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HomeMy WebLinkAboutT12N R3W SEC 33 LT 58B MUNICIPALITY OF ANCHORAGE DEl TMENT OF HEALTH AND HUMAN SER~ .S Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~,~ ~ SEPTIC ABSORPTION ~/~/ ~1 ~ ~S'BUILT DIAGRAM tShow Iocahon of well, septic system property hnes. toundat,on, TANKS ~SEPTIC ~ HOLDING Material~ N° ol Compaamems~ TYPE OF SYSTE~ ~TRENCH ~ BED ~ W. DRAI~ ~ OTHER or,g,nal grade ~ · ¢ FT ~.¢- ~,0 FT O FT ~ FT Total absorphon area ~/~ 80 FiIl Dlstgnce belween hnes ~ PRIVATE ~ OTHER fldentifv~ ~ f~ ~ ~' ' ~'~' ¢ '"= ' ~ ~dily Ihat this inspection was p~dormed according to al 72-013 (3/85) '' " )LI ~W~]III.II [ tEALTH AND E!:NV kk::.,~ I, ~.~Rl::.k.I , AlIClli~lu.~[,~k:.~ Al< } ..~ ~ dl .,: ]]/ "}t" lEE: : ~g I !5~: II~,,J 11:::::' IF:;::,,,,:.,~:" ' I]/,Jt lEE: IL.. ~ ~::':::" lEE II:::;;:t ~l'"'fl ]E "11"' W:I:LI_IAM DWAYIqlE ADAHS 440 I::'IE'I"I IS ROAD ANCH[:II::~A(.')IE !, Al< 99515 ::,'! 76'" 37'7 () BI .O[;K:: N/A I..:i. st'.~d I:)e:l.o~4 ,'4ti',(.:? '[.I)~;? c~p'L:i, cH'/~,; ava:i, lal::)lc~ 'Lo you in designing your' sel:)'L'ic: 'FIE:::' DI!i;F:"II'I 'l'O I:::'IPI!!: BOTT'OM (F'T.) ;5,,0 .ti-I,'. i:')RAVIi~],. DIEP'I"H (F:]' ,, ) C) .. ,',5 'f'OTAL Dr::F:'TH (F::'F.) :];. 5 GI:;t('~VI:].. t4:l:~)'l'l'l (f::'T,,) 17,, () F)I::.' (WI.!:I.. h)RAVI~]. VE)I..t. IM[:i: (CtJ. YDS,, ) ,'21,, ',~ 'IYhNI::: SI ZE (GAl..S) 1,000. () '~'.~{. SOIl.. I:~h't:l:lxl(:} (tiH3,,l:::T,, /liiIR) ,~ i:)l~]':"f'J't '1 [:] I t.I I. BOTTOM < "' ~' ....... ¢ I::'"i".I::d'~],)U I RE~ii~I N~3UL,AT I OJ',I ,~'~,' .DI::F:'I'H I'E) I ...... -' ~ '" ]1 I::. BO"I FOH < 4,,0 I:::'1',, MAY I~E..,,I..I.l. ld~. A I,.iF'I ,~iTA'IION · 1~. 'I"ANI< I"IIJS'I' I'lAVf:i: Al' I..,[::AST I't~'Jf:l COMPPd::;tTMIEN'IS I cr:'r'l:.i Fy l'.hat ~' :l.., ;l: ,~:1ili {",~,'~m:i.].:i. al, ~,,J:i.'l'.l~ 'l..,lic) 1'6!CfI.L;i,I'E.!IIII:.:q'i'I:,!~ ICH' CII]""Eiit(.'~ ~iE~*JC~I"S ~.]lld Forth by thc.::, IdtJrl:~c:J.[ta] J.'[.y of (hlH:::horsg~ (FI[)A) ¢~r'H:J the State of' Alasl::a,, 2. :1: t*.~:i:l.:l, in~H',al:l. 't:.he~ !~iy!is[:.~)iil :i.i] ac::cordanc~.::) ~.~itl'l all MUA ;:!;.,I w:i.l], adhel'~.) t.c) all MI]A and S'Lai:.e of Alaska P~})ql.til'E,ifllEHl'[,~¢ {'CII' '[.HE¢ ~;(:~1:. bac:l.( IF: A I..:I:F:T S"IATIOI',I IS INSFAL. L.I~]) IN AN ARIEA COVERED BY MOA BU 'I'IqEN ( 1 ) AN IdJE[: I'RICAI.. F:'ERMIT AND :I:ItlSI::'EC"I I ON MUST BE []B'I'A]:NIED~ (2) AS-'FdlI LTS W'.I[L.I. NOI' bE AI:::'I::'I:{OVI:ED WITFIE}I. IT AN EI.EITI'F~[I:CAL INSI:::'ECTION REF:'ORT~I AND ([:.[) THE I~].EC'II~I[:;AI. WI:)RI:[ MUST Bh[ Di3NE BY A I..:I:CI~:NSED ELIZ[:'rI::~:I:CIAi~I. DAI'IE. W :1: I, .I.. I F, a DWAYI',IE AD('~['.tS ,. D A'I'E ',: 401 E. FIREWEED LANE ANCHORAGE, ALASKA 99503~2197 (907) 276-3770 ANCHORAGE o JUNEAU BETHEL June 17, 1985 MUNICIPALIT~ OF ANCHORAGE DEPT. OF HEALTIJ & ENVIRONMENTAL PROTECTIOF,I Municipality of Anchorage Dept. of Health and Environmental Protection 825 'L' Street Anchorage, Alaska 99501 RECEIVED Subject: BLM Lot 58B, Section 33, T12N, R3W, S.M. Percolation Test Gentlemen: On June 17, 1985 we excavated at the location of the proposed drainage field on the subject lot. The purpose of the excava- tion was to determine the depth of groundwater in relation to the depth encountered in the original excavation conducted over a month ago. The water level was found to be 8½' below the ground surface compared to 7½' encountered earlier. After monitoring the water level for a month it appears the 7½' depth is the high water level and the septic system should be designed with a 4' separation from this depth. My recommendations regarding the system remain the same as the initial test. A bed system with a 4' separation from the 7½' water level is adequate for the house planned for the lot. Sincerely yours, - Michael E. Anderson, P.E. MEA/jb [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCO LATJ/ON TEST Wm. Dwayne Adams, Jr. PERFORMED FOR: DATE PERFORMED: May 11, 1985 LEGALDESCRIPTION: Lot 58B, Sec 33, T12N, R3W Organics 1 .~ ..... Coarse, rust brown gravel 2 3- QTan, silty gravel 5 6 Brown, coarse gravel with cobbles 7 8 Seepage 9 Bottom of Hole SLOPE / / SITE PLAN 10 11 13- 14- 15- 16- 17- 18- 19- 20- WAS GROUND WATER ENCOUNTERED? YES ~ E IF YES, AT WHAT DEPTH? 7½' Time Water Drop Anderson 2 ~ DEPT. OF HE~.TH & EN~ 'IRONME~L p ,~- CFI iFh PERCOLATION RATE <2 (minutes/inch) TEST RUN BETWEEN COMMENTS Recommend ratinq of 125 ft2/bedroom. vertical separation of 4' from the water consioerlng the high permeability of the PERFORMED BY: Michael F,. An~]~,-eo_,%_' p.~C. ERTIFIEDBY: FT AND FT A bed system with a level should h~ ~equate soil. DATE: June 6r 1985 72-008 {6/79) (//7.-,;r1I Municipality of Anchorage On-Site Water and Wastewater Program < (907) 343-7904 SA F f T, Certificate of On-Site Systems Approval Parcel I.D. 018-182-24 Expiration Date: —/ S-1 7 1. GENERAL INFORMATION Complete legal description T12N R3W Sec33 Lot 58B Location (site address) 3551 E. 144th Ave. Current Property owners) Chris Sawyer Day phone 907-441-9373 • Mailing address 3551 E. 144th Ave., Anch., AK 99516-3925 Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) III Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community El Public Water System ❑ Public Sewer ❑ WaiverNariance request '.r: Distance: Received by: Date: COSA to be rete.. • to the engineer,unless otherwise requested the engineer. OK-c.0 r •k,OhE r -16 rtk VIO , COSA Fee $ Z(, t 9'11 f 00 Waiver Fee $ Date of Payment 11 31 I"1 Date of Payment Receipt Number O'311 I. 6\ Receipt Number COSA# O !1 I o S Waiver# 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. Name of Firm Crewdson Engineering, LLC Phone 907-280-9493 Address PO Box 671389, Chugiak, AK 99567 ) 2 gJames Crewdson Z / //Engineer's Printed Name Date r Note: as engineer of record, the information I have provided on this form satisfies MOA Certificalo f On-Site Systems Approval requirements only, and does not include any statements or guarantee-Wittfvure life and serviceability of the subject systems. .r•cit. ...... •Lq i.'1i 6. DSD SIGNATURE 0°0,• I —*J.:. .y 1/ r / _ System #1 Approved for 3 _bedrooms r 4� L � System#2 Approved for bedrooms ! f/. /4 y pp $0 p:- -riles A, Crewdson :�/ Disapproved q.-3 .• 011527 �i �t �� •_ `g-/':? .• '`, YN Conditional approval for - bedrooms, with he following stt{}t j•SS10N��` r 4 CQ v✓I ��SS L ? ( E AC,z�1 ,,,q ,,,, h-L-e.c.4 E 8.7' 4 tt—i-k A c 7 --n- 6. S ) rV\ Al rr C ovx.ditt-E tiv,- at ��` frp re DS _✓ i t �� Ft/ ON-SATE , NATER AND ' "."�=c� ;1 wASTEINATER o 5 17s1/4pROGRAM �, co .i ��fkrrCPQ.i' / / By: —. �,N, �`�'� Original Certificate Date: 1 I7 The Municipality of Anchorage Development Services Dep (DSD) issues a Certificate 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 bale sheet_S - c If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: T12N R3W Sec33 Lot 58B Parcel ID: 018-182-24 A. WELL DATA Well type Private If A, B. or C provide PWSID# Well Log (Y/N) Y Date completed 6/27/85 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Total depth 118 ft. Cased to 1 1 8 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 6/27/85 3/7/17 Static water level 20 ft. 0 (artesian) ft. Well production 12 g.p.m. 8+ g.p.m. WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 0.293 mg/L Arsenic ND ug/L Date of sample: 3-7-17 Collected by- Crewdson Engineering B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 6/2 0/8 5 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y+ Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping _ �� 0 -79- Pumper A C. ABSORPTION FIELD DATA Date installed 6/20/85 Soil rating (ft2/bdrm) 125 System type Bed Length 3 ft. Width 18 ft. Gravel below pipe 0.5 ft. ' *3� O! Tot l + 3 .4' sr absorption area 612 ft2 Monitoring tube Y* Depression over field N • ~' D fad cy tem W117 Results (Pass/Fail) Pass For 3 bedrooms Fled depth in absorption.fie before test 0 in. Water added 450+ gal. New depth 2 in. EIa TkV" 1 4 . Final fluid depth 0 in. Absorption rate >= 4 5 0 g.p d. Any rej6 ; t ttit�tA�nt (past 12 mo.) (Y/N & type) N If yes, give date "4”.11,J D. LIFT STATION NA Date installed Size in gallons Manhole/Access (YIN) "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 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 25'+ Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 54 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 004 Driveway, parking/vehicle storage 8' Curtain drain none known I ellsb adjacent lots 100' , ) giiiik,iii1/417/1C/q Std r Y Q 0'1/‘ elk vi C F. COMMENTS * Cleanouts/Monitor Tubes: couldn't find..ne 1 of the se.tic tank pi �- •ne(1) of the drainfield pipes. Ground is frozen, so we are applying .r a C.••iti.inal Approval t. -flow ix •■ e pipes during the coming summer months. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and `0�t.IN iiii review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 11 Engineer's Printed N me ok v E's Cre Li� • • • 10, v . • • Date 3 fc J . . . i/k glllNOrOl� .�''+ Note: as the engineer of record, I have provided information on i/ No.a t�f • .9 this form intended to satisfy MOA COSA requirements only, and to• it does not include any statements or guarantee regarding the 11 i - future life and serviceability of the subject systems. LLQ COSA canary sheet_2-6-15 CE.pdf Crewdson_Engineeri.ng,...i.LC CI' James "Jay" Crewdson, P.E. Email: CELLC.1@outlook.com Cell/Text: (907) 280-9493 NI Fax: (907) 688-2295 `mac. - Civil&Environmental Engineering May 25, 2017 Tim Ecklund Municipality of Anchorage On-site Water&Wastewater Program 4700 Elmore Road Anchorage,AK 99519-6650 Reference: T12N, R3W, Section 33, Lot 58B Conditional COSA Request for Full Approval All outstanding items required to approve COSA OSC171085 without conditions have been completed. As such, Crewdson Engineering LLC is requesting the COSA receive full approval. r Thanks, i / 7 �.������ (,{4, ,, • James"Jby" Crewdson, P.E. % ::4 . . � Y Attached: Recertified Asbuilt Survey / 9�,•."ties /+5s C11527 A A LC 1i(9,) 3-01 PO Box 671389 • 18368 Amonson Road • Chugiak, Alaska 99567 PLAT NO. 81-8 LOTS 58A & 58B SUBDIVISION LOT 586 49,545 S.F. S SQ SB'30'E 164.83' • 10'CEA 8 Mu ult.EENT. LOT 58B LOT 58A Mm. m a g F. . %:Th.' 4N %,, 41.7' _ 71.0' &YTIC smut 1 "=4cY a , , A _a 2 -- - - - - -- m7•'3'0.M ROADWAY ESMf. ORIVEIY/0'EA-SD/ENT PER"DEED CREATING N 8C"59'30"E 164.88' ACCESSSEASE41ENT"RECORDED IN BOCK 2974,AT PACE R3R-841. E. 144TH AVENUE .0d * I to gad 4¢ 1 }�A BUILDING DETAIL SCALE 1"=20' NOTE: LOUTS OF A.C.PANIC SHOWN ARE APPROXIMATE DUE TO SMGw COVER AT THE TIME OF lits SURVEY. AS—BUILT I HEREBY CERiTFY THAT I FMVE sun. yED THE CASGLq LAND PROPERTY DEPICTED ABOVE AND THAT NO tmt R N r 04CROACf1NEN15 EAST EXCEPT AS INDICATED. SURVEYING, LLC ♦* OF A �1 JEFF A.CASTALDI. RLS RIS TME RESPOttSIBQ1TY OF THE OWNER TO 4,4„.11:;.c..... CF-........,�4 �� DETERMINE THE E7DSTENCE OF ANY EASEMENTS. 2000 E DDMJMC RD.,SUITE d COVEN‘NTS OR WHICH DO NOT +� ' ti'‘.9 1 r* ANCHORAGE.ALAS 09507 APPEAR ON TME RECORDED SUBOMspN PLAT. s 't: 48Itl *• PHONE 248-5454 UNDER NO CIRCUMSTANCES SHOULD ANY DATA ■ .111 CND DATE H REON BE USED FOR CONSTRUCTION OR FOR •�flrY A.calms SW3r)35 0/25/201 7 ESTAF3LISHING BOUNDARY OR FENCE LIMES. .0 1;1,1....2/1q/j.." `�, 7 , a.^r F B. Joe NO. ' GE RECORDING DIS1RICT,ALASKA �0 'p-i/.. • S.i BUMS NOTE: NO CORNERS SET THIS DATE `4111‘.611- 17-02 i"'I� �♦ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O, Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I,D. # 018-182-24 HAA # GENERAL INFORMATION Complete legal description Lot 58B, Section 33, TI~N, R3W Location (si.te address or directions) 3551 East 144th Avenue Property owner Mailing address Chris Sawyer 3551 East 144th Avenue Day phone Anchorage, AK 99516 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Three (3) TYPE OF WATER SUPPLY: Individual well xxx Community well 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: XXX Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) t~ront 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 end type of structure indicated herein. ] 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, a. pd regulations in effect on the date of this inspection. Name of Firm Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's signature ~/V~-J~ ~' ~ Date 11/10/99 DHHS SIGNATURE Approved for -~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department of'Health and Human Services (DHFIS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional enginee~; 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. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502. Anchorage, Alaska 99501. (907L~l~t Health Authority Approval Checklist LegalDescription: Lot 58B, TI:~N, R3W, Section ParcelI,D.: 018-182-24 33 A. WELL DATA Well type Private If A, B, or C, attach ADEC letter, ADEC water system number Log present (Y/N) Y Date completed 6 ,' 27 / 85 Total depth 118 ' Cased to > 40 ' Casing height (above ground) 2 ' Sanitary sear (Y/N) Y Wires properly protected (Y/N) Y FROM WELL LOG 6/27/85 Date of test Static water level 20 ' Well production 12 g.p.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate Date of sample: 11 / 5 / 99 B, SEPTIC/HOLDING TANK DATA Date installed 6/20/85 Tanksize 1 f 250 AT INSPECTION Foundation cleanout (Y/N) ¥ Date of Pumping //- / 2 - ~/~ C. ABSORPTION FIELD DATA Date installed 6/20/85 Length 34 ' .Width 1 8 ' Effective absorption area 61 2 SF Date of adequacy test 11 / 8 / 99 11/8/99 Artesian Fluid depth in absorption field before test (in.); 0 Fluid depth 0 (ins) Minutes later:. 0 Peroxide treatment (past 12 months) (Y/N) N 72-026 (Rev. 3/96)* 8.4 g.p.m. · 648 mq/L Other bacteria 0 Collected by: MV, A Depression (Y/N) Pumper //c f)O~;z Z; ~' Number of Compartments 2 Cleanouts (Y/N) Y N High water alarm (Y/N) N Soilrating (g.p.d./ff~orff~/bdrm) 125 SF Systemtype Bed Gravel thickness below pipe .5 ' Total depth 3 ' 4 ' Monitoring Tube present (y/N) ¥ Depression over field (Y/N) N Results (Pass/Fail) Pase For 3 bedrooms Immediately after1 f 14~al. water added (in.): 0 Absorption rate = > 4'50 g.p.d. If yes, give date N/A D. LIFT STATION - None on Lot Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot > 1 0 0 ' Absorption field on lot > 1 0 0 ' Public sewer main N/A Sewer/septic service line > 1 0 ' Size in gallons "Pump on" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station "Pump off" level at* SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5 ' Property line > 5 ' Absorption field Water main/service line > 1 0 ~ Surface water/drainage > 1 00 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line > 1 0 ' Building foundation > 1 0 ' Surface water > 1 0 0 ' Curtain drain None Noted on Lot F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. ,~ Engineer's Name Michael E. Anderson, P.E. Date 11 /10/99 N/A >5' Wells on adjacent lots > 1 0 0 ' Water main/service line Driveway, parking/veh c e storage area. Wells on adjacent lots > 1 0 0 ' HAA Fee $ Date of Payment Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/g6)* 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 1. GENERAL INFORMATION Complete legal description Lot 58B, Section 33, T 12N R 3W Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address W. Dwayne Adams 13311 Cove Circle Anchorage, Day phone AK 99515 276 5885 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: Three XXXXXX 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: XXXXXX 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. 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. NameofFirm Anderson Engineering Phone 563-7155 Address P.O. Box 240773 Anchorage, Al( 99524 Engineer's signature ~'/~c(.~,',.g.u(.~. ~-~ ~-~C ~ Date 3/29/96 DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for .2? /10/wY TO ~£ /¢~r1¢¢ bedroo~'~s, with the following stipulations: T~ H/CUE $&PP/c Additional Comments 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. 1/91) Back MOA ~21 Legal Descriptioa: A. WELL DATA Well type Log present (Y/N) y Total depth // SanitaL'y seal (Y/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street Room 502 · Anchorage, A aska 99501- (907) 343-47,t4 Health Authority Approval (~hecklist IfA, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to //~' Y Casing height (above ground) · Wires properly protected (Y/N) 'y Date of test Static water level Well production PROM WELL LOG AT INSPECTION Z~f.;' A },>JTC' b I Pt r',J / Z- g,p.m, WATER SAMPLE RESULTS: Coliform ~) Nitrate O./ rnf/¢ Other bacteria Date of san;pie: .,3"/g 7/ c¢ ~; Collected by: B. SEPTIC/HOLDING TANK DATA Date iostalled /, t:/t'., o Tank size Number of Compartmeuts Cleanouts (Y/N)__ Fotmdation cleanout (Y/N) 'h/' Depressiou (Y/N) P.-] High water alarm (Y/N) Date of Pumping Pumper C. ABSORPTION FIELD DATA Date it, stalled Length :~ ':/ / Width Effective absorption area Date of adequacy test Fluid depth in absorption field before test (in.); Fhfid depth f-;' (ias.) Minutes later: Peroxide trcatmeut (past 12 mouths) (Y/N) Soil rating (g.p.d./ft2 or ft2/bdrm) IZ")~' F'r.. z"System type ,~iHf/t..co i ~ Gravel tbickness below pipe Monitoring Tube present(Y/N) Results (Pass/Fail) / ^/ Immediately ,'ffter ~/~/')gal. water added (in.): · {.~' Total depth ..~. :~ Depression over field (Y/N) P~ For '-~-~Jq'bc:~' bedrooms Absorption rate = ~ t/~-~'O g.p.d. If yes give date '-D.~LiFrSTATION ,~ ,AJt'z,,4z;_~ ozq ~' · -~--~ ' .. Size iii gallons Manhole/Access (Y~) "~[ ln¢~~ High water alarm level at* Cycles tested *Datum "Pump off' level at* .) E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank oa lot [t;'t') ; On adjacent lots t Absorptiou field oa lot '.~ J GO ; On adjacent lots Pablic sewer main t~ ,' (.x: 5 Pablic sewer manhole/cleauout Sewer/septic service liue > ~>'~? / - Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Buildiug foundation '>/O Property line ~/O Absorption field Water main/service line ~ It) Surface water/drainage '> lDO t Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~ /g? Water mail~/service line t Snrfacewater > /l>O Driveway, parking/vehicle storage area Curtain drain AJ~/Ot7 ©t.t ~/~'~Wellsonadjacentlots Property line ENGINEER'S CERTIFICATION I certify that I/,ave determined thrufield inspections and review of Municipal in conformance with MOA II~ guidelines in effect on this date. Date HAA Fee $ q:~F/~) , ~ Date of Payment Receipt Namber Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number