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Home My WebLink AboutPARADISE VALLEY BLK 4 LT 5Paradise Valley Lot 5 Block 4 #020-411-13 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 Name: Ed ~S ~ ~ Wastewater System: ~New ~ Upgrade Address: ~.& ~ [~ ABSORPTION FIELD Phone: ~ ~ IN°'°'~tO°ms: ~eepTre,ch ~ Shallow Trench ~Bed ~Mo~nd ~Other LEGAL DESCRIPTION so,,.~t,.~ Total Depth from original grade: Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe WELL: D New D Upgrade Gravel ~ Numberof lines: IDistancebetweea~ines: Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material: Yield: GPM PumpSetat: Ft. CasingHeightA~ovoGround:Ft. TANK SEPARATION DISTANCES ~Septic ~ Holding D S.T.E.P. TO Septic Absorption Lift Holding Public/Privat( Manufacturer: Capacityin gallons: From Tank Field Station Tank Sewer Lines ~ 1~k Material: Number of Compadments: Surface w~t~ N~.~ No.~ LIFT STATION Lot ~ Size in gallons: ~ Manufaclurer: I Fo~d~,o~ N~I. ~e~ "Pump on" level at: "Pump off" level at: Highwateralarmat: CurtainDrain ~ Ne~ Pump Make & Model Electrical Inspections performed by: Remarks: BENCH MARK Location~ Descriptio · Inspections performed by: ~ ~ Dates: 1st ~/t~ ~ 5~ ;:~ ' Department of Health and Human Services approval Reviewed and approved by: .-~t~% ¢~u-~+ Date: t~)3)'~ (~'~:L, ' ' -' 72-013 (1/91) MOA 25 I I _~. Te~. I I / / I I I I I I I I I I 1.5 0 q 15 30 SCALD 45 60 I': 30 FI, 75 90 TDBBEN SPURKLAND P,E, 203 ~/ 15TH, AVENUE ANCH, AK, 99501 LOT 5 yBLO£K 4 PARADISE SEC, 11, TllW, P3~/ VALL Y SEPTIC SYSTEM ASBUILT DATE, JUL Y !6, !99P SHEET, £/3 GRI~), 3538 EAS£MEN[ LINE lo Cleon ~ut 62,5 Cleon Standord [rench~ 52,5 FT, LDNG 8' [DTAL DEP[H 6' DF SEWER el]OK 3' mln, Cover Mimo£! 140 C{eonou~s 10 £ee~ o£ ~Cep~ic I~ock TOBBEN .SPURKLAND P]E, 203 W15TH, AVENUE ANCH, AK, 99501 94,8 77,7 TESTHDLE NO SCALE ] 6 ~ ~LDCK 4 PA£AgISE VALLEY ED £ASTA~CHE ~ ~DX 104642 Moni~om -- Ex~'~:, 5round TBM TOP DF WELL CASING SEPTIC SYSTEM ASBUILT DATE, JUL Y ]~ ]992 SHEET, 3/3 GRID, 3538 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) 1 2 3 4 5 6 7 8 9 10- 11 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS DATE PERFORMED: Township, Range, Section: 'T'tl]~~ ~.~"~%1,,~ sLOPE WAS GROUND WATER ENCOUNTERED? s L IF YES, AT WHAT O DEPTH? p E Depth to Waler Al(er Monitoring? Gate: SITE PLAN I- N Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN __ (minutes/inch) PERC HOLE DIAMETER __ FT AND FT PERFORMED BY: ACCORDANCE WiTH ALL STATE AND MUN~CIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT. T~ TEST WAS PERFORMED IN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 10 11 12 13 ~ (ENGI'NEER'S SE,~L) Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? Monitoring? Date; SITE PLAN 14 15 16 ~8 20 COMMENTS Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN (minutes/inch) PERC HOLE DIAMETER __ FT AND FT CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920005 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:BASTARACHE EDWARD J OWNER ADDRESS:P.O. BOX 104642 ANCHORAGE, ALASKA 99510 DATE ISSUED: 1/21/92 EXPIRATION DATE: 1/21/93 PARCEL ID:02041113 LEGAL DESCRIPTION: PARADISE VALLEY BLK 4 LT 5 LOT SIZE: 15000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ENGINEER SHALL PROVIDE ADDITIONAL SOILS TEST/PERC TEST AT THE TIME THE /~S-=l~U~I4~/~f~ SUBMITTED TO/~HIS OFFICE. DATE: DATE,/- 2_ 3 - fi2 ~75! W. DIXOND BLVD. ANCHORASE, ALASKA ~9502-~904 {907) 2~8-5095 14ur'~icipalLity o,f Ar]ch(]rr'age D:ivJE~:i.c:)l] (:;)+ Env:i, rc)rlmental I'lea].'L:l'l I)c~par'L'.mer~t o.F Heal'N'~ and Social Servic~?s 820 i[ Str'~:~,e'E Arl(:lllc)m"age,i Alaska 99501 SLd:~ .jec:: t :: I::'er'm:i.'/L .For' Septic:: System I_.ot ',5~ [{lloc;k 4 F:'arad;ise Va:l.].ey ~] arluar y :L6,~ 1992 MUNICIPALHY OF ANCHORAOE ENVIRONMENTAL SERVICES DIVISION JAN 1 G 199 RECEIVED We ar'~ r'eques'h:i, rl(,J a per'm:Lt N;:) upgr'ade the e;.::istir'~g sept:Lc system Tli:i.s Sel:'~l:::i.c: sys'l::eln was ;i.r~,stal].E:~d :i.n J. 982, howev(m" a resiclenc:e was l]c:)vc~l'" cctr]!i~ti'~uchc~lJ so 'l:he systf_]m was I'lf]vor usc)d. This lL(::)t :i.s now up .for' sale,~ arid tf'ic~ lot surv~)y showed that tl~e trE, l'-~c:l'i J.~J loc:at:ed with:Ltl a ut:i. lL:Lty easement,, This J.t~i nc~t ac;C;el)t .... ab]i:.? %o tl"t~;, -F;i. narlc:ia] :i, Fi~;'Li'Lu'l".Jor~ 'Lh~:~r'-~cir'(:~ '~,l'ic.~ tr'encl-i must A tk~si',hole arlc;I pert: test, has been per.l;orn~ed L:o ver"id;y th~;.! soil r"ati ng used in 1982. 'l"lJe g~l]E')l"/,~ !EH3:i. ], c:(]l'ld:L tc31'tE; ~r"(~ the same '~]hC':' OVC)r].F:iyiFI~:I ~xi.l'ky Er~E:IIiI::J :J.E} 'L',hJ.C:J'::f~l" &'It 't:'.J'lit:S ].(:)tlE~tiOl"l ('tI"IEI '[]iE? llia'L'.03r'J.a]. ~ i'H]t C]l'] t. Ji(.,~ C: ]. (~]ll'l ~alld, Th~rE~'¢l:;irEq the dec,Hi, gin :i.% i:;orl~il:?l ....... va'h i v(~. The prc~posed 't;rench is not w:i't, hir~ 'Ll'le~ radius t e s t h c:, ]. e T. Sl~/.tr k 1 and F:'. E£ ,, 203 N 15th. Avenue, Suitm 206 ANCHORAGE, ALASKA 99501 (907l 279-3916 LI~IT SEPTIC SYSTEN DESIGN BLOCK 5 PARAI~ISE VALLEY ED BASTARACHE No Gr"our~d Wa'ker- of Impervious Layer' to 14 Lisle St, and,sr'd Tr'c~nc:l-~ Soil Rating. F'r"om tefs'k Oc:t. 24~ 1S~91 17 rnJ. r~/:i.n =.6 clal/m:i.r'~ 150/,.6 ..... 250 ~.r;q,,'F'E~ ,, Tes'Eho].e "l"c:)'lz,~:l. Dcep'bh I...ez, ss 6 fe~z,t 6 I:~oc: k 14. .F t. ~3 6 'F t [..ertg'EIq o.f: lrenc:h 250 x 5 / (2 x ~{.~ ) ..... 62,5 ft SYSTEI~I C 0 I~IF ! GURFIT I ON STANDARD TRENCH TOTAL LENGTH 62.5 FT. TOTAL WIDTH 5 FT. TOTAL DEPTH 8 FT. ROCK DEPTH 6 FT. COVER 5 FT. FILL I FT. SEPTIC TANK 1000 SAL. EXISTING ABANDON EXISTING TRENCH ,S;el:~ti c: Sy'..'rrk~!m Des~i gn cl::~urses on 'Lh~.s or the al::ljaael"rl: The proposed septic system will not change the general slope 'Lhe ar'ea~ I::'c:)nd:i. ng arid/or C:Ol~cen'Lr'at'.ion o.~: sur'{:ace runo~ will no'L resL.I], t 'Froll] thi ?~ i rlsta~L ]. ~'J::[ of 1. Septic System Design I..ot 4 Block 5 Paradise Valley pg ,, 2 41 4O / o III A iiI VACANT I I I 39 III i//I/ oO 5 \ ¥ A 1 VACANT , N ~_L E Y SO 100 150 RO0 SCALD I' = I00 FT, £$0 300 TDBBEN SPURKLAND P,E, 803 W 15TH, AVENUE ANCH, AK, 99501 L£T 5 BLI2CK 4 PARABISEVALL Y SEC, I1, TIlN, RSV BASTARACH SEPTIC SYSTEN DESIGN DATE, JAN, 6, 1997 SHEET, I/3 GRID, 3538 / I I I I I I I I I I / / I I I I I I I I I I I I I TRENCH PR£P£SEflNEV TRENCH REPLACEMENT TRENCH 15 30 £CALD ELEV, 100,00 4,5 60 75 90 I" = 30 FT, TnBBEN SPURKLAND P,e, 203 W 15TH, AVENUE ANCH, AK, 99501 (9117) P,79-~916 rALLY II SEPTIC :~YSTEM DESIGN DATE, JAN, 6, 1998 sHEET, 2/3 GRID, 3538 ABANDLIN EXISTING T£ENCH EASEMENT LINE 62,5\ ~ ~on~or Ctean [lut Standard Trench, 62,5 FT, LONG B' TOTAL BEPTH 6' OF SEI/ER ROCK 3' ~ln, Cover INSTALL BOUBLE CLEAN OUrS ~ VERIFY INTEG£ITY OF EXISTING TANK INSTALL FDUNDATIIDN CLEAN £UT · Cteonout~ / , / 3~ Cover 10 Feet o£ Septic Rock --/ TESTftDL[ NO SCALE j' Monitor Exist, Ground TOBBEN SPURKLAND P,E, 803 ~15TH, AVENUE ANCH, AK, 99501 L£T 5, JgLDCK 4 PARADISE ED BASTARACHE P,D, BDX 104642 VALLEY SEPTIC ~YSTEM DESIGN ~AT£, JA~ 16 I992 SHEET, 3/3 G~I~, 353B LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Range, Sect on s,oPE (E~GINEER'S SEAL) SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT ,-('; j, 1.¢' J~ DEPTH? p E icj, 'b Oepth Io Water After..~, ,. MonitorinD? ~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE /.'¢~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN .-~'~ FT AND -. ~Z.. FT PERFORMED BY: AOOORDANOEWI'HALLSTATEANDMUNICIPALGUIDELINESINEFFEOTONTHISDATE. DATE: 72'008 (Rev. 4/85) 20~ U~STH. AVE, SUITE 206 SPECIFICATIONS FOR SEPTIC SYSTEM INSTALLATION LOT 5 BLOCK 5 PARADISE VALLEY SEC 11 TllN RSW 1.0 GENERAL 1,, I Owner- is Ec:l Bast. ar~tche~ F:'.O. Box 1C>4642~ Anchorage Alaska 9951() 11.2 Engineer ~s the person or ent:i, ty hired by thcs, Owner 'L:o inspect this pr"c3jec'L. 'l"he Engineer must be recogr):Lzed by the Ser v :L c es ,, ].3 Contractor is 't'he perscin or ent:Lty h:i.r'(n~d by the Owner by the Murl'~(:::Lpa]ity o'f: Alqc:llor'age~ Depcu"t:melrt o'f Hea]til and HL.UD~;d] Serv:i CeS. :i.. 4 ]'he Dr-aw:i.l"J~ls, sheets :i. 't',hroLul;jh 3 ~ shall be par't of this ver i.Eied and may be (nodif:i. ed in 'lihe -(:ielc:l by the Engineer,, 1.7 It ii~n the J"esl:)Ol]~ibi ]. i ty of the Owner or the Contractar to adher'e t(:,) tl'lc~ approved design,~ 'to w.!ri~:y that. the speci f:Led separation distances are met~ and that the r'equirecl 1.S The Contractor (::)r 'tl')c~ Owner sha].l r*epori: to the Engi- neer any (3D!BEH" v~F:,d C:C)IIQ ii. t i 631') ~'~J] :). c::h W[)L,~i d put the sept i c %ys:K~:e(~'l :LI'] vJ. olat[Lon o'~ State ell" ]'4LU]:J.(:ipa]. regLcLatior'l~,, 2.0 SEPTIC I'ANK 2.1 ]1~ 'there is an ~:.:ist:).n(:l sept:it tank,, it may be used it ~I(~)6L,~S the (::~l~jz)tf~(=J. ty i"(~qLcLr(:i, rflen'~: .~o1" the r"esidel](=(.]~ 'J'he ~:ank shal :1 i::)e :i.)~Sl':)ec:L'.ed by t. he Engineer ,~ and J 'Ls water" tigh'tr'ic)ss ~i'~(:] ~trL~c:tLil"~ll ir]t~:)grit, y shall be vem"i.f::Led. 2.2 A n~:~w Sel::rt:i,c tank shall be one ~:abr:i. cated by either' Aed~erage Tank and Welding i::ir Liy Steer Tank Spec:i..F:ic~.ltior)!s .~:or septic:: system install, etlon L o t. ',"J B l c:)c: I:: 4 P a r" a d :i. s e v a ]. 1 ~y pg ,, 1 'l"he septic [:ank ,.'~lla].] be a Ul:::'C-'al:)l:~r'ov(]d 't:wo....compar"tme. r~t t. ank~ c:onst::ructe~d o4: 12 gaug((~ or be'ttor~ steel with b:i. tu ill,'.AE~'~.i(: c:oa'[:.il](:],, 'l'he tank sha].l be set level on L[r]d:LstLLrJ.3(~d soi:L,,The 'Eank shall J:)e c:overed Ni'l::h the equ:iva],er~t o~ four · Feet o,F s(:)i].~ · From the house .t:our~datJon al'lCJ a m:i. rlimLun wel]. serving a s:i. rlgle._~ residenc:e ].C)C) feet 'f:r'om any body o'f ~:eet 'From Class "C';" wells~ and ~"]': 't:e~t 'Fr"om Class A Class B wel:ls. .',:i'.,, 5 A1 ] pi[:)e c:onrlec:t:~ ohs t.o the tal'll,:: shal ]. be mecharlical out?~ sba:L1 [~xtend a minimum (:)~ 12 inches abovca -~:il~Y~]. gr'oLH1C] elevation,, F:'rov:i. sions shall be mad(::z for landscaping and :i. ml:>or-tat~on i.f ~opsoil. 2.6 L:i-,ct s'['.at:i, on sha:l. 1 be as manu.[:ac:'Lured by Anchorag~ Tank and Welding 3.0 ABSORPTION FIELD 3,,:1 Gravel used in the absorption ~ie:ld shall be 0.5 to 2.5 inch screened roe:k, u.~ith less than 3% i:)assing the No,. 200 3.2 Sarld~ used ~of levE::,lin~;J or for ~i].ter'irlc],~ shall hav~* e~.~:.~ec't:ive gr'a:Ln size I:)cei:ween No. 40 sieve and 5% by we:[(;Iht sl'~al], pass tho No. 200 s:i. eve. 3,,3 q.-:Lnch per4:orated pipe shall be ASTM F:810. For pres- ~:~n.u,"~::, clJ.~'['.r'Jl:)LCl:iorl~ pipe shall be Sc:hedule 40 PVC or 3,,4 S(::)].:Ld 4-..:i. nch i::)ip~? shall, be) Cast Irorl or ASTM D3C):34. 3. ',5 Morl:i, tc)l'" sl:,al~dpJ, pcs sha]. ]. be instal ]. ecl as ~.~hou~rl. That s~).)c'L::i, ol'~ (::).~ tf'le~ p:Ll::)e perletra'?,:i.n~l the gravel sha].]. r"a'l:[..xJ~ either' by ch":i.].ling 0.5" I']ol(.:~s on 6-ind'~ center's or by .jo:i.[)J.r'~g ~ se~c:'Eic)fl o.[: F:J~]J.O I::~(er'eora'hed pile to a s;olid sec:'L:ion o'~: p i p e. 3.6 Geo'~'.ex'[:J. ]. c:,~ ~J"~a]. ]. J::)e M:i. r'a~ J. ~ 40,, 3,,7 Znsu].at:Lon shall be extruded direct bur-J.a:L poly%tyrerle. 3.8 Topscd. ] shal 1 be a mix't:ure o-[: 40-6()% organJ, c matter 2('.)"<?~;0% sand and more that 20% si 1 t. All quant i ties ar"e meas~tred by vol ume. 3.9 Grass seed shall Ire Kentucky blue~r'ass,, 4.0 INSTALLATION 4. 1 L. oc:ate al 1 t.tndergrc)ur'~d · Future dri veMay~:~ ~ ~']~.( i t~'~.i ways,~ SLU'"¥aCe ar'id sub sl.u'"~:ace dr"air~a(:le p(:)r~(:l?~ ar'id all (::rther '[:acilities requiring separati(:)n dis tances from t:Juf~ i:)rc)pose:,d sc~p'[:ic sys'hf:~m. Nc:th:i-Fy Owner c)r" Stake alig~lmerlt o'F sys'hem with markers !i.-:hot, d. ng the proi'.e~ct.i ye:, dis'harlcl):,s ~rom ~:~:1. 1 s and water' bc)d:i, es. 4.3 Establish an elevat:i, or'~ ben(::l~mark. This BM shall, be easily id(zmt:i.-fial::)].e,~ s'l:able and permanont.. An ar"bitrary eleva'E:.i on c)~ :L 00 (:::Bi') be assigned. Use top o.f we]. 1 casin{~]. 4.4 Install 'l::he 'hank as !~q'lclwn on the drawings. Record the :i. nl[:~t and outl(.)t e].ew'~'h:L(::~rls o'[: the tarlk. Tank sha].l 4,,5 Ex¢:aw:~te 'El'lc absc~rl:)'hicln .Field,, Bottc~m (:~.t: excavation ~ha].l be level and sc:ari.~ied, i~ side~.~al].s sm(~ars,~ t. hey shall also be by the Ol:)erati(]n o'[ the CC)l']Stl'-L.ic]ti()l'] equipmerr[ shall 4.6 F'lace tim, rock to ~1'~(..~ depth speci'Fied. Do not contami .... tiorl.~ Lew:?l the rock sur.Face (.~ .... :1.") be.t:lm"e installir~] p er ~: c:)r a L I:~d I:1 i p e. 4,,'7 Ins't'.a].]. the distr":i, but. ion pipe. Record tile elevaticln each jl:)int. For pr'essurc~ system sc:llver'rl: weld the .j(:)±r-~ts. fl. ,, [i} Cover the d:i. str:i.l:~ut.:i, or~ pipe ~,~:i.'hh r(:]c::l<,, and ~:::~::~¥(~' ~'l:h geohext:[le! be~or'e back.fiZZ:Lng and pZa(::~ng i ¥ r"[.~E:IL.~J, I'"{~(::l ,, Z] ,, 9 Rec:ord t.l'le 'F :i n:i. shed ground el eva'h:i, on at: tile be(~:i, nn:i. r~l.'.'l ,~ middle and end c:~: '[:r~ncl'~,, Re~::ord the ~ini sh gr~:~und ~].c~va t J c)l, a'k [)ac:h corr'ier and at. thru mi cll::)oin'l:', o-F the bed,, 4. 10 I:::u["nish a (::opy o'F ali. survey notes t:o 'l:he Engineer. 5.0 INSPECTIONS [~F)ecJ.'Ficat:i, ons .{:or" sep'hic sy~_~Yhem iristallation L(:)h 5 ]:ill c:lc:l:: 4 I:::'aradi se val Iey P [] ,, [:.!; 5. 1 f/ mi ri i mum o'F tl'lr'e¢ :i nspec:t i OhS ar~i_~ requ:i, m"ed. -I'h~2 · f:ir~:~t: J, rlspect~cfft ~,~J.:l.]. b[~ D-F the cff:~erl c~xcavat.:ic)r"~,, At t. hi~ The sec:oru::l irl~ff:)c)l:::t~ on wJ 1 :l be a'~:ter" placement o'F (:]ravel ,~ -t-I~e third inspect:i, orl will I')e a~'[:er c:c)mpletion o.F '[.he work. Ar'p/ deficienci~i:s will be ~ii~L.U]I'I CJe'fic::Lc-~,n(::i(as sha].], b~ c:¢::)rl"e:a<::'[:ed wJ. tl"lJ, r] t(~,l"/ <Jay!i;,, All [:O. ml:::tr'ical work r'eqc,tire!~-: either an MOA electrical :i. ri sp c~c:t i orr or cdr t i '¢ i ca{::~ orl by an 1 :i. c ~:.!n !:~ e_,c~ e].ectrici al~. Si,d:)r[lit', pr'<:~<).F i::l.f in!i~p[~c:t, ic)ll c:)r ccert:[.{:icat:[orl itc) t.l"le EncJineeF. 5~ :i"; Submi t ¢::a't',al og clara o-F a]. 1 mec:h.'all:i, caI equipment. 5.4 Noti'f:y Engineer at l~;,ast 24 hour~:¢ :i.n advance c:)-F beg:i.n I'll I]~] aliy S p ~:.=, c i 'f :i c a t i C:)lt s .f {::) r s e p t :i. c s y s t <:'~ m :i. n !=.~t'. a 11 a t i o n I..,(:~k [5 Bl(::~c:k 4, F'aradise valle'y p g. 4 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 WEI.L ~NSPECTION REPORT PHONE N E~"--~ NAME MAILING ADDRESS EGAL DESCRIPTION kOCATION ILiq. capacity in gallons ~1T°p °f ti'" t° `ir'i'h a'a°" ~% Type of crib Crib diameter IAbsorption area Inside len§th Foundation Total Crib deptl~ Building foundation Driller Sewer line Septic tank Dwelling I NOTI~ Material. WidthC:J -(- Nearest Iot~jline Trench width NO. OF BEDROOMS PERMIT NO, No. of Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO, ,9' Distance Between lines Total effective~u~ab 9~tion area inches ~ ~ ~ PERMIT NO, Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Absor ptio~'area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPROVED DA~E LEGAL 72-013 (Rev. 3/78) PERMIT NO. ~'ILIF~ ~ri:~PFtL~'-F%~ 13F FI~4ri:H£1RREiE DEPRRTMENT ~' HERLTH RND ENVIRONMENTRL 3TECTION 825 ~L' STREET~ RNCHORRGE~ BK. 26;4-4720 N]FJ--'~';ITE SE~JER ( 828802 ) RPPLICBNT LOCRTION LEGBL ROBIN BONEN LSD6 PBRRDISE YRLLEY iii3 W FIRENEED LOT SIZE 278-4927 999999 SQURRE FEET TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH ..... , ,_ MR::.~IMI_IM NUMBER. OF BEDROOMS = _~ SOIL RBTING (Stq FT~'B~.)- '?-:~, -- THE REQUIRED SIZE OF THE SOIL RBSORPTION/~'STEM IS: [:,EPTFI= ':1_¢'~ LEI'4,ST~== ~-. ,,-" ... __ JRR .., EL E:'EF'TH~= 5 THE LENGTH DIMENSION IS THE LENGTFI (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SLIRFRCE OF THE GROUND RND THE BOTTOM OF ]'HE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTFI OF' GRBVEL BETWEEN THE OUTFRLL PIPE BND THE BOTTOM OF THE EXCRVRTION (IN FEET). RELqL~ ~ RE[:, _SEF'T ! C TRF,iK S I ZE= 2L~1£~£-i I]RLLri~i'4_'~. PERMIT RPPLICRNT HRS THE RESPONSIBILIT'-r' TO INFORN THIS DEPRRTMEN'r DURING THE INSTBLL.RTION INSPECTIONS OF RNY WELLS R[:,JRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. TPSri, ( 2 ) I F.~SI~Eri:T I ri, N_'!-; RRE REG~LI ! RE[:, BRCI-'.'FILI_ING OF FIN¥ SYSTEM WITHOUT FINFIL INSPECTION RND RPPRO',/RL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWBGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE WELL. OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMEN'rS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS BRE BVRILRBLE TO INSURE PROPER INSTRLLRTION. PERf"I I T E×F" I RES [:,Eri:EMBER Z::::L.. i]-~. 82 I CERTIFY THRT i: IRM FFIMILIFIR WITH THE REG!UIREMENTS FOR ON-SITE SEWERS RND I.'ELL2; RS SET FORTH BY THE MUNICIP8LITY OF RNCHORFIGE. 2: I WILL INSTRL. L THE SYSTEM IN BCCORDRNCE WITH THE CODES. .~: I UNDERSTRND THFIT THE ON-SITE SEWER SYSTEM MBY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THFIN ~ BEr~ROOMS. S I '3)~¢~C,: _ _~ _~_ ....................... PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14~ 15- 16- 17- 18- 19- 20- COMMENTS SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST L-CT' LU'I TH /5'o SLOPE SITE PLAN ( WAS GROUND WATER ENCOUNTERED? ~ ~) SL SANb o P E IF YES, AT WHAT DEPTH? Reading Date Dross Net Depth to Net Time Time Water Drop PERCOLATION RATE i~ ~(V~,~l/~ L (minutes/inch) TEST RUN BETWEEN FT AND -- FT PERFORMED BY: 72-008 (6/79) LEGAL DESCRIPTION: L~T ~ MUNICIPALITY O~ ANCHORAGE DEPARTIV,..~T OF HEALTH AND ENVIRONMENTAL P,,,,~-.~i3ffAGN OF A~HO~'~OLATION 825 L, Street, Anchorage, Ataska 99501 264-4720 DFPT C~ I~ L~:! ,%TEST ENVIRON. ~h,A , ,~ ...... SOILS LOG - PERCOLATION TEST ~' 6V 2 '- 198~ ~C~ ?A~ISE VALLEY' .1 10 11 LEAN S~ kid 15 - 16 17 18- 19 - 2225-E JUNE 20- WAS GROUND WATER N C~ ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH7 Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~O ~t, ¢,,,L~A L (1~ TEST RUN BETWEEN ~ FT AND -- FT COMMENTS PERFORMED BY: 72-oo8 (6/79) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAl. RESOURES Division of GeoIogicGI ~ GeophysicoI Surveys gravely with cobbles wet si ]. t y_j~l_ hard pan bec~rock bedrock H20 4 ,I'~gNIGIPAEiTy OF ANCHO/~A "~vI~NM£NTAL pRO~E~jO~ WATER WELL CONTRACTOR'S CERTIFICATION: Top Dot fern o 45 45 __56 56 65 · ~----' -7'~ 71 110 Drilling Permit No. A.D.L. NO. Section No. S, OWNER OF WELL; Address: Edward Bastarache 7. USE: ~oma~lic [] Public Supply 8. CAS,~,~: [] r--,-- dloln. O in. to /~! fl. Depth Slot/Mesh Size: Length;__ '0. STATIC WATER LEVEL: 6¢~~ ff. / __/ ~] Above or ~ 6elow land surface Dote II , PUMPING LEVEL below lend surface end YIELD 12.GROUTING Well Grouted: [~'] Yes [] No Motorlal: [] Ne~t Cement ~_~ Other: Alaska Now--Well/Vern's Drilling & Ent AA. ~320 ~ ..... SRA Box 15_60 AnchoraAo~ Alaska 995~ ..... 'g'"EUARNS:fiA±sh of well ope~t hole ° [] P EJ c PERMIT NO. ,ii DE~PRRTMENT HEFIL'T'H RND EN',,"I RONMENTRL ,rECT I ON 825 '~. STREET., RNCHORRGE., FIK. 9~z,~ ~ 264-472E~ f:IPF'L I C:FINT I_OCRT I Obi [...EGRL ED BRSTFIR~C:NE L..SB4 PRRRDISE ',,,'RLLE"r' 4005 PRRSONS R',,,'E 4~;2 99504 279-0:1..20 LOT SIZE 999999 :'<QLIRRE FEET MINIMUM DISTRNCE BETNEEN ¢1 WELL RND RN'¢ ON-SITE SEWRGE I::,IE;POSRL c;¥STEM IS . iE~O FEET FOR R PRIVRTE NELL OR 150 TO 200 FEET FROM R PUBLIC 1.4ELL [)EPEN[)ING UPON ]"HE T'¢PE OF PUBLIC WELL. MINIMUM DISTRNCE FROM FI F'RIVBTE WELL ]"0 R PRt'¢RTE SENER LINE IS 25 FEET AND TO R COMMUNI]"'¢ SEWER LINE IS 75 FEET. WELL. LOGS RRE REQUIRED RND MUST E:E RETURNED TO THE DEPRRTMENT NITHIN :~:0 DFI"¢S OF THE WELl_ COMPLETI01'4. OTHER REIZ~UIREI'qENTS I"1R'¢ RF'PL'T'. SF'ECIFICflTIONS RND CONSTRUCTION DIFIGRf:IMS RRE RVRILRBLE TO INSURE PROPER INSTlaL. LRTIOI"L I CER'f'IF'¢ 'FHRT :L: I fll'fl FRMIL. IRR 14ITH ]'FIE REQUIREMENTS FOR ON-SITE SE[4ERS RI",ID 14EL..LS RS SET FORTH B'T' TNE I"IUNICIPFILIT'T' OF RNCHORRGE. 2: I I.,.IILI_ IN9TRLL THE S'¢STEM IN RCCORDRNCE WITH THE CODES. = i ar~L. ;.~.~_= .... %~:-~¢=~ ....................................... Depa ment of Health and Human Se ices Division of Environmental Semites On-Site Services Section 825 "L Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6~50 ~.ci.anchorage.ak. us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel i.D. 020-411-13 1, GENERAL INFORMATION Complete legal description Expiration Date: LOT 5, BLOCK 4 PARADISE VALLEY S/D Location (site address or directions) 18120 Norway Drive Current Properly owner(s) Mr, Ken Burdette Day phone 227- D~,,I O Mailing address 18120 Norway Drive, Anchora,qe, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Ms, Jan Penninqton Day phone 244-3099 Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 3. 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 [] [] Community On-site ,1~ [] Public Sewer [] The Municipality of Anchorage Depadment of Health and Human Services (DHHS) Issues Certificates of Heaith Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days oId. Certificates are valid for one year for properties served by Class A or B wells or a public water system The Municipality of Anchorage is ncr responsible for errors or omissions in the professional engineer's work. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, f verify that my investigation based on procedures outlined in the Health Authority Approval Guidelines for 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 here~n. 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone En,q. Svc., LLC Address P.O. Box 102954~ Anch, AK 99510 Engineer's Pdnted Name Steven R. Pannone, P.E. Phone 272.8218 Date 3/4/2000 6. DHHS SIGNATURE /~ Approved for "~ . bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: ,6dditioD¢l Comments Note: ~ne wel± ~or this propuLLy muuL~ There are nitrates present. It is suggested that periodic testing be performed to insure the we±is contlnue~ suitaD%±lty. ~urrent ninrate concentration is 5.6 mg/1. EPA maximum concentration is 10.0 mg/1. More information on nitrates is available from the On-site Services Program, DHHS, 343-4744. Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Expiration Date: ~, - ;2. ,/. Maintenance Agreements Supplemental Engineer's Report Other x Odginal Certificate Date: Reissue Date: ,< :CEIVI:D Municipality of Anchorage Z~ MAR 1 6 ~000/~1~ Department of Health and Human Services ~ Division of Environmel~t,a,I Services ~ICIPALII-¥ OF ANCItO~ On-Site Services Section 825 L Street Room 502 ' "~MF-NTAI, SERViCES n~ P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIS'I" Legal Description: A. WELL DATA Well type PRIVATE Date completed 3/25/1983 Total depth 110 ft LOT 5, BLOCK 4 PARADISE VALLEY S/D IfA, B, or C provide PWSID # __ Sanitary seal Y_ Cased to 71 ft Date of test Static water level 60 Well production 4 WATER SAMPLE RESULTS: Coliform ~C,'- colonies/100 mi Date of sample: 3/5/2000 B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Parcel I.D.: 020-411-13 FROM WELL LOG 312511983 ft g.p.m Well Log .¥. Wires properly protected ~Y Casing height (above ground) 3§_in. AT INSPECTION 31412000 63 ft 4.6 g.p.m Nitrate . z~-'.,~-~ mg/I Other bacteria'---.~'.~.-. colonies/100 mi Collected by: S.R.PANNONE, P.E. Date installed 7/11/t992 Tank size Cleanouts Y Foundation cleanout ~ Date of pumping 9/2811999 Pumper A+ HOME SVC C, ABSORPTION FIELD DATA Date installed 711111992 Soil rating (g.p.d./ft2 or ft2/bdrm)~ Length 62.5 ft Width 3 ft t500 gal Number of Compartments 2_ Depression over tank N_ High water alarm N~ System type D.T___~. Gravel below pipe 6 ft Total depth 13...._.~9 ft Effective absorption area 750 ft2 Monitoring tube Y Depression over field _N__ Date of adequacy test 3~4~2000 Results (Pass/Fail) PASS For _3 bedrooms Fluid depth in absorption field before test 3.~1 in Water added46._.~0 gal. Elapsed Time: 1440 rain Final fluid depth 31 in Any rejuvenation treatment (past 12 mo.) (Y/N & type) UNKNOWN (Rev. 11/99) New depth4~0 in. Absorption rate >= 460 g.p.d. If yes, give date LIFT STATION Date installed "Pump on" level at __ Datum Size in gallons N/A in"Pump off" level at Cycles tested in Manhole/Access High water alarm level at in Meets alarm & circuit requirements? SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100+ 100+ Absorption field on lot 104 Public sewer main N/A Sewer/septic service line 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: On adjacent lots On adjacent lots 100+ Public sewer manhole/cleanout Holding tank 75+ Building foundation 10+ Water main 25+ Drainage 100+ N/A Property line 10+ Water Service line 70 Curtain drain 100+ F. COMMENTS Property line 25+ Water service line 25+ Wells on adjacent lots 100+ Absorption field 10+ Surface water 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 40 Water main ?0 Surface water 100+ Driveway, parking/vehicle storage Wells on adjacent lots 100 90 G. ENGINEER'S CERTIFICATION I certify that I have determined through f~bld inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Steven R. Pannone, P.E. Date 314100 HAA Fee $ Date of Payment Receipt Number (Rev. 11/99) Waiver Fee $ Date of Payment Receipt Number Pannone Engineering Services, LLC Consulting Engineer P.O Box 102954 Anchorage, Alaska 99510 (907) 272-8218 Legal: Owner: Residence: No. of Bedrooms: Septic System: Date of Pumping: Date of Test: HEALTH AUTHORITY ADEQUACY INVESTIGATION Lot 5, Block 4 Paradise Valley S/D Mr. Ken Burdette 18120 Norway Drive Anch. AK 99516 Three (3) Tank Size: 1500 gallons Absorption System Type: Deep Trench Absorption System Size: 62.5'x3'x6' Absorption Area: 750 s.i~. Installation Date: 7/l 1/92 9/28/99 By: A+ Home Services 3/4/00 o'~', .................. ....... ~..,%. ............ ~.....~ Soil Rating: 188 sffbr Test Procedure: System was inspected visually and measured. The tank was found to have 6 feet of cover. Liquid depth was measured to be 50 inches. The drain field was found to have 90 inches of cover and a total depth of 167 inches. There was 31 inches of liquid measured in the field's monitor tube. Water was added from the well over a 100~rainute period directly into the crib. Liquid depth was measured in the monitor tube. The hquid levels rose 9 inches in the monitor tube with the induction of 460 gallons of water inta the crib. After the water was turned off, the liquid level retnrned to the original level within 14.40 minutes. This system is able to absorb 460 gallons per day. The drain field clean-out was measured to be 106.4 feet from the welt on this lot and 101.9 from the well on the lot north of this lot. The well was tested in conjunction xvith the septic system. The static water level xvas measured at 63 feet below the top of the casing (BTC). Casing extends 35 inches above the ground level. The well produced 4.6 gpm, causing the static water level to draw down to 68 feet BTC. The records indicate this well is able to produce 4..0 gpm. The water was tested for total coliform and other bacteria and nilrates. Results will be attached once the analysis is complete. TEST RESULTS: This system meets the code and operational requirements of Municipality of Anchorage, Department of Health and Social Services for a 3 bedroom house. In conducting an adequacy investigation, I attempt to provide a thorough, conscienhous engineering analysis of the system in accordance wilh MOA DHHS Guidelines & 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, and are only valid for the specific day of the test. Furthermore, because of the limited nature of the investigation, it is possible that there are hidden defects or encroachments, which may not have been detected. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, water usage of the fmnily being served by the system, and types of substances deposited into the system. These conditions are outside the control of the evaluator of this system. Ali systems eventually fail and satisfactoEy test results do not guarantee future performance of the system. PES can therefore not provide any wmTanty for future performance nor give any estimate of how long the system will continue to meet the operational requfl'ements of the MOA DttHS. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 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.# 020 HII I~ HAA# ,~.~%C ,-).~-_c~,_\u1 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Day phone ~ ,_ :~ \(¢:, Day phone Mailing address Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 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 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 verY'fy that m,? 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 ali Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm I<D~ O~'~-~-d ¢~,~ Phone ~7~-%ql ~ Address A0 % I~¢~ Engineer's signature _¢ ~ Date DHHS SIGNATURE ~'- Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: AdditionalCon~s~ The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that a periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 6.7 mg/1. ,~E~P~ C ', . ,. ' 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. (~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L.~//~/ --J'~o,.,r'o.C~.L,~, ~/,~[I.-c,,~f Parcel I.D. ~)~..O- A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal(Y/N) Date qf test Static water level Well flow Pump level 7' Cased to FROM WELL LOG Date completed '~'~,~ ~'"'/~ ,-~ Driller 7'/ Casing height Wires properly protected (Y/N) If A, B. or C, attach ADEC letter. ADEC water system number 7 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ~ ~' Date of sample: Nitrate g.p.m. AT INSPECTION 742 ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~. / ~,~(~ (~ ~/~'/~/¢'Z.~ Ot h e r b act e ri a Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size I.-~ ¢'*~¢::~ Compartments Foundation cleanout (Y/N) y Depression (Y/N) Alarm tested (Y/N) J~//,~ (__.. ,1~ ~ .~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 10 ~ To property line ?,~O Surface water/drainage On adjacent lots ~ /,,~--L.~ Foundation Absorption field ~ 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) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed '7//~///~ Length ~/~ ~-,-'~ Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating ~'~ System type Gravel thickness ~ Total depth Cleanouts present (Y/N) Date of adequacy test ~//~' for 7a'o If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation /¢~/ To existing or abandoned system on On adjacent lots Surface water Curtain drain N E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect On the,~at¢ of this inspection. Signature Engineer's Name HAA Fee $ /~D' Date of Payment / ~ /~--~E'~ Receipt Number '~,~/~ ( ,5¢/7(~/'''') 72-026 (Rev. 3191) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 1, GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address Day phone Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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: 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) 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 regulati_ons in effect on the date of this inspection. Phone Name of Firm ~ ~ ~ ~. -~ Address '~OB Engineer's signature ,~"~ bedrooms. DHHS SIGNATURE __ Approved for Date Disapproved. 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 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 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /_,eT ~, ~ 14 ~ '~'~c~.,~.~z [,/~ Parcel I.D. A. WELL DATA Well type T~ Log present (Y/N) Total depth Sanitary seal (Y/N) lid If A, B. or C, attach ADEC letter. Date completed Cased to '7 / 'tY'/..,/_cG.~ ~(,~,~ Wires properly protected (Y/N) ADEC water system number ~/~ ~-/~-~ Driller Casing height FROM WELL LOG AT INSPECTION Date of test "~,'~"//~-~ ~, ~' fl Static water level ~, ~ (,:. ? '~(~ '* Well flow ~;~? ~'t g.p.m. ~' Pump level ]~o ¢¢/,~w .~,,/'/,~-~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot I Public sewer main Sewer service line ']'~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank '> WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: B, SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size t ~ Compartments Foundation cleanout (Y/N) '~ Depression (Y/N) Alarm tested (Y/N) i'Y'//,z~- N'-6~''~''~ \2~. Pumper ]'-1 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I To property line Surface water/drainage On adjacent lots Absorption field l ~- o '-~Foundation I'-.'"~ Water main/service line 72-026 (Rev, 7/91) Front ' CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at Manhole/Access (Y/N) Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/l ~ / ~ ~ Length ~- Width Total absorption area Depression over field (Y/N) ~/ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating J '~ O System type "~¢I~L~ Gravel thickness -~ Total depth Cleanouts present (Y/N) Y Date of adequacy test /k,/~ ~ for .~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I I~ On adjacent lots /~'~ ~ Property line To building foundation No Jr' I~1 To existing or abandoned system on lot On adjacent lots ~ ¢~"C:' Cutbank ~ Water main/service line Surface water ~'~ ~ Driveway, parking/vehicle storage area Curtain drain '~ ~ ~ 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. Signature Engineer's Name "~ Date HAA Fee $ ,/"~' ¢/~ Date of Payment ~"'-/~ ¢ 7~- Receipt Number ~rF ~-r~ ~"~'~ ~ ~ %~ 72-026 {Rev. 3/91 } Bsck MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Sample I~6UTINZ 5M~L£ COLLZC~ED BY: V~RNS HOWZLL DIIlLLING VER~. Icst~ ?~z!crr,~ed ' Soe Special Ir~:zruct~ons Above Nat Analyzed L~-Less ~h~n, :.-~, cate. ~han ~ S~S Member of the SGS Group (Soci~t~ G~n~rale do Surveillance) CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS RESULTS fee INVOICE # 52668 Chemlab Raf,# 92.1423 Sample # I Matrix: FAX: (907) 561-5301 WATER Client Sample ID ?WSID Collected baoeivod Pteeorved with ED BASTANACHE Client Name :TOBBE~ SPURKLAND, P.E. UA Client Aect :TOBBENS APb 8 92 ~ 10:30 hts. BPO) : PO) :NONE RECEIVED APR 8 92 ~ 13:00 hts. beq# : AS REQUIRED Ordered By : Analysis Completed : APR 10 92 Labomatoty Hupe,~-v~.~.~3..,~'--STEP.HEN C. EDE Released By : ~ ~ ~__~ Send Reports to: 1)TOBBE~ SPURKLAND, P.E. 2) Parameter Resulte Units Method Allowable Limits NITRATE-N 5.6 mg/l EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: T.S. NO TAG EOb THIS SAMPLE. 1 Tests Performed ' See Special Instructions Above UA=Unavailable ND- None Detected "See Sample Remarks Above NA= Not Analyzed LT-Less Than, GT-Oraater Than ~SGS Member of the SGS Group (Soc,~,~ GCn~rale de Surveillance)