Loading...
HomeMy WebLinkAboutWOODHAVEN #1 TR B LT 3Onsite File Woodhaven #1 Tract B Lot 3 #015-281-58 The 1977 trench can only be tested for up to a 4 bedroom COSA approval. 11, Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 3 ON-SITE WASTEWATER INSPECTION REPORT r ✓ Permit Number: PID Number: 015-281-58 OSP211011 Zi Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New W Upgrade Name LIVERS-STASSEL REVOCABLE TRUST ABSORPTION FIELD 0 Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 12101 JEROME STREET *ANCHORAGE, AK ❑ Other Phone of Bedrooms Soil Rating Total depth from original grade 907-441-1149 1.2 GPD/SF JTNumber 8.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade SEE DWG. Ft. Gravel depth beneath pipe 6.52 Ft. Subdivision Block Lot WOODHAVEN #1; BLOCK B, LOT 3 Fill added above original grade SEE DWG Ft. Gravel length 50 Ft. Township Range Section Gravel width 2.5 Ft. Beds: Number of Lines - Distance between lines - Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding I Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 650 Ft2 1 -Ft. Well 100'+ 100,+ - _ 25'+ TANK ❑s Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity GREER TANK 1500 Gal. Surface Water 100'+ 100,+ _ _ Material Number of compartments Lot Line 5'+ 10'+ _ _ NA HDPE 2 Foundation 10,+0 5 LIFT STATION Manufacturer Capacity 1 Remarks OLD TANK WAS DECOMMISSIONED PER UPC Gal. Electrical installed by Alarm location Installer PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield A+ HOME SERVICES Drainfield D3034 COIMTD3034 Inspector GEG AND TIM ECKLUND BENCH MARK (Assumed elevation) 97.57 ft Inspection 151 5/26/2021 2�a 5/27/2021 Location and description 3b 5/27/21 41h TOP OF MANHOLE ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Qo600p�� o� Conditional Approval:Date Qoo .t D Septic System /..,l Q Ge f� A. Gar ess, Q /� -1 o09 G'. c 79 3 Approved Date 02i cQQp Note: this approval does not include well permit requirements. e S S101, AEccee4pf 1? PERMIT NUMBER: PARCEL ID NUMBER: OSP211011 RECORD DRAWING 015-281-58 A I B MH1 69.8 87.4 STI 74.1 92.3 DBL1 75.2 93.4 DBL2 76.0 94.3 FD 76.3 94.7 C01 90.7 106.1 I \ MT2115.4 149.5 \ / + a:• B a. .. w r .. - •. • 00 O_ z I �o 0 wW Im 00 R` A / GN WOODHAVEN #1; TRACT 8, LOT 2 1500 GALLON HDPE GREER TANK DRAINFIELD DURING THE INSTALLATION OF THE CLEANOUT AND MT ON TRENCH IT WAS NOTED THAT THE HOLES ON THE WOODHAVEN #1; TRACT B, LOT 4 DISTRIBUTION LINE WERE "FACING UP" - DUE TO THIS FACT A+ HOME SERVICES REPLACED THE DISTRIBUTION LINE AND INSTALLED THE HOLES "FACING DOWN" - THIS WAS DISCUSSED _ WITH MOA ONSITE DEPARTMENT PRIOR TO APPROVAL OF :♦�P�E y�,♦i 01 M.....t... �� ................... ....� .•. ...• W reyGamer -79 i LICENSE444 '% SS\ �♦ #AECC884 / 01 Tp ENGINEERING .,, SALES , CONSULTING 3701E TUDOR ROAD SUITE 101 'ANCHORAGE, AK 99507 -PHONE (907) 337.6179' FAX (907) 338-3246' WEBSITE. w gamess g meemg com PREPARED FOR PHONE NUMBER: PAGE NUMBER. CHARLES LIVERS 907-441-1149 2 OF 3 LEGAL DESCRIPTION: DRAWN BY: WOODHAVEN #1; TRACT B, LOT 3 D.J.G. TYPE OF WORK: DATE: �, SEPTIC TANK RECORD DRAWINGS 6/7/2021 OF :♦�P�E y�,♦i 01 M.....t... �� ................... ....� .•. ...• W reyGamer -79 i LICENSE444 '% SS\ �♦ #AECC884 / PERMIT NUMBER: PARCEL ID NUMBER: OSP211011 RECORD DRAWING 015-281-58 TH TOP OF TANK AT INTLET = 94.61 INVERT OF BUNG AT INLET = 93.92 TOP OF MH =97 57 FINAL GRADE = 97.2-97.3 MH SF NEW 1500 GALLON H. D. P. E. GREER SEPTIC TANK RATED FOR 10' BURIAL ORIGINAL GRADE AT HIGHEST POINT = 95.55 2" INSULATION RELATIVE ELEVATION AT BOTTOM OF T.H. = 77.55 (G.W. AT 81.88 ON 5/26/2021) 6.52 FEET MT CO 2" INSULATION TOP OF TANK AT OUTLET = 94.59 INVERT OF BUNG AT OUTLET = 93.71 GRADE = 96.1-96.6 - FILTER FABRIC INVERT OF PIPE = 93.57 BOTTOM OF TRENCH = 87.05 Q o .....:........ .............. z ENGINEERING - SALES � CONSULTING .. . 3701E. TUDOR ROAD, SUITE 101 'ANCHORAGE, AK 99507' PHONE (807)3378179'FAX (907)33"46' WESSITE:vnvw.game—gmeermgcom • e '• a•••eee••aa eea 0 --[PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ♦ �+ . re•• Garnes"i 17- CHARLES LIVERS 907-441-1149 3 OF 3# AF '• T-775 ' LEGAL DESCRIPTION: DRAWN BY: �� \WOODHAVEN #1; TRACT B, LOT 3 D.J.G. �j F''• ' 4w TYPE OF WORK: DATE: LICENSE"'F ESS\ O III,SEPTIC TANK PROFILE 6/24/2021 #AECC884 111\\X%��0 i — — — — — — JEROME STREET — 19 5 00007'40" E 157.50' 0 M FENCE N 00°07'40" W 157.50' TRACT E1 0 Zv 40' EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED SUBDIVISION PLAT (70-343) ARE NOT SHOWN HEREON. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR ESTABLISHING PROPERTY BOUNDARIES. JOB # 203458 I NO CORNERS SET THIS DATE I SCALE 1"= 40' OF ,t I :... —...... . J r � r � .��� f.3raku Sa LS -14837 r� �p 6,75/7021 .. AS -BUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: LOT 3, TRACT B, WOODHAVEN SUBDIVISION ADDITION No. 1 ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT THE IMPROVEMENTS AS DEPICTED HEREON EXIST AS SHOWN IN RELATION TO THE PROPERTY LINES, DATED TH15 15th DAY OF JUNE, 2021, AT ANCHORAGE, ALASKA, FIXED HEIGHT, LLC Cp_A, 122554 Land Surveying Services 967.290.8949 225 W 23rd Ave„ Ancharage, AK 99503 VVWW.FIXE0HEIGHT_ COM MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 f. http:/hvww.murfi.arg/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211011 Effective Date: 1/26/2021 Work Type: Septic Upgrade Expiration Date: 1/2612022 Tax Code Number: 01528158000 Site Legal Address: WOODHAVEN #1 TR B LT 3 G:2735 Site Mailing Address: 12101 JEROME ST, Anchorage Owner: LIVERS-STASSEL REVOCABLE TRUST Lot Size in Sq Ft: 47250 Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 5 This permit is for the construction of: R1 Disposal Field 2 Septic Tank El Holding Tank 171 Privy 171 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified In Anchorage Munlcipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (1 8AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, seated, and heated to prevent freezing Received By: "1'707-7 Issued By: Date: 4 A Date: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211011, Rebecca Carroll, 01/26/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211011, Rebecca Carroll, 01/26/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211011, Rebecca Carroll, 01/26/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211011, Rebecca Carroll, 01/26/21 MUNICIPALITY 014, ANCIIORAGE }lea' '% and Environmental ]?rot(sc on Fourth F].oor West 825 L S'treet Anchorage, Alaska 99501 279.-251]., x 22a, 225 SEPTIC TANK: DISTANCE ~ff~/ . / N~JMI~ER OF INSIDE I,.[!NGTH ........... N~ )E WI[)]tl ... Ll(~)ll) [)[{Pill ~-- -.I m()ul[) CAPACII~--_ GALLONS. SEEPAGE PIT: Log Crib ..... Rings__. Crib Size: t)iAMk'l ~ .... DJ)I'H ___ )5TANCr FROM: WELL I O'rAL El FECTIV[{ BUII.I)II,I¢ FOUNDAI'ION ....... NEAItE.:51 LOII INE ...... ABSOtlF'IION ARIEA (WALL AI?EA) ....... Q. FI Well Class: ~_~.~.~ Depth: ..~.._:~_~1_ Well D~s~-~nc~' To: Lot Line Bldg: Sewer Line: Pipe Materials: ~ of Bedrooms: Installer: Remark s: __~'~' i '1t111: I..t!it"rlG I II D ]i t"llii:t",liil; i[ ON iii '-::i; 'Il'ti!i: I.IZI'"IGTII ( ]i I'"t I:::'liili;'l ) O1::: Till:i: I I:;i:1;i1",t(:::1't OF;;'. [:'1:;i:1::1 ]1: NI::: :( lil! I::'. 'It"Il:ii: t)ti[l:::'"l'tl Eli::: 1::1 I't:;i:fi:t",IIZ;H OI;i'. 1:::'iii'1' :i;:::; 'FI'lEi [)]::.!;'I'I:::II'.,ICE: I:ifliiTl'l.,.lli;liiil",t 'IN[ii '.iiil.tl;i'.l::;'F:llT;I] (:il;iuZII...ll'-,l[.:, I::IND t'llli: E',IzrI'T()I,I (:)I:::' III1:; tiT,:.::E::t:::f,,,'l:::f[]]Ol'.,I (:!]1-.,t 'l'lll]!:!:;Uii: ]i'.E; I'.,1():ii;li]'t I,I:[DTII l:::'(:lt:;~'. TI. lIE GI:;i'.t:::IVt!:I. l)tlii:l::"l'H il:f~; 'r'Hlii: I,'I]:N]:I','tl..II',I I)I~iI:::"iH (i]11:;' Eil,]'.l:::lVli:l. liEi:Tl,ll:!:[iil'.,l I'ltli: [iE.I'tI:::i:::iI I I:::'i[1:::'1( I:::tNI:) '11.11!i I:ill]]l't"t(i]ll,I (i]1:;' I'I.-IE tii:::.~:(]i;I:::IVI:::I"I :[ ON (i1:t'.,t il" il.,,.ll k(Z)[ ~:E ;;[;,fi: ][:,, ]E ii"-4 ::iiiii;; IF:::" II!i!il EZ;:' ii' [ii][ [iZ31 lir"',,li ',':iEi;; II::::::ll II::;'~;;: IIE(] !I::Ei: ~iii[ ~i~!! II...ll i]1[[ ~;E:: Iii!i];; II]Z::" EII:::tCI(I:;:][I t-][l'"ll[]i OF: FIl",l"r' S'['E;'Ili]I"I Ir,.ti[TFI[;]I. JT F]]I",II;::IL ]]l',,l!ii;l:::'lii)Z;'t ]iCII",I I:::II",ID FII;~'l;::'l:;i~(])","l:::ll. iii',"~' I)IiT:'I;:II:;i'.IH[:[t",I'I' I,.I]]1.t. I:i',E SI..lt~',..ill:i[(][;I- '10 I'1 iii t"4 :!] t'"t1.1t"1 D ]i :i;'l'l':lt-,fCli:[ li:ETl,.flil;[!]t",l F:I I,.1111!_1.. F:II'.,II) t:::ll",l"r' ON'"S [11-FiE SE;t.,II:::I(:iit~] t];, ;I] iii;I:::'EISF:II. ?.i.':E; I'ti]t'i ] f; :l.li:lEI t:::li]E]l' F'()I:;;'. I;:t I::'l;i:]l]',,,'l';t'lli~; I,.ll:ii]l,.I.. O1:;i: ;::'.El~;::.l I~:'liiili"l' 1:::'OI,]: I:;:1 I:;:'I..II]i',I.,]]C I.,IEI.I .... l,.tl:i[LI. I,(i][]ii::~i, I'::ll:;i:li] I:;i'.lEI.;:!l.I]]l:;i:ti~]]) 1:::1i",11])I"II..IE;I' Ii':I]E li~:lil]'l'l.,ll;~'.l'.,lt[il]ll];, TO 'IIIE Ii])l!i[l:::'l:::ll:;~'.'l'l'"lliil",l'l' l,.li['rH]]l'.,t ]Z:;E:~ OF: '111!( I,.t111[1_1. COHI:::'I I!;'t];(;ff.,I. Fi];I::'f~]C]IiFiI]CI:::I'I ]i(][ll'.,l'.ii; I:::INI) iZ;(]iII'.,I'.ii;'I'I:;i:I..ICt']](JlN l)][l:;:l(]iil;~'.l:::ll',lEi; t:::ll:;.'.lil F:t',,,'l:::l]]l.l:::lliilI.Ji] 'I[) ]il'.,tE:;!...ll;;'.liil ii] I'.,t'.E; I F:II..I.. I:::1 t ][ I]ii N. Department of Health m~d lm~ ~ronmentnl Protechon A.nchorage, Alaska 99507 St)IhS I,()(; - PEII()I,ATI()N TENT P(: Cf'e m~(~d for [)epth Feet . .., 11- 13- Was gr'ound water encountered? _~.F~:~ .... if yes, at wi,or dth)th? ..... ~_~.~ ........ I<cadiny Bate (]ross Time t,let Time DopU to Water Percolation rabe ...... ~,(ii~-, l;epth of Inlet ~ / , I)epti[~})"bb'~tbb'b-f"pit ur trenci, .... ~.( .......... COI.I/'IE~flS: 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. # 1. GENERAl. INFORMATION Complete legal description CERTIFICATF OF HEALTH AUTHORITY APPROVAL FOR A SINGLE-.' FAMILY DWELLING Lot 3; Tract B; Woodhaven Subdivision¢%/ Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent 12101 Jerome Street Address Cecil Osborne 12101 Jerome Street Anchorage¢ AK Day phone Anchorage, AK Day phone Day phone 345-4379 99516 Unless otherwise requested, HAA will be held for pickup. NUI~BER OF liEDROOMS: 4~''' TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water XXX If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site x×× Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on~site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of/this inspection. Name of Firm AlaaIca Water & Waste~,~t~r''~ Phrm¢, 7320 ~t C~ ,r ~ Address A~ho~a~, Engineer s signature / :~[ ~( '~ Date DHHS SIGNATURE _J,// Approved for /:'g) U' ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The D H HS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements, Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage ~1~ DEPARTMENT OF HEALTH & HUMAN SERVICE Environmental Services Division. 825 L Street, Room 502. Anchorage, Alaska 9950¢N]~ ~43-4744 Health Authority Approval Checklist Legal Description'. ~ _OT ~'~, I.~©¢:,~lq,&t)~r.J Parcel I.D.: (~1~-- A, WELL DATA V~ell type B. IfA, B, or C, attach ADEC letter. ADEC water system number Log present (Y/(~ Ho Date completed Total depth Sanitary seal ('~N) Casing height (above ground',, Wires erocerly protectec ~¢~YNI. FROM WELL LOG AT INSPECTION Date of test Static water level ,~ ~--~ ' (/k)' .,~;:~ ~O' ..~~' Well production g.p.m %, O g.p.m. WATER SAMPLERESULTS: ~ ~ ~w~ 0F PU~P~4~ Coliform ~ Nitrate ~ ~ ~/~ Other bacteria ,~ of '- f S Co, ote SEPTIC/HOLDING TANK DATA Date installed ¢~/';~'"'/" Tank size J~-~(~ 6~ Number of Compartments Foundation cleanout (~N) "'//~ Depression (Y/~_~. ~o High water alarm (Y(~ /'~'~ Date of Pumping ~-I~-c~(~ Pumper /~'+' ~,,',¢.e., ABSORPTION FIELD DATA Date installed c~_[(~_:~,~ Soilrating (,q.p.d./ft~or~bdr~ ~,% Systemtype r~E~:,e TgE~J~L Width ~6~' Gravel thickness below pipe Total depth ~, .~, (~1.~:~5, ~/f4T Effective absorption area 5'~'~ cJ~cq, Monitoring Tube present ~f/N) Y& Depression over field (Y/I~ .,~ Date of adequacy test 6//(;/~¢ Results(Pass/Fail) r~p&.% For F~- bedrooms Fluid depth in absorption field before test (in.); ~ ~ Immediately after ¢/¢~ gal. water added (in.): Fluid depth c~ u (ins) Minutes later: ~'/o Absorption rate = Peroxide treatment (past 12 months) (Y/~ ~o1' ~l~:6~-k If yes, give date 72-026 (Rev. 3/96)* -~f¢/'~A'T /4~O C-lo ':E ~g.-[ A-LLF-~o ~ ~,-.J~ OF- .or,, _g,p,d, Date installed ~ v/~, ~ ~ % / Manhole/Access (Y/N) level High water ~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO:. Septic/holding tank on lot Absorption field on lot /00 Public sewer main Sewer/septic service line On adjacent lots On adjacent lots I Public sewer manhole/cleanout /O//~- Lift station SEPARATION DISTANCES FROM SEPTIC/; h,~L~:~;~%~,NK ON LOT TO: Foundation ~O ~4- Property line 6;~ (4- Absorption field ~ Water main/service line /O '4- Sudace water/drainage /OO'"L Wells on adjacent lots ICC SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line lOl+ Building foundation /0 ~¢~ Water main/service line Sudace water ICC' 4- Driveway, parking/vehicle storage area Curtain drain ~or~_ ¢ ~o~..~ Wells on adjacent lots Icc /o 'J ENGINEER'S CERTIFICATION Signature ~_-..-r?,ff~f~lf/"J' Engineer,s Nan~'e//'' ield inspections and review of Municipal rec¢ felines in effect on this date. ~', ,4. ., HAA Fee $. Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* JUIq-23-1998 £6:16 CT~E ESI ANCHORAGE CT&E Environmental 8ervioes In~. 90?5615301 P.03/0~ CT&E Ref,# 982.974002 Cl|ent Name AK Water & Wastowaler Services ~oJ~t Name/~ N/A Client S~tple ~ Woodbaven S/D ~t 3 Matrix Drinking Water Ordered By PWSm 0 Sample R~marks: CLient PO// Printed Date/Time 06/23/98 I 1:51 ColleetedDate/Tbne 06/16/98 14:411 Received Date/Time 06118198 08:30 Technical Director: Stephen C. Ede 0 ~ut/~OO~L ~M18 9222g 06/18/98 0.222 9.100 mg/L EPA 300,0 10 max 0§/18/98 06/18/98 06,20'96 FRI 09:18 FAX 9073455549 OSBORNE ~001 ,JEROME STREET $ N lO' UTi[.[ 157.50 (R) TR. 46,3 .4: I0' UTILITY EASEMENT N 00~07'40'W 157.~0' (RE:C) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONNIENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, brock, subdivision, section, township, range) Location (address or directions) Applicant Name ~c~ / ~'.~,~O~',~ Telephone: Home Applicant Address I ~ ~01; ~.7'~'r'OPt__~. ,/~,"t C 40¢'~.. ~ /:J-I,'r' (b) Business '~ (c) Applicant is (check.one): Lending institution ~; Owner/builder ~; Buyer [2; Other ~ (explain); ~_ (d) Lending institution. Telephone Address (e) Real Estate Company and Agent Address 'Telephone (t) Mail the HAA to the following address: TYPE OF RESIDENCI" Single-Family ~; Multi-Family Number of Bedrooms Other WATER SUPPLY Individual Well [~]. Community E] Public E] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] Public FI Community E] Holding Tank [] Note: If cornmunity 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 (t~/84} ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certified by my seal affi×ed hereto and as of the validation date shown below, I verify that my nvestigation of this Hea th 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 w~ter supply and/or wastewater disposal system ~s ~n compliance with ali Municipal and State codes, ordinances, end regulations in effect the date of this inspection. NameofFirm ~(~ ~C~c~/ ~;~ Telephone Address /~-~O ~C~o ~ ~0~ ~ Engineer's Seal DHEP APPROVAL __ ~.~ ^..,o ed,or Approved Disapproved Conditional __-~- 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 analy~e data before a certifica[e is issued. The Municipality of Anchorage is not responsible lor 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 Descripuon: MUNICIPALITY OF ANCHORAGE DEPT, OF HE:ALTH & ENVIRONMENTAL PROTECTION ]985' WELL DATA Well Classification We Log Present (Y/N). Total Deeth _ ')' 7..~ ~ __ Cased to _,2 Static Water Leve :~'7 ' ~ Casing Height Above Ground ~ ~, n Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Seebc/Holdmg Tank on Lol [ '~' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~, ,4, Cleanout~ Manhole J\h .4. Water San- pie Collected Dy If A. B. C. D.E.C. Approveo (Y/N) Date Comoletee 1~'77 Yield Depth of Grouting Pump Set At _ 73' Sanitary Seal on Casing (Y/N) Deoression Around Wellhead (Y/N) : On Ao.oining LOtS I ~j~' . On Adjoining LOtS / TO Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sar¢ pie Test Results Date Comments B. SEPTIC/HOLDING TANK DATA Date nstanea Size / Standpipes (Y/N) "/'" Air-tight Caps (Y/N) Deeresslon over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) N¢/JJ · ~olalng Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Wel [ ~,9 ' To Property Line 7 To Water Main/Service Line _ /~/. Course ~ lo0' No. of Comoartmems Foundation Cleanout (Y/N) Date Last Pumoed fo- ^h/¢. _ Ten' porary Holding Tank Permit (Y/N) V To Building Foundation o"Y' To Disposal Field ff'~' ' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026 11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~//¢ / ? ? Width of Field ~ 6'" Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test LT'/z~'r.~ Type of System Design Length of Field 38 i Depth of Field ~- ~ Gravel Bed Thickness '7 t Standpipes Present (Y/N) Date of Last Adequacy Test ' Separation Distance from Absorption Field: To Water-Supply Well / .~ ,5-~ To Building Foundation '?O ' Lot t'/,/~. To Water Main/Service Line N, t~h To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Properly Line '~ ~.5- ' To Existing or Abandoned System on ; On Adjoining Lots '~ (oo, To Cutbank (if present) /~h/,~. ~ too ~ D. LIFT STATION N,/:), Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date MOA No. Signed ~--J"~-¢~ Company /~(¢x/-.,Z~i~ Receipt No. ~ Date of Payment Amount: $ Page 2 of 2 72-026 (11184) Engineer's Seal