The URL can be used to link to this page

Home My WebLink AboutROBINDALE #1 BLK 2 LT 5ARobindale # 1 Lot 5A Block 2 #051-052-62 ~ MUNICIPALITY OF ANCHORAGE ~~ ~ · I ' ' ~" ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEcTIoN ~J_a,-~t)g.~,~ /~' ENVIRONMENTAL ENGINEERING DIVISION ~~ ~ ~ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME : PHONE / ~W MAI LING :ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS : DISTANCE TO: Well /~ / Absorptio~re~ Dwelling~ / PERMIT NO. Material No, of compartments ~<~ Z :Manufacturer ~~ ~~ ~ ~ ~ Liq. capacity in gallons ~ Inside length Width Liquid depth /~ ~F HOME.DE: ~ ~ DISTANCE TO: Nell Dwelling PERMIT NO. O ~ ~ ~Manufacturer Material Liquid capacity in gallons ~ Well Foundation~ I Nearest lot lin% PERMIT NO. ~ ~ DISTANCE TO: /~ ' '~ ~ ' ~(~ Distance between lines ~~ ~ ,'N° of~lines ~, ~.Length of each line.~/ , Total /~length of ~nes Trenc~tb inches /~ ¢ ~ ~ ~ Top of tile to finish grade f ' Material beneath tile Total effective a~sorption area ~ Length Width Depth PERMIT NO. ~ ~ 'Type of crib Crib diameter ' Crib depth Total effective absorption area ~ DISTANCE TO: Well Building foundation Nearest lot line ~ Class Depth Driller Distance to lot line PERMIT NO, ~ DISTANCE TO: Building foundation ~ Sewer line Septic tank Absorption area(s) j OTHER PIP__RIALS SOILTECTRATING ~ ¢~;~ LI,)¢~ ~ ~ ~ ~ Russell E. Oysfer ~ /~ ~ ~ "O ~- ~ ~-- ' ~ ~ ' ......... APPROVED DATE LEGAL F'ERMI T NO. DEPARTHENT OF HEALTH AND ENVIRONMENTAL PROTECTION 8~5 '"L" STREET.. 8NC:HORAGE, ~K. 995E~i 264-472~3 780519 > AF'PL I CANT LARRY HAM I L. TON Lf]CFIT I ON : LEGRL : L5 B2,- F,.'APTN,,~_,_ DRLE S,.-"D F'N_ ~,._PN',",.., ,=.._.,x,,:~,=,,~, CHUGIAK LO]' S I .ZE 4o4,:..~, "R-,PlIRF.'E FEE'[' TYF'E OF SOIL ABSORBTION SYSTEM IS: DRRINFIELD MA).::IMUM NIJMBER OF BEDROOMS =-' 5 SOIL RRTING ':.Si'..".! FT,"'BR)=,::.~,-,'"'"'~ _- ,r-- ' ' I-I THE REQUIRED =,I.,'E OF THE ':.;niL AE,=,uRF] I_l'.,I =,'r_ I"EM [:.FF"TH= :-'22: L Ei'-~u3 TH = 1:::6 ,3 F~. R '.,-' E L [:.EPTH:= THE LENGTH DIMENSION IS THE LEN~T.H (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUI'4D AND THE BOTTOM OF THE EXCA',,,'ATION (IN FEET.'.',. THE GRAVEL DEPTH ~S THE MINIMUM DEPTH OF GRAVEL BETHEEN THE OUTFALi. PIPE AND THE BOTTOM OF THE: EXCAVATION (IN FEET). F'EF.:MIT FIPF'LICRNT FIRS; THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING ]'HE INSTALLATION INSPECTIONS OF ANY HELLS ADJACENT TO THIb FF.._FEF..Th' RND THE NUMBER OF F.'.E_,IDEtqr_'.E_, THAT THE WELL WILL ,='- :c:,,,,,,.:' "" h" ' '- ' ' I"1 BH_.KFILLINU OF ANY SYSTEM WITHOLIT FIMAL IN_-,FECTI.N RND RF'F'RO',,,'AL E'Y THIS DEPARTMENT WILL BE 'gl IBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL. SYSTEM IS ±00 FEET FOR A PRIVATE WELL; OR "L5E~ TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WEL, L OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUC:TION [.',IAGRRMS FIRE A',,,'AILRBLE TO INSURE PROPER INSTALLATION. F'EF,;.-:I"-I I 1'" E::-::F' I F-.'E S [:.EC:E f']BER 3:1.. I CER'FIFY THAT t: I AM FAMIL. IRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH E:Y THE MUNICIPALITY OF' ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 2:: I UNDERSTAND ]'HAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 5 BEDROOMS. S I GNE[:,: ..... RF'PLI CANT ~ t_RRR~ HAMILTON O~E GEO, .,HNI CAL E~ DEVEL..-'MENT CO. Russell Oyster 694-2774 Soils ~ Foundations Performed for: Legal Description: Name: Mailing Address: Box 90, Davis St,, Eagle River, Alaska 99577 694-2774 or 688-2280 Earl Ellis SOIL LOG Land Developmerit Depth (feet) Soil Chmractertstic~ 13 16 Ground Water Encountered: Yes / No~ Proposed Installation: Seepage Pit Comments: If yes, what depth /2 Drain Field Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage, ak. us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D. 0~'/- 0,9~ - .-:~- ~ 1. GENERAL INFORMATION Complete legal description Lot HAA#/~//~ ('.~'C?C¢ Expiration Date: 5~ Block 2, Robindale #1 Location (site address or directions) 22544 Robinson Road Current Property owner(s) GeorEe &Aven Strand Mailing address 22544 Robinson Road, Chugiak, Lending agency Day phone 688-5015 AK 99567 Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well 5 TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on propedies served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority 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 sample results less than 30 days old. Certificates are valid for one year for propedies served by Class A or B wells or a public ,.~ater system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S & S ENGINEERING 17034 Eagle River Loop Road NO. 20~ Name of Firm ~. , .... ^,..,...~,~?? Phone ~ g ~ - 3-~ '7~ Address Engineer's Printed Name DHHS SIGNATURE Y Approved for ,~- bedrooms. Disapproved. Conditional approval for Date_ ~/~7/o° .... v.., ~ ~ ~NG NEER S }~}, ~. ~ ~' '~'~ ~ LTL ~ ~ · C~ <~al ~ '~, X ~ ' ~ ~ ~, .. ,-~- .,~ bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: /¢ - /,/- d~ '0 Original Certificate Date: '~ -//- 0 0 Reissue Date: DEPARTMENT OF HEALTH & HUMAN SERVICES ~JUN 27' ~000 ~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (90~L~~ANc~°~ ' ~7i~NT~ SERVICES DIVI~ ~" Health Authority Approval Checklist Legal Description: A. WELL DATA Well type Log present, N) Total depth Sanitary seal, N) IfA, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to /.~e~/ ' / Casing height (above ground) / '~/-- Wires properly protected ~N) Date of test Static water level Well production FROM WELL LOG AT INSPECTION "'7_ /~:~ g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform O Date of sample: B. SEPTIC/HOLDING TANK DATA, Date installed ~/~¢/~ Tanksize Foundatio~ cloanot ~) Nitrate ~' - ~ -)-- Other bacteria 0 Collected by: s & ~ F. NGINI~F_BING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 /~(~'Number of Compartments ~- Cleanouts(?~N)~'-~_~' Depression (Y/~I //~/O High water alarm (Y/N) ,/'Y///~ / Date of Pumping '7/3 /cie/ Pumper ~'~/,,~' A.SCPT,ON FIE'D DATA Date inst~lled~ ~/~/~ ~il~ating ~~ ~ ~ rSystemtype ~ ~ Length /~ Width ~ Gravel thickness below p~ ~ Total depth ~/ Effect~eabsorption area /~ ~onJtoringTubepresen~N)~Depression over field (Y~. Date of adequacy test ~/~/~ Results(Pass/Fail)~ For ~ bedrooms / / . , ' ,, Fluid depth in absorption field before test (in.); -~ Immediately a~er]~al, water added (in.): / / Fluiddepth ~ (ins) Minutes later: ~ Absorption rate = ~ ~ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~J~ ~f~ If yes, give date ~ 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested / ,, Size in gallons "Pump on" level at* "Pump off" level at* *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot / (~O / ../- On adjacent lots /i~O/"/- On adjacent lots / O~_~/~.~ Sewer/septic service line .~-~ '~'J- Lift station .'A/ /,~ / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON I..OT TO: Foundation / (~ / ..,L. Property line /O/'¢' Absorption field Water main/service line /O~- Sudace water/drainage //(~) / ¢ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /(-.~ '~¢'- / Building foundation //, (~) ..,L Water main/service line Surface water / (~)~ / ~ Driveway, parking/vehicle storage area Curtain drain /"~/~A/('- ,/~","V'¢/'~/ Wells on adjacent lots /~0 / '~ F, ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records [l~eCg~f~o~¢ s'j~e~cms are in conformance wi(h ~/lO~4 ~AA guidelines in effect on this date. ~,~, ............. Signature ~ ~, ~ Date ~f ¢~[~ HAA Fee $ ,'~)~., Date of Payment Receipt Number ~)~,,~¢~// Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ASNUILT-N O CORNERS SET THIS DAT~., t HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY~ Robindale Addition No. 1,Lot 5,Blk. 9. AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT lS THE RESPONSIBILITY OF THE OWNE~ TO DETERI~INE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH'~:X3 NOT AP~F./~R ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINE% OR FOR ESTABLISHING BOUND- ARY LINES. ._(~ SCALE, 1"=30' DATE, 1-17-90 GRID' NW 1561 10-51 DRAWN' DMS 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. # 1. GENERAL INFORMATION Complete legal description Robindale Subdivision Addition Block 2, Lot 5 . ,. 22544 Robinson Road Location (site address or direct OhS) Property owner Mailing address SAme Lending agency Mailing address Agent Dick }3rown/'Ta. rgCh k Cheryl Kirwan Address 17034 Eag]_'~- ;'liver %00'0 Day phone Day phone Day phone ';'~,~-23~3 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 5 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. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site 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. 72-025 (Rev. 1/91) Front MOA ¢t21 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 inves_ti_gation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ ..... ~g,e ~,;~ Lo~pj~oad No. 204 Phone /)¢2z//~2~, ~ ~ Add ress Eagle River~laska 9/9~77 ?~xHS SIGNATURE //~. Approved for 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 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. 72-025(Rev. 1/9~) Back MOA #21 Legal Description: A. Well Data Well type Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST ~;2~,~(~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~'~ "Z'~ ~1 6 Driller Cased to \ ~ f~~ Casing height ~, 2--~\'~ Wires properly protectedd(-¥~N) AT INSPECTION Log present ~/N) ~ Total depth \ ~:~c~ ~ Sanitary seal(~N) g.p.m. ~". 7---'~ g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout FROM WELL LOG Date of test ~' ~ 7.~z~ -~"/9, Static water level /---~o I Well flow ¢..~-¢' ~ ~ ~ 0 Pump level1 ~U~, ~t~ ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \ Absorption field on lot , \~-~c~' Public sewer main Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform ~:~ Nitrate Date of sample: \\~-- t,"z.. -~t '5 Collected by: B. SEPTIC/HOLDING TANK DATA ~ ~'~ Date installed (-~ ~'¢'°t" ~ L~ Tank size Cleanouts ~N) ',~ High water alarm Date of pumping Other bacteria ~:~ F. aBle River, Alaslta 99577 Compartments Foundation cleanout (~¥N) ~ Depressi.on (Y~J~ r~ Alarm tested (Y/N) \\~ ~'~ Pumper __~-~', SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ ~'~-\ To property line ~ ~ \ Surface water/drainage On adjacent lots Absorption field Foundation \ Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level .~ Cycles tested Meets MOA electrica~ SEPARATIO~ANCE FROM LIFT STATION TO: VC~'~)n lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~ Level at Surface water D. ABSORPTION FIELD DATA Date installed Length \~o\ Width Total absorption area \ Date of adequacy test \ Water level in absorption field before test Peroxide treatment (past 12 months) (Y~IL~ Soil rating (GPD/FF) Gravel thickness Cleanout present ~¢~YN) Results (~fail) ¢2.~'¢ .s ~.C. ~ I¢:~¢~ System type '~;:~.¢-,~-,'~ ~" ~ Total depth L¢~ Depression over field (Y(~. ~ for ~- / Bedrooms After test ~;)j J If yes, give date "J'/.z- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water \ Curtain drain '~ L~r-~~ On adjacent lots ~. ~:~ Property line ~ ~ To existing or abandoned system on lot Cutbank ¢~../'~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION Signatur~ S&$E ~Engineers/cerlify thatN~r~a~.,~.~. _ ,6~l ha ve checked, verified, or~conformed~ ~ to all MOA and HAA guidelines in effect on t/~b. dat~ Of ihis inspection. Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number 'i11. WA$'TEWATER DISPOSAL Septic Tenk/Abtorptlon System Holding Tank - I Capacity of Tank [] Specify: Discharged To: (Specify Bra .n(~ Name or P~ocess) Other (Specify): · [] {Outhouse, Incinerator, etc.) IDete Installed ~'~),~ [] Other: Type/Manufacturer / ~(~¢~ner/Builder [] Certifi.dNo. In,taller Septic Tank Size (Gallons) Number of Compartments Soil Type or Rating ~ J ~ ~o ~ ~ I~ Type So I Ablorptio. Syltem Dimenlions/S~ze SoiJ Abso~,;on Syitem ~t~,~]&kf,tl Material upd for S0il ~ercoladon Te~t Resul~ Percolati~ Test by: (N~me~ / Minimum Ground Cgver over Ab,orp-l~i~[mu~ Orouqd C~er ove¢ Septic ]~1~ ~ni~e~/Caps Installed on ~1 ~t~~s installed on tion area a Yes No - Yes ~ No ' ' ~, ~ Feet ;er~/;~at ,~y¢~information is co[rec~'.-- ~ Existing System --' -- m ~roun ' Cover o c' Absorp- ~ Mi ....... Ground Cover o~er $eo:,c TOleano ......... Caps msta,le~]~,Q%J [~¢~n'%e~s 'nsta~;e¢ o~ Distance to: J Feet/ Feet J FeetI ~_ Fee, '~re t S-&-S-ENGINEER1NG I c~'t~fy/that th~l~e inforr~ati0n is co c: · IT " 'nte '' ~ NOYE: Must ~ signed by a professional engineer. ' J. I Title ReD/Cert. NO. Init NO . . IV. DIAGRAM OF SySTEM(S) · INSTRUCTIONS FOR DIAGRAM 1, In! a plan view, locate and identify each of the following: a) Well . b) All Structures c) Septic Tank , - d) Soil Absorption System e) Surface Water f) Sources of Contamination g) Property Line . ~ (Include Dimensions} h,) Closest well on an adjacent property i) Closest septic tan~( on an adjacent property j): Closest edge of In absorption field on an adjacent property , , 2. Show dietances between the well end each of the other items li~ted in 1, 3. Show distances between water bodies end each of the other items listed in 1. 4. In a crow section view of the soil absorption area, identify each component and show the depth (thickness) of the following: a) Soil Cover b) Absorption Material c) Water Table d) Bedrock e) Discharge Pipes rid MUNICIPALITY OF ANCHORAGE ® Department of Health & Human Services o DIVISION OF ENVIRONMENTAL SERVICESi 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # 12)6l -(Z�6Q HAA #�� L(�� 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Robin Dale Addn. #1, Lot 5, Block 2 T15N, R1W, Sec.3 Location (address or directions) 22544 Robinson Road Eagle River, AK (b) Property owner H - U . D . Telephone: (home) Business 2 71-4 34 2 Mailing Address 222 W 8th Ave (Box N-64) Anchorage AK 99813 (c) Lending Institution N/A Telephone Mailing Address (d) Real Estate Company and Agent Associated Brokers Address 640 W 36th Ave , Suite #1 Anchorage, AK 99503 Telephone 563- (e) 63- (e) Mail the HAA to the following address: (or check here O, if hold for pick up.) List contact person and day phone number below:. Pick up by Engineer 2. TYPE OF RESIDENCE Single -Family 3. WATER SUPPLY Individual Well R Number of bedrooms —5 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 2 Public D Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 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. 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 Eagle River Engineering Srvs Telephone Address P.O.B. 773294 Eagle River, AK Date 4Z��=d 694-5195 t.i'+s •'�3a ei0 a?r04,i�' !ly �7,.j fi,'y [�gir�C'-SeaI ,per n .. g"� � ocoaga.nosoc®easaaxosaoanaM«- ,a ly iooM 0e03a�....0 mo aa••. a+v� V ccl Louis A. Butes �y• uoa CE -6726 L Dp '7 ROFESSt� �� 6. DHHS APPROVAL Approvedfor bedrooms by Date Approved £errdTtftsTid1" Terms of Conditional Approval CAUTION .,... x , 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. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) i LITY OF A%J4e&&IST - FEBRUARY 1984 EN ENTAL SERVICES DIVISION 343-4744 JAN .12 1990 Legal Description: �� t S �3isr z iPd6,N �(4te A. DATA RECEIVED Well Classification / If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) _ Date Completed Yield S 6-0— I,_61 Total Depth � Cased to t`�� Depth of Grouting "✓/_t Static Water Level !So ' Pump Set At t -/s � Casing Height Above Ground 3/ Electrical Wiring in Conduit (Y/N) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot !S 3 ' ; On Adjoining Lots ; On Adjoining Lots ivv' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line eV—A To Nearest Public Sewer Cleanout/Manhole "JAq To Nearest Sewer Service Line on Lot �y Water Sample Collected by Date Water Sample Test Results Comments -7.2- B. SEPTIC/HOLDING TANK DATA U'V' Date Installed Zf76- Size No. of Compartments �Z Standpipes (Y/N) y Air -tight Caps (Y/N) y Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped 1/70 J fe Pumping/Maintenance Contact on File (Y/N) A/, ;for y Holding Tank High -Water Alarm (Y/N) &IeQ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well !S3 To Buildin9 Foundation j3 To Property Line t1a , To Water Main/Service Line /moo " To Stream, Pond, Lake or Major Drainage Course Comments – To Disposal Field 8� 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �d5 �� 4 -2': Date Installed /f 7s - Width of Field 3/ Type of System Design T1 1e- Length of Field ,L Depth of Field A7 - Gravel Bed Thickness J q i - Square Feet of Absortion Area 16r 7 `/ Statndpipes Present (Y/N) Depression over Field (Y/N) /V Results of Last Adequacy Test c54 t'J SEPARATION DISTANCE FROM ABSORPTION FIELD: Date of Last Adequacy Test To Water -Supply Well /.?.s-/ To Property Line r_ fv To Building Foundation To Existing or Abandoned System on Lot /-s ; On Adjoining Lots - ?,:p To Water Main/Service Line do / To Cutback (if present) -41 To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area t�O Comments s, 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) **Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines n e_ffe,ct on the date of this inspection. Signed _ Eagle Rivcr Engineering Services CompanyF. U. Box D3294 f ,z Eagle River, AK 99577 � _-�� Engineer's Seal 694-5195 Date ��o MOA No. <. Receipt No. Receipt No. Date of Payment / - / Z — ��O Amount: $ /-70 _(rn Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2