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Home My WebLink AboutGREENBROOK BLK 4 LT 4 Municipality of Anchorage Page __L_[ of ~ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: '~J~,J~ J~ '~:~-" PID Number: ~1~[1~ Name: ~Upgrade ~~ ~~ Wastewater System: ~ New Address: ~[ ~~~ ~ ~ ABSORPTION FIELD ~ ~ D Deep Trench D ShalJowTrench~ed D Mound D Other Total Depth from original grade: LEGAL DESCRIPTION SoilRating: ~' ~ GPD/Sq. Ft. Lot: ~ Block: ~1 ~ ~~~Subdivisi°n: Depth to pipe bottom~, ~ ~Ft.fr°m original grade: ~ Gravel depth beneath p~p~ Township: Range: Section: Fill added above original grade: Gravel length: WELL: D New Q Upgrade Grave~ ~:V~ l~, Number of lines: I Distance between lines: Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: ~ Pipe meterial~[ ~ ~riller: Date Drilled: StaticWater Levek Installer: Date ipstalled: Yield: P,mp Set at: Casing Height Above Ground: TAN K GPM Ft. Ft. SEPARATION DISTANCES ~]~5~ ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/PrivateManufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines [ f Material: Number of CompaAments: su~f.c~ ~'+ ~o'+ ~ ~ LIFT STATION Water -- Lot -- I Line .~ ~ ~ ~ Size in gallons: Manufacturer: ~ "Pump on' level at:~p off" level at: ~ High water alarm at: Foundation ~ ~'~ ~ CurtainDrain ~ ~ ~ ~ ~ ~ ~ ~ Pump Make~ ~ Electrical Inspections pedormed by: Remarks: ~~ ~ ~~t~ BENCH MARK Location and Description: ENGINEER'S SEAL inspections performed by~~ ~'~'~ateS: Department of Health~ H~m~n Servj~ approval ,~.~...... No. O~, .'¢~'~' ~ 72-013 (1/91) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION 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 WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT NUMBER:SW910382 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:LAMOY DEXTER & OWNER ADDRESS:6821 TERESA CIR ANCHORAGE, AK 99516 PERMIT /~)~9c~ 3~, DATE ISSUED: 12/27/91 EXPIRATION DATE: 12/27/92 PARCEL ID:01743113 LEGAL DESCRIPTION: GREENBROOK BLK 4 LT SEC 26, T12N, R3W, SM LOT SIZE: 48236 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: CONFIRM INTEGRITY OF SEPTIC TANK.~-'~ MAINTAIN AS MUCH SEPARATION AS POSSIBLE TO DITCH ALONG WEST PROPERTY LINE. NOTE PRIOR WATER MONITORING FOR OLD ABSORPTION FIELD SHOWED GROUNDWATER AT -6.0', ENSURE THAT PROPER SEPARATION TO GROUNDWATER IS MAINTaINeD. , RECEIVED BY: N,~ ~[/. ~/_~2/2~' DATE: ISSUED BY: DATE: December 21, 1991 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DES[GN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, Alaska 99501 REFERENCE: Lot 4; Block 4; Greenbrook Subdivision 6821 Teresa Ct. Request you issue a permit to upgrade the septic system serving the referenced property. We recently performed an adequacy test on the existing septic system and found the absorption capacity of the system adequate for a 3-bedroom house. At that time we applied for a Health Certificate. We were informed that during a site visit by your office, liquid levels within the leachfield were abnormally high, therefore, a Certificate could not be issued. Test holes were excavated on the property and percolation tests performed. Attached is the proposed upgrade design. Due to the fairly large lot sizes in the subdivision and the fact that it is served by a community water system, we do not anticipate any adverse effects on the neighboring properties by the installation of the proposed system. If you require additional information for your review, please contact US. Sincerely, Roger J. Shafe~, P.E. RJS/bn 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~- ~ ~"-/ LEGAL DESCRIPTION: ~,..-'~ 1~ Z~ ~T[~,~-~-~/..~7:ownship, Range, Section: 1 2 3 4 5 6 7 8 10 11 12 13 14 15- 16- 17 18 19 20 SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Deplh to Water Alta SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop ~ ~-~--,~t 6-',t~ ¢, ---- W'*/~~ - . PERCOLATION RATE ,~"'2.~ (minutes/inch) PERC HOLE DIAMETER TEST RUN E~ETWEEN ~ FT AND '~ ET COMMENTS PERFORMED BY' 17034 Eagle River Loop Road .o. ,~.~'~ ~..~ERTiFY THAT TH,S TEST WAS · 6a~le River, Alaska 99577 .... Y~ ~ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ONJTHiS DATE. DATE PERFORMED IN 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: '~vl.~,,_/ LEGAL DESCRIPTION: L..-/~ ~ ~~l/._.Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E Depth to Water After - t | I r, lonitorinD? ~ ~'2- Date: SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop "5 A ~ ~' ~(~" PERCOLATION RATE ~'C;' (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN ~' FT AND ~- FT $ & $ ENGINEERING '~b~, ~ PERFORMED BY: ~'~f~,~ ~.~l~ D; .... I ... o..~ kl~ ~ I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE W~Lt~XT~b~AL GUIDELINES IN EFFECT O THIS DATE. DATE: ~-%~q I 72-008 (Rev. 4/8,5) SCALE l~ ' ',,_,,×' MUNICIPALITY OF ANCHORAGE 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 //~,~ lPHONE 4~'N EW -~EGAL DESCRIPTION We Absorption area ~ , Dw~l~ng ~ DISTANCE TO: ~~ ~O~ ~NZ Manufacturer ~ ~. Materia~~ ~o. o, comoartments ~ Liq. cap~ ~ns IF HOMEMADE: Inside length Width Liquid depth ~ Dwelling PERMIT NO. ~z ~ Manufacturer ' Material Liquid capacity in gallons ~ Well~ ~ Foundation '~earest lot }}n~ , ~[~MIT NO. ~ ~ DISTA~C~ TO: --Z~ / O~ ~ ~ inches * ~ ~ Top of tile to finish grade~ -- ,__~ Material beneath tile Total effective absorDdo~r~ ~ ' inches Length Width Depth PERMIT NO. ~ ~ Type of cri Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE~O: Class~~~ ~, / Depth Driller Distance to lot line PERMITNO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ~ , /~, REMARKS t .. 13 (Rev. 3/78) AF'PLI:RNT HRRRISKIN CONST. BOX ~:7:-:R 9950? ~,~]t LOK:R]~MUST BE WITHIN '25" GF T. H.~ LEGRL L4B4 GF.'EENEF."] 2~:' LOT SIZE 4¢3E'~C'~C'~ SQURRE FEET T'?'F'E OF sr_iIL RE:$)DF.:F'TION S"r'STEM IS: DRRINFIELD F ~- ~ MRX!MUM NUMBER OF BEDROOMS = ':".: : SOIL RRTING (SC! FT,-"BR)= 275 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: L E F" THE LENGTH DIMENSION IS THE LENGTH <IN FEET::' OF THE TRENCH OR DRRINFIEL. D. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GRCIUND RND THE .E:OTTOM OF THE E;:.:;CR',,,'RTIGN (tN FE~ T'HE: TE.E~"-~C:H l.--i ][ [:.TH ][ E; , ~ FEE'T'. =F.H,EL DEPTH IS THE MINIMUM DEPTH OF GRR.,EL BETWEEF~THE OLITFFtLL PIPE THE P" '- !aND THE BOTTCIM OF THE E'?,CRVFtTION ,.'.IN FEET). F'EF.:MIT HFFLI_.HNT HR_ THE RE.=,FUN.u,_E, ILIT-,- TO !N. FOF,:M THIS DEF'RRTMENT DLIRING THE INSTRLLRT!ON INSF'ECTIuNS OF RN'¢ WELLS RDJRCENT TO THIS PF._FEF. IT RND THE NJMBEF.: OF F.:E'--;IDENCES THRT THE WELL WILL SER',,,'E. BRCKFILLING CIF RNa' S'¢STEM WITHGLIT FINRL INz, FE_.TION RND FIF'PROVFtL BY THiS DEPRRTMENT WILL E:E SUBJEF:T l'O PROS, ECUTION. MINIMUM DISTRNC:E BETWEEN R WELL RND RN¥ ON-SITE SEWRGE DISPOSRL SYSTEM tS ±EiO FEE7' FOR R PRI',,,'RTE WELL OR t50 TO .'.'."OE~ FEET FROM FI PUBLIC WELL DEPENDING UPON THE T'.¢F'E OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRI'v'RTE WELL TO R PRI',,,'RTE SEWER LINE IS 25 FEET RND TO R COMMUNIT'¢ SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MR"r' RPPL'¢. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRIL.FtBLE 'FO INSURE PROPER IN'.STRLLFITION. F-.E.=. E E:P"tE:ER ]:::L.. - F' E F-': f-1 I T E :=~; F' .I -'" =' "=" [:" C: 1_- .=. :1. I CERTIFY' THRT ±: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RN[:' WELLS RS SET' FORTH BY THE MUNICIPRLIT'¢ OF RNCHORRGE. 2: I WILL INSTRLL THE S'¢STEM IN RCCORDRNCE WITH THE CODES. ]:: I UNDERSTRND THRT THE ON-SITE SEWER S'¢S]'EM MR¥ REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ]: BEDROOMS. S I GNED: _~~,:.-¢ ............................. APPLICANT HARRISON CONST. ISSUED E:~.' _. ' ~'~ ~ _DR'I'E_ . ',,,'4. Depth zn Feet From 0,0 0.5 0,5 6.0 6.0 15.0 Table K ~0 #A19708 Date: 3/14/81 Logged by: T. Krupka Sol]. Descri~t:ion Peat F-4, Brown Silty Sand, SM, moist, firm F-3~ GrAvei. l_y_ Silt_~V Sand, SM, occasional cobbles, moist, firm, beco,nes saturated at 12' Set 3/4" perforated PVC pipe to run perc test and to monitor water .table elevation. Perc Rate = 40 minutes/inch. Bottom of Test'Hole: Frost Line: Free Water Level: 15.0 Feet 1.0 Foot 3/14/81 - 12.0 Feet 3/18/'8'1- 6.0 Feet 3/23/81 - 6.8 Feet 4/9/81 - 7.0 Feet 4/16/81.'. 8.3 Feet .'FF : L l I I 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. # _C~)~,"-~ -~ ~,.;c~\~ I. 1. GENERAL INFORMATION Complete legal descriPtion Lot 4; BloCk 4~ Grcenbrook Subdivision; Location (site address oE directions) 6821 T~r~sa Circle PEoperty owner Mailing address Lending agency Mailing address B~tsy Lamoy · 682.1 ,Ter6sa CirCe Anchorage, Day phone Alaska 995~6 345-6907 Day phone Agent Sue DeVorak FORTUNE PROPERTIES Address 3000 A Street Suit6 Day phone 562-7653 Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well XX NOTE: Public water If community well system, provide written confirmation from State AD£C attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer 72-025 (Rev. 1/91) Front MOAI~21 ×X NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Address Engineer's signature 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 ' $ & s ENGINEERING Phone 17034 Eagle River Loop Roa~l NO, .20,~ Eagle River, Alaska 99577, Date ['- ~'' [ ~Z~ DHHS SIGNATURE .~/~_ Approved for DisaPProved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments ~ ~ /~ / / By: Date 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 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. 72-O25 (Rev. 1/91) Back MOA#21 (~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description'~?-~-~'~---424~;~-~----~l~?[;~ L~l/----/Jc'~Parcel I.D. A. WELL DATA Well type ~>< Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed . Cased to FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service, line ?...E)O ~ ADEC water system number "~"~ [ ~'~-~ ~"~ Driller Casing height Wires properly protected (Y/N) AT INSPECTION g'P'~' ~ <:~ LJ,.I On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed -'-7~r".[.-'~:~l Tanksize [~::~:)~ ~----t~L.-" Compartments Cleanout~l~l~ :::,: ':~: ,i:i.i',' ~ ?.oundation cleanout (Y(~) ~ Depression (Y~ High water alaim' ('~/~:: 1~'/~~';: Alarm tested:(Y/N) Date of pu?pi~ ti ~ '[~ ""~' I' i~ Pumper Ad' -[-1~t'--(~_. ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot i.:' -.' '"' ' "' On adjacent lots ..~:~ t_j~ Foundation To property line ,Z~-~ ! :_j._ ~ ~..~ ' Water main/service line Surface water/drainage AbsorptiOn field 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ Meets MOA electrical codes (Y/N) ~ SEPARATION DIST, ANC~E"F~ROM LIFT STATION TO: Well on lot ~~ On adjacent lots Manufacturer ~ M~ (Y/N) "Pump off" level at Cycles tested Surface water D, ABSORPTION FIELD DATA Date installed I/I ~.)/~ ~ ~.2. '~ Length ~¢~;:). 3' Width "~'~ ' Total absorption area I ~'00¢ ptb Depression over field (Y~) ~ Results (pass/fail) t~,~<.l,,,,J, ~'"/~__.-.-(-~_.~ for ~ Peroxide treatment (past 12 months) (Y(~ I'~ Soil rating Gravel thickness 0 .~'~ ' Total depth Cleanouts present~) Date of adequacy test __ 1~/~- System type '-1;;;_~.~__~ . ~.~ '~/-+. 0 / bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I,J/,t~. On adjacent lots -'~-~E~ + Property line To building foundation "'Z~(--~r '-~ To existing or abandoned system on lot On adjacent lots ;;2~) ~q~ Cutbank F--I~,..~-~-~ Water main/service line Surface water Curtain drain Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. g Riv r, Alaska 99577 Date HAA Fee $ ! ' ~1C_.), ~ /'~ Waiver Fee: $ Date of Payment \ ~ .¢.~ .--) .c~. / ~¢~f"'N Date of Payment Receipt Number ';~ ~ ~-~ '~J --¢'~ ~¢'~' Receipt Number 72-026 (Rev. 3/91) Back MOA 21 DEPT. OF ENVIRONMENTAL CONSERVATION WALTER J. HICKEL, GOVERNOR ANCHORAGE DISTRICT OFFICE 3601 "C" STREET, SUITE 322 ANCHORAGE, ALASKA 99503 (907) 563-6775 December 27, 1991 FOR: S & S Engineering PWSID # 210348 My review of the records on file in this office reveals that the Greenbrook Subdivision Class "A" Public Water System, is in compliance with the routine coliform bacteria sampling requirements listed in Table C, and with the inorganic sampling requirements listed in Table B of 18 AAC 80.200. Sincerely, Byron Roys Environmental Engineer BR/cf Parcel I.D. Cf 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 DWELL HAA: 1. GENERAL INFORMATION Complete legal description Lot 4; ~loc~ 4; Subdivision Location (site address or directions) 6521 tirol6 / Property owner Mailing address Lending agency Mailing address Agent $u6 Vvora/z B~tsy Lamoy ~ '~ ¢ 6821 T~resa Cir.& FORTUNE PROPERTI[ Add ress __ Unless otherwise requested, HAA will 2, NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well lng to 4. TYPE OF WASTEWATEI ;POSAL: Individu~ )n-site Holdin NOTE: nity on-site Publ sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Day phone 545-6907 Alaska 99516 Day phone Day phon~62-1655 held for pickup. XX provide written confirmation from State ADEC attest- ~tatus of system. 72-025 (Rev. 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 th¢ information obtained from the Municipality of Anchorage files and from my investigation and 2ection, the on-site water supply and/or wastewater disposal system is in compliance with a Municipal and State codes, ordinances, and regulations in effect on the date of this inspectio Name of Firm $ & S ENGINEERING Add ress ~. 70_~4 E~.~!e ~P. er Loop ~oa~ N~, 204 Eagle River, Alaska 99577 Engineer's signature Phone DHHS SIGNATURE Approved for r)isapproved. Conditional approv bedrooms, with the following stipulations: Additional Comments __ By: Date 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 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. 72-~25 (Rev. 1/91) Back MOA t/21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~-~-r' ~ ~v4z. ~ ~¢-,e.~_,.~¢,,~-00¢. Parcel I.D. A. WELL DATA Well type A Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to ADEC water system number Driller Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. AT INSPECTION MUNICIPALITY OF ANCHORAGE ~;t¢¢J~ONMENTAL SERVICES DIVISION t~0V 2 7 1991 g.p.m. RECEIVED SEPARATION DISTANCES FROM WELL TO:. Septic/holding tank on lot ?...c>~, ~ ~' Absorption field on lot %.° o Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhoie/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed '1 ~ c~, I Tank size Collected by: Other bacteria, \ c~c~ cz> Compartments Cieanouts ~IN) 7 Foundation cleanout (Y,~ /"J Depression (Y~i) High water alarm (YN~ /d Alarm tested (Y/N) Date of pumping I~ ~1. ~-'~, Pumper ,~4- ~o~-'t-~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot '7,-o ~ ' ~r On adjacent lots "~) ~, Foundation *Z~' ~ Topropertyline lc~t'k Absorption field IJ ~ Watermain/S~rviceline to ~' Surface water/drainage :J ~"~ ~ ~ 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical cod~ ~ SEPARATION DIS_..T.A'fq~E FROM LIFT STATION TO: On adjacent lots D. ABSORPTION FIELD DATA Date installed "~ ~' ~' I Length "L. ~ "b, Width Total absorption area ~ ~.~' ~ Depression over field (Y~[~ /,4' Res u Its~i~?/fsil) CA4'~ for Peroxide treatment (past 12 months) (V~) /k/o/~/~. /~,/V/~ I, JA/ Manufacturer Manhole/Access (Y/N) :'" f.~O~ off" le~,el at .~"~Cycles tested Surface water Soil rating '~"~ ¢ ~'/¢',~ System type Gravel thickness E>, ~' / Cleanouts present .~/N) Date of adequacy test If yes, give date Total depth Z ,-~' //- 'Z-(. - c// bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot "Z--~ ~ ~ '~ On adjacent lots ¢//~ Property line To building foundation \ ¢>~ ~' To existing or abandoned system on lot On adjacent lots_ Surface water Curtain drain Cutbank lA Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines ~n' effect on..::-{~e:' .'~.?te.;,...~.~.,°f.~ .this inspection. ~ & 5 ENGINEERING ...... 17034 Eagle River Loop Road No. 204 SI~Hd[U/~ [~ar~le ~iver, Al~slca 995~ Engineer's Name ..... HAA FeeS Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 3601 "C" STREET, SUITE 322 ANCHORAGE, ALASKA 99503 WALTER J. HICKEL, GOVERNOR 563-6775 November6,1991 FOR: S & S Engineering PWSID # 210346 My review of the records on file in this office reveals that the Greenbrook Subdivision Class "A" Public Water System, is in compliance with the routine coliform bacteria samples requirements listed in Table C, and with the inorganic sampling listed in Table B of 18 AAC 80.200. Sincerely, Byron Roys Environmental Engineer BR/cf ~ prinled on recycled pape~ b y C ,~ -' APPL[ ,NT FILLS OUT UPPER HA' ~ONL~ Property Owner ,¢'7~~ ~'~ '''7~'"~'~ V'- Ma,,,noAddre Z /: A- : -i f z'pcode / ~'/I / Address ~ ;;~ //11/~/ -~ Zip Code Lending Inst'itution Address] Zip Code' ~.~ Realty Co. & A~nt ' Phone Address ///' //[ ,~ · , Zip Code Type of Residence ~[~'~Si ngle Family [] Multiple Family No. of Bedrooms [] Other Water Supply [] Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. I~.Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility ~k~lndividual Year individual Installed: ) FJ ~] Public Utility When Connected to Publio Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE ~NITIATED. Time Time Time Time Date Date Date Inspector Inspector Inspector Inspector Fietd Notes: ( .:~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE '7-'~ ~ ~ ~ Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received ") --(~t Well to Tank Septic Tank Size 72.023 (3182) MUNICIPALITY OF ANCHORAGE DE.ARTME.T O. HEALT. .UMA. SERV,CES 7 DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner Mailing Address Telephone: Home Business (c) (d) Lending Institution Mailing Address Telephone Real Estate Company and Agent 7'~/'~ /"~-----C'~---/~"~ Address Telephone (e) Mail the HAA to the followina address: or: Check here r-I, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family,~ Number of Bedrooms WATER SUPPLY Individual Well [] Communit¢' Public 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 [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State De attesting to the legality and status. ~artment of Environmental Conservation Page 1 of 2 72-025 fRev 8/86~ Front leUO!UpuoO le^oJdd¥ leUO{Upuoo ~o suJJel pe^o]ddes!G '-'~/~ pe^oJdd¥ Xq suJooJpeq ~/~ZCY,~ ]oI pa^oJddv "lYAO~dd~ SHHO ua ~ae~je u{ suoi~elnSe~ pue 'seoueu!p~o 'sepoo a{e~S pue led!o{unlAI lie UW~ eoue}ldUJoO Jo/pue Xlddns Jale~ al!s-ua aq{ 'uolloedsu} pue UOile6iiSaAU{ XW WOJ pau}elqo uoile~JO~U! aU{ ua paseq leU{ XI}]aA Jeqpni I 'u}aJau pe{eo}pu} aJnianJ{s eienbepe pue leUO{{ounl 'e~es si ~a{sXs {esodsip Je~e~eise~ ~o/pue Xlddns Je{e~ aUs-uo qUeeH siM{ lo uo}ieb}1seAu{ ~ ~eU{ XIiJeA I '~oleq u~ous e{ep uo{{epileA eU~ NOI&~OJNI ON~ Y&YO 'HOM~S ~]lJ 'S&S]~ 'SNOI&O3dSNI 9NIOIAOMd ~lJ 9NIH~BNIgN3 ~-J MUNICIPALITY OF ANCHORAGE ~r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date /,7/'~/~'F GENERAL INFORMATION (a) (b) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name (.,)/],,'FE7~ ~/~ L/~Lf~JS'J~.. Telephone: Home Applicant Address Business (c) Applicant is (check one): Lending Institution/~ Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Famil¢ 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 Conservation 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 Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ~ ,to ~ ,:Jeed '~JOM s,Jasu!eua leUO!SSajoJd aql u! sue!ss!u JO Jo sJOJJS Jo~. alq!suodseJ )ou s! a6eJoqouv )o ,q!led!o!unv4 eqJ. 'penss! s! a~eo!j!p@o e aJo)sq m, ep sz,qeue JO suo!~osdsu! ],onpuoo leu op aaH(] jo ssS~OldLUq 's~USLUSJ!nbaJ a]e~s pus leJapsJ u!epa3/~)s!les el J@pJo u! suo!~ni!lsu! 8u!pual J!eq], pus sswoq jo sJsseqsJnd o~ XsslJnos e se s!ql esop d=IHQ sq± 'eHsel¥ jo sielS aqi u! psJs)s!SaJ JSSU!6Ua leUO!SSSjoJd luepusdspu! ue Xq s^oqe ~ qdeJ6eJed u! ua^!8 suo!le~uesaJds] aql uodn ,(Isles paseq ss~eo!~!lJso le^oJddv /~lpoqln¥ q~leSH senss! (deHQ) uo!losjOJd le)UeWU°J!^u~ pus qlleaH jo ~uewuedeQ a6eJoqou¥ jo X~,!ledpunl/~ NOI/ClYO leUO!l.!puoo leAoJddv leUO!l.!puoo jo SLUJSl psAoJddes!C] ~' paAoJddv ~q suJooJpsq('./~' ~/~/~. ,.~/_.' JoI psAoJddv 'IYAO~ddV d':lH a '9 uo ~osJ~e u! suoBelneSJ pus 'ssoueu!p]o 'sapo3 ale,S pus led!o!unv~l lie ql!M eoUe!ldLUo3 u! s! LUS~SXS lesods!p ]S~eMaiSe~ ~o/pue ,qddns ~e~e~ al!s-uo aLii 'uo!Josdsu! pus uo!~e6!~se^u! XLU LUOJJ pus sal!~ See]OLIOUV JO X)!ledp!unv4 SLp. LUOJ~ peu!ejqo uo!),euJ~o~u! alii uo paseq jeqJ Xjpa^ JeLIPnj I 'u!a~eq ps)eo!pu! a]nion]~.s jo sd/~j pus SLUOO]paq ~O ]SqLunu aLI~ ~O~ s~enbape pus leUO!lounJ 'a)es s! uJ als/,s lesods!p ]S~eMe~Se~ lo/pus Xlddns JSieM Sl!S-UO sql leLR SMOqS le^o]dd¥' q)leSH s!qi )o UOp, e6!)SSAU! ,~LU ~eq~/~)!JSA I 'MOleq UMOqS slap UOi~ep!leA sql ~O se pus o~,sJsq psx!De leas ,~uJ Xq paU!lJSO sV NOI.L¥1NI::IOJNI aNY yLYO 'HOt:tV=IS =1114 'SIS=I/'SNOI.L:)=IdSNI ~DNIOIAOt:Id INEII:I 9NII:I:I=INIgN3 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legar Description: Z~' WELL DATA Well Classification .~z~,a~-/~Jl7~q If A, B, C, D.E.C. Approved (Y/N) _ I Well Log Present (Y/N) ~'""~ate Completed Yield // Total Depth Cased to Depth of Grouting ~" Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (~__ Electrical Wiring in Conduit (Y/N) Depression Around~N'ellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot _/;; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ?'/"; On Adjoining Lots ___ To Nearest Public Sewer Line ..~To Nearest Public Sewer Cleanout/Manhole J ' To Nearest Sewer Service Line on Lot Water Sample Collected by j' ; Date Water Sample Test Results/ Comments B. SEPTIC/HOLDING TANK DATA Date Installed ! Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~: To Property Line ,,?-~:~"~ To Water Main/Service Line ,/C2~, Course · Comments Size /OCO f""' No. of Compartments ~ Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N) ¢k~ Date Last Pumped ¢1t-/¢7 ~ ; for ~'J i']~ Temporary Holding Tank Permit (Y/N) ~/~ To Building Foundation ~,-~ ~ To Disposal Field ('o ¢P To Stream, Pond, Lake, or Major Drainage -- ! ! Page I of 2 72-026 (Rev 8/86) Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date installed Width of Field c. Square Feet of Absorption Area ~'~'~E:.,¢-~-,;~' Standpipes Present (Y/N) Depression over Field (Y/N) ~ Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: 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 Type of System Design-''--c-t° Length of Field Depth of Field ~.~ Gravel Bed Thickness O, To Property Line To Existing or Abandoned System on ; On Adjoining Lots ,/C~'/-/~- To Cutbank (if present) 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 Manhole/Access (Y/N) ~ "Pump Off" Level.aL.~'~'~-~ V_~nt¢(Y/N) .... "' Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checke,4J, veri.fie¢', or/iconformed to ail MOA and HAA guidelines in effect on the date of this inspection. Signed :~_'/~,~/'~*,¢/~/~'[ . .~A.~;,_~,.x.-~DALe_..~ ¢/'~'/~7 Gompany ' ~ r MoA N'o. Recei pt No. d_/C") C'~/{~ ~ ~ ~I/~L~C,,,5,A..~.Y O5. EAA~H&ORAG~. Date of Payment /' -~ /- ' Dg~. O~ ~ Amount: $ /~) . O~ ~NVI~ME~AL p~OTECTtON 1. 3 1987 Page 2 of 2 72 026 IRev 8'861 Back DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 3601C STREET, SUITE 1334 ANCHORAGE, ALASKA 99503 STEVE COWPER, GOVERNOR 563-6775 DATE: ..... ~U~UAi_!g._!2~Z ..... PUSID: 210346 To Whom It May Concern: According to records on ?ile in this o?¢ice, the GREENBROOK ...... SUBB~W!6!Q~ ............. Water System is in compliance with the State Brinking Water Regulations ?or monthly bacteriological sampling only. Sincerely, / Michael P. Lewi~ Environmental Engineer HOME SERVICES 15900 Francesca Drive Anchorage, Alaska 99516 345-1890 or 345-2444 INVOICE # 1482 CUSTOMER Besse, Epps and Potls 2229 E. 88th Anchorage, Alaska 99507 Block ~z lot ~/// Greenb~ook S~b. DATE DESCRIPTION AMOUNT 1-8-87 Pump SepfJn .... : ~ 65 00 6821 Teresa CirCle Hillside, '~' '"~ ..... eArmoun, VonSh~bon DELIVER BILLING TO BEPS OFFICE AFTER PUMPING. · ' · TOTAL 65iO0 REMARKS · - ,.- .- ~6~'~) ~al!ons [~pt~c .Cosspool ~ Standpipes limo ~ NEEDS TO BE DONE AGAIN IN 6 MONTHS /- ~ Good Shape ~-Sludge buildup on bottom ~'~ater on top CJ Jim cap missing or : Cut standpipe to 1' above ground ~-Needs Septictrine needs replacing --PLEASE PAY FROM THIS INVOICE-- D~PT. OF ~N¥1RONMENTAL CONSERV/~TION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 BILL SHEFFIELD, GOVERNOR Telephone: ,Addre~: 274-2533 DATE: November 17, 1986 PWS I.I).# 210.346 To Whom it May Concern: According to records on file in this office the GILEENBROOK S/D Water System is in compliance with the State Drinking Water Regulations Sincerely, Michael P. Lewis Environmental Engineer