HomeMy WebLinkAboutPARADISE VALLEY BLK 4 LT 4Paradise Valley
Lot 4
Block 4
#020-411-12
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage. Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~¢,t/ ~'?D/¢~ PIDNumber: ~;~111,,~
Name: ~ ¢/,~ ~/~ ~ Wastewater System: O New ~Upgrade
Address: I~11~ ~¢r~y ~ /.,~. ~ ¢¢~/~ ABSORPTION FIELD
Phone: ¢.~_ ~_~ ~No of B~drooms: ~eepTrench ~ Shallow Trench ~Bed BMound ~Othe,
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION /.O ~.o/sq. ~.
Lot: ~ Bleck:~ ~..~l~Subdivisien:~./'~ Depth ,o pipe bDt,om bom original g,ade:~. ~ Ft. Gravel d~;~eneath pipe Ft.
~ Secdon: ¢ill added above original grade: Gravel length:
Township// ~ Range:~ ~ ~ ¢~6, // ¢ ,r Ft. 7~ Ft.
I
' Number 0f lines: D~stance belween li~es:
WELL: Q New ~x,Y~,~ Upgrad~ Gravrwidth: ~ Ft. / ~ ~ ~ Ft.
Classification (Private. A,B,C): Total De~ Cased To: Total absorption area: Pipe material:
Driller: ~ Date Drilled: StaticWater Level: Installer: Date installed:
Yield: Pump Set a,: Ft, TAN K
/GPMI ~t.Icasing Height AbOve GrOund:
SEPARATION DISTANCES ~septic ~ Holding ~ S,T,E.P,
To Sepl{c Absorption Lill Holding 2ubtic/Privat( Manufacturer: Capacity in gallons:
Well / ~ ~ / ~ ~ ~ ¢~ ~ Material: ~7~ ~ Number of Cempa~ments:
Surface *
w~to~ 4~o' , ~/~o ~/oo' LIFT STATION
Line
Foundation ~¢' ~¢' ~/ "Pump on" ,evel~mp oil" level ~t: I High wa,er alarm at:
CurtainDrain ~ ..... ~ __. ~ Pure.ode, ]Electrical inspections ps,formed by:
Remarks: ~¢~*,~ r*~-~ /,~ ~,~ BENCH MARK
Location and Description:
Assumed
Inspections performed by: ~A ~,'v.~ E?~../,'~ ~ 7/A~/¢ ~ """'
,ea.. ,uma. Services a,, ova
Department
72-013 (Rev. 9/91) MOA 25 ' , . , /
Permit No. SW970194
Page 2 of
Municipolit), of Anchorage
DEPARTMENT Of HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Paradise Valley Lot 4 BIk 4
PID No.: 02041112
2
A
SWING TIES
A-C = 42.7'
B-C = 78.0'
A-D -- 83.9'
B-D = 19.9'
TH1
ELEVATIONS
(NOT TO SCALE)
House
TEST HOLE
MONITOR TUBE
SEWER CLEANOUT
WELL
EASEMENT
NEWLEACHFIELD
EXISTING LEACHFIELD
Scale 1"=40'
7/21/97
ENGINEER'S SEAL
?':'..t
~".' ,~ kouis A. Butero .'" ~
Rick Mystrom,
Mayor
Municipality of AnchOrage
Department of Health and Human Services
825 "L" Street
P,O, Box 196650 Anchorage, Alaska 99519-6650
August 8, 1997
Lou Buteca, P.E.
Eagle River Engineering Services
PO Box 773294
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 4 Block 4 Paradise Valley Subdivision
Waiver Request #WR970044, BID #020-411-125 HA970310, SW970194
Dear Mr. Butera:
Your request for a waiver of the required 10 foot separation
between an on-site wastewater Rispo~al system and a lot line has
been approved. The waived distance is 7 feet from the absorption field
to the west property lime.
This approval applies to the existing on-site wastewater disposal
system lot line separation only. Any future upgrade to the on-site
wastewater disposal system will require all separations be met or
another approval from. this department.
If there any further questions or concerns regarding this waiver,
please call our office at 343-4744.
Sincerely,
Engineering Tech
On-Site Services Program
Cook Property
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR~[]~\~t~y%L%~ PID~ 020-411-12
Date Received: Au§ust 7, 1997
HA# HA9703 I0
Permit
Legal Description: Lot 4 Block 4 Paradise Valley Subdivision
Engineer: Lou Butera, P.E., Eagle River Engineering Services
PO Box 773294, Eagle River, Alaska 99577
Applicant: Lynne Cook
Waiver Requested: Lot lane waiver of ?~?. feet of the lot line
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver
List Conditions or Reasons for above:
is Granted: Waiver is NOT Granted:
Na~e of Reviewer~ '
Rec ~: 03040/6104 ~ount: $115.00 Date Paid: August 7, 1997
7' '2o-97
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUM~ SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970194
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NANE:SHIVEN DAVID
OWNER ADDRESS:18110 NORWAY DRIVE
ANCHORAGE, ALASKA 99516
DATE ISSUED: 7/17/97
EXPIRATION DATE: 7/17/98
PARCEL ID:02041112
LEGAL DESCRIPTION:
PARADISE VALLEY BLK
4 LT 4
LOT SIZE: 13277 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18A3~C72) AND DRINKING WATER REGULATIONS (18A3~C80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SANE DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
SEPTIC TANK SHALL BE UNCOVERED FOR INSPECTION BY EN-
GINEER WHO SHAL~ VERIFY INTEGRITY. /
DATE:
DATE:
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
July 7, 1997
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re:
Paradise Valley, Lot 4, Blk 4
Narrative & Permit Application
Dear Mr. Cross:
The proposed septic system upgrade will have very limited impact on adjacent properties for the
following reasons:
I. The surrounding lots are large, allowing sufficient room for Septic sites.
Immediate neighboring septic systems are all +20' distance. Wells are sited for
minimal interference.
Reserve space is adequate, due to absorption capacity this is the 2"a system for this
lot and the existing system will be utilized by installation ora diversion valve.
4. Drainage will not be affected and is not a major consideration in our design.
The lot has a +25% slope break at 30' west from the leach trench however this slope drops only
5' vertically to a bench and then there is another +25% slope which is at 50' distance. Both
slopes are vegetated and should not be a concern for effluent leakage.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera,~P.E.~'
\ 1997~97-027-IqAR.DOC
~ ~V~LL * ~oo,
~ TEST HOLE
· MONITOR TUBE
o SEWER CLEANOUT
+ WELL
NO SURFACE WATER .... EASEMENT
PROPOSED LEACHFIELD
NO ~NOWN CURTAIN DRAINS ~- EXISTING L~ACHFIELD
WELL/SEPTiC S~TE PLAN
OWNER:
CONTRACTOR: N/A
JOB~ 97--027A/DATE: 07/~7/971 SCALE 1" : 40'
EAOLE RIVER ENGINEERING SER VICES
EAGLE RIVER, AK. 99577
(907) 694-5195 FAX.. (907) 694-3297
g - TEST HOLE
· - MONITOR TUBE
o - SEWER CL~NOUT
~ - WELL
NO SURFACE WATER ..... ~SEMENT
NO KNOWN CURTAIN DRAINS PROPOSED LEACHFIELD
~- EXISTIN0 LEACHFIELO
WELL/SEPTIC S~TE PLAN
LEGAL: P~ADIS~ VAlLeY ~4, ~
co~c~o~: ~/~ .
Jo~ ~7-~7~1~r~. o~/~7/~7~ sclc[ ~ = ~, ~~.~
EAGLE R~VE~ ENGINEENING SERWCES
P.
O.
EAGLE RIVER, AK. 99577
(so7) ss4-s~ss FAX.. (~07) SS4-3~S7
Eagle River Engineering Services
Louis Butcra~ P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Paradise Valley, Lot 4, Blk 4
7/2/97 - Revised
A. GENERAL
1. The well & septic plan is for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. AIl materials and workmanship shall meet the Anchorage Department of Health requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi~family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location of any
easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
1. If noted on the permit under special provisions the septic tank is to be uncovered at the end for
inspectiou by the engineer. Any new septic tank shall be a minimum of 1000 gallons and shall be of
approved MOA design.
C. TRENCH
1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 10' at any point.
4. The effiueut line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoffi
8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any
Class "C" well, or 200 feet to any cotnmunity well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 10' GRAVEL DEPTH = 7' under pipe, 2" over pipe
TRENCH LENGTH = 32' TRENCH WIDTH = 3'
SOIL RATING-- 1.0 GPD/ft2 BEDROOM CAPACITY = 3
Twenty-four (24) hours notice required for all inspections.
\1997\97-027-spec
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Bo× 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
Paradise Valley Lot 4 Block 4 - 07/3/97
Single Family 3 Bedroom Dwelling
LEACHFIELD SIZING
3BR = 450gpd
Soil perc rate = <1 minutes/inch
Soil acceptance rate = 1.0 gpd/SF (sand)
Required absorption area = 450 SF
trench size 7' gravel depth, 32' long, 3' wide
G:\WPDOCS\ 1997\97-013-CAL I
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: ~.~/'-z~ ~.~' z7 /'~, ,.--~ a%'~- Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
/.../4 / / ~'~ SLOPE
/
'2>
~'.
/
19-
20-
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
Depth ID Waler After
Monitoring?
I
N
Reading Date Gross Net Depth to Net
Time Time Water Drop
I ~-~'*?) 1,3-: ~>. ,2. ,-~.~, ~' ' K"
PERCOLATION RATE ~'~// (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~_ FT AND ~'' ~-- FT
PERFORMED aY: ~'~'~'..r I ~'~~'--- CERTIFY THAT THiS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELLNES IN EFFECT ON THIS DATE, DATE:
72-008 (Rev. 4/85)
,,r MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO, ECTtON
ENVIRONMENTAl- ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99601 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI.L INSPECTION REPORT
PHONE
L N
NEW
J~UPGRADE
NAME
MAILING ADDRESS
111'5 L,V./
LEGAL DESCRIPTION
uJ
LU
Inside length
Dwelling
NO. OF SEDROOMS
PERMIT NO.
,0.0 f comp~n~,s ~..~
Liquid depth
PERMIT NO.
Matmial Liquid capacity in gallons
DISTANCE TO:
Eoundatio~ ~)
Total length of lines
Material beneath tile
Depth
Nearest lot line
No. of lines
Top of tile to finish grade
Width
Length
PERMIT NO.
Distance between lines
PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Wel~ Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line /PERMIT NO.
DISTANCE TO: Building foundation Sewer tine Septic tank [ Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
APPROV E~,~T~
72-013 (Rev. 3/78)~
LEGAL
i'! 1i!:: !;i:[!i):;!U :i1F~L-'~D ;~; ]: ZE: OF THE: ~:;i::~ :[ L. F:II!?,~!:;OF'.P 'f' ~ I::)t'.,l tS"r'tSTEPI :[ L"'~;:
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':5I;i!:T 1,.! :r f::,'THF;-'OF'
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F'!i~t::i:!,l:['i I'::IF:'F:'I..:I:I:]:I:::!t'..!'T ilf::t~!:i; 'THi]i:: I;i:EE~i;F'OI'.,Hi;:!:E::[L.]:T'~.' TCI
:[N:~i;Ti:::I!.L.FIT)'(]IH :[?..!:!i!:F'!ii.:CT:[CH~.,IZi; OF' I:::tN'?'
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::LOO !:::E:~:::-i' l:::'l:i)l:,~: FI F'F?.]:'v'FI'I"EZ I,.I!:EI..L O1,~'. ::LE50 '1'O 200 F'E!:[¥!"
I..IF;'ON THE T'.r'F:'E:: CH:::' F'LJi.:fi..:[C !,Il:i::[..!
l',! ~: t'..! ]: f,ll..IH E:, ~ ~:;'1 F:II'.,!(::Ei: !:::'F;?OH I:::t F'I:?. Z[ ',,,'l::l"l'!i: HE:EL TO FI f:::'I:E~ Z[ ¥1::1'['1~i: ::ii;tlE:f,.ll_'~:l:;;~ L :[ NE: J: S ;;frU I::'l.~:l:i: 'F F:IHD
'1'CI 1:::I I::::(:~HHI. li'.,!Z!ZT'-,.' :E;~:i:!,l~:!:t:;;: !..:t:t'.,I1!!: ?5 ';."'.:5
!,}D:I..I__ [.OG'_:i!; I::tF:E!: IE:I:E:i:;!I..I:t:I;i:~:::f::, I:;ll",l[) !"'lI.J'Ei;t' I?,Ei: I:;~:E!:'FLII:~;'.h~!EI:)
CH::: 'tlIEE I,.!~i:!.!..
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l::tYFI]:[.f:tl.E'.!.[ii: TO :[N'_.'51..It:;~'.I:Z F'F.:OF~!i:F:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~(]/ SOILS LOG
[] PERCOLATION
TEST
LEGAL DESCR PT ON:
3
SITE PLAN
/6
10
11
13-
14-
15-
16-
17-
18-
19-
20-
W^SGROONOWATER
ENCOUNTERED?
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
COMMENTS
TEST RUN BETWEEN FT AND FT
PERFORMEOBY: ~'~CL~['tr '? ?'~Z~_//4~-r~'/
72-008 (6/79)
GARY JLAYER VBN"TURES
CONSULTING GEOLOGIST
October 17, 1977
Visual Soils Examination: Lot 4, Paradise Valley Subdivision
Material encountered were GW (well graded gravel) £rom the surface
do~m to a total depth o£ 12 feet below ground°
The material will rate 85 square feet o£ seepage pit wall per bedroom
to be constructed.
No groundwater was encountered°
Bedrock was not present to to~al depth.
Please excuse this sloppy £ormat~ but my regular £orms are somewhere
else.
Sinoere~
Gary ~. l~layer
Consulting Geologist
DrilLing Company Nam
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
U.S.G.S. Local No.
Oril)ing Permit No.
LOCATION OF WELL J Please complete either la, lb, or lc. A'U'L' HO'
la. Borough Subdivision Lot Block lb. Fraction Section No. Township Range Meridian
/ / / N/S E/W
lc. Oistance and Direction From Road IntersecClons 3. OWNER OF WELL:
Address:
SLreet Address and Area of Well Location
-- 6. USE: E]Domestlc E~]Publlc Supply [] Industry
E]lrrlgation [~]Recharge [~]Co~rclal
E~Test Well ~]Other:
7, CASING: ~Threaded ~Welded
~A~ve ~Beiow land surface
/0 Type of Measure~nt;
~O~//xO-~ '0. PUHPING LEVEL belowland surface
~ ~,~ ~ I I. WELL H~O COHPLETION: ~ mn AppKoved Pit
~Je~ ~Other:
: . .... · TONY KNOWLES, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
DIVISION OF ENVIRONMENTAL HEALTH
DRINKING WATER AND WASTEWATER PROGRAM
555 CORDOVA STREET
ANCHORAGE, AK 99501
http ://www.state.ak.us/dec/home/htm
Thomas & Elisabeth Church
18110 Norway Dr.
Anchorage, Alaska 99516
RECEIVED
MAY 22 1998
Munic~pahty ol AnChorage
Dept, Health & Human Services
Telephone:(907) 269-7696
Fax: (907) 269-7650
May 18, 1998
Subject;
Lot 4, Block 4, Paradise Valley Subdivision, Anchorage, Alaska, Class C Public
Water and Wastewater Disposal Systems, ADEC Project Number 220, Review
Dear Mi'. and Mrs. Church:
I have reviewed your April 28, 1998 submittal regarding the upgrade of your single family home
into a Bed and Breakfast. Based on this review, I have the following comments.
From the submitted information, it appears that the existing water system met all regulations and
guidelines when it was installed. Based on this information and the fact that the demand on the
existing water system will not be increased, it appears that the water system will be able to meet
the demand without modifications. Therefore, the existing Class C Public Water System serving
the one two bedroom Bed and Breakfast and a two room single family residence located on the
above-referenced property is approved for the concerns of this Department. A final Operation
Certificate, constituting this approval, is enclosed.
By opening a Bed and Breakfast in your home, the existing water system classification changes
from private to public. The Department is assigning Public Water System Identification
(PWlSD) Numbers to all public water systems. The PWSID Number assigned to your public
water systems is 218570. This number will need to be placed on all forms requesting analytical
results. The nitrate (as nitrogen) level found in your water has increased from 0.15 mg/l (sample
collected on May 9, 1997) to 6.63 mg/1 (sample collected on March 30, 1998). Based on this
increase, I recommend that you yearly monitor for total coliform bacteria and nitrates (as
nitrogen). From the submitted information, the water samples should be collected between
January 1 and March 30 of each year.
Since the existing wastewater disposal system has not been operating at full capacity, it should be
able to accept the volume of wastewater fi'om an one bedroom Bed and Breakfast and a two
bedroom single family residence. Thus, in accordance with the provisions of 18 AAC 72,
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
Parcel I,D. #.
020-411-12
HAA# /~000 I ~, l
1, GENERAL INFORMATION
Complete legal description PARADISE VALLEY SUBDIVISION: LOT 4. BLOCK
Location (site address or directions) 181 lO NORWAY DR,
Property owner
Mailing address
Lending agency
Mailing address
RON & ELIZABETH CHURCH
18110 NORWAY DR
Day phone 5&5-2295
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup,
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well xx
Community well
Public water
NOTE:
ff community 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
Holding Tank
Community on-site
Public sewer
NOTE:
XX
ff community wastewater system, provide wdtten confirmation from State ADEC
lng to the legality and status of system.
72-025 (Rev, 1/91) Front MOA #21 Compuler Version
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
wastawatar 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 an, r ~tata codes, ordinances, and regulations in effect
on the date of this inspection. , g /
/
Name of Firm ALASKA WATER &/WAS/TE~ATER bONSULTANTS, INC. Phone f907)337-6179
Address 6901 DEBARRRID'AD, S~I't//"c/~IC'/~I_'~HC/~.GE, ALASKA 99504 ,
, lEngineer's Signature~ ~'~' '"~ ~" -'L---~/'~//~'"~,7~ [/ ~ Date 3./.z~//cs ,
analysis of the system In accordance with ADEC and MOA DHH$ Guidallnea & Regulations. The reported
results deacdbed the performance of tho system under the condflfoes encountered at the time of the the
teat, and separa#on distances measured to readl~/ Identifiable fitaturoe. The operational life of all wells
and septic syaleme depend on the local soils condiifon, ground water levels that mayfluctuate during the
year, and the water usage of the faml~/ being sen/ed by the system. These eandi#oee are outalde the
eantrol of the evaluator of the system. All systems eventual~/ fall and satisfactory teat reau#s do net
guarantee furore performance of the system, nor do they guarantee that there are no hidden defects or
encroachments, AWWC, tho. can therefore not provide any wan'anal for fufere performenoa nor give any
eat/mate of how long the system will continue to moat the opera#onal requirements of the ADEC or MOA
DHH$. The content of this report Is for the sole benefit of the owner listed above. Any retienoa upon er use
of this report by any other person or par~y Is not autho#zed, nor will It confer any legal right whatsoever.
2, Alaska Water end Waalewatsr Consultants, Inc. shall be paid $1000.00 at, or plier to, ctoalng for the
angthoedng oe/vlcea proCded.
6. DHHS SIGNATURE
/ Approved for -.~ bedrooms
Disapproved
Conditional approval for.
bedrooms, with the following stipulations:
~4 Additio~al Comments
eta: rne we±± ~or tnzs property meets existing State and Municipal Codes.
There are nitrates present. It ~s stt~e~f-~.4 th~ p~r~c ~st~'~ hP
performed to insure the wells continued suitability. Current nitrate
~re information on nitrates is available from the On-site ~ices Program~
DHHS, 343-4744. ~ ~ ~-~-~O
The Municipalify 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. 1191 ) Back MOA ¢Y21 Computer Vemlon
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
,, . Environmental Services Division
825 L Street, Rm 502 Anchorage, Alaska 99501 (907) 343~[~
Health Authori Approval Checklist
A. WELL DATA
Well Type PRIVATE
Log present (Y/N).
Total depth
Sanitary seal (Y/N)
110'
If A, B, or C, attach ADEC letter. ADEC water system number
Y Date completed
Cased to 81'
YES
1/25/8,]
Casing height (above ground) 14"
wires properly protected (WN) YES
020-411-12
N/A
FROM WELL LOG AT INSPECTION
Date of test 1/25/83 3/24/00
Static water level 62' 64'
Well production 8 - 12 g.p.m. 6.7
WATER SAMPLE RESULTS:
Coliform ~
Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Collected by:
Other bacteria ~
A,W.W,C., INC,
Date installed 7-2O-97 Tank size
Foundation cleanout (Y/N)
Date of Pumping 9-9-99
C, ABSORPTION FIELD DATA
Date installed 7-20-97
Length 32' Width
Effective absorption area. 448
Date of adequacy test
Soil rating (g.p.d./ft2 or ft2./bdrm) 1.0 System type DEEP TRENCH
Gravel thickness below pipe 7.0' Total depth 119"
Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
3/25/00 Results (Pass/Fall) PASS For 3 Bedrooms
1000 Number of Compartments 2 Cleanouts (Y/N). YES
YES Depression (Y/N) NO High water alarm (Y/N) N/A
Pumper. A+ HOME SERVICES
Fluid depth in absorption field before test (In.);
Fluid depth 0 (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-028 (Rev. 3/96)* Computer Vemlon
0 Immediately after 700 gal. wateradded (in.): 28
1440 Absorption rate =. 450+
- If yes, give date -
g.p.m.
Legal Description: PARADISE VALLEY SUBDIVISION; LOT 4-, BK 4 Parcel I.D.:
D. LIFT STATION ~
Date installed
Manhole/Access (Y/N) ~evel at* "Pump off' level at*
H~flhw to~ *Datum
.....~sted
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
100'+ On adjacent lots 100'+
100'+ On adjacent lots 100'+
N/A Public sewer manhole/cleanout N/A
25'+ Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+
Water main/service line 10'+ Surface water/drainage 100'+
Absorption field.
Wells on adjacent lots
5'+
100'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
**7' FROM OLD TRENCH TO PROPERTY LINE
Property line 10'+* Building foundation
Surface water
100'+
Curtain drain
**WR970044
F. ENGINEER'S CERTIFI,
I ce, ify that/
with M A
Signature [ ~/V~
NONE KNOWN Wells on adjacent lots
field inspections and review
~ systems are in conformance
! on thls date.
,
JEFFREY A. GAF{NESS
. 10'+ Water main/service line 10'+
Driveway, parkingNehicle storage area 10'+
100'+
HAA Fee $
Date of Payment.
72-028 (Rev. 3/06)* Computer Vemlon
Waiver Fee $.
Date of Payment
Receipt Number
0~"2g-0(] 15:4g FRO~t-CTE ENVIRONMENTAL
zt~_, CT&E Envimnmen,al Services Inc.
T'riO P.02/03 F-gSI
CT&E Rd.#
Clieat Name
Project Name/,
Client Sample
Matrix
Ordered By
PWSID
Sample Remarks:
1001303001
AK Water & Wastewmr Consultan~ Inc.
Lt 4 Bk 4 Paradise Valley
18110 Nor, ray
Drinking Water
Client PO#
Printed Date/Time 03/2=9/2000 12:26
Collected Bate/Time 03/24/2000 9:00
Received Dateffime 03/24/2000 13;45
~AT~RS flEPT
0 cot/lO0~. $N1~ 92R2B
0)/~/00 dDT
03/20/00 15:29 FAX 907 273 8440 PRUDENTIAL VISTA REAL ES ~005
LEGEND:
HUB AND TACK
EAELE RIVER AEBuIL T ~URVEY ~' ~'
~04~ VF~ ~P/v~ OWNER: SHIVEN ERES Projec~ Nu~er~7-O~7
E~gle RJve~, AlonZo ~577 CAOO File N~e; g?-~7Ai~V~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Sectioh
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
ECEIVED
JUL 1997
Municipality of Anchorage
Dept. Health & Humar! 8e~ic~e_s
1. GENERAL INFORMATION
Complete legal description PARADISE VALLEY, LOT 4~ BLOCK 4
Location (site address or directions 18110 NORWAY DRIV~
P[operty owner LY[',~E COOK
Mailing, address 18110 NORWAY DRTVE
Lending agency
Mailing address
A~erd[
Ad dress
Day phone 345-5822
ANCHORAGE, AK 99516
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
NOTE:
TYPE OF WASTEWATER DISPOS,~L:
NOTE:
Individual well x
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
Individual on-site Z:
Hoiding 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-O25 (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 Approva~ 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.
'.~. ~ox zl~zV,), UaCe l~.iver, AK 99577-3294
Address
Engineer's signature
7-22-97
Date
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisf7 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~)25 (Rev. I~1) Back MOAt21
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
Municipality of Anchorage JUL 24 199,
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division R E ¢ E ! V
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type /PY~ ~/~
Log present (Y/N)
Total depth ~/' 7 3 i
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to t- ~,'~, i Casing height (above ground)
Sanitary seal (Y/N) ~/
Date of test
Static water level
Well production
FROM WELL LOG
g.p.m.
Wires properly protected (Y/N)
AT INSPECTION
5%5 /
7~ cD g.p.m.
· WATER SAMPLE RESULTS:
Coliform ,~
Date of sample: -~ ~"~ ~-
Nitrate zP,/,~- ,,,,~-/,~ Other bacteria
'5'-~? ' 5' ) Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed / 5 '2 ?
Foundation cleanout (Y/N)
Tank size /~/-~ Number of Compartments ~ Cleanouts (Y/N)
/P' Depression (Y/N) ~ High water alarm (Y/N)
Date of Pumping /v~, ~,,-//c Pumper
C. ABSORPTION FIELD DATA
Date installed /'~?'~ ,~'~/? Soilrating orft/bdrm) /;~
Length ~,~- / Width 3 / Gravel thickness below pipe
Effective absorption area ~'~' '~ Monitoring Tube present (Y/N) ~'
System type
;2 ' Total depth /~' /
· Depression over field (Y/N)
Date of adequacy test i~//,'¢- Results (Pass/Fail) ~ For
bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately after ~ gal. water added (in.):
Fluid depth '--' (ins) Minutes later:.
Peroxide treatment (past 12 months) (Y/N)
Absorption rate = _g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date inst all~,,~
Manhole/Acco~Y/N)
High water alarm I~l at* *Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /
Absorption field on lot /
Public sewer main /~ ~,~
Sewer/septic service line
Property line
Surface water
Curtain drain ~/,~
F. ENGINEER'S CERTIFICATION
"Pump off" level at*
Size in gallons
"Pump on" level at*
On adjacent lots /-/¢~"
On adjacent lots ,~/'~ ~'
Public sewer manhole/cleanout
Lift station ,"J/'4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~' Property line -~o ' Absorption field
Water main/service line '/~/~' z Surface water/drainage '~""'~"
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /~'~' / Building foundation :~'~ /
Wells on adjacent lots
Water main/service line ~-/~ '
Driveway. parking/vehicle storage area
Wells on adjacent lots '~"/~,~ /
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
Date '~ - :z
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $ /~'/
Date of Payment
Receipt Number
,~ CI&E Erwironmental Services I~c.
Sampl~ Remarks:
Cllem IOg
l'riatml Datefl'Jnm 05114/97 17:07
Coll~ D~Tlme 051~gl97 11:55
~D~ 05~9~7 12:15
T~b-iml D~or: ~hm C. ~
CT&Ii Microbiology Ddaking Water Program certification s'tat~q is provisional as of 418197.
0.100 mg/L SR18 4500-NO,~F lO mx
co[/lOrJmt, r~18 ~
05/09/97 JSL
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
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner ~_]C~ ~
Mailing Address / ~ ~ \ I~
(c) Lending Institution
Telephone: (home) Business
Telephone
Mailing Address
(d) Real Estate Company and Agent
Telephone
(e) Mail the HAA to the following address: (or check here~ if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-FamilycE%' Number of bedrooms
3. WATER SUPPLY
Individual Well,,~', Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site/~ 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-o25 (Rev. 7/88) Page 1 of 2
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5ulpual J!eql. pue seu~oq jo sJeseqoJnd m, /,salJnoo e se sjql saop SHHQ aq.i 'e~selV J.o elelS eql u! peJels!~eJ
JeaulBua leuo!sse~.oJd luepuedepu! ue Xq aAoqe S qdeJ§eJed u! ue^!6 suogeluas@JdaJ eql uodn ~lUO peseq pel. eo!J!Jeo
leAoJddv ~l!Joqmv qllBeH sanss! (SHHQ) sao!AJe$ ueLunH pue ql. leeH ~o lueuJl. Jedaa al~eJOLIOUV jo ~l!led!o!un~l eq.L
'T/6~ 0'0~
sT UOT3~uaouoo ~n~Txe~ V~ '~/6~ L'9 ST UOT~e~u@ouoo
a~e~T~ -~TTTqe~TnS panUT~UOO sTTa~ aq~ a~nsuT
o~ p~zo~zed aq 6uT~sa~ oTpOTzad ~eq~ pa~saB6ns ST ~T
pue a~egS BUT~STx~ sg~ A~doAd sT~ Aog iiaA aq~
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leUO!l!puoo pa^oJddes!C] ~ pa^oJdd¥
~¥AO~ ~NNa
~NC~L~IPALITY OF ANCHORAGE (MOA)
t¢~C~'~ ~,~,~'~¢~. ~alth Authority Approval (HAA)
..oc~/,~l~,~.~] CHECKLIST - FEBRUARY 1984
~ 9 ~9~9 343-4744
Legal Description: ~z/~/~:
A. WELL DATA
Well Classification ~7~/~ ) O;/~/~/d?/' If A, B, C, D.E.C. Approved (Y/N)
Total Depth_//~ / ' ' (
Cased to ~ Depth of Grouting L/)~/~d2
Static Water Level ~ ~ / ~'
- Pump Set At _ /~2~
Casing Height Above Ground ~-/ ~ Sanitary Seal on Casin~N)
Electrical Wiring in Condui~)/N) Depression Around Wellhead (Y~
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot .'/~ ~'~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot //~/ ~ ; On Adjoining Lots
To Nearest Public Sewer Line /V/~ . _arest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by ,~? ~5'~C~ ;Date
Water Sample Test Results ~.:~'~ [ ~)~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~,,~f'6:~- Size
. _ ~,,~/ . of Compartments
Standpipe~?~?N) Air-tight Cap~Y)'N) Foundation Cleanou (~.Y)N)
Depression over Tank (~ Date Last Pumped _~¢~/~//~ ~"
Pumping/Maintenance Contact on File (Y I~/¢--/~/,~' ; for
Holding Tank High-Water Alarm (Y/Ni /// Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEP'~,L~j/HOLDING TANK:
To Water-Suppiy Well /(¢'~('~/E'¢'~ .~.'~ To Building Foundation
To Property Line ;'~-~-~ / ~") ~ ~'- To Disposal Field /./
To Water Main/Service Line '~ _¢(~ ? ~ ~
To Stream, Pond, Lake or Ma or Drainage Course
72 026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA ~'~ ~// ~ /~ ~'~7'
Soils Rating in A,bsqrptiojn Strata /~¢. '/,-/~:~ Type of System Design
Date Installed 7/~7./~
Length of Field
Width of Field '~' /~ ~/~ Depth of Field
~' 4¢
~2 ~ ~. ~Gravel Bed Thickness
Square Feet of Absortion Area ' ~-~ Statndpipes Present'N)
Depression over Field (Y~ ~ Date of Last Adequacy Test
Results of Last Adequacy Test ¢r~¢~ ~,)(~ ~
SEPARATION DISTANCE FROM AB¢~RPTION FIELD:
To Water-Supply Well // '/ ~1 To Property Line
To Building Foundation ~ ~ / ~ To Existing.( Abandoned System
Lot ~/~ ;On Adjoining Lots /-
To Water Ma n/Serv ce L ne ~ ~ ' ~ To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments 5/ ~, >¢/ (~/,~ /'-/ :./ /~.c~ ,.~> ~:?,~
D. LIFT STATION
Date Installed
Size in Gallons
Pump On Level-a'c- .
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
D~mens~ons
Ma?~hole/Access (Y/N)
"Pump Off" Level at
~e_nt (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
inspection~
Signed
MOA No.
Receipt No ¢~. / O C ,=,~.
Date of Payment
Amount: $
Receipt No
72-026 (Rev. 7/88} Back
on the date of this
Engineer's Seal
Waiver Fee: $
Date of Payment
Page 2 of 2
NORTHERN TESTING LABORATORIES,
600 UNiVERSiTY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479 3115
2505 PAIBBAN KS STREET ANOHORAGE, ALASKA 99503 907-277 8378
[54].0 Switzerland Drive
Anchorage AK ,99516
Samp]e ID#: A030689--]
DaLe Arrived: 03/06/89
Time Arrived: 1521
])ate Sampled: 03/06/89
Time Sampled: ]440
Date Comp] eted: 03/(19/89
Parmneter Unit Result ADEC MCC*
Nitrate-N rog/1 6.7 ]0
Reported By: /~ ~ Date: 03/09/89
France:is Rod:Lgari, Anchorage Operations Manager
* MCC -- Max:imum Contaminan't Concen'[;ration
NO THE N TESTING LABO ATO ES
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907.479 3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Quality Control Report
Client: James Sizemore
ID#: A030689-- ].
Listed he]ow are quality control assurance reference semp].es with a known
concen'tration prior to analys:is. The acceptable limits represent
a 95% confidence i.nterva] established })y the Enviranmenta]. Prote~-%ion
Agency or by our laboratory through repetitive analyses of the
reference sallple. The reference s~llples indicaged ])slow were analyzed
al. the same hims as your sample, ensuring the accuracy of your resul%s.
Sample # Farmllet~'r Unit Result Acceptable Lim:i t
EPA WP284-3 Nitrate N g/1 0.14 0.10 0.]8
Reported By: ~/~ ~/( Date: 03/09/89
Francois I{odigar:i, Anchorage Operakion Maaager
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPAKTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION ~Y)R HEAL%~I AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date _~/- £/~"'//' _
legal D~scription{inclu.de lot,bloe~, subdivision, section, township, range)
Location (add~,ess oF directions)
Applicants Nar~ /~6~ £)//) .~P~O~7) ~?/q ~lepho~
Applicants Ad.ess ~~_3L~=C~m~{/~ ~ -_
Applicant is (che~ 0~) I~nding Institution ELI. ~bul].~r ~;
I~nding Instltutlon Te lepho~
(a)
(b)
(c)
(d)
Address
(e) Real Estate Co. & Agent
Address
Telephone
2. T~of I~s_idence_
Single-F~unily ~ Multi-Family El_--f
Numbe~ of Bedroc~rs
3. water su_qj2p
Individual Well'~ Corm~]nity
Othe~ ( de sc~,ibe )
R]blic E]
Note: If cc~runity well system, must have %~ritten confirmation £~¢m the State
Boparha~nt of Envi~oran~F~tal Conservation attesting to tho legality and status.
Is the mi1 adequate fo~ the number of bedrocms si~.,,cif:i.ed in this HAA~(Y/N)
4. ~ Disp_osal
Is the wastewater disposal system adequate fcr the numbe~, of bedrocms/fY~
[Page 1 of 2]
2-15-84
5. En__~ineering Firm P~oviding In_spections, Tests, Data and Infomnation
I oertify that I have checked, verified, o~ conformed to all MOA [{~A Guidelines in
effeet on the date of this inspection.
Signed ~//x . ~..
Signed by
Date
(ENGINEER SEAL)
6.pHEP Ap~ova 1
Approved for '~ bedr oozes
Approved ~i Disapproved
Terms of C6nditional Approval
Cor~it io~al
The Municipality of Anchorage D~pa~tment of Health and Enviro~ntal Protection dces
not guarantee the continued satisfactory performance of the water supply and/(~ the
wastewate~ disposal system° 'l~is approval indicates that, as of the validation c~nte
show~ above, based on the data and information fut, nished by an engineer regist~l, ed in
the State of Alaska, ~le %¢ate~ supply and wastewater disposal system is safe and func~
tional for the number of beck, ocms and type of structure indicated.
( D~EP SEAL)
7. ~il the }~ to the foll~ing ad,ess: /*'~ ~-74~>. ~ '/~J~'
KB2/d5/s
[Page 2 of 2]
2-15-84
NCHORAGE
I Ik"ALTPI &
PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
RECEIVED'
~ ,.
c,
Well Log Present ~/N)
Total Depth / / 0 ! Cased to
Static Wate~ Level b~ ~
Casing Height Above G~ound
Electrical Wi~ing in Conduit~/Ni
Separation Distances f~om Well:
To Septic/Holding Tank c~n Lot .~-/~D/
Date Completed
'
Pump Set At
,~'
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot .V-/~9/~ ; On Adjoining Lots
To Nearest Public Sewe~ Line /~//~ To Nearest Public Sewe~
Cleancut/Manhole /~/~/$-- To Nearest Sewe~ Service Li? on LOt
Wate~ Sample Collected By ~~- _ ;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed '~/?'~_~ Size I~0 NO. of C~,~a~tments
Standpipes ~7~) Ai~-tight Caps.) Foundation Cleanout~)
~ession ove~ Ta~ (Y~ ~te ~st P~d ~./~
P~ing~intenan~ ~n~act on File (Y~) ~/~ ; fo~
Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~a~y Holdi~ Tank ~t (Y~
~p~ation Distan~s ~ ~ptie~olding Tank:
To Water-Supply Well
To Property Line
To ~ter M~n/~vi~ Li~
k
Cour~ ",
/ ~'l
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, o~ Major Drainage
[Page 1 of 2]
2~15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~ [~ Type of System Design
Date Installed ~. '~//~/~ ~Length of Field
Width of Field ~ ~5'~ Depth of Field ~ ?
Gravel Bed Thickness ,~/'
Square Feet of Absorption A~ea Standpipes P~esent~N)
Depression over Field (Y~ Date of Last Adaquacy Test
Results of Last Adequacy Test ~3/./~T-
Separation Distance f=om Absorption Field:
To Water-Supply Well .~-//D f ~--' To P~operty Line
To Building Foundation ,~7~ To Existing or Abandoned System on
Lot ~3/~- ; On Adjoining Lots .~- ~3 ')¢
To Water Main/Se~vice Line 4-,~/~6- To Cutbank(if present) ~/~
To Stream/Pond/Lake/c= Majo= D~ainage Course ~J/~-
To D~iveway, Pa~king A=ea, or Vehicle Storage A~ea ~(9
Con%Tents J~ ~
D. LIFT STATION
Date Installed Dimensions
Size in Gallons M~nh~le/Access (Y/N)
",Pu,mp, On" Lave 1 at
Hlgh Water Alarm Level at ~J~/~ V. ent !Y/N) _
Tested fo~ ~ Cycles du~ing Adequacy Test. Meets MOA
Electrical Codes (Y/N~/
Coranents
_/
** Check Pe=mitted Bed~oc~ Rating Against HAA 9equest
I certify that I have checked, ve=ified, o~ conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed ~._ :~/b4~fJ'-'/ Date
Co'ii,party 0 h~-~-~ j,/,~a~' .. MOA NO.
KBi/d5/s
[Page 2 of 2]
APPLI, .NT FILLS OUT UPPER HAl ONLY
Buyer
Address ~ ~ ~)~ ~ 2 ~ ~ , ~ ~. ZipCode
Lending institution Phone
Address Zip Code
Realty Co. & Agent ~ Phone
Address ,~ Zip Code
Street Locati~
Ty~ of Resi~nce
Single Family
~ Multiple Family No. of Bedroo~
~ Olher
Water Supply
'~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach log if avagable).
~ Public Utility
Sewer Oisposal
~ Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE tNSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
inspector Inspector Inspec 'l ~~5~ ~ I
Field Notes:
( Lq *.PROVE~ .~gR~OUS 'CON~mO.S O~ *~P.OWL
( ) O~S~.P.OV~