Water I ~ 0 N ~ Lot Size in gallons. ~ Manufacturer: Line ~1 ~ ~ Foundation ~ ~/ ~/ "Pump on" ~eve, at: [ "Pump off' level at: [ H,gh w~ter atarm at: Curtain Pump Make & Model ~ Electrical Inspections performed by: Drain ~ Remarks: BENCH MARK 0 /,~ CV~ L°cati°n and D' scripti°n: ....... ENGINEER'S SEAL Inspections performed by: DateS:2ndlSt Department of H~alth a~ ~ LServioes approval , L,,. ' ' ,.. Reviewed and approved Zk [ I L ~ Date: )2-1~-¢'~(* ~ ' . ,' . :,'."':' "' ,, ,,, 72-013 (Rev 9/91) MOA 25 J SWINO r/ES: lO00 GAL SEPTIC TANK STANDARD TRENCH: AC 72 FTpuMP OUT BC 67.5 5$FT LONG AD 85 DOUBLE CO'S 12 FT DEEP BD 79 ? fEET OF ROCK, EFFECTIVE AE II6TRENCb~C.O- BD AF !!I MONITO~ BF I09,5 ~5 0 25 50 75 lO0 125 150 SCALE; 1" = 50 FT, TOBBEN SPURKLAND P.E. II 203 W 15TH, AVENUE II ARCH. AK. 99501 N1~2, LOT 65 SEC. 9, I'15N, Rl~ 20756 AURORA BOREAL/S, BIRCHWOOD MICHAEL STARKEY SEPTIC SYSTEM AS BUILT DATE: NOK 75, 1996 SHEET: 2/$ GRiD:MW IJ5~ PN SW960363 PID 051-104-29 PRIMARY TRENCH (~ Monitor C{eon Z}u~ Standord Trmnche5~ ~' W/de 35' LcD9 l£' ?eep 7' Sewer rock l,i FL giN REPLACEMENT TRENCH (~ Non/tot Cleon l~u~J NO SCALE /E 89.5 ?ii t.'bo nm/em 82.2 7 Fi. o£ Sep~/c Mon/~;om ~ 5' Cover 94~ /000 90( Septic ton/~ IE ND SCALE s ft 82.2 IE 89. 75 lO00 9oL septic tan/< ANCHORAGE TANK 9ENCH NA£K, TOP ?OUNDA~ON ASSUMEP ELEV. lO0, O0 TDBBEN SPURKLAND P,E, 803 WlSth Ave Anchopage Ak 99501 LOT 65 SEC 9 T15N Ri W SEPTIC SYSTEM SCHEMATIC SEPTIC SYSTEM AS BUILT DATE: NOK 15, 1996 SHEET, GRID: PN SW960365 PID 051- 104-29 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT NUMBER:SW960363 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWlqER NAME:STARKEY MICHAEL JOHN OWNER ADDRESS:21640 AURORA BOREALIS RD CHUGIAK, AK 99567 PAGE 1 OF 1 PERMIT \ QfY% DATE ISSUED:ll/08/96~ EXPIRATION DATE:il/08/97 PARCEL ID:05110429 LEGAL DESCRIPTION: T15N R1W SEC 9 LT 65 N2 LOT SIZE: 45450 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ~- ~ DATE: 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 9950 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN N1/2 LOT 65 SEC 9 T15N R1W Municipality of Anchorage Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 October 26, 1996 We are submitting an application for the installation of a system upgrade for this lot. The lot was originally developed in 1968 with no documentation of the septic system. A field investigation indicates that the septic system consist ora steel tank and a log or concrete crib. A well log for the property do exist and is included with this application. The submittal consist of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests ofapplicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 18 Use Standard Trench Soil Rating. <1 min/in = 1.2 gal per sq.R/day See Sieve analysis No. of Bedrooms 3 Required Area per Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 125 x 3 = 375 sq t~. Invert Existing Tank 91.33 Ground Elevation at Testhole 94 Distance Existing Tank -Proposed Drain Field 80 ft Elevation Loss At 2% plus 6 inches for tank-- 2 ft Testhole depth 18 feet Bottom elev. 76 Bottom Rock At 12 feet Elev. 82 Top Rock at 89 Rock Depth 7 feet Total Trench Length 375 / 14 = 26.8 SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 30 FT TOTAL WIDTH 2 FT TOTAL DEPTH 12 FT ROCK DEPTH 7 FT COVER 5 FT 1000 GAL SEPTIC TANK REMOVE OLD TANK, ABANDON CRIB. The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Municipality of Anchorage DEPARTMENT OF HEAL'TH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST [ENGINEER'S SEAL) 4- 5- 6- 7 I0- 11 13 14 - (~ ~- ~. ~,' 4...~, L~ 16- ~ ~r~v~ 17 18 19- 20- PERFORMEDSY: . ~ .~ DATE PERFORMED Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER Time Time Water Drop PERCOLATION RATE ~ (minutes/tach} PERC HOLE DIAMETER TEST RUN BETWEEN ~ FTA~/O ~FT : ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THiS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THiS TEST WAS PERFORMED IN 50 0 SO 47A + ~ell ~Z,fC ~ Z ~p 4? EXISTINO IMPROVEMENTS TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ANCH. AK. 99501 N1~2, LOT 65 SEC. 9, T15N, R11¢ 207S6 AU£O£A BO£EAUS, BIROflWOOD MICHAEL STARKEY SEPTIC SYSTEM DESIGN DATE: OCll 26, 1996 SHEET: I/$ GRID:MW I$58 1000 GAL SEPTIC lANK STANDARD TRENCH: $0 FT LONG 12 FT DEEP 7 FEET OF RODK, EFFECTIVE TRENC~ PR/WARY ~ GR 945 BW 100.00 ~ IE 91,3 REPLACEWENT TRE~ICN N i~ 49~h ;N SPURKLAND NO CE-2225 ABANDONE CRIB TANK mmmmmmm 25 50 75 S£AL£~ /" = 50 FZ I50 PROPOSED IMPROVEMENTS TOBBEN SPURKLAND P.E. J 203 W 15TH, AVENUE I ANCH. AK. 99501 F907] N~/2, ~o~ 65 $E0.9, T~SN, R~Y 20756 AURORA BOREAL/S, B/RONWOOD MICHAEL STA£KEY II SEPTIC SYSTEM DESIGN DATE: OCT. 26, 1996 SHEET: 2/J GRID:MW lS5g PRIMARY TRENCH Monitor Stondord ?renches; Sewer moor Cover REPLACEMENT TRENCH Iv Cleon Duf Clean Du ND SCALE Cieonouts Mon/tom Cover lO00 9o1 Septic tonk Ex/st Ground Cover H h 70 nk ,~i[ tho mm'em · Pt o£ Septla Rock ND SCALE 6 fl BENCH NA£K, fop FOUNDAtiON ASSUMED ELEV, ]00,00 ITBBBEN SPURKLAND PE. 203 WlSth Ave Anchora9e Ak 99501 777-~?1~ INly2 LOT 65 SEC 9 T15N Ri~ I SEPtiC SYSTEM SCHEMATIC ?£O?OSED CONSTRUCTION I SEPIIC SYSTEN DESIGN I DATE: OCT2S, 19~S I / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL · P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-7904 Parcel I.D. CERTIFICATE FOR 051-104-29 GENERAL INFORMATION OF HEALTH AUTHORITY APPROVAL A SINGLE FAMILY DWELLING Expiration Date: ~ - ! - O ::2._ Complete legaldescripfion T15N, R1W, SECTION 9, LOT 65r Location (site address or directions) 20736 AURORA BOREALIS Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address RICHARD &: KRISTI FULLER 20756 AURORA BOREALIS ROAD ROAD * CHUGIAKt AK 99567 Day phone 688-6717 · CHUGIAK, AK 99567 Day phone BONNIE HOCHSTEIN w/ REMAX PROPERTIES Day phone 2600 CORDOVA STREET * ANCHORAGE, AK 99505 242-3135 Un~sso~erwise mqueste~ HAAwillbeheMbyDSD ~rp~kup. 2. NUMBER OFBEDROOMS: 5 3. TYPE OF WATER SUPPLY: Individual Well M Individual Water Storage J-'] Community Class Well [--I Public Water System ['"J TYPE OFWASTEWATER DISPOSAL: Individual On-site lib Individual Holding tank Community On-site r-~ 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 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of flue (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 pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a pedod 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. INote: Alaska Water and Wasfewater Consultants, Inc. shall be paid $1000.00 at, orpdor I to closing for the engineering services provided. I 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 Health Authorib/ 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 b/pe 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. NameofFirm ALASKA WATER &: WASTE'WATER CONSULTANTS, INC. Phone 337-6179 Address 6901 DEBARR'ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFR[Y A. GARNESS, P.E. Date Engineer's Comments: In conducfng this evaluation, AWWC, inc. effempted to provide a thorough, ' ' conscientious engineering analysis of the system in accordance w/th ADEC and MOA DSD Guidelines & Regulations. The roported results desc. dbed the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily idenfffiable faa~ures. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the 'year, and the water usage of the family being served by the system. These condiffons are outside the control of the eveluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can thereforo not provide 'anY warranty or futuro estimate of how long the system will continue t° meet the operational requirements of the ADEC or MOA DSD. The content of this report is for ' the sole benefit of the ownerlisted above. Anyrellence upon or use of this report by any other person or party is not authorfzed, nor wiil it confer any legal right whatsoever. DSD SIGNATURE ~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Note: The well for this property meets existing nitrates present. It is su~sested that periodic State and Municipal Codes.There are testin~ be performed ~0 insure the well continued suitability. Current nitrate concent~a~ion concentration is 10.0'm~/1. More Services Program, at 343-7904· Attachments: HAA Checklist Septic System Advisory Well Flow Advisory is 5.58 m~/1.EPA mmwqm,~m Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: (Rev. 12.,'00) Municipality of Anchorage Development Services Department ' '" ~ · Building Safety Division On-Site Water& Wastewater Program 4700 8outh Bmgaw SL P.O. Box 1~6650 Anchorage, AK 99519-6650 vnaw. ci.anchomge.ak.us (907) ~3.79o4 Legal Description: A. WELL DATA Well type Pa~'A'rE, Data completed UNKNOWN Total depth 41+ fL Date of test Static water level Well production WATER, SAMPLE RESULTS: HEALTH AUTHORITY APPROVAL CHECKLIST T15Nr RlWr SEC 9~ LOT 65, ~1/2. Parcel ID:,. 051-104-29 If A, B, or C provide PWSIl:~ N/A Well Log (Y/N) NO 8anltmyseal (Y/N) YES, Wires properly pmtectad (Y/N) YES Cased to 40+ ft. Casing height (above ground) 12+ In. FROM tNELL LOG AT INSPECTION UNKNOWN 10/12/01 UNKNOWN ,fL 32 fL UNKNOWN g.p.m, 4.5+ , g.p.m. Depression over tank (Y/N) NO Pumper $oli rating ~r ft=/bdrm) 1.2 Width 2 ,ff. Other bacteria , AWWC~ INC. 0 ,colonies/lO0 mi. Date Installed 11/11/g6 Cleanouts (Y/N) YES High water alarm (Y/N) N/A JR'S PUMPING System type ~ TRENCH Grovel below pipe 7 Depression over field Coliform 0 colonles/lOOml. Nitrate 5.58 mgJl.. Date of sample: 10/17/01 Collected by:. B, SEPTIC/HOLDING TANK DATA Tank Type/Matarial STEEL Tank size 1000 gal. Number of Compartments .,, 2 Foundation cleanout (Y/N),YES Data of pumping C, ABSORPTION FiELD DATA Date Installed, 11/11/96 Length 35 It, Total depth 13.5 fL Eft. absorption area 490 Itt Monltorlng tube YES Data of adequacy tast 10/12/2001 Results(Pass/Fall) PASS Fluld depth In absorption field before test ,12.5 in. Water added, 481 gal. Elapsed Time: ,, 1 O, mln. Final fluid depth 17.5 In. Any rejuvenation treatment (pest 12 mo.) (Y/N & type) NONE KNOWN Absorption rata >= NO For 3 bedrooms New depth 1g.5 in. 450+ g.p.d. ~ If yes, glve data - Cycles tested Meets ala~rm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankllift Station on lot 10o'+ Absorption field on lot: lOO'+ Public sewer main N/A Sewei'/septic s'e-rvice line'25% On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/c!eanout Holding'tank r N/A SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO: Building foundatlott' 5'+ Property line 5'+ Absorption field Water main N/A Water service line, 10'+ Surface water. 5'+ 100'+ Wells on adjacent lots 100'+ SEPARATION'DISTANCE FROM ABSORPTION FIELD ON LOT TO: property line 10'+ Water sen/ice line 10'+ Curtain draln NONE KNOWN Building foundationr 10'+ Surface water 100'+ Wells on adjacent lots 100'+ Water maln N/A ,Driveway, patldtil~/ehlcle stota-g~ 10'+ F. COMMENTS G. ENGiNEER'S,CERTIFICATION I certify fhat I have degermlned through field Inspections and review of Municlpal meotd$ that the above eysfems aye ,In conformance with MOA HAlt guidelines in effect ol~ this date. Engineer's Printed Name Date JEFFREY A. GARNESS NAAFee$ eo Da,of Payment /~/~'//~ / ReCeipt Number / Z./Z~ ~ WalverFee $ Date of Payment Recerpt Number 0CT-2~-01 i ! ,'2~} FRO~CT&E ENVlRO~NTAL "~TK CT&E Environmental Services Inc. §075615301 T-295 P.01/0Z F-868 CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 10173~001 AK Water & Wastewater Consultants lng. TISN, RIW, Section 9 Lot 65 TISN, R1W, Section 9 Lot 65 Drinking Water Sample Remarks: Client PO# Printed Date/Time 10/25/2001 11:24 Collected Date/Time 10/17/2001 8:30 Received Date/Time 10118/2001 12:15 Technical Director Stephen C. Ede Released~ Parameter Results De_~arbment: 5.58 Units Mclhod 0.S00 mg/L EPA 300.0 Allowable Prep Analysis LimiU Date Date Init (<10) 10/18/01 SCL Mierobiolo_c~y_ Labora~:or~r_ Total Coliform col/100mL SMI8 9222B (<1) 10/18/01 KAP 0CT-25-01 11:30 FROtF. CT&E EN¥1RONI/ENTAL SR¥ 9075615301 T-295 P.02/02 F-668 CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING S4MPLE MUST BE C0~'PLI=~i'tfl3 BY WATER SUPPLIEI~' I I I I I PUBLIC WA~R P~VATE WATER SYSTEM Send Results {3 Send Invoice 200 W. Pot~er Drive Anchorage, AK 99518-1605 Tel: (907) 562-2343 m $~ndRe~ult~ D Send In voice AI.,~ .I~. WATER & WAfi'I'EWA'I~R CONSULTANTS, INC. c~,~ 6901 D~ RD._ RT~ ~ ,~NCHO~GE. ~ ~5~ SAMPLE DATE: Month SAMPLE TYPE: n Routine t:l Repeat Sample (for routine sample with lab ref. no. rn Special Purpose SAMPLE LOCATION _ Day Year F, ax: {907~ 661-5301 TO BE COMPLETED BY LABORATORY ]Ak~ysis shows this Water SAMPLE to be: (~ Satisfacto~ n Unsati.sfacmry Sample over 30 hours old, results may be unreliable D Sample too long in transit; sample should · not be over~10hours old at examination ... tO indicate reliable results. Please send new sample via special delivery mail. Date Received t' Ot~/ Analysis Began ~. '~10 ·Ana. lyUe. al M~thod? ,~Membrane Filter · . ~ ' MMO-MUG Treated Watea Untreated Water Analyst Time Collected Collected By - * Number of colonies/100 mi. Result* 1 01 721134 Anch Fbks Jun L-~ Foxed Date: Time: Client notified of unsatisfactory results: Phoned Spoke with Date: Time: BACTERIOLOGICAL WATER ?aNALYSIS RECORD MMO-MUG Result: Total Coliform Membrane ['liter:. Direc~ Count Verification: LTB ~ Coil O Colonies/100 mi BGB COLIFIRM Comments: Fecal Coliform Confirmation Final Membran~/~~u_~uJt~~_ Reported By _ ~~-'~%- Time Coliform/lO0 mi [] Foxed TN~7- T~ Numerout ro count OB ' Othw ~ncWrio ~~B Member of tho 8GS Group (Sociit& Ganat.le de Surveillance) ENVIRONMENTAL FACIUTIES IN A~LASKA, CAUFORNIA, FLORIDA, ILLINOIS. MARYLAND, MICHIGAN, MISSOURI. NEW JERSEY. OHIO, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I,D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address ~'~ {'CL~ S ~-e. ~-- ~,~ Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: ~ 3. TYPE OF WATER SUPPLY: Individual well {,// Community well Public water NOTE: ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: If Community well system, provide written confirmation from State ADEC attest- Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER' ) r [ ~ ' As certified by my seal affixed hereto and as Of the vahdabon date shown below, I verify that my nvestigation 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 verity that based on the information obtained from the Municipality of Anchora.ge files and from my investigation and inspection, the on-site water Supply and/or wastewate'r, disposal System is in cOmpiian(~e With all Municipal and state codes, ordinances, and regulations in' eff~e~t on the date of this inspection. · Address ~ :~ 'i~'" / 5'-~-7 " Date Engineer's signature __ w DHHS SIGNATURE Approved for -~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Note: The well for this property meets existing State,and Municipal Codes. There are nitrates present. It is sum~e~edtha~ a Deriodic testinK be performed to insurethe wells Nitrate concentration is 6.54 mg/1. ~EPA Date /- p_~Z , ~'7 IHS do not ,. 1/91) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Dlvisionof EnvironmentaIServices ' On:Site services Section ' ~. , P.O. Box 196650 Anchorage. Alaska 99519~6650 343-4744 CERTIFICATE OF HEALTH APPRovAL FO~{ ASINGLE F GENERAL INFORMATION p~lete I,e~al descrl (site address or directions) roperty owner' Mailing 'address Lending::'agency Mailing addresS. ~'~'~'~' ~"~ Day phone, Day phone Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well community WeF · NOTE: ~v¥/RO~E,, ~r OF AiV - lual on-site 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 verity 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 d .sp°sal ~yStem iS in compliance With all Municipal and State codes, ordinances, and regulations in effect on the date of this'inspection. ~ Name o! Firm Address Engineer's signature Phone .... DHHS SIGNATURE ' ~ Approved for 3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Commen~ Note: The well for this property meets existinm State and Municipal Codes. There are nitrates present. It is -",'contihued suitability. Nitrate concentration is 6:54 mg/1. EPA Date The Municipa ty of A~Chbmge D. epartment of Health and ~urnan Services (DHHS) I 'ApprOVal CertlfiCatesbased ~nl~; Upon the'rep~esentations given' 5 above b =onduCt ins responsible for errors o Legal Description: A. WELL DATA Well type ~'~ Log present (Y/N) Total depth Sanitary seal (Y/N) Mumclpahty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · Health Authority Approval Checklist If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to /~ ,~ ! ? FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: ColifOrm ~) Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping g.p.m, g.p.m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Nitrate ~,~/'¢/ ~l Other bacteria N ~ Collected by: ~, -~ Tank size l u~c> Number of Compartments ~-- Cleanouts (Y/N) y Depression (WN) ~ High water alarm (Y/N) Pumper C. ABSORPTION FIELD DATA Date installed t ~ I ~\\ Length ;.~ I Width ,,~ Effective absorption area Date of adequacy test Soil rating (n n d/ff~ ~,=,u...,,.,~ /' '~ System type / Gravel thickness below pipe Total depth J~ / Monitoring Tube present (Y/N) "/ Depression over field (WN) Results (Pass/Faill ~/ For Fluid depth in absorption field before test (in.); Fluid depth ~/ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Immediately after ~/gal. water added (in.): Absorption rate = ~ g.p.d. If yes, give date -~' bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) E gh water alarm level at* "Pump on" level at' *Datum "Pump off" level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot '~ ~) (~ Absorption field on lot J ~..-0 Public sewer main Sewer/septic service line I On adjacent lots On adjacent lots ) l O-~ Public sewer manhole/cleanout J~[ 0 ~,I -~- Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~ ~, ~~ I Property line '~ ~ / Absorption field Water main/service line / ~0 / Surface water/drainage ~ ~ ~_ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line "'~,:~ ~ Building foundation ~O I Surface water J~l l) ~, ~ Welts on adjacent lots '~/~-~ Water main/service line Driveway. parking/vehicle storage area I Curtain drain ~'~o v, .~- Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records fn conformance with MOA HAA guidelines in effect on this date, .~ ~"~ Signature HAA Fee $. ~ ' ~ Date ofPaymen, Receipt Number ~?//'//~/',/'~,'P'~ ."~// 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID Sample R,~mark3: Sample c6ilected by: T.S. 966060001 Tobben SpurklandP.E. N1/2Lot 65 Sec9 N 1/2 Lot 65 Sec 9 DfinldngWa~r Client PO# Printed Date/Time 11/15/96 11:26 Collected Date/Time 11/11/96 15:00 Received Date/Time 11/12/96 12:20 Technical Director: Stephen C. Ede Released By ~~" Nitrate-N Total Coliform Results 6.54 0 PQL Units 1.00 mg/L 0 coL/lOOmL ALLowable Prep AnaLys~s Method Limits Date Date Init SM18 4500-NO3F 10 max 11/14/96 WEP S~18 9222B 11/12/96 TAV 01~'17.-97 12:03 /]:F:&E ESt ANC:HORAGE * 2?66013 NO. 937 Environmental Services Inc, '.]T&E Ref,# Client Name ?roject Name/# Client Sample ID ~,{atrlx Ordered By PWSID 970259001 Tobben SpurMand P,E. Potable Water N 1/2 Lot 65 Sec, 9 Drinking Water Sample R~narks: ¢mnple Collected By: T. Spu]:klaed Client PO// Primed Date/Time 01/17/97 07:10 CollectedDate/Tlme 01/14/97 16:30 Received Date/Time 01/15/97 08:50 Technical Director: Stephen C. Ede Relea~qed By .,4,/ / t pQL Units Method AtLowabLe Prep An~lysls Limits Date Dmte uitrate-N 7.82 0.500 mg/L 8H18 4500-NO3F 10 max 01/15/97 JSL Total Coliform 0 co//lOOmL SM3g 9222B 01/15/97 TAV