HomeMy WebLinkAboutT15N R2W SEC 25 LT 28BT15N, R2W,
Section 25
Lot 28B
#051-281-64
WATER WELL RECORD
STATE OF ALASKA
OEPARTMENTOF NATURAL RESOURES
Sent By: RE/MAX OF EAGLE RIVER~ INC,j
9076960214~ Sep-6-O0 4;41P~1 Page 1/1
- It. O0 06) 30" g.
o SHIg$ STREET
-Z
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENI'AL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
[] UPGRADE
MAILING DRESSY_
~ Dwelli g PERMIT NO
Mateda
Liq. capacity/~ ~o[n gallons iF HOMEMADE: Inside~le~ Widt~ Liquid depth~
O ~ ~ Manufacturer ' Liquid capacity in gallons
~ DISTANCE TO: ' /O~ F°unOa~o~ ~ Nearest '°7~e PERMIT NE,~ ..
~ Ne. of lines, ~engthQfeach,lJne Total lengthoflJne~ Trench~i~ Dista~cebetwee, li,es
m m DISTANCE TO: WO~ ~uilding foundation Nearest lot line
~ ~ Class Depth Driller~ ~/ ~e PERMIT NO,
~ DISTANCE TO: Bui~, ~ ~ Septic tank Absorption area(s)
OTHER
72-013 (Rev, 3/78)
~MUNICIPALITY OF ANCHORAGE
Department/ ~
~ , ~. Health and Environmenta:'?rotection
~' '- 825 ~ Street, Anchorage, AK. ~9501
264-4720
"~ F ~ * * * HANDWRITTEN PERMIT * * *
Permit ~ ~ ~ WELL AND/~ ON-SITE SEWER PERMIT
Applicant: ~)~_~ ~A~ Mailing Address: ~,~,
Phone Nunfoer:
~L~_ ~/P, Lot Size:
Location:
Legal Description: L~ ~
Type of Soil ~J~sorption System Is:
Trench: . Drainfield: y _
Maximum Number of Bedrooms: ~
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br)
The Required Size of the Soil ~bsorption System Is: '
DEPTH ~7!
LENGTH ~--~L~-GRAVEL DEPTH .~/WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(H'6-LDiNG) TANK SIZE = /~d) GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will' be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feel
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimur~ distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days Of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 3L i 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth bY the Municipality of Anchorage.
Signed .' ~ ~ ~.,.~, ,~/~/ Issued
' :licant Date: p/~/.~
~SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCR PT,ON:
1
4-
5-
6-
7-
8-
9-
10-
11
13-
14-
15-
16-
17-
18-
19-
20-
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
PERCOLATION RATE /'~J / ~ (minutes/inch)
TEST RUN BETWEEN , FT AriD/ i , FT
Gross Net Depth to Net
Reading Date Time Time Water Drop
COMMENTS
PERFORMED BY:
72-008 (6/79)
SITE PLAN
WAS GROUND WATER
:R ANCHORAGE AREA BOR'~'iGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
NAMEjO*f
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
NUMBER OF
U
INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY ~(~0 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS ~ DIAMETER ~//~'
LINING MATERIAl /~(2 '(~ CRIB SIZE;
BUILDING FOUNDATION ~,)1, NEAREST LOT LINE
OR WIDTH 1~';, LENGTH /~,/ DEPTH
DIAMETER'~ DEPTH ~t DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
.SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
DEPTH
DISTANCE FROM:
NEAREST
SEWER LINE
REMARKS.
SEPTIC
TANK
SEEPAGE
SYSTEM
DISTANCES:
/~0~ ~A~ DIAGRAM OF SYSTEM
INSTALLED BY:
PIPE MATERIAl -
LOT SLOPE:
REMARKS;
Form No, EQ-031
#1:
· ~ MUNICIPALITY 'OF ANCNORAGF~- EAGLE RIVER AR~A~
DERARTME~ ~ OF HEALTH AND ENVIRONMEN'] ~- PROTECTION C, It}~N.~x~
· 825 ~t. Street, Anchorao~. Ala~A 99501 k~
264-4720 ~. ~ ~..,, ~ 3.
~ ~ ~O~'~ ~,~C~ Date Receive~: DecemberS9, 1977
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: Lomas and Nettleton Company
Mailing Address: 4449 Business Park Boulevard Phone: 274-7661
2. Property Owner: J. Kornegary
Mailing Address: % Selective Realty, 694-9524
Phone: 803-293-3106
3. Legal Description: T15N R2W Section 25 Lot 28
4: Single Family Residence: (s)
Multiple Family Residence: ( )
Number of Bedrooms: Two
Number of Bedrooms:
Well System:
Permit #
Construction
Individual well (x) Community/Public System ( )
Depth of Well ~' Well Log on File
Bacterial Analysis
Sewage Disposal System: On-site System (x) Public Utility ( )
Permit ~ Installed ~q~g/. Installer
Septic Tank Size I..~!~) ~JS Manufacturer ~,~ ~/~
Absorption Area ~ ~.' Soils Rate Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
' . ,qUN]C[PAL!TY OF ANCHORAGE
~epaytment of Health and Environmental Pro~ectio~
825 L S~reeh, ~cho~age, Alaska 99501
279-2511, e~k. 224, 225 - 4th Floor
for Approval of Indmvzdual Sewer and WAter
Property Owner: J. Kornegary
%Regen~ lowers
Mailing Address: 2511 So. Ocean Blvd., Mertle Beadh,
South Carolina 29b//
Phone:
803-293-3106
Name of Buyer:
William Wendell E. West II
Mailing Address: Palos Verdes Apts., Apt. #208
Phone :594-9542
Lending Institution:
Mailing Address:
The Lomas & ~ettleton Company
4449 Business Park Blvd., A.A.
Phone:
274-766l
Realtor/Agent:
Mailing Address:
Legal Descriptmon:
Street Location:
Selective Real~z
P.O. 3ox 1065, Artillery R~
Eagle River, AK 99577
Lot 28, Sec. 25T 15N R2W, S.M AK
(Andrew Street) (Kamkoff Avenue)
Phone: 694-9524
Single Family Residence: (X) Number of Bedrooms;
Mu].tiple Family Residence; ( ) Number o~ Bedrooms:
W~ter Supply: * Individual Well (X)
If Individual Well, well depth
If Community System, name of system
Public/Connmunity System (
Sewage Disposal 'System: On-site System (X) Public System
If On-site System, date of installation:
*NOTE: A well log ms required on AL1, wells drilled since 6/~5.
3/77
LegaI Description: T15N R2W Section 25 Lot 28
Comments:
Affadavit Attached:
Approved:
Disapproved:
Letter Attached:
Date:
Date:
Department Worksheet
(a3elsod snld) ~Og--"IIVW O31tlJ. a:]O $0.4 ldl.qO3~J
Parcel I.D. #
MUNICIPALITY Of ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, A~aska 99519-6650
(907) 343~,744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOP, A SINGLE FAMILLY DWELLING
051-281-64
HAA# (~00 z--/~ ,.~-' 0
1. GENERAL INFORMATION
Completelegaldescription LOT 28B. SECTION 25. T15N. R~W
Location (site address or directions) 16216 SHIMS STREET EAGLE RIVER. AK 99577
Property owner DEBRA EVANS
Mailing address c/o BROOK STILTNER
Lending agency
Mailing address
Agent BROOK STILTNER w/ REMAX OF E.R. Day phone
Address16600 CENTERFIELD DRIVE EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Day phone
16600 CENTERFIELD DR EAGLE RIVER, AK 99577
Day phone
(907) 244-6742
5
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site xxx
Holding Tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
ing to the legality and status of system.
72-025 (Rev. t/gl) Front MOA #21 Computer Version
Note: Alaska Water and Wastewater Consultants, Inc. shaft be paid $1,100.00 at
or prior to, closing for the engineering services provided.
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 a,l~:t State codes, ordinances, and regulations in effect
on the date of this inspection.,,//~[/
Name of Firm ALASKAWA~W~ ¢~'F~V~;IZE~R CONSULTANTS, INC. Phone (907)337-6179~
Address 6901DEBARRR(~AD, sL~t/¢f /2B/.~I~CH~RAGE,ALASKA 99504 ,' / --
In conducting thio evaluation, AVWVC, /nc.~t~m; !d to ~st4d~ a thorough, conscientious engineering analysis of the
system in accordance with ADEC and MC~A l~HH, Guidelines&Regulations. The reported results described the
performance of the system under the conditions ehcountemd 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, ground water 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 ,=~'~ r-
the evaluator of the system. Sstisfacto8/ test results do not guarantee future performance ~:~x ~.
of the system, nor do they guarantee that there are no hidden defects or encroachments. ~z~" ////~' '/' ~ ~-~
AW!/VC, Inc. can therefore not provide any warran~l for future estimate of how long the ~c~.'."//C
system will continue to meet the operational requirements of the ADEC or MOA DHHS. ZC..w.:.:,..~.~ ~-~..~....!."...~.
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,~47,,'..~'~" ~"." -~ ..... .~ .:...
nor will it confer any legal right whatsoever. ~ ¢ ...~ ~rr . .:
b/' Approved for .-~ bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By: ~--~,,/~,_,~/ f/_/2. /~~ Date ~l-,'~-/-CO
The Municipality of Anchorage Department of HeaIth 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. 1/91) Back MOA #21 Computer Version
Legal Description:
A. WELL DATA
Well Type
RECEIVED
Municipality of Anchorage SEP i~"~Z000
DEPARTMENT OF HEALTH & HUMAN SERVICES
· Environmental Services Division__M~ICJPAL/TYI ITY OFANCH0
825 "L" Street, Rm 502 Anchorage, Alaska 99501 (90~J~i~i~TAL
Health Authority APproval Checklist
LOT 288, SECTION 25, T15N, R2W, Parcel I.D.: 051-281-64
PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) YES
Total depth 125'
Sanitary seal (Y/N)
Date of test
Static water level
Well production 2.0
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: 9/13/00
FROM WELL LOG
10/15/83
Date completed 10/15/83
Cased to 80' Casing height (above ground) 12"+
YES Wires properly protected (Y/N) YES
AT INSPECTION
9/15/00
NOT GIVEN 34'
B. SEPTIC/HOLDING TANK DATA
g.p.m. 4.84 g.p.m.
Nitrate ' '~' Other bacteria
Collected by: A.W.W.C., INC.
Date installed 10/83 Tank size 1000
Foundation cleanout (Y/N)
Date of Pumping 9/13/00
C. ABSORPTION FIELD DATA
Date installed 10/83
Length 36' Width
YES Depression (Y/N) NO
Pumper OLD McDONALD'S
Number of Compartments 2 Cleanouts (Y/N) YES
High water alarm (Y/N) NO
Soil rating (g.p.d./ft2 o~
85
5' Gravel thickness below pipe
System type. TRENCH
2' Totaldepth 8.5' +/-
Effective absorption area
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth 0" . (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72q)26 (Rev. 3/95)* Computer Version
324 SQ.FT. Monitoring Tube present (Y/N) YES Depression overfield (Y/N) N0
9/13/00 Results (Pass/Fail) PASS For 3
0" Immediatelyaftar 1187 gal. water added (in.): __
12 Absorption rate = 450+
NONE KNOWN If yes, give date -
Bedrooms
3'~
D. LIFT STATION . ~-
Date installed__ ~ .
Manhole/Access (Y/N) ~t* "Pump off' level at* ~.
High ~eer~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot '103%
Absorption field on lot '104'+
Public sewer main N/A
* FROM EDGE OF WELL
TO EDGE OF STANDPIPE
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout_ N/A
Sewer/septic service line
25'+
Lift station 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+ Absorption field
Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots __
IO0'-F
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main/service line 10_%
Surface water
Cudain drain
100'+
NONE KNOWN
Driveway, parking/vehicle storage area 10'4-
Wells on adjacent lots 100'+
eld Inspections and review
/stems are in conformance
this date.
F. ENGINEER'S CERTIFICATIOn/-/
I certify that lha)~e'~toNn~'~th/'u
of Municipal rg~erds ~h~t ~h,~ ~l~ve
Signature "----~"1"11v ~ t
Engineer% Name/t UJEFFR%
Date ~'/I 8/O3
A, GARNESS
HAAFee$ ~:~ c~
Date of Payment ~//
Receipt Number ~ ~-~or~
72-026 (Rev. 3/98)* Computer Version
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE ~ ~,~
DEPARTMENT OF HEALTH & HUMAN sERVIcES
Division of Environmental Services ,~,u_k~[~;~.sE~.Vt¢~.
on-site Services Section ,qVt~
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLIN(~
1. -' GENERAL INFORMATION
Complete legal description Lot 28B; Sec 25; T15N; R2W
Location (site address or directions
16216 Shims Street
Eagle River,. AK
Day phone
Eagle River, AK 99577
Day phone
/%.l~roperty owner steve & Debbie Crouch
16216 Shims Street
~ ........ Mmhng add
ress' ' '
3'~""'-~'kending agency· ·
:;-:i' Mailing address
% .Agent
Address
Day phone
694-1058
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
!ndividua, I on-site
Holding tank
Community on-site
Public sewer
xxx
NOTE: If community wastewate¢ system, provide writte~ confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91} Front MOA#21
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.
$ a $ ENGINEERING Phone
Name of Firm
· Address Eagle Rive~, .Alaska?9577.
Engineer's signature Date /I / I~/~ 7
DHHS SIGNATURE
/ Approved for
Disapproved.
Conditional approval for
bedrooms.
CE - 8801
bedrooms, with the following stipulations:
Additional Comments
Date_ /~'' [' q '~
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 DH HS 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.
Legal Description: LOT'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVI~
Environmental So.ices Division
825 L Street, Room 502. Anchorage, Alaska 99501 · (907)
~Health Authority ApprovaLChecklist
~c7~0~ ~ 7~ ~ ParcelI.D.:
A. WELL DATA
Well type
Log present ~/N) ¥'~ ~
!
Total depth '1 ~ 5-
Sanitary seal (~N) ¥ '~ J-
Ifa, B, or C, attach ADEC letter. ADEC water system number
Date completed ] o / /,.F-/6 ~
Cased to ~' 0 Casing height (above ground)
Wires properly protected
FROM WELL LOG
Date of test / O /
Static water level
Well production o%- g.p.m.
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform O Nitrate
Date of sample: ~
B. SEPTIC/HOLDING TANK DATA
Date installed /o / ~' ~5 Tank size
/OOO
Foundation .cleanout
Date o[.PumPihg I~/;~3/47
C, AB$OIRp~ION FIELD DATA
Date icftu!led
Length; ~
Depression (Y~)
Pumper ~ ~
Other bacteria 0
Collected by: $ & S ENGINEERiN¢.
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 9~$77
Number of Compartments ~ Cleanouts (~/N).__
/" ~ High water alarm (Y/~
f Soil rating (g.p.d./ff~ o*;~ ~'
Width ~ Gravel thickness below pipe
System type ~-,~- ~,'~¢ ~/
Total depth
/'r Monitoring Tube present~'~'/N) ¥~'$ Depression over field (Y(~
Effective absorption area ~5~"7
Date of adequacy test i~ 1 /? /~ ? Results(~/Fail) /3~$J For "~
Fluid depth in absorption field before test (in.);
Fluid depth '~ ~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N) ,~
Immediately after z/~'gal, water added (in.):
Absorption rate = '~/~6. -f- · - g.p.d.
/<'/.,o~qJ If yes, give date
bedrooms
J~
· 72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) ~level at*
High water alarm level at* ~ *Datum .
Cycles tested ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ]0 ~
Absorption field on lot /06
On adjacent lots
On adjacent lots // 0
Public sewer main
Sewer/septic service line 'c)- $- Y Lift station
SEPARATION DISTANCES FROM sEPTIc/HOLDING TANK ON LOT TO:
/
Foundation ~' 't'- Property line '~- '~ Absorption field
Water main/service line
Public sewer manhole/cleanout
/0
)O -~' Surface wateddrainage /OO "Y- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ) '/ Building foundation ~ ~' Water ma n/serv ce line.
Surface water / O0 / 'h- Driveway, parking/vehicle storage area. (¢ 0
Curtain drain /~'¢,~/¢ /.(,,~o ~-, ~ Wells on adjacent lots ]o O '~'
F,
ENGINEER'S CERTIFICATION
:,7%~ OF,
~ ~ertify that ~ have determined thru fie~d inspecti~ns and review ~f Mun~pa~ rec~ the a
SignatureinC°nf°rmancoWitff72m~u~°sinoffoct°nthisdat°'o~/~'~/
Engineer's Name ~¢ ¢1J~-¢ ~
Date II /I ~ /
f~ ;,.', .... .,'.~
HAA Fee $ ~" ~
Date of Payment
Receipt Number
Waiver Fee $.
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
~Lot 28B; S~c. 25, TISN, R2W, S.M.
Location (address or directions)
16216 Shims
(b) Property owner A~thon~/ R. Hanson Telephone: (home)
Mailing Address HC 78 Box '$250 ChugZak, Alaska 99567
. Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent TARGET. INC.
Address 17034 North Eagle Riv6r Loop Road
Telephone 694-~88 ~:
(e) Mail the HAA to the following address: (or check here)~, if hold for piok up,)
List contact person and day phone number below:
ATTN: Pete 0st~ik
Eagl~ Riv~rrAk. 99577
S & S ENGINEERING
17024 ~a~le Ri~ I ¢,,",,~
~gJe River, Alaska 995~
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well r~x. Community [] Public []
Note: If community well system, must have written confirmation from the State Depm:tment of Environmental
Conserva[ion. 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.
72-025 (Rev. 7/88) Page 1 of 2
· NJo~ 8,JaeU!i~ua leUO!SSeJ°Jd eq~ u!
suo~es~u~o Jo sJoJJe Jol alqmuodseJ ~ou m a~eJoqouv Jo A~ ed~o~unv~ @q/'penss. s. ~eo!l~]Jao e eJoJ~q e~ep aZAleUe Jo
suo.~oadsu~ ~onpuoo ]ou op SHHQ ]o sea,%ldLU3 's~uauJeJmb@J e~e~s pue leJepej u e~Jeo,~eqes o~ jap Jo u suol~m, ~,sul
6u!puel J!eq~ pue seuJoq jo sjeseqoJnd O] ~se~Jnoo e se s!q~ saop SHHQ eq.L 'eNsew Jo ele~S eq~ u!
jaau~bue leUO!SSeJ, oJd ],uepu@depu! ue Aq e^oqe ~ qdeJ§eJed u! ue^.b suoRe]uaseJdeJ @q~ uodn ~lUO peseq
le^oJddv A~!Joq~,nv q~,leeH sense! (8HHQ) eao!^Ja8 ueuJnH pue q~leeH 1o ~ueuqJedeQ ebeJoqouv jo,~!led!o!unlM eqJ.
leAoJddv leUO!].!puo0 tO euJJ@.L
leUO!~!puoO- pe^oJddes!C] - / pe^oJdd¥
' 'lVAO~dd¥ SHHa '9
euoqdele±
tuJ!-t Io eLUeN '
'uo.loedsu! s!q3 jo e3ep eql uo 1oetJe u! suoRelnSeJ pue 'saoueulpJo 'sepoo e~eIS
-.
puc led~mun!AI lie ql~M eoue!ldLuoo u! s! uJe~s/~s esods!p ~e~eMeiSeM Jo/pue/~lddns jeleM e~!s~uo eq~, 'uoiloedsu!
pue uo.le6ilseAu~ Auu Luo~t pue sel!l e6eJoqouV lo /~liledlo!un~ eql Luo~ peu!elqo uo.leuuJo,Lm eq~, uo peseq
~eq~/~tpeA Jeq~Jnt I 'u!aJeq palea.pu! eJm, on~3s to @dA~, pue euuooJpeq jo JeqLunu eq~ ~ot elenbepe pue' leUOgOunJ
'ales s! uJm, SAs lesOds!p jeleMelSeM Jo/pue /,iddne Je~eM e~!s-uo eql.leql SMOqS ~Ao~ddv ,~Ipoqlnv q31eeH
s!q), jo UO.3~6!~SeAm/%U ~eql/~,Lpe^ I 'MOleq UMOqS eiep UO!lep!leA equo se pue o~aJeq pex!lte lees/~u Aq pehqlJeo sv
NOI.L¥1NWO4NI aNY ¥.LYa 'HOEI¥:IS ~nl:l '$.l.S:lJ. '$NOIJ. O:IdSNI 9NlalAO~d INI~1-1 9NII~:I::INION:1 .cj
<q
/,~--~g MUNICIPALITY OF ANCHORAGE (MOA)
,/~j~,~o~4 Health Authority Approval (HAA)
.,,c,~?i,,t~'~ O[~.-~q~ CHECKLIST- FEBRUARY 1984
$~ ,~ ~o~ Legal Description: ~
Well Log Present ,~/N)
Total Depth ~ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (~/N)
SEPARATION DISTANCES FROM WELL:
To Septic/~ Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ,,'~
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
Date Completed
¢O/ Depth of Grouting
Pump Set At / /.//¢~/Z-2.Cf//')
/~ '~"/' Sanitary Seal on Casing tiN)
/V Depression Around Wellhead (Y/~)
If A, B, C, D.E.C. Approved (Y/N) /~//.~
/0-/-'~'- ¢:~,:~ Yield~ ~ -Z ~ - q ~ )
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
/
B. SEPTIC~ TANK DATA
Date Installed /~" ~:~ ~ Size .¥~7"'~-. No. of Compartments
Standpipes ~/N) .Y Air-tight Caps ~/N)
Depression Over Tank (Y/~::~
Pumping/Maintenasce Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ,/_¢'D~ / To Building Foundation
To Property Line '~' / ¢ To Disposal Field
To Water Main/Service Line
Foundation Cleanout (Y~
-/
Date Last Pumped ~-~ -
; for
Temporary Holding Tank Permit (Y/N)
To Stream, Pond, Lake or Major Drainage Course
Comments '"/~/'~ d:;:~/~ ,~/'2'~ ,~/~
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (~-'~4) /V'
Date of Last Adequacy Test
/
SEPARATION DISTANCE FROM ABSORPTION FIELD:
· To Property Line
To Water-Supply Well
To Building Foundation
· et
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage, Area
Comments
To Existing or Abandoned System on
; On Adjoining Lots
/E~p/W' To Cutback (if present)
/¢2~/ ¢-
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
inspection.
Signed
Company
Date
MOA No.
ENGINEERING
17034 Eagle River Loop Road No. A04/
~_~; ,~hte,,,, ~AIn~ka 99577 "~
this
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) 88ck
Receipt No
Waiver Fee: $
Date of Payment
Page 2 of 2
~, APPLIC HT FILLS OUT UPPER HAl' ~ONLY
Prope[ty O"wner J~XJ
Mailing Address
Address Zip Code
Address Zip Code
Type of Resi~nce
~Singte Family
~ Other
~ Individual A~ACH WELL LOG. A w¢l log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if ~vailable).
Sewer Disposal
~ Individual Year Individual Installed:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
~MUNICIPALITY OF ANCHORAGE
DEPT. OF H~i',LTII
ENVIRONMENTAL PROTECTION
OCT 2
RECE! ED
( "~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
DATE J~:)-- ~
BY: ~ C~--~
Soils Rating Date ~ewer Installed Well To Absorption Area ./ O ~ Well Log Received
~____~.~"'"-' ~ -- ~ Well to Tank // ~) ~- Septic Tank Size ~/~ ~,~
--
'~ .Og ~90 O0 °~
/~i ~-~UNICIPALITY OF ANCHQRAGF/~
~ :', DEPARTMEN OF HEALTH AND ENVIRONMENI'~ ):ROTECTION
_~ '' '82'5 ~ Street, Anchorao~. Alaska 99501
264-4720
Date Received: April 5, 1978
#1: Time 11 a.m. #2: Time
Insp Pr~ _' Insp ~
Time
Date
Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request:
Mailing Address: Pouch 7-012
Alaska Bank of Commerce
99510 Phone: 279-5641
2. Property Owner: Karl A. Bohlin Phone: 333-2606
Mailing Address: 3500 Northwood Drive 99503
3. Legal Description: T15N R2W Section 25 Lot 28A (Lot 28 Kornegary)
4: Single Family Residence: (x) Number of Bedrooms: Four
Multiple Family Residence: ( ) Number of Bedrooms:
Well System:
Permit #
Construction
Individual well
Depth of Well
6. Sewage Disposal System:
(x) Community/Public System ( )
130' Well Log on File (
Bacterial ~malysis qo-$~t%~c~O~3.,
On-site System (x) Public Utility ( )
Permit #
Septic Tank Size
Absorption Area
Installed 1974 Installer
Manufacturer
Soils Rate Material
7. Distances: Well to Septic Tank
to Absorption Area
to Sewer Line
Nearest Lot line
Absorption Area
to Nearest Lot Line
'"~'~%~ *D'epar~m~nt of Health and Environmental Protection
f~ ' 825 L Street, ~chorage, Alaska 99501
~' ~equest for Approval of Individual Sewer and Water Facilities
e
Name of Buyer:
Mailing Address:
Lending Institution~~
Mailing Address:
o
Realtor/Agent:
Mailing Address:
Phone:
Single Family Residence: ('//' Number of Bedrooms:
Multiple Family Residence: ' ( ) Number of Bedrooms:
7. Water Supply: *Individual Well (/ Public/Community System ( )
If Individual Well, well depth )~O
If Community SYStem, name of system
8. sewage Disposa%..System: *~n-site System (~[~ Public System ( )
If On-sit? system, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/77
Page Two~
6epartment of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: T15N R2W Section 25 Lot 28A (Lot 28 Kornegary)
Comments:
Affadavit Attached:~.,
Disapproved
Letter Attached: ( )
Date:
Date:
Department Worksheet:
/__n~ ~ ~/4.