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Home My WebLink AboutPARADISE VALLEY BLK 2 LT 10Paradise Valley Lot 10 Block 2 -//'020 424-11 MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE I E~NEW .3 7¢ os7 ~ []..GRADE MAILING ADDRESS t~'zt o LEGAL DESCRIPTION NO, OF BEDROOMS J DISTANCE TO: W~I I e(L'~ '1 Abs°~ft~nare~ D,~elli~)~,~ PER MIT NO. ~ ? O?~[~ ~--'"~ Manufacture · ~ JLi~p~n gallons IF H MEMADE' Inside length Width Liquid depth .t ~_% 'U ] O . ~,s,~.c.~o: pc,, ~e,,i.. .**~.o. Manufacturer Material Liquid capacity in gallons w~,, . , * ~ O J Tre,:~i~h inches I Distancebet~e~n~s No.~.lines ~ Length ~f each ~ne Total lengt~of lines ,/~y~t~h~de Mat~ri~beneath inches Totaleffectiveabsorpti~a;17O ~'r- ~ 'Width Depth PERM T ~O, Type of crib Crib diameter Crib depth Total effective absorption area Nearest lot tine DISTANCE TO: Well Building foundation JClass Depth Driller Distance to lot line PERMIT NO, DISTANCE TO Building foundation Sewer line Sept c tank Absorpt on area(s) OTHER P. LP~ MATERIALS '-V~sTto ~1~.5 fo SOIL TEST RATING I NSTA~LER x REMARKS -L,~ g/~/p Z~'~', o~J APPROVED DATE LEGAL 72-013 (Rev. 3/78) BIG DIPPER DRILLING .... x~T/ 7529 E. 6th Avenue Anchorage, Alaska 99504 · (907) 333-6435 WELL LOG 5 (,ALLONo PER MINUTN STA'PEMENT L6s }-'<~el: ,4ri 11<~,{ .~.l c-;,,l ; :;;20.00 p,,z- !;uJ Idinq pad! a '.-/i !,mi,,' i,)l \[, , ' ,,,. . , ' you fo] 5,:;,~c.'i i .'l:i i BIG DIPPE;RER DRI[,],I,,... ~<,t r Licensed · Bonded · Insured 2.6 d. 4'? 2 0 A I"t C I t( :)R A (i~!]: ~, ('4( V ? 5:1 3 4 5 "()',i7 .0'1 I .J(-¢ t I,I (~IJI:)D:[VIt~]:[H',h: I:'AI:;~AD:t]St:'] VAllEY I.O'/;~ :1() I;ll..[i[)K:~ 2 ',:}h:C] ]: [!N ',', :L :1. I I')WNSI I I F:' ': :1. ;t]\l I:l¢/1".1(!)1: :: ;:i;W :L. tlA (!~(:.)',,, I:'l ,, JIF;,' ?~d:]Idi:',~i ) (~RI:I]CI:i: ~',( ',,11 I I:l".J(:";'l[I > /,~ t;:l',, P,I.tJJ.LI* iHlll.ltl:::'J.l:i: I:;:UHIi (i~.li]]' I:!:XCI:I:D):t',tG ,>LC FI'. I::ACii) IANK I'tItSI ItAVE I:YI' I.EA!i'I I"t,',ll] CX)MI::'AI;;I'I'4I!dqT[; 'ti:: A t.:1:1: i Ii'I'AT]:Ot',I ~..:~ ..t,h.>lAl.ll.I) II'q Alq AREA I;;l'i',?l:::J:ll:i:!) Fl-Il]iq ( I ) ('lt',lIl.l(, I ,.l,¢ I. l:::'J:l:.fl"ti['t Ah.iD "l',l~::il:'i:;('.'l ]]lin i'¢tllli'l' I,,,I ILl.i\II]T "' ~ ' " :. iit'J"l',J~'}J ..) I,,]):'llli)tlT (il',1 l::l :t,ll~. J. I ]] I',ISi:;'I:!]]T ]: i IN I:;fl]::'(]J(t~ AND (..,) Till: '.:i [ [ ii',tl]: ~:) hl:'l:'l .]l](;hl',l ;: POL .t 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #: 840865 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 10 Block 2 Paradise Valley Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on--site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, SupeYvisor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 437 '!E" STREET, SUITE 200 ANCHORAGE, ALASI<A 99501 BILl. SHEFFIEI. D~ GOVERNOR Telephone: [907) Address: 274-2533 Constructing Engineers 9601 Buddy Werner Drive Anchorage, Alaska 99516 Dear Sir: Subject: Wastewater System Lot 10, Block 2, Paradise Valley Subdivision (8521-DA-004) We have reviewed the plans and specifications for the subject project. The plans are approved, conditioned on adherence to the following items: 1. screened rock back fill in deep and wide trenches (3/4" - 3"). 2. screened rock back fill in absorption bed (3/4" - 1 1/2"). 3. sufficient area plotted on as-built for replacement system. This letter constitutes the permit required by A.S. 46.03.720(a) for plan approval of sewerage systems. It should be remembered that final approval will necessitate the submission of Engineer As-built Plans to include photographs as indicated on page 13 of enclosure. This will consequently mandate that a professional engineer conduct basic inspection of this project so as to be able to sign off on as-built plans. Arrangement for this inspection work is the responsibility of the developer. Sincerel~ ~ Environmental Fieltt Officer dFH/msm Enclosure cc: Robbie Robinson (MOA) As-built Plans submitted by Date; Approved by Date: I L,l:d I), ¥ NO,~ L.E)'F '::'" 7' ::' .' I"I(:~X ::=" :: .... ,,c:,,, SI.I,t':~D ]: Y ]: S :t:(:)l',l :~ I:::'(.~I::¥'~D :[ SE M(~I..LEi:Y I..t"]T :~ :t. 0 SE[C'I':[£:~I',I= :1. :1 'TQNI",ISH]:F:'= :!. :1,1',1 I:~(:'d',l(!:ilE,~ :1.. Elf, (Ell:,) ,. F'I". EIIR (IC'l':ili;!:D) .x..>~. (!3l::~(/\,qE).. I.J:::I,I(:.~IH :::' :7D FT,, I:qIE(;;!LKI:F,:EEi I ltll...I ..I L.[. IRt_IIxIS (N(3T IEXCIEI'ZI):I:IqG 7',"5 I:::"1',, '"~¢" ~' fear"Lb by the HL~ni.c::i,I]a],:i. ty of (~nc:hc~'~.~e (HD~) arid 'l:l'~ 2,, ): ~¢:i.].], J,n~i'L¢~:l.]. t..h~;~ ~iy~i'l:.~fit :i.n au:::c:cmda~c;a~ t.~:i.'Lh at:t,). I~1(](~ (:::c:~di;:~i :5. :1; ~.~:i.].:l. at~ll'l~::~l'(:] Lc:) ~ct].:l: I~'IE)~ cd~d EH'..a'I'..¢~ cfi' (,~:L~'~:;,I.ca~ ~'eqL~:i.~'~:m~c:~r~t'.r~i PERFORMED FOR: 'MUNICIPALITY OF ANCHORAGE DEPARTMf-NT OF HEALTH AND ENVIRONMENTAL PROTECTION SOILS LOG- PERCOLATION TEST /--' D (- L-'-/~. ' ' ' [] SOILS LOG :i ' "'~ '~' ' SLOPE D- I ~r'/~'~ ~c % .L' //~ : ~' -' I- fL,~ .... s,/ll ,~ ~ ( . ' - · ' , ro,T WAS GROUNO WATER ENCOUNTEREDZ : ~ ~ 1 2 3 4 5- $ 8 9 10 11 12 13 14 15 16 17 ~8-j COMMENTS DATE PERFORMED'.. ,../-c.c. c./:+' .' SITE PLAN IF YES. AT WHAT DEPTH? Read,fig Date Gro~,s Net; I"'~th' to ' ' Time . Time , //-/~ Z¢~/ ' - '" "~""; ': ":-'~"'-'":" :~- //.,~ z~.~ ..~, ' ........ PERCOLATION RATE ~:~L~ - ~:.: TEST RUN BETWEEN Z-~'/ FT AND ALASKA 9950~ December 31, 1979 Leon Windeler Star Route A Box 2].3 Anchorage, Alaska 99502 Permit ~ 790646 Subject: Lot 10 Block 2 Paradise Valley SubdJvi%ion A permit issued by this department for well and/er sewer system has expired. Pe~nits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If an engineer has inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz, R.S. Senior Environmental Speci~t'ist LNB/ljw enc: Copy of Permit L..EGI::IL. 'Th'?E OF' ,.::j;r:' ]:1.... I:::iB:!!i 3!:;:t::'T'I:OI'-,I . : I..11 :t::~:~ · 1 EJ;; ~:::" '"'~'" JJ'"":~ ~ ......... X~}~}~ .... ;;:::i II ti:m* ~'"',,~ ~'"':~ '"'F' ~'""'~: ....... ;;?' *):::~ (;E~ .. ".-:~'. 1(:2~ ~::;;;[,: f::ll ,,,? ~E~:: ~ ....... "I"HtE !....tEN(:~"r'H D :[ !','tE:N:E; ]: OF,t :[ S THE [...[~:i'.,ll::~i"i-J...l ,:: :1: N l::l:~[FJ~:"[' ) CIF: "['l...ll~ "r'l:~:J~:l'.,ll:::l...I OF;~: [::q:;;~F:! :!: NF:' :!: EL..D. THE [)[~:F"t'H OF' F:t T!:~'.EENC:H OF~: F:':[T :[:~E; THE [::, :[ ~;TFINCE~: BE:'TI.,.tE:E:h! "I"HE :~g..JF~:F::'FIC:E OF:' Gl:ROUND FIND THE [~;O'T'TOP'I OF:' 'T'H[E E:;:.::C:FtVFF'F:[C~N 4 :IN F'EET::,. 'T'HEF'::E :[ S NO rE;lET N Z D"I"H F:OF~: 'T'F;:ENCHES. THE: GF~:FtVE~:L 13, EP"I"H :[ S THEE P'I :[ N :[ I"lI.Jfq DEF'TH OF' 6Fi:F!VE:L E:E~:TI.,.IE:EN THEE OI...ITI:::'FiLL.. F:!NI::~ THE E~CI'T'"I"OI'd OF' THE: E:Y,C:I:::t',/FIT :[ ON ,:: Z N F'EE~/'T' ). f::'E:F~ffq:.[.T t:::ff:'F:'L.:[C:FthI'T' l-..IF::r/.!; THE .t:Rt!.:.':~ii;F:'ON:':'i:![ii~:i:L..:[Th.' TO :[NF'OfRt"! "F'I.-I]::E~ I:)IEF::'t:::!I:;i:TI','tI!ii:NT E.',UI:;i::[NG 'THIJE ZN:ii?r'F:IL. LFtT:[ON :[I'.,i!i'.:;F'EC:T:[ONS O1::' F:tNh.' NEL. L.:i.::; FID,LI'FICE:NT TO "!"H :!.' :i~ P!:~'X:)F:'I:'i!:!:~:T"r~ !:::IN!?, 'THE lqLJf"l[ii~E:Fi: OF' FREr!!~:[DENC:E!:'.'~ 'T'HI:::IT THE NEr. L.L.I.,.I:[L.L.. :ii!:E!:FR',/E:. !!!i:I:::IC:I<:F:' ]: L.L.. ~[ P,!G (:Ii:::' F:lh!h'* Sh/L::!;TEi:PI 1.,.1 :[ 'TI'"iOUT 1::: I I',tF:IL :[ NSPECT :[ Ot',I FIN[) I:::I!:::'F:'F;[:CIVF:It.... B"r' "1"t'"1 :[ :iii; [)I!EF'I::II:~:TI'"IENT I.'.t:[L.L. Ii31::.'!: ~!!;I.JB,LrECT "r'cI ]: C:E:Fi:'!":[F:".r' "FHF:IT :!..: :1: Fti"I I:::'F:tt"'III..~,.'t.'FIt:~: I.,ti'TH THE: R[E(;!U:[Fi:[ii:t"IEi:NT:i!i: I:::'Oi:~: ON"'"::~;].'TE!:: SEi.,.IIi~::F?.'Jii: F::IND F'OF;[:TH l.:!!?'r' THE !"It. JN:[C:t.'F'FtL.:[T'~'' Cfi::' ;ii~:: :t.' NZL..L. ]:t",!STFIL. L 'T'H['Z '.'":i;"r':!!FT'[!!:i"t :1:1",1 F!CCOF,.':DF:II",!C:E I.,.t:[TH THE: 2i:: :[ UI",II.')[:':Bi::!~!;TFtND THFtT TH[ii: OBI.....~i:J::.r.T[E ::~;EI.,tE:Fi: ~ii;"r':!~::T[EP1 PtF:!h" IRE(..".!UZI",i~E: E!:NL..F:IFi:(:!iE.tqE!:NT ZF:' "!'HE Fi:E:S:!:DEht(:Xiii: ~T, IE:IE:P'I(3I)t!EL..E[)TO, ]:NC:L.U[)E!: l"'!OFi:l!i~ 'T'HFIt',I 6 ,/) [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-222'~ SOILS LOG - PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 3 4 § ? O- 13- 14- 1§- 16 17 18 19 2O COMMENTS DATE PERFOR~ED~ SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop /l-JO Z40 O l, PERCOLATION RATE ~-~ ~'~' (minutes/inch) 72-008 (7/76) ParcelI.D,# MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING # 020-42~-11 · 1. GENERAL INFORMATION Complete legal description PARADISE VALLEY SUBDIVISION: LOT 10, BLOCK 2. Location (site address or directions) 5945 GREECE DRIVE ANCHORAGE. AK 99516 Property owner Mailing address Lending agency Mailing address ~ON WINDELER c/o HANORA DREW Day phone 5943 GREECE DRIVE ANCHORAGE. AK 99516 Day phone Agent BOB CAMPBELL WITH DYNAMIC PROPERTIES Day phone Address ,3111 "c" STREET. ANCHORAGE. AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: (907) 261-7600 ff communtty well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site ×xx Holding Tank Community on-site Public sewer NOTE: If community wastewater system, orovide written confirmation from State ADEC lng to the legality and status of system. 72~25 (Rev. 1/91) Front MOA #21 Computer Version Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1400.00 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, t verity 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 verity 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 e~d State codes, ordinances, and regulations in effect on the date of this inspection. ~ ,..//~ Address 6901 DEBARR ROAD,/SU, r ! 2B/~ANC"DRAGE, ALASKA 99504 , / Engineer's Signature [,..--,~/t,~, I(:Y~--'-""~.. ~- Date In conducting this evaluation, AV~V~, ,n~/ a,en ted to pr~de a thorough, conscientious engineeribg analysis of thc syslem in accordance with ADEC and MOA 'DH~ ~ Guidelines & Regulations. The reported results described 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 ail wells and septic systems depend on lhe 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 the evaluator of the system. Satisfactory test results do not guarantee future perlormance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty for future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DHHS. 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 olher person or party is not authorized, nor will it confer any legal right whatsoever. 6. DHHS SIGNATURE L--''/ Approved for /'~ Disapproved Gonditional approval for bedrooms bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisty 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 PRIVATE Log present (Y/N) Total depth 162' Sanitary seal (Y/N) RECEIVED Municipality of Anchorage ,JUN 09 DEPARTMENT OF HEALTH & HUMAN SERVICF h (. ^u y ,, , Environmental Services Divlslon "mmNMENTAL 825 L Street, Rm 502 Anchorage, Alaska 9950'1 (907) 343-4744 Health Authority Approval Checklist PARADISE VALLEY S/D; LOT 10, BLOCK 2, Parcel I.D.: # 020-4-24-11 IfA, B, or C, attach ADEC letter. ADEC water system number YES Date completed Cased to 162' YES Date of test Static water level 162' Well production 5.0 WATER SAMPLE RESULTS: Coliform 0 Date of sample: 5/24-/00 B, SEPTIC/HOLDING TANK DATA Date installed 10/28/85 Tank size Foundation cieanout (Y/N) Date of Pumping 5/23/00 C. ABSORPTION FIELD DATA Date installed 10/28/85 Length 2 ~ 65' Width Effective absorption area 1170 SF Date of adequacy test 5/25/00 FROM WELL LOG 11/1 4/~4 11/14-/84- Casing height (above ground) Wires properly protected (Y/N). AT INSPECTION 5/24-/00 N/A 18"+ YES 150' g.p.m. 5.0+ g.p.m. Nitrate 3.39 m~]/L Other bacteria O Collected by:. A.W.W.C., INC. 1250 Number of Compartments 2 Cleanouts (Y/N) YES YES Depression (Y/N) NO High water alarm (Y/N) N/A Pumper A+ HOME SERVICES [PRESOAKED WITH 2000 GALLONS ON 5/23/2000J ESOUTHWEST TRENCH/ NORTHEAST TRENCH] Soil rating (g.p.d./ft2 or ff2/bdrm) 287 System type TRENCH Gravel thickness below pipe 4.5' Total depth 8' +/- Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO Fluid depth in absorption field before test (in.); Fluid depth DRY/36.5" (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-028 (Rev. 3/96)* Compuler Version Results (Pass/Fail) PASS For. DRY/28" Immediately after 84.7 289 Absorption rate = NONE KNOWN If yes, give date 4- Bedrooms __ gal. water added (in.): DRY/4-2" 600+ D. LIFT STATION ~ Date installed Size Manhole/Access (Y/N) ~at* "Pump off" level at* High wa~~Datum .~sted E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot. Absorption field on lot Public sewer main 100'+ 100'+ N/A On adjacent lots 100'+ On adjacent lots 100'+ Public sawer manhole/cleanout Sewedseptic service line 25'+ Lift station N/A 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 5'+ 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main/service line 10'+ Surface water Curtain drain F. ENGINEER'S CE I cor#fy that I~)~w of Municipal ~coJ with MOA H~IA gl Signature ~,- ~. Engineer's Nam/ Date ~'/~ 100'+ FIq/~I'IO, N NO~J~ KNOWN Driveway, parking/vehicle storage area 10% wells on adjacent lots 100% field inspections and review , systems are in conformance on this date. JEFFREY A. GARNESS Date of Payment d~,/'? /'~'~) Receipt Number /~ g, P-%~' (' Z/,D .~'") 72-020 (Roy. 8/~6} Oomputor ¥omlon Waiver Fee $ Date of Payment Receipt Number 00'01'00 00:5i FRO~'CTE ENVIRONg4~NT^L ZtK CT&E EnvJr. nmnn,., Sen/ices Inc. 6615301 T-615 P.01/02 F-373 CT&E Client Name Pro joel Name~ Client Sample Matrix Ordered By PWSID 1O02485001 AK Water & Wastcwater Consultants Inc. Paradise Valley Lot 10 BM 2 Paradise Valley Lot 10 BII~ 2 Drinking Water Sample Remarks: Client PO~ Printed Date/Time 06/01/2000 8:49 Collected Date/Time 05/24/2000 16:00 Received Date/Time 05/25/2000 ] 1:00 Technical Director Stephen C. Ede Released B~ WATERS DEPT 3,39 0.500 m~/~ EPA ~00.0 10 men 0G/25/00 SCL MICRO LAB Total Cotiform 8 ¢ot/lOOinh $H18 9222B 05/Z5100 dOT MUNICIPALITY Of ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-47'44 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ('"') 1. GENERAL INFORMATION Complete legal description Location (site address or directions) ~'~ ~ d-:,,,,,_~..~, l~r Property owner ~ (JJ'~,~,_l. ~.,- Day phone Mailing address Lending agency Mailing address Day phone Agent Ad dress Day phone = Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: individual well Community well NOTE: Public water 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 NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #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. Name of Firm C-~'r,.t~r~ ~_-~,,~ ~-~- .~i~--~¢ Phone Address ~i ~u~-~ ~ ~C ~ Engineer's signature ~~~ Date D,/~S SIGNATURE ~ Approved for ~-¢z~,~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: ~ ~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev, 1/91) 8ack MOA #21 I [ Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST L I 0 [~ ~ '-~e,¥ ~',.~'V,~)~[ Parcel I.D. ~ ;,~---/~)_ A. WELL DATA Well type 'P~hv ~-r~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) O/'o ~-t~-~' ~Pr~ Date completed Mo,J ~9~),~ Driller "~IG"~IP~-Tz'-~LLPJ~ ) ¢o 7_ ?_G~" Total depth l (o 7_ Cased to Casing height Sanitary seal (Y/N) "/ Wires properly protected (Y/N) )/ Date of test FROM WELL LOG AT INSPECTION Static water level Well flow Pump level ~,0 4.0 g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main +t OD~ Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank oD --'r IOO WATER SAMPLE RESULTS: Coliform ~Z~ Nitrate Date of sample: ~- 15~ 97.- / B. SEPTIC/HOLDING TANK DATA ~' Date installed Tank size Cleanouts (Y/N) High water alarm (Y/N)~ Date of pumping I' "~ Other bacteria Collected by: I '7_.%'0 Compartments Foundation cleanout (Y/N) "/ Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: t Well(s) on lot + IOO On adjacent lots To property line -~ 'Z.<J' Absorption field Surface water/drainage +to0' -+- ) ~o0 Foundation t o ' Water main/service line 72-026 (Rev. 7/91) Front . ' "CONTINUED :ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) . Manufacturer Manhole/ACC~rx z "Pump on" level at ~ / ' ¥'~' "Pump off" level at High water alarm level ~r,J! Cycles tested Meets MOA electrical co~~''~'~ SEPARATION DI~J.~CE FROM LIFT STATION TO: WeJJ..err'rot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Oc.% ~9g$ Soil rating Z'~7 ~'/~/~v"~System type Length ~ ~ G~' Width ~' Gravel thickness Total depth Total absorption area I1~O 5~ Cleanouts present (Y/N) Depression over field (Y/N) ~ Date of adequacy test ~- 1%- Results (pass/fail) ~ ~ for bedrooms Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water -~ ~oo' Curtain drain On adjacent lots -+ I OO' Property line To existing or abandoned system on lot Cutbank +IoO' Water main/service Nine Driveway, parking/vehicle storage area W- ]O ' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on Signature Engineer's Name Date c.(, HAAFee$ /~)'~ Date of Payment /-1z~2 2"'~ Z. Receipt Number ,~ .~ ~'/'~,~ L/"l~¥'1¢/~ 72-026 (Rev, 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ALA~KA P.O, Box 110232 ^hICHORAGE. ALASKA (907) ~44-2632 344.2 ~,t 53 I I 8" D Y ~EOEIVED BY I · TOTAL -All claims and returneo goods MUST be · ~1 NORTHERN TESTING LABORATORIES, INC. Constructing Engineers 9601 Buddy Werner Drive Anchorage AK 99516 Attn= - Al16899 L10, B2 Paradise Valley Hose Bib Water Our Lab #: Location/Project= Your Sample ID: Sample Matrix: Comments= Report Date: 04/20/92 Date Arrived: 04/15/92 Date Sampled: 04/13/92 Time Sampled= 1500 Collected By= AL MDL = Method Detection Limit Flag Definitions B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Method Parameter Units Result Flag MDL Analyzed EPA 353.3 Nitrate-N mg/1 1.7 0.5 04/14/92