HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3 BLK 4 LT 20Thunderbird
Heights #3
Lot 20
Block 4
#051-582-39
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEAl. TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
c-id ~llons
Nearest lot line ~ PERMIT NO,~.~?~ ~
Trench wid,~t~(_~ inches
DISTANCE TO: Foundation
No. of lines Len9th of each tine Total length of lines
Top of tile to finish grade Material beneath tile
Dsorptjon area
Length Width
Depth PERMIT NO.
b depth ~tion area
DISTANCE TO:
Depth Driller Distance to lot line 'PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
DISTANCE TO: 4 _~.~, .~ ~ O'b ¢- ~..- ~-;, ~ ~,~ ~-
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
APPR ED ~ DATE
72-013 (R'e'v, 3/78)
LEGAL
~]i~ ~-,,~ -- S; ~: ]"' E
F'ERMIT NO. ( 8::1.1~I074 >
I=IP F'L I CRNT
LOCR'f: I ON
L.EGRL.
KLEIN CON':S'I'F::LtC T I ON
F..'RME N L.C)OP
[;:'EPFtRTI'IENT .... HERL. TH RND ENVIRONMENTRL.. '~:crf'E:CTION
: :~....~d;.1..
,:,,:~..., "'~¢ .: I F4. EE]. FINCHORRGE., RK. " *'
.... E...IL..Itb~:.F;. F .E5..'£1~ .,J'l :ti: 'TH ¢
E:O',:'.', 2524 F'FIL. MER RK
7'4.g-2:TS:L
L20 B4. THUNDERBIRD HEIGHTS
LOT SIZE 2:LEE~9 '.'=;QUR,~;~:E FEET'
T'T'PE OF :SOIl.. I=IE~SORPI'IC~N S'¢S'f'EM IS: "f:RENCH
MR,'."::IMLIM NUMBER OF 8EDROCIMS = S
SOIL. RFI"f'ZNG ,::SQ FT/BR)= 85
THE REQLIIRED SIZE OF THE SOIL. RBSI]RPTION SYSTEM
THE LENGTH DIMENSION IS THE LENGTH (IN FEET)', OF THE '['RENC:I-I OR DRFIINFIELD.
THE [:,EPTH OF' FI TRENCH OR PIT I:=.; "f:laE DISTFINCE BET,WEEN THE SIJRFRCE OF THE
GROUN[:, RND THE BOTTOM OF' THE EXCRVRTION ,::IN FEE]").
TH-ERE I!:"; NO SET klI[:,TH FOR T'RENCHEL:':;.
THE GRFIVEL ['.,EPT'H ]:S THE MINIMUM DEPTH OF GRR',,,'EL BET.tqEEN ]"PIE OUTFRLL F:'IPE
RNI]:, THE BOTTOH Of:: THE EV, CRVRTION ,::IN FEET).
F'ERM !'l" FIF'PL I CRNT FIRS "rile RESPONS I B I L I"["T' TO INFORM THIS DEPiRRTMEF,f:I" DUR I NG 'f'HE
I NS-I'RL. LFfl" Z ON I NSf::'ECT 1 ON'..':.:; OF:' FII'.,I'¢ NEL.L:S RDJRCENT TO "I'H I :S PROPERT'.r' RND THE
NUMBER C)F RESIDENCES T'HFIT T'HE klELL.. 1.4ILL SER',,,'E.
BRCKFILL..ING OF Ri'.,l'-? :S'¢STEM I,.IITHOOT FINFIL. Zlq'.'.~;PEOTIOIq frd'.,!D FIf::'Pf:~:OVRL. IB¥ "fHIC;
DEPI:::IRTMENT' klIL. L BE SUBJECT TO PROSECUTION.
MINIMLIM [)ISTF:IF,ICE E:IZ"fklEEN R kIEL[... AN[:, RNY ON-SITE SEklFIGE [:,ISPOSRI_ SYSTEM IS
J..r...!~O FEET FOR R PRIVRTE I,.IELL. OR :t.50 TO 200 FEET FROM R PUBL. IC 14ELL DEPENDING
UPON THE T"r'F'E OF I-"LIE:I_IC 1.4EL.L..
MiI",IIMUM [:'I~TRNCE FROM R PRIVRTE 1.4E]_L. TO R PRIVRTE SEWER L. INE IS ~5 FEE]' FIND
TO R COi"li"~UNIT*? SEI.4ER LIIqE IS 75 FEE']'.
OTHER REQLJIREMEi'4TS MR¥ f:IPF'L'TL S;PEC:IFICI~TION2'; RND CONS'f'RUCTION [:,IRGRRMS RRE
RVF:IILRE',L.E TO INSURE F'ROPER INSTRLLRTION.
I CERTIF'¢ THRT
:::L: I RM F'FIMILIFIF:: klITH THE REQtulIRL"]'qENTL=; F:OR ON-'SITE SEI4ERS FiND I.,.IELLS FIS SET
FORTH B'¢ THE MUNICII='RL IT'¢ OF RNCHORRGE.
2: I klILL INE;TRLI... THE S"r"?f:EM IN RCCORDFINC:E ,t,.IITH ]'HE CODES.
3:: I I.JNDERSTFIIq[:, THR'f' THE Oi",I-E;I'I'E SENER SYSTEM MR"r' REQLIIRE ENI_RRGEMENT IF THE
RESI[:'ENCE IS REMO[:'ELE[:' TO INC::I~[~ MORE THRN S BE[:,ROOHS.
..z,I o l.,IEr:,: .................................. .........................
RPFt. I CRNT I<L.71 1' ~/Z I:;ON~-.;TRIJCT ~ ON
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
2
3
9-
10'-
11
12,
13-
14-
15-
16-
17-
18-
19-
20-
[] PERCOLATION
TEST
DATE "ERFORMED,
SLOPE SITE PLAN
COMMENTS
PERFORMED BY:
ENCOUNTERED? ~
E
iF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
;OLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND , FT
[[~'& B ~nqbee~dz~rj'
CERTIFIED
72-008 (6/79)
,t
• Municipality of Anchorage
On-Site Water and Wastewater Program "Li(907) 343-7904 a SEP s A
w
Certificate of On-Site Systems Approval `' 01 6 g L
Parcel I.D. 051-582-39 Expiration Date: 12_' L O / 7
1. GENERAL INFORMATION
Complete legal description Thunderbird Heights #3 Block 4 Lot 20
Location (site address) 24615 Teal Loop
Current Property owner(s) Marc & Lucy Viens Day phone
Mailing address 5409 Rambling Rd. Greensboro, NC 27409
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System Public Sewer ❑
WaiverNariance request for: Distance:
Received b. • L � L.L�; 44,_ /A Date:
q/(2q) --1_
COSA to be released to the engineer, unless otherwise requested by tengineer.
COSA Fee $ 5260 - Waiver Fee $
Date of Payment _ gligir? Date of Payment
Receipt Number o5-an4 Receipt Number
COSA# 05['fi1aWaiver#
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, based on procedures outlined
in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at
the time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
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 the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 9/13/2017
• of Ak•ANkkh
,i • y- SFA
.*
6. DSD SIGNATURE
/J Steven tt. l onnane
System #1 Approved for bedrooms };.• C'W*0'' =fir
System #2 Approved for bedrooms •
s %
Disapproved kk�/'R0iFESSfONP'
Conditional approval for bedrooms, with the following stipulations:
t c l [X /eaA,c( 04_0 it
,..,,,\.\\-(\( OF
ersk
ON-SITEWI
WATER AND
WASTEWATER
0::
PROGRAM • -
Y? SER\Au
By: Original Certificate Date: -L -20._17
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_c •
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Thunderbird Heights #3 Block 4 Lot 20 Parcel ID:051-582-39
A. WELL DATA
Well type Public If A, B, or C provide PWSID# Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height(above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/16/1981
Tank size 1000gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A
Date of pumping 12/7/2016 Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date installed 9/16/1981 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 SF/BDRM System type TRENCH
Length 26 ft. Width 3 ft. Gravel below pipe 5 ft.
Total depth 9.5 ft. Eff. absorption area 260 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 9/11/2017
Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 456 gal. New depth U in.
Elapsed Time: 120 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d.
N
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION ������`�\u
I certify that I have determined through field inspections and /�oj� ,4,..'•:'•v%
review of Municipal records that the above systems are in 0*: . • / •* �
conformance with MOA COSA guidelines in effect on this date. ;
Engineer's Printed Name Steven Pannone ' •':�}everi •IR. •'annone: �A/
9/13/2017 r6-0:-.. CE-8149 ., I
Date ..+
COSA canary sheet_2-6-15 doc
Municipality of Anchorage
Development Services Department
Building Safety Division
OmSite Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
w~wv.ci.anchorage.ak.us
(907) 343-7904
Parcel I.D.
CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ..'_
Expiration Date:
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Lot 20;
24615
Block 4; Thunderbird H~ights Subdivi-.ion~}
Teal LOop Chusiak; AK
Current PropertY0wner(s) ,~o..~.~ph ~, ~'hy l.,_,eero Day phone
3916 Mehaffey Ln. Solon, IA 52333
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent Day phon'~
Mailing Address
Un/ess otherwise requested, HAA wi/I be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank r-']
Community On-site i-]
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
enoineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
titl~ (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon reqdest lo homeowners. Cedificates of Health Authority Approval are
valid for 90 days from the date of issue for propedies served by a private or Class C well and may be reissued with
nevi ,,,tater sample results. (Certificates may be reissued for a period of up lo one yea. r with valid ,,,tater samples.)
Certificates are valid for one year for properties served by Class A or B Wells or a public water system. The
Municipality o[ Anchorage is not responsible for errors or omissions in the pro[essional engineer's work.
Municipality of Anchorage
Development Servicos Dopartment
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL::CHE'CKLIST
,dC Description: D,r 4
DATA ,i~'/~;~f.~ ~
WELL
System type _ ~/t/~_.
Gravel below pipe
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material '~-:I~PT'I t.,, /
Tank size !O00 gal. Number of Compartments
Foundation cleanout (Y/N)~ Depression over tank (Y/N) /J
/
C. ABSORPTION FIELD DATA
Date installed . ! Soil rating (g.p.d./ft
Length ~ ft. Width ~ ft.
High water alarm (Y/N)
Well type ~ If A, B, or C provide PWSID
Date completed Sanita/al (Y/N)
Total depth__ .ft. ~,.¢dt0 ft.
-. FROM/~LL LOG
Date of test' .
Static water level ~ ft.
Well production /. g.p.m.
WATER SAMPLE ~.SULTS: '
Colifor. m , /olonies/100 mi. "Nitrate ~ mg.&.
Arsenic:
Date installed
Cleanouts (Y/N)
ft.
Total depth ~ ft. Eft. absorption area~ ft~ Monitoring tube Y Depression over field ~
Date of adequacy test I/"~[ fi~ZCr' Results (Pass/F"'~, .~z~ For ~._ bedrooms
Fluid depth in absorption field before test _0__ in. Water added~gal. New depth._~.
Elapsed Time:~')O min. Final fluid depth 0 in. Absorption rate >= 4~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) ,/~'Z3~'-,~cf""f,/'z~ v¢ ~ If yes, give date '-'
Well Log (Y/~
Wires properly p,~cted (Y/N)
;;~,~, heighpove ground, in.
ft. *
/Other bacteria colonies/1 O0 mi.
VCollected by:
· . . . ::" .:.:: .:':'; :,.'.? ..:j:.. ':.... :': '. ~ ..... : .:..
: .. i.:..'.-:..'.?.:..':'..'?... :'.:>~ .:...i"..."."..':i"' .. '~'-~' ' .:'..
· ... ,.....::?; i..;:"'.-:!o .:.,.. ...;:.:...::..:;:::.:'..':'.:: ·
· ,' . /~?°.~.L~¢.".~/. ~- /e ?, ~¢. · . . · . ,...,
, -. '~,~ - _". .................. :....:,_ :.:::~'---; -;- ~ ......... . -- · .... ;' - ~_... ..... . - ¢ ..
11 ""' ,. : l .... ': '':' :" .. 'I ' ' ' 1 · :
,',.'.. nL.:.~ ~' ' ' ~i:' ":..;' ':.-'...':.." '",,'~" ' · ~....· . ·
.$' ...... i:.l' ,-.]t ' ,-~[. "':'.'. '"'.. '.~'.:.': 'c~.l ' ' ,.
.. .~ -.'.; .... .... ..... . .... .'.,-.....,,~_. . · · .
!": ".-~-.-.,~-~ ~~,.~,~-'tm~.~:~ %k. ·, . .... i~'.
! ":. ~_."'~~~ · 'd'~ ===================== ,-,~_~ ~ _,.-,,:'-' . · t~'
· . .~ ~_~..~-=- . , ....::.:.....:.. :: ~,:,-...... . ~ ~,.,,,, .....
0 . ,, . ..'~ .......... . ..... ..-.. · ... ~ .
. . . ,.- ' -, .... *~.: ,.,.,- . ,,'¢- ...... ....... _.~.. . -, .
~: "" ~1""~"'" "" I' """'"'" .... !~ ..t-
_ '.'~ ~ t., '-,Z "'! ..' .' · '.~. ";;~.:'" :.~."~.'1~' ' ~, · , ' .
.~' ,:---'--: ...... -'- -~ ~ '.-- ' ' ~--"-:- ---L, ~_';-s.'...'.:..:.....'.::.:. '~ '
.I ~,.. -'-. t '.4 I ·' :.rsc.;,c../'.z~.'....'.'.':?' I. ,. . · . .!.,,~
~ . ~ , .... ;--..,"~. "...'..:..".: I' , l. ·
~ ,. .. .. ~' ,, · · ~o - :...: ~ ;: .. .:.:. : ~ · · · · . · , . ,,,,..
· '., I .,-- I · ~' ,~,,-.~, ... 'ii,, .-:'..:...:~'r~--,,.Z ~ . . · t,_
.~ ' '<.1 :~ -I ~d~ .'.'.:! .~ "-' ..':'.~ I..t:/~'A '. . 17' ! ' ·
: .. · . _,,,i: ". .. ~,,,.,,-,~,. , :' .l....~:'.::::-:L.:'.,~IZ"~I · i,._..I
~. ' .. -. ~1 -,,.... ~ '.....~'~-:_:'..'~.~-~::.-r:~ . . -. . · '.1 ~.
~,' ....· .' rd ~ -'- .~ ' ' · ...... -' ': ..... · · -' ,.1'~
,~' ". · "~'-~i ' ' '" '"::':":::"':' ":".: '' ': ' '· 'l"'
· .-,~ . ' ' ~,~' ' '~.,~., ~" ,.4.- ." ; . '.
·· . . ../9 ¢. ~'~. ~,~ - ~ tS',e,, ~.~ " ·" i
· .- · ' ~,,I.· . · '
I~OTE$: . ! , . . ' . · .
a . P. '- :,, .' ' :'' '-.' :~% ~'w'," ' ' '~;'~
[~, Undmr t~ ctrcums n . . ..... ,~ ..,... · . -'.~: . .u,-_~...
· ' ' · ' · · " '~-':
.:I,:T ...... :---:--.'- ': .... ;. ·. .. ~ -. "'~~ /
· ., :; :,~,.~,~,.,,, . . . ~. · './.: . .:.:.' : ..,,~," 'o 'i,~,~ ,,,,,~ .. . r'.
'.....~CHORA6E RECORD· IN~.Z'!_..S_ZR!.C;}T..._::::..4;!_::::::~:'.::'~",';..__!... .'.. , ...... · ".'_._
· i · · .~ /~,o~R sr~gr....:. ::" ' .~ ..... --------k---~
Parcel I.D, #
1,
· ~ 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
051-582-39 NAA # ',~'~",~'5[..('~
GENERAL INFORMATION
Complete legal description
Thunderbird Heights #3
Lot 20, Block 4
Location (site address or directions)
24615 Teal Loop, Chugiak
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Lewis A. Shookman
Day phone
24615 Teal Loop. Chugiak. AK 99567
Seattle Mortgage / Cathy Riordan Day phone
4300 B Street, Suite 206, Anchorage, AK
688-7057
562-5626
99503
Century 21 / Rae Hall 'Day phone 696-8600
11901 Business Blvd., Suite 103, Eagle River, Ak 99577
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
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 xx
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.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown belowl 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 Eagle River Engineering Services
Address P.O. Box 773294, Eaqle River, AK
Engineer's signature
Phone 694-5195
99577
Date'
DHHS 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
p rofessional 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 emissions in the professional engineer's work.
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
June 25,1991
WALTER J. HICKEL, GOVERNOR
563-6775
FOR: S & S Engineering
Ray
PWSID #211156
My review of the records on file in this office reveals that the Eklutna Thunderbird Heights
Subdivision Class A Public Water System, is in compliance with the provisions of 18 AAC
80.060, State of Alaska Drinking Water Regulations.
Sincerely,
Keven K. Kleweno
Lead Engineer
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
563-6775
DATE: August 8, 1989
PWSID: 211156
To Whom It May Concern:
According to the records on file in this office, the Eklutna/
Thunderbird Heights S/D Water System is in compliance with
State of Alaska Drinking Water Regulations.
the
Sincerely,
Cindy Thomas
Environmental Engineer
~MVI~,ONMENTAL
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) ~-~4
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type ~'~(/zA,~/~ /E-*
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
D~ ofe'~sample:
Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number ~
Date completed ~
Cased to Casing, g,g~eight-'~(above ground)
,~ir se~propedy protected (Y/N)
FROM WELL LOG/ AT INSPECTION
'/"// g.p.m, g.p.m.
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOL~31NG TANK DATA
Date installed ~)~"/~/ Tanksize /~)0¢ Number of Compartments .~.- Cleanouts (Y/N)__
Foundation cleanout (Y/N) ./,,//~ Depression (Y/N) ///2 High water alarm (Y/N) /~////J
Date of Pumping /¢.///D/~[.,~ Pumper
C. ABSORPTION FIELD DATA
Date installed ,¢ Y/~' /
Length ~ ~' ! Width ~'~
Effective absorption area ~-~.¢,'~
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth ¢ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Soil rating (94~;lgft-~er-fF/bdrm) ,~, z-.~ System type ~"-z~£¢/~/g,/-/
/ Gravel thickness below pipe ~:~ /Total depth o
Monitoring Tube present (Y/N) yZ~.~ Depression over field (Y/N)
Results (Pass/Fail) ,/~/)-,S'~' For '~' bedrooms
¢ Immediately afterz/-~''¢ gal. water added (in.): /
Absorption rate = z/,j~,~ g.p.d.
/~//Y If yes, give date --
72-026 (Rev. 3/96)*
D. LIFT STATION ./")/,'~
Dateinstalled
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons __..-.-,~-~
"Pump o_~el-'a't*~ ' Pump off" level at*
~Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
S~tic.~r. vice-l,n'-~
On adjacent lots
Lift station
SEPARATION DISTANCES FROM SEPTIC/H~)L-DING TANK ON LOTTO:
Foundation "7 z Property line ~/~' ~ 7 I
Absorption field
Water main/service line f-/~ ' Surface water/drainage )~/D~ / Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
Water main/service line
Driveway. parking/vehicle storage area
Wells on adjacent lots /
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
in conformance with MOA HAA guidelines in effect on this date.
Signature ~
Engineer's Name ~Og~/3' ~ G[~t~,, ~ ~
Date /dj -~ /~-~
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
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
HAA # /,(./¢¢/4
1. GENERAL INFORMATION
Complete legal description
Lot 20; Block 4; Thunderbird H~ight~ Subdivision ~
Location (site address or directions) 24615 (137) T¢.~ Loop
Property owner John Slocum Day phone 552-3641
#688-1581
Mailing address H(f 7g Br~ 1.~7 Ch~x'~k: A£~z~ka 99567
Lending agency
Day phone
Mailing address
Agent E-,~_en ~¢__Gau,,~.¢~_ P,~f,/Hr)MEQIIITY Day phone
Barbara Parker Jack White Company ~ Anchorage, Ak.
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well Xx
Public water
NOTE:
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:
XX
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 #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ~ & s ~NGIN,~ERING Phone
17034 F.~:gie River LOOp R~ad ['40. -~04
Address ~,:~,!~ ~i,,or, Alaska ¢577_
Engineer's signature
Date
6. DHHS SIGNATURE ~¢
~ Approved for ~/A4C/',-~,~bedrooms.~ ~'~
Disapproved.
Conditional approval for
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.
72-025 (Rev* 1101) 8ack MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Descri pt ion: ~-,'~ 7.-o
A, WELL DATA
Well type A If A. B, or C, attach ADEC letter.
1991
ADEC water system number '~.J J/ 5~
Log present(Y/N)
Date completed
Driller
Total depth Cased to
Casing height
Sanitary seal (Y/N)
Wires properly protected (Y/N)
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
g,p.m.
AT INSPECTION
;On adjacentlots
; On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Public sewer service line
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts .~/N)
High water alarm (Y/~
Date of pumping ~'~$-~ /
Tank raze \("DOC:>
Foundation cleanout (Y~)
,'V/ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line J ~'
Surface water/drainage
' ~'~ On adjacent lots
~ ~ Absorption field
/6:>(::>' w-
Other bacteria
/Compartments
,. uepression (Y/~ /J'
Foundation / J
Water main/service line
72-028 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in;gallons
Vent (Y/N) "Pump on" level at
High water alarm level ~
Meets MOA electrica eo~F~/~)
S~ANCE FROM LIFT STATION
TO:
C/Cell on lot On adjacent lots
Manhole/Access (Y/N) .~----~-
.----~-~Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ':1 - I L~ ~ ~,
Length '¢'~ ~'~ Width
Soil rating
Gravel thickness
~/~ ¢-~ System type
'~- ~ Total depth
Cleanouts present (~/N)
Date of adequacy test (,~ _
If yes, give date
Total absorption area ~ L,¢,-o '~
Depression over field (Y/~) Y'/
ResultS(~/fail) /¢A~..~
Peroxide treatment (past 12 months) (Y~)
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 7~°~-~ ~ '~
To building foundation
On adjacent lots
Surface water
Curtain drain /~'
On adjacent lots '~'1~.~ Property line
To existing or abandoned system on lot
Cutbank "'~ Iff,- 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 in effect on the date of this inspection.
Si~naturee ~., -, :,~; ~:: ............. .-
Engineer's Name
Date ~ ,'"~.'~ /~(/'
/
HAA Fee $
Date of Payment //7 ~ / .~ ~ / ~"
72-026 (Rev. 3/91) Sack MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcell. D.# ~\-~O/--~-r~-~.O~ HAA# ~F~°tL_~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
(b)
(c)
(d)
(e)
Location (address or directions)
/
Property owner ~c-P¢~,/~,!
Mailing Address ~./
Lending Institution
Mailing Address
LOOP DR
./iA ~E A~' ~£/~,~ Telephone: (home) Business ~"~ /
Telephone /~/~
Real Estate Company and Agent
Addreaa A/
Telephone _/k.j/~
Mail the HAA to the following address: (or check heretO, 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 D' 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 iD" 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
'~JOM s,Jeeu!l~ue leUO!SSajoJd eq~, u!
suo!ss!Luo Jo sJoJJe Jo,[ eiqjsuodseJ ~,ou s! eDBJoqouv,Lo ,~uIBd!o!unl/~ eqj. 'penss! s! elBo!jRJao ~ eJoleq m,~p eZ,~IBUB JO
suoRoedsu! lonpuoo leu op SHHC] ~o see,~old Lu~ 'sjueuJeJ!nbeJ ale,s pub i~Jepel u!~peo ,~js!~s el Jap Jo u! suoRnulsu[
6u!puel J!eql pub SeLUOq JO BJes8qoJnd el ,~sepnoo ~ s~ s!ql seep SHHQ eq.L 'm~S~lV ~.o elelS eq~, u! peJels!SeJ
Jeeu¢~ue i~uo!sse,toJd 1uepuedepu! u~,~q eAoq~ 9 qdeJ§~J~d u! UeA!5 suo!leluaseJdeJ aq~, uodn/[lUO paseq pm, eoNpeo
I~^oJddv XUJoq~nv qUBeH sense! (SHHQ) seo!AJeS u~LunH pu~ qll~eH jo ~,ueuJpedea ae~JoqouV jo Xul~d!o!un~ eq.L
IBAoJddv IBUO!Upuo0 lo SLUJBL
~ / elec]
iBUO!Upuo0 peAoJdd~s!a ~ pe~oJddv
~AOlddd~' SI4HO '9 '
IBeS s,,Jeeu!6u~
ssaJppv
· uo!loedeu! S!L!~ ~0 el~p eq], uo ]eerie u! BuoR~lnaeJ pub 'BeeuBu!pJo 'sepoo Bia~S
pu~ I~d~o!unw I1~ ~l!~ eoU~!ldwoo u! s! wele~s I~sods!p J~8~88~ Jo/puB ~lddne Jel~ ~Us-uo e~l 'uo!loedeu!
pu~ uo!~D!ise~u! ~w woJl pu~ e~l!I e~Jo~ouv ~o ~Ul~d!o!un~ e~l woJl peu!~lqo uo!l~Jolu! ~l uo pee~q
~ql ~I{JeA JeqlJn~ I 'u!eJeq pe~olpu! eJmonJis io ed~l pu~ s~ooJpeq ~o Jeqwnu eqi Joj elenbepe pu~ leUOl~ounj
'e~es s! meisXs lesods!p JeleMeiS~M Jo/pu~ Xlddns Jel~M eUs-uo aql leq~ SMOqS I~AOJddv XUJoqlnv qUeeH
si ql Jo UOIiebI~SeAU{ X~ ieqi ~IJaA I 'Moieq UMOqS el~p UOlleplleA eq{ ~o se pue oleJeq PaXl~je lees X~ Xq pellilJeO sv
NOI~V~MO~NI aNY v&va 'HOaVaS ~qlJ 'S&S~ 'SNOIZO~dSNI 9NlalAOad ~al~ 9Nla~]NIgN~ 'g
/~°~.,,OX'~MUNICIPALITY OF ANCHORAGE (MOA)
[~¢~'~ Health Authori!y Approval (HAA) ~u~,~l~
~.d. O~ .l~.J CHECKLIST,. FEBRUARY 1984
~(~O¢ ,-..%,~ . ~ Legal Description: L ¢ ¢- ~4)
A. WELL DATA
Well Classification ~d)/~/,,~4z ~ ~/~. '5' ~ If A, B, C. D.E.C. Approved (Y/N)
Date Completed ~/~ Yield
~/~ Depth of Grouting ~
Well Log Present (Y/N) ~//~,
Total Depth ~/,~- Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) /',1 ]~
Pump Set At /~l //~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
; On Adjoining Lots ~] ))4 ; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot '~'~(-'~')¢
Water Sample Collected by /~_,
Water Sample Test Results ~'/~
To Nearest Public Sewer Cleanout/Manhole
;Date ~//¢¢-/5°4~
B. SEPTIC/HOLDING TANK DATA
Date Installed /~/ Size /('.;~O,~q/ No, of Compartments
Standpipes (Y/N) Y Air-tight Caps (Y/N)
Depression over Tank (Y/N) /~/
Pumping/Maintenance Contact on File (Y/N) It(///I
Holding Tank High-Water Alarm (Y/N) ~,J/~
Y' Foundation Cleanout (Y/N) Y
Date Last Pumped ~'//(:/~
:for ~t /~
Temporary Holding Tank Permit (Y/N) t~/ //~t
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~ '~'¥r~/ TO Building Foundation
To Property Line /O~ -h To Disposal Field
To Water Main/Service Line ">2~-¢
To Stream, Pond. Lake or Major Drainage Course LI//Et
Comments
/1'
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
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~'~O
To Building Foundation /(~'
Lot
To Water Main~f~rvi_ ce Li?~ ~,--~-ff
To Stream, Pond, Lake, or Major Drainage Course
To Driveway. Parking Area, or Vehicle Storage Area
/
Length of Field ,~ (,; ~
Depth of Field ~ ~
Gravel Bed Thickness -~/
Statndpipes Present (Y/N)
Date of Last Adequacy Test
Type of System Design
To Property Line /O ~ f-
To Existing or Abandoned System on
; On Adjoining Lots ~--(,~ '
To Cutback (if present)
Comments
Date Installed
Size in Gallons
"Pump On" Level at~
High Water Alarm LeveN
Tested for
Meets MOA Electrical Codes NN)
Comments
**Check Permitted'~/Bedroom Rat'~g Against HAA Request**
~ .... ~ HAA
I certify that l ~ ~,h~cked, y/~i~;~d, or conformed to all MOA and
Signed
Company
MOA NO.
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
uidelines in effect on the date of this
,,~., Engineer's Seal
Receipt No, -
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
D,4 =~EIVED
INSPECTION A?POINTMENTS
TIME TIME TIME
DATE DATE DATE
NSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANC, HUK/~
MUNICIPALITY OF ANCHORAGE DEPT. OF IfEALlil &
//~7,~:~-.~-% DEPARTMENT OF NEALTH& ENVIRONMENTAL PROTECTr~).IRONMENTAL ,P,-;OTECTION
825 L Street - Anchoraee. Alaska 99501
(~)) ENVIRONMENTAL SANITATION DIVISION OCT 1_
Te,e,ho.e 26*,729 R E C F. I V F. D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
P RERTY OWN PHONE
MAI G ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAI LING ~AC)DR ESS
;3, L E NDINI~'~'NSTITUTION PHONE
MAILING ADDRESS
4, REALTOR/AGENT PHONE
MAI LI Nd A-D d ~ESS
E. LEGAL DESCRIPTION
S, TYPE OF RESIDENCE NUMBER OF EEDROOMS
[] One [] Four
),rd SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six'
7, WATER SUPPLY
L-__J INDIVIDUAL*
COMMUNITY
PUBLIC UTI LITY
[] Other
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Io9 if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVlDI. JAL/ON-SITE** //Cf/ YEAR ON-SITE SYSTEM wAS INSTALLED.
[] PUBLIC UTILITY [~t~ C7~ II~ ~c~l
NOTE: 'FHE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~]INDIVIDUAL/ON -SITE DATE INSTALLED
[~]PUBLIC UTILITY
Connection Verified. iNSTALLER
r~Septic Tank or [] Holding Tank ......
Siz~e: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Li~e Nearest Lot Line
Absorption Area to. nearEst Lot Line . , .. , , . - '.
5. COMMENTS , , .
[] APPROVED FOR BED,R, OOMS
[] CONDITIONAL APPROVAL (Getter must accompany certificat0)
[] DISAPPRQVED
DATE BY . ,
(Rev. 6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Engironmental 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
051-552-~3~ HAA# H~ ?~)~'~
1. GENERAL INFORMATION
Complete legal description
Lot 20; Block 4; Thunderbird Hts #3
Location (site address er directions)
24615 Teal Loop
Ch~giak, AK
Property owner
Mailing address
Paul & Sharon Zelzter Dayphone
P2:M. Box 344 12118 Business Blvd. #6 Eagle River,
AK
Lending agency
Mailin. g address '
Agent Ronna Fekrat Prudential Jack White
Address
Day phone
Day phone
762-581 5
99577
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
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 xx
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. l/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 verifythat 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 corn ~liance with all Municipal and State codes,
Address
Enginee¢s signature
ordinances, and regulations in effect orC~t~at~
Name of Firm Wastew~a~er
.... Alas~;~ W~er: &
Wastewater Consultants, Inc,
Shall be PAID $~00~ at,
or prior to, closing for the
Engineerin~l Services Provided,
6, DHHS SIGNATURE
/Xv' Approved for 3 bedrooms.
Disapproved.
CellfiC, inspection.
~at3t$,//14t. Phone
~u~ 28
Conditional approval for
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 pu mhasers of homes
and their lending institutions in order to satisfl/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.
' tCEIV I
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SI~R~-~+E~'
Environmental Services Divisio~Nv~°N~N¥^Ls~wc~s ~,~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: THUNDERBIRD HTS #3, LOT 20, BLOCK 4 Parcel I.D.:
051-582-59
A, WELL DATA
Well type P,~ A~ "A" If A, B, or C, attach ADEC letter. ADEC water system number 211156
Log present (Y/N) Date completed
Total depth Cased to
Sanitary seal (Y/N) ~
FROM WELL LOG
Wires properly protected (Y/N) _
AT INSPECTION
WATER SAMPLE RESULTS:
Coliform Nitrate
Other '
Date of sample.'
B. SEPTIC/HOLDING TANK DATA
Collected by:
Date installed 9,/! 6,/8! Tank size ! 000 Number of Compartments 2 Cleanouts (Y/N). YES
Foundation cleanout (Y/N) Nfl Depression (Y/N) NO High water alarm (Y/N). NO
Date of Pumping Q,/14,/c~e
C. ABSORPTION FIELD DATA
Pumper
~ANITARY PI lldPFI~R
Date installed 9,/16,/81
Length 26' Width
Soil rating (g.p.d./ft2 or ft2/bdrm) 65 System type TRENCH
3' Gravel thickness below pipe 5' Total depth 8.0' - 8.5'
Effective absorption area ~Z6I:LSQ~J~_ Monitoring Tube present (Y/N)~fZ.~s_ Depression over field (Y/N) NO
Date of adequacy test 12/! n/cra Results (Pass/Fail) PASS For
bedrooms
Fluid depth in absorption field before test (in.); (3" Immediately after587 gal. water added (in.): 0"
Fluid depth _ (ins) Minutes later: _ Absorption rate : 450+ .g.p.d.
Peroxide treatment (past 12 months) (Y/N) NONE KNOWN If yes, give date
72-026 (Rev, 3/96)*
LIFT STATION a~
Date installed Size in g
Manhole/Access (Y/N) ~ "Pump off" level at*
High water ~ *Datum
E. SEPARATION DISTANCES
COMMUNITY WELL
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot ~ts
Public sewer main P~blic sewer manhole/cleanout
Lift station
EPTIC/HOLDING TANK ON LOTTO:
I'PER INSP. REPORTI
Foundation '5'+ Property line 5'+ Absorption field 5'+
Water main/service line
10'+ Surface water/drainage 100'+ Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
10'+ Building foundation UNKNOWN Water main/service line 10'+
Surface water 100'+ Driveway, parking/vehiclestorage area 5' +/-
HAA Fee $
Date of Payment
Receipt Number
Curtain drain NONE KNOWN Wells on adjacent lots 200'+
ENGINEER'S CERTIFICATION /
I certify that/Ch~ dr~d~ ,ru field inspections and review of Municipal recur ~..~~ms are
in confor~nce ~it~A ~A ~uidelines in effect on this date.
Signature~,~-
II II ~1~ ~ I
Engineer's Na~e[ ~ ,EFFR~ A. GARNESS ~ ~.~.~:....~
Date , ~ ¢/~¢
-- ,~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
h~n on thtl A54ullt Ire
reca~d'ed plmb and,are sO~-
~ny ~asmqnts b~f~r~ a~
~. UnUmr n~' ~i~un{t~'d{ sheuld any umta h~h~n' . · '
.~b ',: , ., ,' ,. ~ . . ,
