HomeMy WebLinkAboutZANTHA VISTA #1 BLK B LT 7Onsite File
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72
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MUNICIPALITY OF ANCHORAGE
DE' :TMENT OF HEALTH AND HUMAN SERI
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SI'rE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Namo
Address
bEGAL DESCRIPTION
TANKS
S["PTIC
El HOLDING
TYPE OF SYSTEM
[] TRENCH E~ BED
~W. DRAIN L~ OTHER
FT ~
WELLS
[] PRIVAI'E
REMARKS:
[] OTHER fldentifvl
Fl
DISTANCES
SEPTIC ABSORPTION
TANK FIELD WELL
WELL '2.0 ~- ~ / ~
LOT LINE ~c[ ,.5~¢ ~ f° ~"'
pc
FOUNDATION
ET
FT
Fl FT
Scale; ,~ 7~
Inspccbons Performed by:
/% // ,J..,e /?,Y'6
IM ,__ certily Ihat this inspection was pedormed according Io all
ENGINEER'S SEAL
Health De
72 013 (3/85)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysi¢olSurvey$
Oriiling Permit NO.
Merldion
Peel Below
4. WELL DEPTH: (final}
E] Auger E~]detted [~Dored E~Other:
7. USE: ~ Oomestic [] Public Supply [] Induslry
[] Irrigotlon [] Rech.rge [] Commerical
[] T*~ W~ll [] Ofher:
FINISH OP WELL:
fl.
II. PUMPING LEVEL below lend surface end YIELD
IS, PUMP: (if available) HP
Length of Drop Pipe ft. capacity g.p,nl
I='IEI::~M I ]" NO:
DA]I}] I SSLJED:
CI0 I='I::;,'A F'I
:l,l~lOt;' C]:NI,)Y LEE LAN[-:
AN[:I 1t3RA~lii:, AK 99~J()7
',562 ' D982
M(.~X Ethi, L)ROLIMS ~
SUBDiVIS]:ObI: ZAN'TH VI,E~FA I..OT: 7
SEC I I i:.)l'.l: ;~Zl ]' E)WNSH i F:': 12~lq RAN[=)Iii: ~',3W
:i ,, ;:~',SA (S(:,! ,, i::: I ,. 01~ ACF;,'I'!]i~)
zt.
i;t.:i]:*lll 1(3 F:':[I::'Ii:: I:IO'I]OM (1:::'1 ~ ) 4,, 0 4.0 4,, ()
i:~F(A'v'E::I Dli!;l::' tH ~,1:: '1 ~ ) :]; ~ 0 0 ,, 5 2 ,, 0
I [Yl (,'q, i)lii F:' I II (F' l". ) '7 ,, 0 z! ,, '7:; 6 ,, 0
GRAV!EI., W:[DIIi (1::1,,) ;~?,,5 20,,() 5.0
GFiAVI~].. [..1:~:1",1() I H (l::;"l' ,, ) 8,¢J ,, ()'~ ~' 38 ,, 0 7() ,, (%
GI~AVE'I. V(::)LUME (CU. YDS,, ) ',:~'7~ 3 2'.1~. 2 32,, 5
TANK S ]: ZE (t=iAI ,S ) 1,2~.5(),, 0 '~"~ :1,250 ,, 0 '~"~ 1 :, ::,? ~';K) ,, 0 '~{'~
SOIL. RA]]:NG (SQ.I:::F~ /BI~) 125 ].2.~5 :1.25
~.1~. E}RAVI!i].. I.l!i:fgl:illJ > 75 I:'1'. REQUIRES FIULFIF:'I.Ji!: RUNEi (bll]'l li~XCIEI!i}:D]:N(:~) 75 F'I',, EACH)
li.~ I AI',IK MI.IS'I IIAVE A'f LEAS'I IW(]
{c:,r'tJi I::~y 'l'll(~:~ Mun;i.c:ipat:i. ty cH' Anchorage (IqO6) arid [.["H~) Sta'Lra c)t' Alasl,:a,,
i. ,¢~i.1.:1. :ins't'.a].i 'Lhe sy~it:.cCm :i.~ accc~'ciarlc:t? w:i. th a].:l MOA codes a~nd
]. k*~J.I} adl",er(..;~ I:.o all I"I(]A and SLa'tte c:)i' AZLaska requJ, t'emel~L~zl {'or' Lhr:~ s~;~L ba(::k
&qly (SH'i],:¢~I (:jE~Hll~.:f)['. bi~] :l I'E)C:It.~J. PE$ an addiL;i, ona]. perm:i.t.
]1':: ¢~ l.t:l:: I :~lAIIi3bl J]S II',i'.:;IFfl,,LE:D .IN AN AREA [:;[:)VI.i:.F<ED BY MOA bU]:I.,,DINL) DODE[~,
I ltli:~t",l ( J ) AN E]_.I:i:C 1R I CAI.. ~E]:?M:E I AhlD I fxlSPIEC f ]:ON MUS] BIE E)B'IV.~ I NI:~:Di] (2) ¢?"'BiIII.TS
t,g.U_l.,,i',lOI BE. AI:::'F'I:(OVI:ED Mi~I]1IOUt AN IE],.ECII:~]:CAL ]]'4SF:'E:CT];ON REF:'OR'I"; AND (3) 'I'I'IE
%
AF:'I:::'I..[CANI ~ i::',/i:) I='RAI'I CONS I'F~UI:;'i , ~. /~c-~,~F~
1200 West 33rd Avehue, Suite B
ANCHORAGE, ALASKA 99503
(907) 551-5040
SHEET NO
CHECKEO BY
sc^Lc
DATE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorege, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
(ENGIN[~AL)
8
9
10
11
12
13
14
15-
16-
17-
18-
19-
20-
Township, Range, Section:
SLOPE SiTE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~L
V
DEPTH? p
Depth to Water Alter ~/ /
Monitoring'2 '~ /~'
_ Ii
i
Reda' [)ate Depth to Net
(;ross
Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
TEST RUNSETWEEN __ FY AND FT
PERFORMED BY: -~¢~ ~ ~]~ ' ~ /¢;~'"' CERTIFY THAT THIS TES' WAS PERFORMED IN
ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DA~E:
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
"ERPORMEO POP:
LEGAl_ DESCRIPTION:
4
7
10
I1
12
13
14
15
20-
DATE PERFORMED:
(ENGINEE~L)
wi-c-
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth lo Water Alter ~ . -.~.,
Monitoring? -/-~O /~ Date: ~"-~! ~
SITE PLAN
"~Re~ Gross Net Depth to Net
· ~ [)ate -Fime Time Water Drop
_ ' _~..~.
PERCOLATION RATE
_ (m~nutes/~nch) PERC NOLE DIAMETER
T,,EST RUN 13ETWFEN ___ FT AND
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECTON THIS DATE. DATE:
72 008 (Rev. 4/85)
WATZR WELL LOG
FOSS DRILLING ASSOCIATED A0~ 7 1980
909 CHUGACH DR. #37
ANCHORAGE, ALASKA 99505 R E C E IV E D
WELL OWNERCarl Luchsinger USE OF WELl, Domestic
WELL LOCATION I,ot 7~ B~,,qck B Zantha Vista Subdivision
SIZE OF CASING 6" DEPTH OF HOLE, 70 FT. CASED TO
STATIC WATER LEVEL 56 FT. G. P. M. 5 WITH
REMARKS
70 FT.
12 FT. OF DRAWDOWNo
DATE COMPLETED 7/22/80
PUMP TO BE SET AT 69'
0 to 28 Till: grey and hard
28 to 32
32 to 42
42 to 48
Sand and Gravel: brown color~ with water;
Alluvium: brownzmedium hardness
Till: grey and hard
3g.pom.
~ to 6~5 Alluvium; brown color, medium hardness
65 to 68 Alluvium: grey and hard
69 to 70 Sand and Gravel; grey, with water
to
to
to__
to
to
to
to
to
to
to
PERMIT NO.
DEF'FER. TMENT HEFILTH FiND ENVIRONMEENTFEL '~:OTECTION
82.5 ~. STREET, FINCHORFEGE., FEK. ~-_,._
264-4720
E L b. Fg ~-.! E,-':" C) IP4 --".-~ :E -r E >']: lB I...I i ~: F=' EE R r.1 Z -r
800347
FEF'PL l CFIN'F
LOCRT 10[4
LEGRL
LUCHS l NGE[R
LO]' ~ I3LI< B ZRNITHFE; VISTA
PO BOX
LOT SIZE
TYPE[ OF SOIL RBSORPTICIN SYSTEM IS: 'I'RENCH
Z.'.44-50~6
54000 SQLIRRE FEET
MRXIMLIM NUMBER OP- BEDROOMS
SOIL RRTING (SQ FT/BR)= 250
T'FIE REQUIRE[:' SIZE OF ]'t4E SOIL RBSORPTION SYSTEM IS:
C, E: IF:." -r H = :~L ~ L E i"-.I I.S -IF H ,= 7'5 G F?. FIi "..." E L E':, E F:" -f' 1-4 =
]'HE LE:NGTH DIMENSION l~ THE L. EENGI'H (IN FEET) OF ]'HE TRENCH OR DRFEINFIELD.
THE DEPTFI OF FE TRENCH OR PIT IS ]'FIE DISTRNOE BETHEEN THE SURFRCE OF TFIE
GROUND FEND TFIEE BOTTOM OF THE EXCFEVFETION '::IN FEET:).
THERE IS NO SET HIDTH FOR TRENCHES.
THE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETNEEN TFIE CIUTFRLI_ PIPE
FIND THE BCITTOM OF THE E>~CRVRTION (IN FEE'F).
PERMIT RPPL. ICRNT FIRS THE RESPONSIBILITY 'FO INFORM THIS DEPRRTMENT DLIRING THE
INS]'RLLWf'ION INSPECTIONS OF RN"r' I,IELLS RDJRCENT TO THIS PROPERTY FEN[:' THE
NUMBER OF' RESI[:,ENCE':; THRT THE WELL WILL SERVE.
BFiCKFILL, ING OF RNY SYSTEM 14ITliOUT FINRL INSPECTION ~ND RPPRO'¢RL BY THIS
[)EPRRTNENT HILL BE SUBJECT TO PROSECUTION.
MINIMUM DIS'FFEI',IC:E BETWEEN R WELL RND RNY ON-SI'rE '-';EP.IFEGE DISPOSRI_ SYS'FEM IS
100 FEET FOR FE F'RIVRTE NELL OR :1.50 TO 200 FEET FROM R PUBLIC HELL DEPENDING
UPON THE; TYPE OF PUBLIC WELL.
MINIHLIM [:,ISTFENCE FROM R F'RIVFETE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMI'`IUNITY SEWER LINE I~C; 75 FEEl'.
WELL LOGS RRE REQUIRED FEND NUST BE RETURNED TO THE DEPRRTf`IENT NITHIN ]:0 DRYS
OF THE NELL COMF'LETION.
OTHER REQLIIREMENTS MRY FEPPLY. SPECIFIC:R]'IONS FEND CONSTRUCTION DIFIGRFEMS FERE
PI',,¢RILFEBLE TO INSURE PROPER INSTFILLRTION.
F:' ES: ~:~'.: I".'l fl: 'F IE ::--', F" :[ I.;--: E %=:; E:. F_' E: [E I'¢I E: EE F-: Z': ::L .. ::L :9 ~9 ,:Z~
:1: CERTIFY TFIRT
'L: I FEN FFEMILIRR I.,IITH THE REQUIRFMENTS FOR ON-SITE SENERS RND NEL_LS IRS SET
F'ORTH BY THE MLINICIPRLIT"r' OF I=tNOHORFEGE.
2: I HILL INSTRLL. ]"HE SYSTEM IN RCCORDRNCE WITH THE CODES.
:3: I UNDERSTFI[4D TH[ET THE ON-SITE SEHER S"r'STEVI MFEY REg!UIRE ENLFIRGEMEN'F IF THE
RESI[:,ENCE IS REMODEt_ED 'TO INCLUDE ['lORE Tt4FEN 3: BEDROOMS.
S I GNED: .............................................................
RPPL I CFENT LLICHS I NGER
V4.. 0
PERMI]~ HO.
OF HERLTH RN[:' EI,-I;/I~:I:INP'~F'NfHL H'NUIb. L:I zYr'4
F'ERPl I T
[:,EPRRTMENT
825 STREET., FINCHORFfGE. RK. 9.5
264-4720
~.IELL F-Ir-4 _E:, ClPR--S I TE :SEL.~ER
( )
LOT SIZE
.~- c~6e 0 S~;!URRE FEET
flR~.~IMLfd iqUf'IEEF~. OF E, EDR.OM:, :
SOIL RRTING ,:SQ FT/BR)= ~ .S Cb
.~,I.~E OF THE SOIL plE,=.ORFTION _,¢:,TEM IS:
'rilE REQUIRED ~ ~' -,.'- ,, c, ,-
[:, E F' T H = /0 L E 1%1,3T H == -~ ,3 R R '...' f' L r-:, E F' -r' H -- ~
THE LENGTH DII,dENSION IS THE LEHGTH (IN FEET) OF THE TRENCH CIR DRRINFIELD.
THE DEPTH OF Fi TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUHD RND THE 80TTOM OF THE E>,:CFWFITIOH (IN FEET).
THERE IS NO SET tRIDTH FOR TRENCHES.
THE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF GRFIVEL BETWEEN THE OLITFRLL PIPE
Ri.ID THE 80'FTCIM OF THE EY, E:RVRTION (IN FEET).
R E _f2-. I_11 F-: E E:, SEF'T I C T FI r-.I I-:.:] ¢--. I Z E"' = /DO O Ii FI L L m], I'-.I S
PERI,qlT RPPLICFIHT HRS THE RESPONSIBILITY TO INFORM THIS DEPFIRTMENT D_II~'IHI] THE
INSTRLLRTION INSPECTIONS OF FINY HELL=, RDJRCENT TO THIS PRLFERT~ RNC, THE
HUMBER OF RESIDEHCES THRT THE WELL IRILL SERVE.
TL.-ICI 6. 2 ) I I'-ISPEE:-T I ]_nl*.lS I.--'-¢1 ~-~-. I--'' F.: E 6'-~. LI I RE[:,
BRCKFILLING OF RN'¢ S"r'STEM ~-,IITHOI_IT FIf'.fRL INSPECTION RIND RPPROVRL E:,'*' THIS
[>EPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRHCE BETWEEN R WELL RND RNY CS,I-SITE SEWRGE DISPOSRL SYSTEM IS
100 FEET FOR R PRIVRTE WELL OR 150 TO 2C~0 FEET FROi"I R PUE'.LIC WELL DEF'ENDII,RG
UPON THE TYPE OF PUBLIC WELL
HINIMLIM DISTI~NCE FROM R PRIVRTE WELL TO R PRIVRTE SEHER LINE IS 25 FEET FIN[:,
TO R COMi'dUNIT'¢ '-]EWER LIHE IS 75 FEET.
WELL LOGS FIRE REQUIRED RHD MUST BE RETURNED TO THE [:,EF'FIRTMENT I,.~ITHIN ]:0 DRYS
OF THE tRELL COMPLETIOH.
OTHER RE~UIREMENTS i'dFW RPPL~.'. SF'ECIFICF~TIONS FIND C:OiqSTRUCTION DIRGRFIMS RRE
RVRILRBLE TC[ INSURE PROF'ER. INSTFILLRTION.
P E Rr~1 I
I CERTIF'¢ TP
1: I RM
FORI'H B"¢ TH[
2: I !.RILL I
~: I
RESIDENCE I
R
'IL H I
LL
T
:qP I F-:ES [:,E[]E'i"IE:ER _'2':--:_'L.. :.1..'~=~- :BO
:TH THE REQUIREMEN'TS FOR ON-SITE SEWERS AND WELLS FIS SET
IPRLIT¥ OF RNCHORRGE.
THE SYSTEM IN RCC:ORDClNCE WITH TIRE CODES.
RT THE ON-SITE SEWER SYSTEM f.'iR%.' REQUIRE ENLRR. GEMENT IF THE
ELED TO II,RCLUDE MORE THR~..I _~ 8EDF.:OOMS.
I SS, I_IED 8'T'~ ................. -//----
TRACE GItAVEL, Brown 3.5'
GRAVELLY SkND W/
TRACE sILT
Many cobbles
Brown
..... 7.5'
SOME
SILTY S~ID
Fine, Lt. Brown
S~]DY GRAVEL (GP)
Fi%ny cobbles
Lt. Brown
..... 10.0'
SAND ~I/SONE SILT
AND SOLVE C;RAVEL
Hany cobbles
Lt. Brown
SILT W/soME SAND
Lt. Brown
1'7.0'
19.0'
SILTY SAND w/SOF~]
GP~tVEL
Lt. Brown
S~IIDY filL~VEL W/ /
sOME SILT (G!'Q /
Lt. Brown, Uet
Refusal on Boulder at 24'24, TI) " 24.5'TD
No Water Table No Water 'cable
These lo9s represent subsurface soil' conditions within
parcel 41, ~{%, SectiOn 24, T12N, R31~, Anchorage, ~
...... "~'"~]R TEST l{OI~S
. ]~pSO J. NO 6S6317
OnlE: 10~25776d II ~.~
CARL LUCHSINGER
R & M NO. 656317
EI~PSED
TIME
12:00 0
12:01 1
]2:02 2
12:03 3
12:04 4
12:05 5
12:06 6
12:07 7
12:08 8
12:09 9
]2:10 10
12:15 ].5
12:20 20
].2:25 25
12:30 30
12:40 40
12:50 50
1:00 60
INCHES
15.5
20.5
24.0
26.0
30.0
33.0
35.0
37.5
40.0
42.0
44.5
52.5
59. 5
65.0
70.0
78.5
86.0
92.0
DROP
INCIfES
0.0
5.0
3.5
2.0
4.0
3.0
2.0
2.5
2.5
2.0
2.5
8.0
7.0
5.5
5.0
8.5
7.5
6.0
76.5 Inches T(YI'AL DROP
0.78 min/inch
SGS Ref.#
1076627001
Client Name
Anderson Engineering
Project Name/#
Zantha Vista Lot 7 Blk B
Client Sample ID
Zantha Vista Lot 7 Blk B
Matrix
Drinking Water
PWSID
0
Sample Remarks:
Parameter
Results PQL
01/08/2008 10:20
Collected Date/Time
Metals by ICP/MS
Received Date/Time
Arsenic
ND 5.00
Waters Department
(<10)
Total Nitrate/Nitrite-N
6.52 0.100
Microbiology Laboratory
Total Coliform
0
All Dates/Times are Alaska Standard Time
Printed Date/Time
01/08/2008 10:20
Collected Date/Time
12/26/2007 13:00
Received Date/Time
12/26/2007 13:30
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Units Method Container ID Limits Date Date Init
ug/L
EP200.8
C
(<10)
01/02/08 01/07/08
TK
mg/L
SM20 4500NO3-F
B
(<10)
01/02/08
LCP
coU100mL SM20 9222B A (<I) 12/26/07 SDP
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
z/7 - ! ? NAA#
1. GENERAL INFORMATION
Complete legal description
~oT 7, F~F- F~ Z/4t4TH-A '~/lgTA ¢/
L. ocation (site address or directions) 110~¢O ~t¢~,,J?~_ I')r';v4-
Property owner
Mailing address
I.ending agency
Mailing address
Agent ~ ,-,.~,./
Address
Day phone
Day phone
Unless otherwise requested, HAA will'be held for pickup.
NUMBER OF BEDROOMS: ~ '~
TYPE OF WATER SUPPLY:
Individual well
J
Community well
Public water
NOTE:
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAl.:
Individual on-site v/'
Holding tank
Community on-site
Public sewer
If community well system, provide written confirmation from State ADEC..attest-
NOTE: If community wastewater system, provide written confirmation frorn State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1/91) I:ronl MOA ~21
o
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 I ¢ ~.~'/ -~O ¢ ~-lct ~¢¢' '~'~-- Phone
Address
Engineer's signature
DHHS SIGNATURE
~ Approved for
'~Z.d-F~(~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
,,,,¢.,, .... ~(;.~, % .
" ' '
?By: 'r,. Vrv~ Date
~[.,Ahchorage Depa~ment of Health and Human Se~ices (DHHS) issues Health Authori~
%Approval Ce~ificates based only upon the representations given in paragraph 5 above by an independent
P~ofessionai ~ngineer registered in the State of Alaska. The DHHS does this as a cou~esy to purchasem of homes
and their lending institutions in order to satis~ cedain federal and state reeuirements. Employees of DHHS do not
conduct'inspections or analyze data before a cedificate is issued. The Municipali~ of Anchorage is not
responsible for errors or omissions in the professional engineeCs work·
MUNIGIP^LI]¥
Municipality of Anchorage ~NVIRONMENTAL $11RVIC['8
DEPARTMENT OF HEALTH & HUMAN SERVICES
, , Envirenmental Services Division FEB
825'L' street. Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
RECEIVED---
Legal Descripuon:
A. WELL DATA
Well type
Log presell((Y/N)
Total deptb
Sanitary seal (Y/N)
Date of test
Static water level
Well prodocuoo
Health Authority Approval Checklist
~)'(i'~ ~-,4,-/Vr, z/~ Parcel I.D.:
V 1%T ~t
If A. g. or C, attach ADEC letter. ADEC water system nulnber
Date cmnpleted
Cased to ~ ~
FROM WELL LOG
7D
g.p.ln.
CasJn~ beJ~ht (above ~round)
Wires properly protected {Y/N)
AT INSPECTION
_
7o
,/
Z
g.p.nl.
WATER SAMPLE RESULTS
Coliro.,,_ lq I)
Dateol'sample:
Nitrate __ q,u26 Other tlacterm
Collected by: __
B. SEPTIC/itOLDING TANK DATA
Date installed ~/f///~/~ Tank size_ /~O-/9 Number of Companmems ~ Cleanoots (Y~/
Foundation cleanout (Yin) ~ Del)ression ~) ~] High water alarm ~m/
C. ABSORPTION HELD DATA
Date ilIstalled /-~//~///~O'~.~ Soil rauag (~.-de~~ or ft'¢odrm)
Width O -~ / Gravel thickness below pq)c
Effective absorption area Oe~29
Date of aden(lacy test ~/0/e'2 Results (PassPFail)
Fluid depth in absorptiou field before test (itl.'):
Fluid depth d~"/ (illS.) Miuutes later
Peroxide treatment (past 12 ntontbs) (Y/N) _
Monitoring Tube present(Y/N)
¢/y ,, ,
7 Total depth /It/ t~'M
Depression over field (Y/N) ~
For ~> bedrooms
~mmediateb after bgPgaL water added (in.): ~ ~
Absorpuon rate = ~ ~6-~ g,p,d~/'&{~°
Iryes, g~ve date
D. LIFT STATION ["~/^
/./~r
Date installed
Size iu gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump ofF' level at*
High water alarm level at*
*Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank ou lot ?/20 J
Absorption field on lot ~>' / ,~ ~9 /
Public sewer main /x//,,&
Sewer/septic service line ~'~'~'~'~'~'~'~'~'~/d~"O /
;Onadjaceutlots ~ /O"~) }
; On adjacent lots '~ / too
Poblic sewer manhole/cleanout /"///'~-
Lift station ~//~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building fouudation ~.~ t
Water main/service line .~oq.~ I
Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ! 0 'P Water main/service liue
Surface water V,/ I C)
Curtain drain b'l l ~
Drivexvay, parking/vehicle storage area 10 ~
Wells on adjaceut lots ~' / ~ Property line
Fo
ENGINEER'S CERTIFICATION ·
certify that I have determined thru field inspections and review of Municipal records ~hat'the above ,ysrems are
m conformance with MOA It.4A guidelines in ~[fect on this date.
Eagincer'sName /OS* ~q ~))9'o¥'V'~[Ctva~? E~/gineering Seal Here.
IIAA Fee $
Oute.Pa,meut
Receipt Number
Rev. 8/95 eSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
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
Lot 7; Block,,I~ Zantka Vista Subdivision
-Fl l
Location (site address or directions) I 1060 Snow,in6 D~Lve
Property owner
Mailing address
Lending agency
¢/o Jack White Company.
Anchorage, Alaska 99503
Day phone 346-1949
3201 "C" Street. Suite I00. _
Day phone
Mailing address
Agent _ B~n~ie_Hock~¢~Ln / JACK WHITE 00MPANY Day phone
Address 3201 "C" Street, Suite 100, Anchorag&, Alaska 99503
762-3135
Unless otherwise requested, HAA will be held for pickup,
2. NUMBER OF BEDROOMS:
3, TYPE OF WATER SUPPLY:
NOTE:
Individual well
Community well
Public water
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
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation trom State ADEC
attesting to the legality and status of system.
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type _~¢-1¢/~
Log present I~N)
Total depth
Sanitary seal (~/N)
/~Loc~ ¢,, ¢--~/,.¢H~ ~.~7~ r/~Parcel
If A, B, or C, attach ADEC letter.
Date completed
Cased to ~oO
FROM WELL. LOG
Date of test ~'/'~/~'~
Static water level //0 '
Well flow Z~
Pump level /JOT Kk)ObJtJ
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main /
Sewer service line 100/4
ADEC water system number _ /V/~
_ Driller vEr4N~5 ~¢'~l~.~.ltJ~, '¢" ~ T
Casing height /Z (¢
Wires properly protected~N) ~% ~ ~
AT INSPECTION ~ ~ ~
g.p.m,
~OT KgO~
g.p_~n~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
/DOM
,,uoT-
WATER SAMPLE RESULTS:
Coliform OZob kF,'I
Date ofsamp,e: I -/Z 3/ Z
.. TA. DA A
Date installed ~[IO(~*
Cleanouts~N) ~
High water elerm (Y~ ~o
Date of pumping . .1Z/Z~/q Z
Nitrate
Collected by:
Other bacteria (~)
Tank size_ ['Z,.~O C~4L_ Compartments
Foundation cleanout ~) Y'd~ Depression (Y/~
Alarm tested (Y/N)
Pumper A~ ~'lO~
SEPARATION DISTANCES FROM SEPTIC~TANK TO:
Foundation ¢~
Water main/service line_
Well(s) on lot ~O0
To property line
Surface water/drainage
On adjacent lots
_Absorption field
72 026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
ON ~
Date i nst alle'd'--~ Manufacturer
Size in gallons ~ Man~)
Vent (Y/N) "Pu~ "Pump off" level at
SEP~ DISTANCE FROM LIFT STATION TO:
/.~Wgll on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
D~te installed ~:~//0 /~'S
Length cPO / Width.
Soil rating /~-~' ~'' System type k)
Gravel thickness ~"
Total depth
Total absorption area
Depression over field (Y~) ."~/~
Results (~'~f a il)
Peroxide treatment (past 12 months) (Y/N)
Cleanouts present ON) _
Date of adequacy test
for
/L.)O,(JE-' ..%/tJdcd,,,j If yes, give date /f-~/'/~
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /OO
To building foundation
On adjacent lots ~-~
Surface water ~u,~/d~ ?,~¢¢¢,,j7-
On adjacent lots /Oo ~ Property line
To existing or abandoned system on lot
Cutbank/J¢'~¢ /°'~e-.c¢,'J? Water main/service line
Curtain drain
Driveway, parking/vehicle storage area /O
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA g
$ & $ ENGINEERING
17034 Eagle River Loop Eoad No, 204
Baffle River, AJasJcn 99577
Signature
Engineer's Name
Date
~ of this inspection.
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev 3/91) aack MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTFf AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Propertyowner Fh, I
Mailing Address ~.. O. ~o,'~/I
(c) Lending Institution ~1"-¢.4-C
Mailing Address
(d) Real Estate Company and Agent
Telephone: (home) ¢ '¢~--~'c~ 7E)_ Business ~"5'..?- 77~"3
Telephone
(e) Mail the HAA to the following address: (or check here ~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms ~
3, WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. [ further verify that
based on the information obtained from tl~e 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.
Telephone
Name of Firm
Address / ~/ ~-~ O ~C Ad
Date _ I'~o
,~'
~,~ . tHeOdOre
~ ..% CE-~o~9 ..' ,~ Engineer's Seal
6. DHHS APPROVAL
Approved for z¢/ _bedrooms by
ApproCed_~ ~Dieapproved
Terms of CondWonal Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 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 (MOA)
(, ~ji~.;'%~ ~ Health Authority Approval (HAA)
MUNICIPALII~,.lk~'e~I~f~/~OqA¢3~ CHECKLIST- FEBRUARY 1984
~ N V I R O N M t N TAI%.~:I~.F, S DIVISION 343-4744
,,. 5 !989
A. WELL DATA R E E E I V E D
Well Classification _ ['~r'; u c~ ~-¢
Well Log Present (Y/N) ~" Date Completed
Total Depth
Cased to ~¢ Depth of Grouting
Legal Description: /-.¢, f: 7/
Z,~-~ g/',.r/~ -g' f.D
Static Water Level ~' ~) ¢
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL.:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C. Approved (Y/N)
~'//7/~ Yield ~.3 ~-,~'/¢,~
To Nearest Public Sewer Line /V,/~.
To Nearest Sewer Service Line on Lot _
Water Sample Collected by
Water Sample Test Results
Comments Du..c'm,~ C~{[
II O~
Pump Set At ~ 7.~ '
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
N
; On Adjoining Lots ,;:> fOc~ '
; On Adjoining Lots "~ Ioo '
To Nearest Public Sewer Cleanout/Manhole ~/' 4[·
;Date_ I~/..?O /~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~///( t/¢ff Size
Standpipes (Y/N) ~
Depression over Tank (Y/N)
Air-tight Caps (Y/N)
N
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well '~O E ¢
To Property Line ..¢ 5' t
To Water Main/Service Line___ 1> ES- '
To Stream, Pond, Lake or Major Drainage Course
Comments
No. of Compartments
Foundation Cleanout (Y/N) ~
Date Last Pumped II / z.l ~ &~- .ZTc,:z~¢-¢
; for Al,/¢ .
Temporary Holding Tank Permit (Y/N) N, ~L.
To Building Foundation
To Disposal Field
72 026 (Rev 7/88) Fro~l Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~' / ( I / dj'u/'
Width of Field .§ ' oK.
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
cl'/_~r.~ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
E'/7'
To Water-Supply Well
To Building Foundation /
Lot /¥,
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line ~ 7 ¢
To Existing or Abandoned System on
; On Adjoining Lots ~ 7~ '
TO Cutback (if present) /V, ,~.
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed ,~-~ ,~'
~': ~"~ ~ Engineers Seal
Date AIo
MOA ,o.
Receipt No
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEAI..TH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILtTY
2(34-4720
Application Date /0/~/
GENERAl.. INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
~-,~,~'/~.* .¢,,'~ to. Z'lo~,~ ~ LEt ~- '~'~', ~ 7 /~
(b) Applicaht Name P'I;'I..~: . ) ,-,, ~-. Telephone: Home Business
(c) Applicant is icheck one): Eonding Institution []; Owner/builder ; Buyer []; Other [] (explain);
(d) Lending Institut,i,o,n Telephone./-"
Address
(e) Real Estate Company and Agent
Address I',J l'&
Telephone _..~-/
(f) Mail the HAA to the following address~,/
TYPE OF RESIDENCE
Single-Family b~ Multi-Family []
Number of Bedrooms ~-
Other
WATER SUPPI. Y
h~dividual Wail ~ Community [] Public
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ Public D Community [] Holdieg Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 z2-o25 (13,84)
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA~ A 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 ~ndicated herein. I further verily that based on the information obtained
from the Mumcipality of Anchorage files and from my investigation ~nd inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all MunicipaJ and State codes, ordinances, and regulations in effect on
the date of this inspectiom
Name of Firm /t I~l~c, ~,~,~,~.~m~'.~/~./ ~;~'/ ~' Telephone ~- ~ /
Address / ~,~ o ~ .~;.5 '"~ ~ 4 ~ A ~' ¢-~'~ ~'
Approved for _/%'9¢'£,-~ _ bedrooms by~%~'~
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 ii above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. -the Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
' ..~O'<"?; \02 MUNICIPALITY OF ANCHORAGE (MOA)
~>~'O~.~~> ~ CHECKLIST- FEBRUARY 1984
¢ ~o~ ~,'~ <x _ .
WELL DATA ~
Well Classification ~r,'¢ ~ -~o,her~~c. If A, B, C, D.E.C. Approved (Y/N)
Well Log Present ~) Date Completed ~- ~-¢~
Total Depth 2. go Cased to
Static Water Level
Casing Neight Above Ground
Electrical Wiring in Conduit .~)N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot _
To Nearest Public Sewer Line.
Yield ~/~'
Depth of Grouting /vo
Pump Set At ¢/o~.r,~, .r,,~,
Sanitary Seal on Casing (~N)
Depression Around Wellhead (Y/I~
; On Adjoining Lots ~1- zoo
; On Adjoining Lots '~/' ~oO
To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
NFl
To Nearest Sewer Service Line on Lot
; Date ,,~ - zz. - ?~
B. SEPTIC/HOLDING TANK DATA
Date Installed /o ~/~n¢ / ¢0¢~ Size
Standpipes ~J4~) Air-tight Caps
Depression over Tank (Y/f'~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well 2.O 2..
To Property Line
To Water Main/Service Line
Course
No. of Compartments
Foundation Cleanout
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
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 /Z S-
Date Installed / '~2 //
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/¢
Results of Last Adequacy Test
Type of System Design ,-¢' z4~,' ¢,~ ~",-,~,-,~
/ ¢~P¢' Length of Field ~ O
Depth of Field
Gravel Bed Thickness
Standpipes Present
Date of Last Adequacy Test ~-'.4-
Separation Distance from Absorption Field:
,2/).
To Water-Supply Well
To Building Foundation
Lot A/~
To Water Main/Service Line ~7" /O
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
ToPropertyLine ,¢¢'.¢ 5¢,,,~,~t~ 2.-'¢. ¢o e~,~
To Existing or Abandoned System on
; On Adjoining Lots gT 3o
To Cutbank (if present) W '~
/6
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions/
Manh~(Y/N)
Jump Off"Levelat
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify t h at I~J:~¥e,~hecked,,~erified, or co,nformed to all MOA and HAA guidelines in effect on the date of this inspection.
.
Company //¢
Receipt No. /()
Date of Payment
Amount: $
Page 2 of 2
72-026 ( 11/842
I0' I.J'r'~LIT'Y'_
.b