HomeMy WebLinkAboutT15N R1W SEC 18 LT 99T1
N I IW
ction 18
Lot f)
051 - 17;
-30
MUNICIPALITY OF ANCHORAGE
,~" m DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PI-lO-NE L~ NEW
LEGAL DESCRIPTION -
Absorption aee
~Z ManufactUrer ~ /'~ ' PE~O~
~ ~ O ~ ~ Materi~ No. of com~tments
Liq,~i~in gallons IF HOMEMADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well · / Dwelling
PERMIT
NO.
= DISTANC~ TO: /¢° f/ Foundation Nearest lot lin PE
Totallengt of I'nes
~ No. of
~ [ ~ Top of tile to finisl~: Material beneath tile
Length W~dth / Depth PERMIT NO,
~--< ~ Type of crib Crib d~/~ Crib depth Total effective absorption area
~ ~ DISTANCE TO: Well ~ Building foundation Nearest lot rine
~ Class Depth Driller Distance to lot Hne PERMIT NQ.
~ DISTANC~O: ~ldi~g f~n~ati~ Sewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RATING
.... KA 99577
3/78)
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE [] NEW
~ ~ Manufacturer ~ Ma~. NO. of com~tments
Liq. capeci~in gallons Inside length Width Liquid depth
JOO~ IF HOMEMADE:__
G ~ DISTANCE TO: Well ~ / ~ Dwelling PERMITNO.
OZ~ Manufacturer~ / ~ Material Liquid capacityin gallons
~3~ DISTANCE TO: Wel>~0 ,~ Foundation Nearest ,o, lin, PE~O~
Distance e en line~
~ ~; Z Total length
~ No. of lines/ Length of eachtiin
! Trench w~t~
~ Top of tile ,o ,,nisl~a~e ~ '~ ¢ Materlal~' beneath tile~, '~ inchesinChes Total ef~5%~p~rea
I Width / Depth PERMIT NO.
Length
~ ~ Type of crib Crib di Crib depth Total effective absorption area
~ ~ DISTANCE TO: W~II ~ Building foundation Nearest lot tine
~ Class Depth Driller Distance to tot line PER~IT
~O ~ldi~g f~un~ati~ Sewer line Septic tank Absorption area(s)
~ DISTANC :
OTHER J ~1~
SO,L,~S~,~ ~o?~ .
INSTALLER ~ ~
· ' '.'":
..... , ............ ,,.... c~L.
~... ~. ,,,,.~ .,~$. [ .
: ,~.., ....;~ ~ ~ ,~/ /'
.,,...,. ....
13 (Rev. 3/78) /
PERM I T I'.,I0. ,::
F:IPPL :[
LOC:F!]' ]: ON
LEGF~L.
FIDR I F:IN ~.:.; T'.
LOT ~i~?.~ :~i;E(":. ::LB "r::LSN R:I.H
LOT SIZE
TYPE OF SOIL F:IBSORP]"iON :~];"r't!!;TEM I:E;: T'RENCH
MI::I::.:::I:I'dUM Nt...IM[~:ER OF 8E[:,RCICIM'.~; =
:E;OIL F~:F(I"II",tG (SQ FT',-"I:],'R) .... 85
T'HE REQUIRE:[:, SIZE: OF:' THE E;OIL f:tE~'-'E;ORF'TION SYSTEM I:E;:
THE LENGTH [:,IMENSI(31q :IS THE L. ENGTH ( IN FEET'::, OF' "FHE TRENCH OR DRFIIF,IF:[EL.[).
THE DEPTH OF FI TRENC:I-'! (3Fi! F:'IT ]:~!~; "rFIE D]:S'¥'F~NCE E~E'T'HEEN THE r~;I...IRFF~C:E OF ]'HE
GROUNE) FIN[)"I'HE [;.~OTTO[','I OF THE E,'.,',CFIVF~TION (Itq FEET).
]-HERE I?, NO ':'~.:E]" I,.IIE~TH FOR TRENCHES.
'THE (.~IRI:r~VEL [:,EF:'TH J:.'.2; THE P'IINZMLIM [)EPTH OF C~RF!~,,,'EL. BETWEEN 'f'HE OUTFF:IL.L F'ZPE
FINE) THE E~OTTOM OF THE EF,;CF:i',/FiTIr.]I'.,I (:IN FEET).
F:'ERMIT FIPPLICF~NT !.-IFIS "rile RE:.'~;PONSI[~ILIT'.~' TO INFCIRM
INSTtaLLFtTIOIq II'-,I'.;~;PEC:TIOIq'..3 OF' FIN'.r' I.qEL.LS FI[)JFK]ENT TO ]"HI'i::
NUMBER OF' REt!~;:[DEI",ICES 'THFIT THE klELL I,.I:[L.L SER',/E
[:,E]:'FIR'TT,111~]',rT' [)UR I NG 'T'HE
FIND THE
E[FIC:KF:' I L..L.. Z P,IG OF' F:ff.,l'~.' E;YE;T'EM H I 'T'HOUT I=' I NFIt... I N~i~;F'ECT ! O1'-,! FIN[) t=IF'PRO',,,'FIL. E:Y TH I Ei;
[:,EF:'F:tl;[t'T'MEI'-,IT I.,.IILL 8E :E;UE:..IEC"E "1"O F'RCI:E;ECU'T'ION.
M]:NtMUM [::,!::~;T'FIf'.,!CE: BETHEE.['.,! FI HEL. L I;:INE:, FINk' ON-:F.:;:I:TE SE],.IFIGE E:d:%F'OS[:tL.
:[.Iil)lli) FEET FOR fa F'RI',,,'fa'E'E HEL. L. OR 1!!3Ei TO 2Ii)El FEET FROhl I::1 ~:::'I..JEi:L. IC HEL. L [:,EPENb:[NG
UF:'CIN THE 'T'YF'E OF PUBLIC HELl_
M I N I MUM [:, I STF:II'.~CE FROM FI PR I ',/FITE HEL. L. "['0 I::1 PR I ',/RTE rSEI.,.IEI;~: L. I NE I $ '2~ FEET
]"0 F~ COMMUNIT'.~.' SEHER LINE I~E; ';::'~]~ FEET.
O'T'HE]:[: REt]:!U I RE]HENT$ MF:I'~' f~F'F'L"r'. ~E:PEC :[ F l CFI"[' I OI",]S laN[) CI]NSTRUC:"I" :[ ON [:, :[ FIGRI::IM:~;
I:::I',/t::[IL[:IE~]LE TO INSURE F'ROPER IIqSTf~LL. FITZON.
:[ C:ERT:[F~'r~ 'T'HFrT'
:L: :[ FII'! F'Fff'IILIF:tF~'. H I"I"H THE RE(;]UIREi"IENTS FOR ON'"'~'~;ITE :!!;EI.qE[;;::~; FIND I,]EL.L~J; FIS SE"I'
F'OR'FH B'~" THE MLINIC:tF'FILZT"r' OF F]NCHORf'~GE.
2.: t HIL. L. INST'FILL. THE S'~"?t"EM IN FrlCCORDF~NCE HI'TFI THE CODES.
2:: I UNDER:E;]'FIIqE:, THFrT' THE/ ON-SITE SEHER t~2:"r':E;TEM MI::Pr' REQUZRE ENL. FIRGEMENT ZF:' THE
REt~;I[:,EI",ICE I$ REMO[:,EL[[)TO INCLUDE MORE THF~N ]: BEDROOMS.
·
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1 __
2
3
4
5
6
7-
8-
9.~
10-
11
137
14-
15
16
17
18
19
20
COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
t
DEPTH?
[] PERCOLATION
TEST
DATE PER FORMED: ~ 4~'~ ~
'E PLAN
× Gross Net Depth to Net
'Beading Date Time Time Water Drop
/
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AZ~2,~ FT
72-008 (6/79)
CERTIFIED
Gt 'TER ANCHORAGE AREA BORO; H
OI:,-~RTMENT OF ENVIRONMENTAL QUALII ~
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME ../'Z?z,~j/21/ .~- . ____,'~ ~C]'~''''~'~ ..... ADDRESS ~-~.~.,.-
LOCATION~';~//-~ .~'/~3/~:~-~L_~/,.~;*'~'$'-'~'~r'' ~",";~ LEGAL DESCRIPTION .~'
SEPTIC TANK:
'" NUMBER OF
DISTANCE FROM WELL ////~' MAIERIA[ ~2~-~'2-~:~ .COMPARTMENTS ~
LIQUID
LIQUID CAPACITY .~¢~/¢J'~" ~' ' _ GALLONS. INSIDE LENGTH ~ INSIDE WIDTH ~'~ ~DEPIH
SEEPAGE SYSTEM: SEEPAGE PIT:/
.~ ~-,/.7~'~]~';~-,c~.~.~... ~.<"~-~J~¢/~.-~/.~_ .
NUMBER OF PITS ...... / __OUTSIDE DIAMETER / OR WIDTH ~/"~ /
LINING MATERIAL ~ ~ ~/.~'%"'~ DISTANCE FROM WELL__~/_/'],~.~'(
NEAREST LOT LINE ...... Z~ ......... [OTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
/
· LENGTH /-~ , DEPTH~ /
BUILDING FOUNDATION
,/,.~,~r.:-',,~ SQ. ET. '~
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION , NEARES] LOT LINE
DI~ LINES TRENCH WIDTH
~.SCk F~ LENG'B~.~CH LINE ~__.~...._,~~'~''''~
DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
, OF LINES
IN. TOTAL EFFECTIVE
N. ABOVE T LE
WELL: ~,'-~/~;./ -~'~r;~,~TZ-~-~. " DISTANCE FROM
TYPE...~.'¢J"'~"~'~:~" _, DEPTH /..~2/_.f2 ·,BUILDING FOUNDATION·
LOT LINE z/'~ ~';~ NEAREST / SEPTIC //g~.,' -/ SEEPAGE
, SEWER LINE ., TANK , SYSTEM__
WATER
SAMPLE. -~'/~'('~ . NEAREST
,CESSPOOL/~'z'~/]'/-. SOURCEs__OTHER ~._~-
DISTANCES:
DIAGRAM OF SYSTEM
DATE
APPROVED
G.A.A.B.
GRE:AI~E:R ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD POUCH 6-650
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
NAME OF APPLICANT ~~//''///c/ ~' ~I~"//K'~ MAILING ADDRESS ~'~'/~" .'~ ~' PHONE
[NSTALLATION LOCATION ~ ~//~~ ~/~/ /~ ~/~///~
INSTALLATION OF: SEPTIC TANK SEEPAGE Pit , DRAIN FIELD OTHER
TYPE AND ~lze Of fAC]LITY TO be SERVED ~ ~~ ~/~
COMPLETION DATE A NT'GIPATED /~/ /
NOTE~ THIS PERMIT IS NOT VALID WITHOUT SOIL
FINAL INSPECTION~ 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION,
SEPTIC TANK SIZE TYPE
SEPTIC TANK TO SEEPAGE PIT WALL
WELL TO SEPTIC TANK ~:~ ~ , SEEPAGE PIT
SEEPAGE PIT
SEPTIC TANK, ,~u"~'"'~ / / '~'
SEEPAGE PIT
SEEPAGE AREA SIZE /'~/~/"~'~.~/~ TYPE
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH D[AMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
HEALTH AUTHORITY
OR
LICENSED DESIGNER
] CERTIFY THAT [ AM FAMILIAR WITH THE REQU[REMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCR[BED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE APPLICAHT', SI,NATU.,
SULLIVAN WATER WELLS
-:" P.O. BOX 272, CHUGIAK, ALASKA 99567 'e TELEPHONE 688-27~9
OWNER OY LAND ~Z, ~ ~ ' '..;
- ~ . - /
' ~ ~ ~ " 'r:' ~ ' ' · ~ATIC LEVEL OF WATER FT.
ADDRESS o ,x -t ~ ?o~ ~ ~ '-~ '*~ ~ 'C', ..... ~ ,,
LEGALDESCRI~ION '~ ~?~t' r,7,;~:,~,,.~ ~' DRA~DOWNF~. : ..... ~ ':
DATE - Started'- C~ / / ~:3-' Ended </ / -~ 3'''< GALS. PER HR
PE~IT NUMBER - KIND OF CASING
KIND OF FORMATION:
From '~) .Ft. to ' Ft.
From
Ft. to / ;~ Ft.
From Ft. to · Ft.
From Ft. to Ft
From "~C) ~' Ft. to '~ 7 Ft.
From. ' Ft. to Ft. Fi'om Ft. to ' Ft.
From'-'-:L '7 ,c- :. ' -
Ft. to.'~z7'~ :' Ft. ~'"~"~- '~'2"~;~ '~':'d~/"~'From Ft. to Ft.
' Ft. to
From -~"/
c~ ~;-' '-' '<. - ">- From "' Ft. to Ft.
-' From' '~",.. Ft. to '
-~ '~,~ ~ ,~,~ ,~ From _Ft. to_ ',. Ft ' ~ ~
....
z~, ~E' ~- From Ft. to F
.C', z ~ v~,>~ cYz ~[ From Ft. to . ' Ft.
From .Ft. ~.__ Ft.
From Ft. to ' Ft.
From ~':" Et to ...... ": Ft "~' ?"';:"' "*
From Ft. to .Ft
From Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME. , ' ~-.<. t ...........
Municipality of Anchorage
Services Department
Development
Building Safety Division
On-Site Water & Wastewater Program
4700 Braoaw Street
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 051-172-30
1. GENERAL INFORMATION
COSA# 0 ~ (7.
Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
· Mailing address
T15N, RIW, SECTION 18; LOT 99
19816 ADRIAN AVENUE * CHUGIAK, AK * 99567
DAVID ALLEN Day phone 854-2.347
19816 ADRIAN AVENUE * CHUGIAK, AK * 99567
Day phone
CATHY GERACI W/ GREATLAND REALTY Day phone 694-9125
11411 OLD GLENN HWY * EAGLE RIVER, AK * 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 5
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 [] 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 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 certified by my seal affixed hereto and as u, ~,e vo,ua,,u,, da,~o,,~,,,,, below, ~ .... ;¢" '~"* ~",
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 t,~e Municipality of Anchorage fi!es and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with afl applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Phone 537-6179
AddreSs 5701 Eo TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's.Printed Name JEFFREY A. GARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering 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 operat¢onal 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 conditions are outside the control of the evaluator 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. GEG, LTD. 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
other person or party is not authorized, nor will it confer any legal right whatsoever.
DSD SIGNATURE
%'"'~' Approved for ~
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 11/05)
Arsenic Advisow
Maintenance Agreements
Supplemental Engineer's Report
umer
Original Certificate Date: //O -. ,.~. ~ ~//~.~
CERTIFICATE
Legal Description:
WELL DATA
Well type PRIVATE
Date completed
Total depth 55
MuniciPality of Anchorage
Development Services DePartment
Building Safety Division
On-Site Water & WasteWater Program
4700 Bragaw Street
P.O. 'Box 196650
Anchorage, AK 99519-6650
www;muni.org/onsite
(907L343-7904
OF ON-SITE SYSTEHS
T15N, RlW, SECTION 18; LOT
*ASSUMED BASED UPON SURROUNDING
If A, B, Or C provide PWSID# N/A
4/;1985 Sanitary ~eal (Y/N) YES
ff. Cased to *40'+ ff.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Arsenic: ND ug./L.
SEPTIC/HOLDING TANK DATA
FROM WELL LOG
4/1985
20 .ft.
APPROVAL CHECKLIST
99 Parcel ID: (~ ~/" / 7,,~- '~ ~)
WELL LOGS. SEE AI-I'ACHED.
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
10/20/2010
22
5 g.p.m. 25
Nitrate 5.85 mg./L. Other bacteria__
Date of sample:l 0/18/2010 Collected by:
*DOUBLE CLEANOUTS
Tank Type/Material SEPTIC/STEEL
Tanksize 1000 gal. Numberof Compartments 2
Foundation cleanout (Y/N) *YES
Date of pumping 5/27/2010
ABSORPTION FIELD DATA
Dat~..installed 6/8/1982
Length. 32 ft.
Depression over tank (Y/N) NO
Pumper.
I'BELOW EXISTING (~RADE]
Soil rating (g.p.d./ft2o~ 85
Width 5 ft.
g.p.m.
0 colonies/lO0 mi.
GEG Ltd.
INSTALLED PRIOR TO TANK.
Date installed 6/8/1982
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
JR'S PUMPING
System type TRENCH
Gravel below pipe 4 ft.
Total depth *9.4 ft. Eft. absorption area 255 ft2 Monitoring tube**YES Depression over field NO
Date of adequacy test 10/20/2010 Results (Pass/Fail) PASS For 3 bedrooms
*** 12
Fluid depth in absorption field before test in. Water added 910 gal. New depth 50 in.
Elapsed Time: 120 min. Final fluid depth 18 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date -
**MT ONLY EXTENDS 50" BELOW INVERT. TOTAL DEPTH IS CALCULATED. NOTE: HOUSE WAS
VACANT
*** 18"
AT TIME OF TEST. DRAINFIELD was PRESOAKED UNTIL 100% FULL ON 10/19/2010.
BELOW INVERT.
D. LIFT STATION
Date installed
"Pump on" level at in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons Manhole/Access ~ ~
"pump off" level_.aL~. High water alarm level at
Cycles tested Meets alarm & circuit requirements?
100'+
Septic tank/lift station on lot
Absorption field on lot 100'+
Public sewer main N/A
Sewer/septic service line 25'+
Animal containment areas 50'+
.in.
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout
Holding tank N/A
Manure/animal excrete storage areas
N/A
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water service line. 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Absorption field 5'+
Surface water. 100'+
Property line 10'+ Building foundation 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots, 100'+
Water main N/A
Driveway, parking/vehicle storage
1'+
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 COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
COSA Fee $ /'-/? 0 ~
Date of Payment / O
Receipt Number '~)
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmor¢ Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsit¢
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 101271
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
99 of T15N R1W Section 18 subdivision. This inspection revealed a nitrate
concentration of 5.83 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
~- 8355G
z
! < _q
< LOT 96B
/
<,. _./
oo o
T ~ ADRIAN AVENUE
i EAST 329.93
~ ~ 33' R.O.W. RESERVAITIONI
: 107.4 ~ ~ I ~
417. ~. I
o & Frame _~ ~
-- d Hous~ 13.77r ' /
~ ~ ~~ / / 30~: 55 6 - '
· ¢ ~
= 2oo~ I e /
LOT 100 ~ aecK , I~ - ~- Wire fence
- ~ 30.0 LOT 98
c ~ouble strand electric - ~
O wire c0rral fence (~p) LOT 99, ~/ /~ J o o
o ° ~ SECTION 18, /~
¢ ~ T15N, R1W, S.M., AK ~ ~/
o
- 835 ~ ....
'~ 56'1 ' I11 8 ~ .... ' ~ouble strand electric
Covered Storag~ ~ ~ w~re corral fence (~p)
c 56.0 ~ ~
EAST 329.98
LOT 127 I LOT 128 i LOT 129
· ¢~;~ [,.,.-. AS-BUILT NO CORNERS SET THIS DATE
~-~%-' ~ '~ ~ I hereby ce~i~ that 1 have peffo~ a Mo~gagee's inspection
~ ~.' 49th ~ '~ '~, ofth~fo,,o~i.gd..o.b.dprop.~: LOT 99, SECT,ON ~S,
~'~ · .- /- - ~ ¢. T15N, RlW, SEWARD MERIDIAN, AK
¢ ~" ~ .... ~" ' ~ ......... ~ Anchorage Recording Precinct, Alaska, and that the
¢. ~ . Ehz~be~ L. ~l~tk~. ~ ~ improvements situated thereon are within the prope~ lines
adjacent thereto, that no improvements on the prope~ lying
~ '~ ~ ' · · · · · '¢~ ~ adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
~ ~ ~ ~~ visible easements on said prope~ except as indicated
hereon.
SCALE: 1 "= 40' Dated at Anchorage, Alaska
EASEMENTS OF RECORD, OTHER THAN this 25th day of October ,20~0
THOSE SHOWN ON THE RECORDED FRED WALAT~ & ASSOCIATES
PLAT ARE NOT SHOWN HEREON. FB 10-7, pg 46 BE (907-248-1666) Engineers and Su~eyom
JRS SEPTIC
PAGE 01
JRs Pumping
PO Box 773~15
Ea~le l~ver, ~K 99577
(907) 694-6454
~~a,tio__n ]
David Allen
Po Box 877382
Wasilla, AK 99687
(907) 688-5881
[Job Site Information
David
19816 Adrian Avenue
Chugiak, AK 99567
(907) 688-5881
269-1150
Additional Location Comments Diagram:
Brown 2 sto~J home w/no #'s. Dogs
in kennel, padtal fencing
3bdrm septic to the left side and
visible
Service Type
Septic Sen/1000K
Job Description:
P.O. Number:
Terms:
Salesrep;
Map Book:
Cross Streets:
lO00g
Service Agreement
Number: 030972
Order Date: 21-May-2010
Service Date: 27-May-2010 12:0
Technician: Dave
Net 30 Tax %:
Dawn-Dawn Job Type: Repeat
Map Grid: 41
Mile 2,1 Birchwood Lp Rd
Job Comment~;
Last Service *04/02/2008*
Electrical Fence - Won't be HOT!
Tank levels normal
lots of solids
recommend line jetting tank t o field
1000g
S:\Diaqrams;1.7973.bm~
Gallons Planned: 1000
Qty Price Each Tax?
t $185.00 No
Gal. Actual:
Hose Length: 2
Double Tank: [] ~
Pump System: [] ...._..
Baffles Inlet: [] ~
Baffles Outlet: [] -
Extension Actual
$185.00
NonTaxable Total
Estimated Charges; $185.00
Taxalcle Total
$o.o0
Tax Total Grand Total
$0,00 $185,00
Actual Charges; _
Customer agrees to the terms and conditions shown. THIS IS A BINDIN~AGREEMENT.
-- Date
Sl~,c.~ure.~ "~ (~1,/~, ~
-~,°C-epted~by JRs Pumping Date Accepted
For your added convenience we accept; Amedoan Express, Dloover, Visa and Master Card payments over the phone,
After 30 Days account will be turned over to COLLECTIONS. $30.00 For NSF Checks Returned,
.¢.
FROM THE DESK OF:
.Raymond l:l.. l'tolmsen
WELL'DATA:
Drilled well . .~
LoEation: in yard
Distance to:
Building'sewer or other drainage pipe - 40'
Septic tank- 50'
· Cesspool - 100'
Material:
Building sewer- Wood, Transite
Well Casing Material: Steel DiAmeter - 6"
Depth - 150'
Length ~of drop pipe: 100'
Water Depth from bottom: 147'
~Pump loEation: In well
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
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ('~z~ _\~,..~ ~ .~ ,HAA # ~.~--~c~\ (~ ~,~
T15N;"R1W~ Sec. 18; LO~ 99
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailin_g address.
19816 Adrian
Chuqiak, AK
Bill McDonald
P.O. Box 671188 Chuqiak,
Day phone
AK 99567
Day phone
688-9626
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
XX
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Hol~
Xx
D. LIFT STATION 14/~
Date installed Size in gallons
Manhole~ "Pump on" level at" ~level
High water alarm level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/.be~,i~ tank on lot J oQl~' On aojacent lots
Absorption field on lot JOe t..{- On adjacent lots
Public sewer main 1'4//~ Public sewer manhole/cleanout
Sewer/septic service line '7.~; I.i. Lift station
SEPARATION DISTANCES FROM SEPTIC/F. II~I~IN~ TANK ON LOTTO:
Foundation ,,~ I~. Property line ~ I-t' Absorption riel(;.
Water main/service line Io~4'' Surface water/drainage Iool't' Wel~s on adjacent lots
SEPARATION DISTANCE. FROM ABSORPTION FIELD ON LOT TO:
Property line ~O~4' Building foundation lO t~ Water main/service line
Surface water l°°l'~ Driveway, parking/vehicle storage area
Curtain drain ~ot~E ~--'~.;~ .~ Wells on actjacent lots
F. ENGINEER'S CERTIFICATION
in conformance with~A~2li~offoct on this date.
Signature ~,~__.:~.../-v_~k.../ ~_ ~
Engineer's Name t'/L-)~ ~ '
HAA Fee $ '~ ~ i ~TT~) Waiver Fee $
Date of Payment /-~/~ / C~;) Date of Payment
Receipt Number ~ ~7~/ {~' ~ Receipt Number
72-026 (Rev. 3/96)*
CT&E Environmental Services Inc.
Laboratory Division
200 W. Potter Drive
Ancllorage. AK 9951~
Tel' (907;, 562-2343
Fax. (907) 50'1-530~
ChemLab Ref ~ 99 1470 Client PO#:
Chant Name: AK water & Waatewa[er Cons. Pt~ntecl Date/T~me: 4/91gg I
Project Name Lgg, Sac18, T15W, R1W Collem~ Date~ime: 4/8/99 08:35
Che~t Sample tD: O~t~oe ~ose Bi~ R~elVe~ ~a~l~e: 418199 11:~5
Matrix: Drl~tnO Wamr TaChnlcal ~irecmr: Stephen
Sample Remarks. . ................ - -- / ..... ~,r:~
SM9222B. Total Coliform Analysis performed by No~thern Tesiing L~berateries of AnchOrage, AK.
Allowable Prep An~Jy~is
_Parameter ReSults PQL un,ts Method L~ts Date Daze
Nittate 2.708 0 5 mg/L EPA 300 lO.O 4/8/99 SCL
- It~O W, Pofler Dove
3rinking Water Analysis R~port for Total Coliform Bacteria ~.~"*'q~, ~ s~l.~ ~
uACTEH~OLOGICAL WATER ANAL¥$~ RECORD
MUNICIPALITY OF ANCHOti~GE
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
1. GENERAL INFORMATION
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~'~ ,.4,'~,¢ ,T),¢~4 ~./c~ Telephone: Home
(b) Business ~
Applicant Address .~"~¢~r-~ /(~' I R.~23g~ ~-J~.,~[~.~- /~'~< ~2.~'(.o')
·
(c) Applicant is (check one): Lending Institution []'; Owner/builder~; Buyer I-]; Other [] (explain);
(d) Lending Institution
Address ~' ~ ~'
(e) ileal [state Company and Agent
Telephone
¢¢577
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family¢ Multi-Family []
Number of Bedrooms -~
Other
WATER SUPPLY
Individual Well,~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conserval
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conserva~
attesting to the legality and status.
Page 1 of 2 ?2-025 (11
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 /Vf~.~.,/~},~ ~'. ~ -- ~--~ ~ ,~, Telephone
Address
Date
Approved for ~ bedrooms by ~ I~ te
Approved i,~ Disapproved Conditional "~ r
Terms of Conditional Approval
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
WELL DATA
Y'~'~,~ DateCorrpleted /¢/'/?/~ /?'~?.5- Yield
Depth of Grouting ./~',W'~'A/~,O,~)
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Arouno Wellhead (Y/N)
If A. B, C, D.E.C. Approved (Y/N) ,~,/~
Well Classification
Well Log Present (Y/NJ
Tota Depth ~ / ~ ~ Cased to
Static Water Level ~;~('~/
Casing Ide~gnt Above Ground
Electrica Wiring ~n Conduit (Y/N)
Separation Distances from Well;
To Septic/Holding Tank on Lot f/~-- ·
Tc Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~,.~//~
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
. On Adjoining LOtS
On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on LOt
;Date
Comments 3 ~ ,f~,A~ (~.... ¢-;¥, ,,,~,~,,~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~/~
Standpipes (Y/N)
Depression over Tank (Y/N) ~/(~
Pure ang/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~
Separauon Distances from Septic/Holding Tank:
To Water-Su pp~y Well
To Property Line
To Water Main/Service Line
Course
Comments
Size ~ NO. of Compartments
Air-tight Caps (Y/N) ~/~---~ Foundation Cleanout [Y/N)
Date Last Pumpea /- ~/-''t/
'.for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream. Pond. Lake. or Major Drainage
Page 1 of 2
HEMICAL & GEOLOGICAL LAB(f~ATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
_~/,// TO BE COMPLETED BY WATER SUPPLIER
'~' '~/TT~r U I I I I I I I ()seeh°n~ack
. --ATER sYSTE : ~ I.D. NO.
Mo. Day Y~
SAMPLE TYPE:
[] Routine
E] Check Sample (for routine sample
with lab tel. no. )
E] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
, I
4 I
, I
Time Collected
IPALIIY ut- ^NCHuK~,~c
~EPT. OF HEALTH &
DNMEI, ...... OT .......
F~BO ~!9~
RECEIVED
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
,~atisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
Indicate reliable results. Please send new
sample via special delivery mall.
Date Received ///~/~-S ~
'rime Received /~"*'-~ ?
Analytical Method:
n Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result*
r-FI
n-1
BACTER IOLOG ICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter. Direct Count
Verification: LTB
Final Membrane Filter Results//
Collform/lOOml
,.,.
Time: /--~/~ a.m.
BGB
Collformll00ml
TNTC = Too Numerous To Count
Comments ~-;~o Conditional Approval
( ) Condl~onal hp~o~al
Date Sewer Installed Permit No. Septic Tank Size
Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLy
Address
Lending Institution Phone
Address
RealtyCo.&Agent~~ ~ ~/~ ~/~ -- d~yc~ ~ Phone
Typ~f Residence
~ Single Family
~ Multiple Family No. of Bedrooms ~
~ Other
Wat~Supply
~ Individual A~ACH WELL LOG A wel log s required for all wells drilled since June
~ Community 1975, For wells drilled prior to that dete, give well depth (attsch og f
~ Public Utlllt~ awilable.)
Sew~e Disposal
~ Individual Year Individual Installed: /~
~ Public Utility When Connected to Public Utility:.
~ Holdln~ Tank ',,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESBING CAN BE INITIATED.
CHEMICAL & L
TELEPHONE (g07)-279.4014
274-3364
_ .,OGICAL LABORATORIES ,_. ,' ALASKA, INC.
ANCHORAGE INDUSTRIAL CENTER
5633 S Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: III I I[I
Water System Name
TO BE COMPLETED BY LABORATORY
Analvsm snows tins Water SAMPLE to be
[] Satisfactory
[] Unsatisfactorv
Mailing Address
Phone No,
city
SAMPLE DATE: ~
MO.
State
Day Year
SAMPLE TYPE:
Code
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
SAMPLE
NO.
1
2
3
4
5
[] Treated Water
[] Untreated Water
LOCATION
Time Collected
Colleote¢ By
Samole too long n transit, sample should
not De over 48 nours old at exammauon
to ndmate rehable results. Please sen(]
new samDl6
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
'/, ' '*'?' ,/ ' ?~
I
I m-FI
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (0)
Rev. le78
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collectod SoUrCe
Time Recelve~ Lab, No,
Presumptive ],Omi 10mi /Omi 10mi 10mi 1,0mi O,Zml
24 Hours
48 Hours
Confirmatory
48 I-louts
April 22, 1982
Vincent and Joyce Porte
S~ I Box 2380
Chugiak, AK 99567
Lot 99 ~ 12 n' ~
ADprov;~l :for the individual sewer and water :a~zil. t~es[ e ..... cannot
be granted until the followlnq items have been completed.'
depression or pit aronnd the well casing needs to be
filled with l.mp~.rvious type soil so that ~t sloDes away
the well casing.
° The we].l casing needs to be extended twelve (12) incites
a'bove ground level.
q']%e septic t~nk ptl~lpe(} with a reeezpt submitted to
d,~pa rt me nt.
An adequacy test needs to be performed on the existing
leaching area. 791is test will determine if the system is
adequate according to ~,~ational Standard~. A listing of
private firms performing the test is enclosed. This report
n,~eds to be submitted to this office for our review.
A 1.000 gallon septic tank needs to be ins.tailed. A permit
must be issued prior to the installation.
The sewer system that was installed on Auqust 4, 1.971 was
approved by this Department for a 3 bedroom home. However,
before final approval, may be granted, it ~!ust bp. teste<! '.for
adequacy.
The well serving your property was approved as a semi-public
well in 1971. ?%erefore, if you choose to put a retltal unit
on ~st property, this Department would have no objection as
long as the system is tested for adequacy and shows '~e system
is functioning properly,
It should be note~] that there are 2 sewer systems o~3 t,lls ??re-
petty. The one beinf4 used will need to 'be upqraded by adding
a selptic tank and tested for adequacy.
The second sewer system is currently not being used and does
not have a dwelling serving it.
Please notify this department for a reinspection Wh(;n the
noted discrepancies have. been corrected. If there are any
further questions, please call %his office at 264-4720.
Sincere~',
Robort C. Pratt
Associate ~,nvironmental c, pecJ. alist
Enclosure
0
~ .~30
°~<~
~u!s~o ~ul~slx~
1st
MUNICi:PALITY OF ANCHORAGE
,~EPART~ENT, OF H~A~ AND,ENVIRONMENtAl, PROTECTION ~ ~.?,.~
825' 'L Street, Anchorage, Alaska 99501
279=2511, ext. 224, 225
Da'ce Received: March 22, 1977
Inspection: Time 2:00 p.m.
Date 3-23-77
Inspector Buchholz
2nd Inspe~g~: ITime
REQUEST FOR APPROVAL OF
Lending Institution Reque~.'0~
Mailing Address:
Property Owner:
Mailing Address;
Clarence Torledson
· Star Route Box 700 99567
3, Legal Description: T15N R1W 99
4. Single Family Residence: ~ :
Multiple Family Residence: ( ) Number of Bedrooms:
2
Well Data: Type Individual
Construction ~.
Depth 100' Well Log Filed (
Bacterial Analysis _ ~ //~ ~.-
6. Sewage Disposal System: On-site system [x~ PubI~c Utility ( )
Permit $ Installed Installer
Sepnic Tank Size
Manufacturer
Absorption Area
Soils Raue
Material
Distances: Well to Septic Tank
to Sewer Lines Nearest Lot
Absorption Area to Nearest Lot Line
Line
to Absorption Area
1. Type of Inspection:
2. Property Owner:
Mailing Address:
MUNICIPALITY OF ANCHORAGE J ~4UNICIPAU~-,
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
CMRO VA .FHA
RECEIVED
CONV
Day Phone:
3. Name of Buyer:
Mailing Address:
4. Name of Lending Institution:
Mailing Address:
5. Name of Realtor or Agent:
Mailing Address:
6. Legal Description:
Location:
Day Phone:
Phone:
Phone:
7. Type of Facility to be Inspected:
8. Water Supply
No. Bdrms. ~J~'
Type of Supply: Public Utility
If Individual, number of dwellings presently served
Individual
!
If Individual, depth of well
Sewage Disposal System
Type of System:
/o-0
Public Utility
Individual (on-site).
If Individual, date of installation
72-003(3176)
Page Two ....
~'~?~ %~'- Depart~e~t of~ HSalth~ah~"En~ironment~l~'~o%e.etion
Request for Approval of Individual Sewer and Water Facilities
Legal Description:
T15N R1W Section 18 Lot 99
Comments:
Affadavit Attached: ( ) Letter
Approved: Date:
Disapproved: Date:
Department Worksheet:
Attached:
( )
C, ABSORPTION FIELD DATA
Soils Rating in Absorpuon Strata
Date Installec
Width of Field (~/!
Sauare Feet of Absorption Area
Depression over Fielc (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
TO Water-Supply Well /¢ 7 '
To Building Foundation ~.~ /'
Lot ,,~,4-./~
TO Water Main/Service Line -~-~/
To Stream/Pond/Lake/or Major Drainage Course
Type of System Des gn
Lengm of Field ..~ Z. /
Depth of Field
Gravel Bed Thickness '~
Standpipes Present (Y/N)
Date of Last Adequacy Test / -,~'~ -.~
TO Property Line
To Existing or Abandoned System on
On Adjoining Lots /.~:~l ~-
To Cutbank (if present)
To Driveway, parking Area. or Vehicle Storage Area
Comments
Date Installec
Size in Gallons
"Pump On" Level al
High Water Alarm Leve~ at
Testeo for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adeouacy Test Meets MOA
Comments
"Check Permitted Bedroom Rating Against HAA Request **
certify that Iha~Ce.checCed, y~fified, or conformed to all MOA and HAA
Signed ./~,~. ,~?_~ Date /
~ \,j/~-- . ,--'
Company ,/L'~'T~-~27~.~,~/~e - C::;~," MOA No
.,__,,,
ReceiPt No.
Date of Paymem
Amount: $
Page 2 of 2
72-026 11/841
guidelines in effect on the date of this inspectio,n.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES APR 0
Environmental Services Division ~,v,~^L,Y oe an~[E.~..~~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) ~}4/~4,Tva~T^g s~Rvlces DIVISION
Health Authority Approval Checklist
Legal Description: L~I" q~ . '~'t~l~. R[~ ,~ ~..~te~ ~ Parcel I.D,:
A, WELL DATA
Well type ~R.~'t'~ If A, B, or C, attach ADEC letter,. ADEC water system number
Log present {~N) ~.~ Date completed ~/S~"
Cased to
Total depth .~/4~ ~ u
Sanitary seal {~/N)
Casing height (above ground)
Wires propedy protected ~/N) Y~
FROM WELL LOG AT INSPECTION
Date of test L~./~,~-- "~/.~/~t~
Static water level Z.o I I~
Well production ~;. O g,p.m.
g.p.m
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ~,/~'/~'Z., Tank size
Foundation cleanout (Y/~ Ik~o
Date of Pumping
Nitrate
~, F ~'Y~.~/~ Other bacteria
Collected by: ~, ~.u~ .~.....
ieee Number of Compartments
Deoression (Y,~ J~J o High water alarm (Y/~)
Pumper
C, ABSORPTION FIELD DATA
Date,nsta,,e
Length ~'?-~.Width
Soil rating (~or ~ S~'
· ~ Gravel thickness below pipe
System type
Total depth
Monitoring Tube present (~N) ~/~ Depression over field (Y/~)
Results t~__~/F'afl) ~A~J;' For ~ ~edrooms
~ Immediately after~ gal, water added (in,),"~~'~''Z't!
Effective absorption area
Date of adequacy test ~
Fluid depth in absorption field before test (in.); '~'
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/~)
72-026 (Rev, 3/96)* ~.y~
Absorption rate = z~'~'O '+' g.p.d.
If yes, give date ~t/~
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 con;
ordinances, and regulations in effect on the date ~
NameofF rm
Engineer's signature ~-'~ ~ ~
Alaska Water &
Wastewater Consultan~ts,
Shall be PAID_ $ It~-- -at,
or prior to, closing for the
Engineering Services Provided.
bedrooms.
pliance with all Municipal and State codes,
his inspection.
Phone -~_____~ '7- r°l'7 ¢~
B
"'-- Date
DHHS SIGNATURE
'-~ Approved for~.~
Disapproved.
Conditional approval for
bedrooms, with tt~e following stipulations:
By:
Additional Comments "i~',,~'~Rg~ov~ C\~o~vxov~ Io~ ~