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HomeMy WebLinkAboutWOODRIDGE BLK 1 LT 2Woodrid lock I Lot 2 020-093 -07 Municipality of Anchorage Page r)EPARTMENT 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: ~oll~ PIDNumber: · ~ ~ ¢~ ~ Wastewater System: ~ New ~ Upgrade Address: ~o ~ ~-, ~ ~z/ ~cq~ ABSORPTION FIELD Phone: ~¢-~ ~3 O DeepTrench O Shallow Trench O Bed g'Mound D Other LEGAL DESCRIPTION so,,~,.,: i¢ GPD/Sq. Ft. Total Depth from ori~al grade: township: J Range: I Section: Fill added above original grade: Gravel length: ~.-fl ~. ~ ~. WEI. L: ~New ~ Upgrade Gravelwidth: ~.O Ft. ~'J ~'~-- ~ Ft. SEPARATION DISTANCES ~Septic ~ Holdin~ [] STE.P From Tank Field Station Tank Sewer Unos ~ ~ Well ~0~ ~ ~ ~ N~ Material: ~2j Surface w~ter [~ I1~ LIFT STATION Remarks: ~~ ~% S~ ~q BENCH MARl( Inspections performed by: _~o~ ~e,~ Dates: l st~ Department of Health and Human Services approval Reviewed and approved by: ~--~' ~~ ~ate:/~'-/-~ 72 013 (Rev 9/gl ) MOA 25 PermitNo. 5;vdq$oil~-t- Page ~- of ~' Municipality of Anchorage 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 Legal Description: ~ VIRGO AVENUE PID No.: PermitNo. CW~?,o~l~. Page ~ of ~ Municipality of Anchorage 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 Legal Description: 2:~50 0+00 o o o o 0+50. 1+00 PID No.: 0 0 40USE CO 1 0 2 ~oo 1+50 2 2+00, ENG 'I~EE R'S' ~EAI~' CE - 7760 72-013 A (U93) ' STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD LOCATION OF WELL - --~---'--=-~~ N ~.TP~ SEC~[O N TOWNSHIP RANGE MERIDIAN .... WELL ~M'-~SURED FROM:[]¢asing top I-]ground surface Depth From To BOREHOLE DATA: Material Type and Color WELL D,PT": DATE OF COMP,.SrION Depth of hole: ft ~.~ '-~ ~5 Depth of casing:~-~ c~- ft / __/-- DEPTH TO STATIC WATER LEVEL: "~ ft below F~ILtop of casing Date: 6 / 7 / ¢--~ [] ground sudace RECEIVED JUN 0 9 METHOD OF DRILt. ING: ~"air rotaw [] cable tool E] other OF WELL: [~domestic [-I irrigation [] monitor public supply [] other CASING STICK-UPi A ~ fi, Diam: ~-~ in. to Cas ng type: ~ ~-~ in. to WELL INTAKE OPENING TYI~E: [] open end [] screened ~ perforated L--~pen hole Depths of openings: to ft SCREEN TYPE: ,, Diam: in. Stet/Mesh Size: '~' ft GRAVEL PACK TYPE: Volume used: \ ._ Depth to top: Dept. He \ GROUT TYPE: Volume: _ · Depth: from__ ..fi to ft DEVELOPMENT PUMPING [.EVB. AND yI~EL/D: after ~7 hrs I ' / ' ' PUMP INTAKE DF. FI'H: ft Horsepower:. /' -. WELL DISINi, ECTED UP_ON COMPLETION? ~J YES LJ NO '""1 ,', , -: · fl ,-%-.~c¢ . /~r~ ¢; // '*':' -:---'""'"LOGTO. "' :: . d ..:: ~1 Re~Ls~?e,d Bus.ine~s. Ua,m~ /. : ~. ' 'l e'.; '_'PLEASE MAIL WHITI: [;U~E~ ...... , .. ,,. ~...~ __. .~ :.-..: .....:. ........... .,;. . .~ .... __ . . . . . .., .. . . · .. ¢.Z:.¢~..-',.i.~-.'--..' ' --",%'. ' r.'-:/,.-: '- . .~- PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930114 DESIGN ENGINEER:MOUNTAIN ENGINEERING OWNER NAME:REID ROLLAND R & CONNIE M OWNER ADDRESS:840 K STREET, SUITE 202 ANCHORAGE, AK 99501 DATE ISSUED: 5/21/93 EXPIRATION DATE: 5/21/94 PARCEL ID:02009307 LEGAL DESCRIPTION: WOODRIDGE BLK 1 LT 2 LOT SIZE: 43561 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED liN 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-.4329 OR 343-4681 AFTER BUSINESS HOURS 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: THE TOTAL DEPTH OF THE BED SHALL NOT EXCEED 1.0 FT. A SAND LEVELING/FILTER LAYER OF ~qFEET WILL BE INSTALLED. THE TOTAL F T.BOTTOM AREA OF/~7{jEfB~/~/ED MUS~ NOT BE LESS THAN 643 SQ.~~~ ~P~7 RECEIVED DESIGN CRITERIA AND NOTES Project Scope: Well and On-Site Septic System Design Legal Description: Woodridge Subdivision, Lot 2, Block 1 Date of Report: May 5, 1993 DESIGN CRITERIA This design is for a three (3) bedroom single-family on-site well and septic system. Two test holes were excavated at locations indicated on the attached site plan. Percolation rates were 3.9 min/inch and 3.3 min/inch for Test Holes #1 and #2 respectively. No water was encountered during excavation of Test Hole # 1, but water was at 6.5 FT depth after the monitoring period. Water was encountered at 7 FT during excavation of Test Hole #2, and water was later observed at 5 FT. A mound system will be required to maintain the 4 FT ~ninimum vertical separation distance between the bottom of the drainfield and the water table. Based on three bedrooms, the daily design flow is 3 X 150, or 450 gallons/day. The application rate (for both test holes) will be. 8 Gal/Day/SF. The required area is thus 450/.8, or 563 SF. We have selected an area (20 FT X 30 FT) for the mound down~gradient from the proposed house. The bottmn of the drainfield (bottom of the washed rock) will be at the existing grade. Prior to placing the drainfield, the approx. 6"-8" orgmfic layer will be removed, and brought to original grade with a leveling course of clean sand. The septic tank will be a 1,000 gallon steel septic tank, with two compartments, Anchorage Tank or pre-approved equal. The lot slopes downhill to the west, and the area of the proposed mound is approximately 6% slope. Test Hole #2 was excavated and tested by Tobben Spurkland, P.E. Although this hole is not critical for the design (because the original and replacement beds can fit in the radius of Test Hole #1), this information is presented for future use. ~-' . MOUNTAIN ENGINEERING ~ .... : ,c ' " Mark Pearson, P.E. ~ 6~.,. CE - 7760 Z ]IqN]AV O0~IA  Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 LEGAL DESCRI.TION: ~i&~ ~ ~ ~ g¢~l Township, Range, Section: ~~ --i(O[~( ~ SLOPE SITE PLAN 1 2 3- 4- 5- 6- 7 8 9- 10- 11 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Moniloring? Date: _ 13- 14- 15- 16- 17 18 19 20 Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~' ~ (m,nutes/inch) PERC HOLE DIAMETER ~:~ II TEST RUN BETWEEN _ [ __ FTAND ~'~ FT COMMENTS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~'~ /~I''~ 72-008 (Rev. 4185) i Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST .(ENGINEER'S SEAL) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18- 19.- 20- COMMENTS DATE PERFORMED: Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? DEPTH? , / pO E Deplh to Water Alter/ ~//'/ / Reading Date Gross Net Depth to Net Time Time Water Drop ~ I,t~ (mmutes/~nch) PERC HOLE DIAMErER TEST RUN BETWEEN ~ FT~rdD Y~'~ FT PERFORMED BY: I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 41851 CERqlFY THAT THIS TEST WAS PERFORMED IN DATE: ~ ~'~ COMMERCIAL TESTINGi & ENGINI-'ERING CO. ENVIRONMENTAL LABORATORY SERVtCES ~"~'~ REPORT of ANALYSIS Chemlab Ref.~ :93.6104-1 Client Sample ID :ROLLAND REID kL~v,-~.~z[~l~i Matrix :WATER 5633 8 STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Client Name :MOUNTAIN ENGINEERING WORK Order :73140 Ordered By :MARK PEARSON Report Completed :11/15/93 Project N~e : Collected :11/11/93 @ 13:45 hrs. Project~ : Received :11/11/93 @ 16:30 hrs. PWSID :UA Technical Director:STEPHEN C. EDE Released By Sample Remarks: ROUTINE SA~L°LE COLLECTED BY: B.E. QC Allowable Ext. Anal Parameter Results Qual Units' Method Limits Date Date Init Nitrate-N 0.18 mg/L EPA 353.2/300.0 10 11/12 LL/H * See Special Instructions Above UA = Unavail~le ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than ~ S~"'~-~ Member o; the SGS Group (SociOt~ G~n(~rale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO. MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA COMMERCIlkL TESTI~NG ENVIRONMENTAL LABORATORY SERVICES & ENGINEERING CO. PUBLIC WATER SYSTEM LD. # ~PRIVATE WATER SYSTEM .Ycnd R~ul~ 5633 a STREE'[ AHCHOR^GE, AK 995~8 Drinking Water Analysis Report for Total, Coliform Bacteria (907) 562.2343 FAX: (907) 561.530~ READ INSTRUCTIONS ON RE VERSE SIDE BEFORE COLLECTING SAMPLE TEL: M2.JST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMI:'LE to be: Send.Results Cl Send lnvo~ce Day Year O Treated Water o Untreated Water Unsatisfactory Sample over 30 hours old, results may be unreliable 8ample too long in cransit; sample st?uld not bo over 48 hours old at exarmnatmn to indicate reliable results. Please send new sample via special delivery mail. ate Received x\ / \ ~ Time Received \ ~' Z O SAMPLE DATE: [T~ Month SAMPLE TYPE: /~ O/~OR°utine Repeat Sample (for routine sample with lab ref. no. -) · O Special Purpose Analysis Began Analytical Method:'-'J~ Membrane Filter [3 MMO-M~G · Number of colonies/t00 mi. [,ab Ref. No. Result" Time Collected SAMPLE LOCATION Collected By Phoned Spoke BACTE~OLOGIC~ WATER ~YSIS E. Co~ _ Sent to A.D,E.C, ~Fb 'k~ Jun [] Foxed Date: [[/l~']OJ~ Time: Client notified of unsatisfactory results: Foxed I~o-MUG Result: Total Coliform Membrane Filter: Direct Count _- BGB Verification: I.,TB .... ~_~'~ . Colonlesll00 mi . C OLD.* IRM. Fecal Coliform Confirmation -- ~'-~ ~' polo __ ~ hrs ENVIRONM, ENTAL S:RVIC~S IN ALASKA COLORADO uTAH ILLINOIS. OHIO, MARYLAND. WEST VIRGINIA, NE',',/ JERSEY· SOUTH CAROLINA Municipality of Anchorage Development Services Department CERTIFICATE FOR A Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 OF ON-SITE SYSTEHS APPROVA SINGLE FAMILY DWELLING Parcel I.D. 020-095-07 1. GENERAL INFORMATION cos,cc Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address WOODRIDGE S/D; BLOCK 1, LOT 2 16701 VIRGO AVENUE * ANCHORAGE, AK * 99516 ROLLAND & CONNIE REID Day phone P.O. BOX 10697 * BAINBRIDGE ISLAND, WA * 98110 Day phone JERI JEFFREY W/ PRUDENTIAL Day phone 762-,3108 ,3801 CENTERPOINT DRIVE, #200 * ANCHORAGE, AK * 9950,3 Unless otherwis'e requested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site [] Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System [] 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, cer[ificates 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 of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 5701 E. 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 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 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 fight whatsoever. DSD SIGNATURE L///' Approved for. ~'~ bedrooms. Disapproved. Conditional approval for . .. ON-SITE WATERAND : WASTEWATER . . ~ bedrooms, with the following st~pulabon~ ,. PROG~M Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev. 11/05) Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: 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 (907) 343-7904 CERTIFICATE OF ©N-SITE SYSTEMS ,PPROVAL CHECKLIST Legal Description: WOODRIDGE S/D; BLOCK 1, LOT 2 A. WELL DATA *BEDROCK AT 43 FEET. .Well type PRNATE If A, B, or C provide PWSID# N/A Date completed 6/7/1993 Sanitary seal (Y/N) YES Total depth 227 ft. Casedto *50 ft. g.p.m. FROM WELL LOG 6/7/1995 SURFACE 4 Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O colonies/100 mi. Arsenic: ~/~ ug./L. Nitrate[- ~ L~.mg./g Date of sample: 8/5/2010 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank Size 1000 gal. Number of Compartments Foundation cleanout(y/N) YES Date of pumping 8/4/2010 C. ABSORPTION FIELD DATA 2 Depression over tank (Y/N) NO Pumper {*BELOW EXISTING GRADEI Parcel ID: 0,2..0 ,' ~:~ ~ 3-' 0 '7 Well Log (Y/N) Wires properly:protected (Y/N) Casing height (above ground} YES AT INSPECTION 8/5/2010 25 ft. 5.69 g.p.m. Other bacteria O Collected by: YES 12+ in. colonies/lO0 mi. GE(:; Ltd. Date installed 6/21-23/1993 Cleanouts (Y/N) YES High water alarm (Y/N) N/A MCDONALDS PUMPING Date installed 6/21-23/199,3 Soil rating ~or ft2/bdrm) 0.8 Length 38 ft. Width 20 ft. Total depth *5-6.3 ft. 'Eft. absorption area 785 ft2 Monitoring tube YES. Date of adequacy test *'8/5/2010 Results (Pass/Fail) PASS Water added 470 gal. in. Absorption rate >= 450+ NONE KNOWN If yes, give date 2000 GALLONS PRIOR TO TEST. Fluid depth in absorption field before teSt 0 in. Elapsed Time: - min. Final fluid depth 0 Any rejuvenation treatment (past 12mo.) (Y/N & type) **HOUSE WAS VACANT AT TiME OF TEST. PRE-SOAKED WITH DRAINFIELD REMAINED DRY THROUGHOUT ENTIRE PRE-SOAK. System type MOUNDED BED Gravel below pipe 0.5 ft. Depression over field. NO For ,3 bedrooms New depth 0 in. g.p.d. D. LIFT STATION Date installed "Pump on" levetat__ Size in gallons Manhole/Access in. "Pump off" ~igh water alarm level at Meets alarm & circuit requirements? 100'+ 100'+ On adjacent lots On adjacent lots Cycles tested Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 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'+ 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 Surface water. 5'+ Property line 10'+ Building foundation 10'+ Water .main Surface water 100'+ Wells on adjacent lots. 100'+ in. Water service line 10'+ Curtain drain NONE KNOWN 100'+ N/A Driveway, parking/vehicle storage 5'+ 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 $ t,~,~ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number SGS Ref.# 1103888001 Client Name Garness Engineering Group, Ltd Printed Date/Time 08/18/2010 8:28 Project Name/# Woodridge B1,L2 Collected Date/Time 08/05/2010 10:55 Client Sample 1D Woodridge B1,L2 Received Date/Time 08/05/2010 11:53 Matrix Drinking Water Technical Director Stephen C. Ede Saml~le Remarks: Allowable Prep Analysis Parameter Results LOQ. Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/13/10 08/16~10 NRB Waters Department TotalNitrate/Nitrite-N 1.34 0.100 mg/L SM20 4500NO3-F B (<10) 08/06/10 AYC Microbiology Laboratory E. Coli Negative 1 100mL SM20 9223B A 08/05/10 DLC ' Total Coliform Negative 1 100mL SM20 9223B A 08/05/10 DLC MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# (~QI©-Ebc~%-("}-~ HAA # 1. GENERAL INFORMATION Complete legal description Wooc]ridge Sub, Lot 2, Bloc]( 1 Location (site address or directions) Property owner Mailing address Lending agency Mailing address Rolland Reid Day phone 258-7777 840 K Street/ Suite 202/ Anchoraqe, AK 99501 Day phone_ Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBI-'R OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Iqdividual well x Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality an.d status of system. TYPE OF WASTEWATER DISPOSAL: 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. 79~025 (Re','. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Mnnn ~-,a ~ n ~nO~ nr~r~r ~ no Address 3868 Shannon Ci rt~] e, Anr:_hora~¢_, Engineer's signature '~?.~.,~._~-- _ A K Phone 562-1 99508 Date DHHS SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. CL 7700 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 DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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 Departrnent of Health & Human Services HEALTH AUTHORrrY APPROVAL CHECKLIST Legal Description: [~fooo~r~o~ I J¢'O~- ~ I A. WELL DATA Well type ~'¢~*VT.~J2. If A, B, or C, attach ADEC letter. Parcel I.D, O;z-,O (-P q ¢~-Jc-~- Log present (Y/N) _ ~ Date completed _ Total depth '(~?-' ~ Cased to_ ~ Sanitary seal (Y/N) ~' FROM WELL LOG Date of test Static water level Well flow L-~ g.p.m. Pump level "~,-?,,-C) ADEC water system number Casing height ( ¢ Wires properly protected (Y/N) ~ AT JNS~OTJ~VIRONMENI'AL S~RVIC,ES DIVISION RECEIVED g,p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line ; On adjacent lots ; On adjacent lots . Public sewer rnanhole/cleanout Petroleumtank I\lov--4L WATER SAMPLE RESULTS: Coliform ¢ Nitrate ' j~ Date of sample: t~l ~tlq''5 Collected by: Other bacteria SEPTIC/HOLI)ING TANK DATA Date installed g[~l¢~ Tank size Cleanouts (Y/N) "( Foundation oleanout (Y/N) High water alarm (Y/N) ~/I~' Date of pumping ~,/¢-,~J Compartments ~' Depression (Y/N) Alarm tested (Y/N) ~ J~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot JO ~ On adjacent lots To property line_ JO'S/ Absorption field Surface water/drainage [R'O / Foundation (o J Water main/service line 72-026 (Rev. 3/91)Fron[ MOA21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons '~,ump on" level at Vent (Y/N) High water alarm level ~ Meets MOA electrical codes (Y/~__ _ \ SW~ I~Ao~o'riON DISTANCE FROM L~(~) nS aTd~;:~n~ ITc tgi Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested D, ABSORPTION FIELD DATA Surface water Date installed L~l~-~ I<:::[ ~ Length '~4~ ~ Width ~ ~ Total absorption area ~.~ ~-- ~-L Depression over field (Y/N) ~ Results (pass/fail) N//h, Peroxide treatment (past ~2 months) (Y/N) ~ Soil rating Gravel thickness I / Cleanouts present (Y/N) Date of adequacy test for System type .Total depth Y bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots On adjacent lots tct~ ! Propertyline ~1 To existing or abandoned system on lot Cutbank ~LS'Y'~- Water main/serviceline Surface water Curtain drain Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, er conformed to all MOA and HAA guidelines in effect on th_~ d.~ate of this inspection. Signature 7,.'J '; ' · ' Engineer's Name HAA Fee $ ~.~¢Od ¢ o Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 ~g 06 i0 04:10p Bill McDonald (907) 337-0558 5432 E. Northern Lights Btvd, S~ite .'~ ncn orage, (PO~) 338-44 76 ..Cotd~lT*: L . .... ~'- Dar ~ . ,~ Date of Service: Description mice per unk Amount Septic tank pumFed Sludge in tank Leach weatment Bio-mat in leach [{7ater level in leach ~ Cap on Stand Recommendations: 1.55/o interest x.vi[l be charged monthly on unpaid bills until paid.