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HomeMy WebLinkAboutMINDYER MANORS BLK 2 LT 5Mindyer Manors Lot 5 Block 2 #020-091-72 dU 14:47 1 1 a TRYCKNYMAN HAYES INC ` FAX N0. 9072767679 P.02/03 Qy �' La 25+.73.56 N71 .CONSTRUCT. SSMI STA �. -28+11.13A cl) 4j 0 \tn INi Q 0 .. ........... ......... .. ......... ......... ......... .. ......... ......... ......... .. ......... ......... ......... .. ......... ......... ......... .. ......... ......... ......... .. ......... ......... ......... .. ......... .. ......... ......... ......... •.••\Qy6�i�::: 493! /2-v 10 lnev. 3//61 -+_� I MUNICIPALITY OF ANCHORAGE ` DEPARTMENT OF HEALTH tip ENVIRONMENTAL- PROTECTION ENVIRONMENTAL. ENGINEERING DIVISION 825 L Street - Anchorage, Alaska .99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR .�.��.� ,�_. WELL INSPECTION REPORT .���.. NAME _.��.s�m - PHONE Q 16E W love 341�T­;Z4/8e ❑UPGRADE MAILING ADDRESS \ P f LEGAL DESCRIPTION LOCATION _ NO. OF BEDROOMS /'J� E DISTANCE TO: Well - Absorption area / Dwelling ^- /• PERMIT NO. 1 w U Y a aQ Manufacturer Material No. of compartments LU F c' j• -e. Liq. capacity in gallons • IF HOMEMADE: Inside length Width Liquid depth �,_ z DISTANCE TO: Well Dwelling PERMIT NO. Manufacturer Material Liquid capacity in gallons DISTANCE TO: WeJ,ly..; 7v. Foundation J Nearest Iqt I'neo PERMIT NO. e. w= J LL Z No. of lines Length of each line Total length of lines � Trench width Distance between lines F- Z ¢ inches — Q f. Top of tile to finish grade Material beneath the Total /� // effective absor tion area L- O inches Length Width Depth - PERMIT NO. LU 6h w4 Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING 50 INSTALLER.P - - REMARKS -j wed D— v UNCIPA 11 F NC C4yt- vii �Oo HE/ LTH & N �� •° ENV RON EN AL L:OT CTI 4 Idko. am* o. Tinnibat APPROVED'WA%*e N0. 4069_E o" ��.® DATE LEGAL �QRp R�F�oo5iQNPtiC' /2-v 10 lnev. 3//61 -+_� I ����1 0 13"" FIR L_ 1 -T %.-5 F'.- ��C:� V4 F H��g 9 E =" ^ DEPARTMENT O HEALTH AND ENVIRONMENTAL ' lTECTION � ^ 825 'L\~*�TREET, HNCHORHQE/ AK 9999`l--,,± ^ ' 264-4720 9-0 L_ ���� L_-_ff 'A 3E 'T_ E--:- E.E. 1-9 E-_ F;� FE--- F -e- I'l��� PERMIT NO. ( 810817 ) APPLICANT HENSLEY ENTERPRISES INC P. 0. 10~2157/ HNCH. ]45~2084 LOCATION VIRGO ST. LEGAL L5 B2 MINDYER MANNERS S/D LOT SIZE 54000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: DRHINFI�LD MAXIMUM NUMBER OF BEDROOMS ] SOIL RATING (SQ FT/BR)== 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: �����-1 = E-'~ �5 L_ PA 0"T "= �T:---; 10 F�` -4. THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD' THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCHVHTION (IN FEET). ���� ������� ������� �� �. ��ED � ����. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCHYHTI0N (IN FEET). F-:` E -::'FA U 1 P -"E=- EN �FEE F-:0 -Ir 1 9::� �F-I PA �I = E:-:-� PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT' THE WELL WILL SERVE. ��1C.-Y < > I I COPA.'=-- �F;3.0 EZ F;? EE CZ! 91 1 F:l, E.'T-- r. -a BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY 0N --SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR R PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE QF PUBLIC WELL MINIMUM DISTANCE FROM 8 PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 3,30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY, SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F:�EE��M I -r I ���� I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. / 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ' 3: I UNDERSTAND THAT THE ON --SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE � RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED:�U, !: ��fP�I[HNT HENSLEY E���RPRISES INC� � SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264.4720 (4-D) . " SOILS LOG — PERCOLATION TEST PERFORMED FOR: zO to, L- ti��� DATE PERFORMED: 3� q Sr I LEGAL DESCRIPTION:_ LqT S 6\ a L c t. M 11 1 O V F? 1Z AA& N N F_12 S SU & CyEp HS SLOPE SITE PLAN hd 11 WAS GROUND WATER S ENCOUNTERED? 2 S L 0 12 I P IF YES, AT WHAT E DEPTH? 13 q�wo��q�4 14 Date Gross Time �Q�.e..e..!•.e'Gn��A 15 Net Drop 2 r `4j A 3 ''"",> )e, '."4n-T4 Clf •°^avly>vranch• 4 5 1seN, lSo s �Q No l? Ralph 8 9 A 10 11 WAS GROUND WATER S ENCOUNTERED? 2 S L 0 12 I P IF YES, AT WHAT E DEPTH? 13 q�wo��q�4 14 Date Gross Time �Q�.e..e..!•.e'Gn��A 15 Net Drop f n- t t ''"",> )e, '."4n-T4 Clf •°^avly>vranch• eQ 1seN, • r •.• ee .lokeloNO. No l? Ralph 17— 1995-E to r„ ■MEN MIN 19 MIMMULN 20 PERCOLATION RATE TEST RUN BETWEEN Reading � Ey Date Gross Time Net Time Depth to Water Net Drop ON eQ No�� No ■MEN MIN MIMMULN MINE Reading � Ey Date Gross Time Net Time Depth to Water Net Drop eQ COMMENTS FT AND (minutes/inch) — FT PERFORMED BY; COIfCtIi�CT I tV C- EN4lN�F1L� CERTIFIED BY: �.. �TOt-..0 tc DATE; 72.008 (6/79) x e DAILY DRILLING LOG SYREN BROS. DRILLING, INC 2701 Eagle Street Anchorage, Alaska 99503 274-6437 OWNER OF LAND......John 112. Hensley DEPTH OF WELL .......... 24 O.�.... ADDRESS........P.�.�.�....ox„10-2157... AnchorageA..AK__.99511 .............................................................. STATIC LEVEL OF WATER FT gound level WELL - SITE .... j��..,53.,.Blk. 2 Mind Your Manners Sub. .... .............................................. ........... DRAW DOWN FT.................... DATE - STARTED....... .-2-1 ................................................................... ? GALS. PER HR/MN.................................................................. 9-29-81 DATE - ENDED......................................................................................u ......... . .. . KIND OF CASING......... ...../..A... 5.)/GrdL... A... steel. casing, KIND OF FORMATION: 4 it plastic liner casing FROM ........ 9.............FT. TO....... 3............. FT.wet...c1a ?... ...gravel FROM........................FT. TO....................... FT................................... FROM ......... 3............ FT. TO....... 5FT.ciay `..gravel ........... ... FROM........ 2.5..........FT. TO.......382........FT.wet clay d'c gravel FROM........................FT. TO....................... FT................................... a. 3/4...gp..m ..wat'e r , FROM........ 3?. 200........FT. FROM........................FT. TO.......................FT................................... ...... FT. TO...... soft bedrock 200 24.6 y1,2 gpm total, FROM........................FT. TO.......................FT..b.e.dr.Q.p,j.............. FROM........................FT. TO.......................FT................................... FROM ........................ FT. TO....................... FT................................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TO....................... FT................................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TO ....................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TOFT................................... 1 ....................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TO....................... FT................................... FROM........................FT. TO....................... FT................................... FROM....................:...FT. TO....................... FT................................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TO....................... FT................................... FROM........................FT. TO....................... FT................................... FROM ........................ FT. TO....................... FT................................... MISCL. INFORMATION: Steel casing to 4.0'; plastic liner casing throughout remaining hole. R 'ren............................ DRILLER'SNAME ..............tephen...D.:... Municipality of Anchorage ° Development Services Department Building Safety Division - 4. • .. ' �_- On -Site Water 8 Wastewater Program Individual On-site 4700 Bragaw Street Individual Water Storage P.O.Box 796650 Individual Holding tank Anchorage, AK 99519-6650 Community Class Well www.w.muni.org/onsite Community On-site (907)343-7904 Public Water System CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.02�=72 COSA#D `jn 1 6 4 9—/0-0q 1. GENERAL INFORMATION Expiration Date: -! — / 0 — 0 q Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MINDYER MANORS: BLOCK 2. LOT 5 4620 VIRGO AVENUE *ANCHORAGE, AK AMY SCHUMACHER Day phone 440-7800 4620 VIRGO AVENUE 'ANCHORAGE. AK Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered In the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems 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 samples. (Certificates may be reissued for a period of up to one year with valid water samples.) 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 not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application. shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD 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 all wells and septic systems depend on the local soils condition, groundwater 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 performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. 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. S. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Phone 337-6179 Date (0 1 'r-10 Conditional approval for bedrooms, with the fllowing stipulations: Attachments: c/ COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other - t A. or essr ' E 79 . 14 �1 S�D 9. cNAp u� 60 ofeyy�Q�o >Q y, ON-SITE•• '•�Ci; WATER AND WASTEWATER PROGRAM By, GlJ Original Certificate Date: - 1 0 — O 1 (RM 11105) Municipality of Anchorage (• Development Services Department Building Safety Division On -Site Water 8 Wastewater Program Y 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.orglonsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: MINDYER MANORS; BLOCK 2, LOT 5 Parcel ID: 02 D- t el I.- %Z A. WELL DATA Well type PRNATE If A. B, or C provide PWSID# N/A Well Log (YIN) YES Date completed 9/28/1981 Sanitary seal (YIN) YES Wires properly protected (YIN) YES Total depth 246 ft. Cased to 40 ft. Casing height (above ground) 12+ in. FROM WELL LOG Date of test 9/28/81 Static water level GROUND LEVEL Well production 1.5 —g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Arsenic: 0 ug./L. B. SEPTICIHOLDING TANK DATA Tank Type/Material Tank size gal. Number of Compartments Foundationcleanout(Y/N)_ Depres ioaever n (YIN)_ AT INSPECTION 4/30/08 23 ft, 1.7 g.p.m. Nitrate 0 mg./L. Other bacteria 0 colonies/100 ml. Date of sample: 4/22/2009 Collected by: GEG Ltd. PUBLIC SEWER Date installed C. ABSORPTION FIELD DATA i4BELOW EXISTING GRADE Date installed Soil rating (g.p.d./ft'o /bd)_ Length ft. Width ft. Total depth ft. Eff. absorption area_ ft' Monitoring tub Date of adequacy test Results P High water alarm (YIN) System type - Gravel below ion over field For bedrooms Fluid depth in absorption field before t _ in. Water added _gal. New depth _in. Elapsed Time: Final fluid depth _ in. Absorption rate >= g.p.d. A venation treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off" leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100+ Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER. Building foundation Property line Absorption field Water main Water service Wells on SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water service line F. COMMENTS G. ENGINEER'S CERTIFICATION Building foundation Wells on adjacent lots I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date COSA Fee Date of Payment 6 Receipt Number l n 4 q (Rev. 11105) Driveway, parking/vehicle storage Waiver Fee $ Date of Payment Receipt Number SGS RCEM 1091550001 Client lame Garness Engineering Group, Ltd. Project Namc/R 4620 Virgo Ave Client Sample ID 4620 Virgo Ave Matrix Drinking Water Printed Date/Time Collected Date/Time Received Datelrime Technical Director 05/0412009 16:53 04122/2009 10:50 0412212009 11:10 Stephen C. Ede Sampic Remarks: 450ONO3 - Total Nitratc/Nitrite - The sample AIS is outside of QC criteria (biased low). The LCS is within QC limits. Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Dam Inst Metals by ICP/HS Arsenic ND 5.00 Haters Department Total Nitrate Nitritc-N ND 0.100 Microbiology Laboratory Colony Count 0 Total Coliform 0 Fecal Coliform 0 ug/L EP200.8 C (<I0) 04128/09 05/01/09 NRB mg(L SM204500NO3-F D (<10) 04123/09 1DZ col/100mL SM209222B col/l00mL SM209222B col/100m], SM209222B A (<200) A (<I) A (<I) 04/22/09 DLC 04/22/09 DLC 04/22/09 DLC f (b51wG\� - a 0.f 9[tP I. LOT 6 s 4 LOT 4 �JA el '?q W INIES iPttS 'A OR[[ YWRNNI2 G4YfNf A- � (¢NRYLO ON SIRw 11.4nn1 \\ O LOT 5 IN Z nl N lY U II J 1ClCC07u. & ELEC. USEuENI 89'55'55' W 110.00' LOT 3 ' (iGU9a IKIt(S 11 Y uY w+«: ww.eYtr to wl�mw• ul.aN�. xl V IN, MIKE FE SON M.nYMw M^1P•Y 1. sIT^�4. NY4NI. •A',I w W [ppt> ^ W Itsaw! YMMI /bl. NOR: s/PlN •A'Y`N •Arn0 1}.' YYOi Q) •O.YC.t 4) .Iilh MCF CONSTRUCTION. INC. 1AWI[ ^• •.IrNY^w• Y'^+1e ^1 ^I• "•^^ ^• •Ib 1ei wa t•a u a ¢AnrIAA nut. uwt(oI nw w.s+•Iw • VANINIC-agumm Parr v+P •I Yw ss•II1 ^ ^.� .e u+ .®aas- E rro •w w1 r" Yw..e..�u .iwua In.. owxrt- i ^ Y. w1M M plpN11 w•• •e0 .e ^veeN1- A'. •MIYI. �. Mab 1+.1 Mnw IM roIN P•MI. AS—BUILT 04: I(Oy 0{(OITIKN:"'C 1'•'�P'+*' n• w��=®— LAND , I V U Y -PLANNER$-ENGNI ER$ 440 VEST BENSON BLVD. / 103 (Im) 561-6625 LOT 5. BLOCK 2. AN010iACE. ALASKA 99501 (907) 562-5391 + 2. �°°' 1%50' �I'°-"' 71A m1iJs M I N D YE R MANORS 2 0 01 4-6 ,Z-' I^Y°n 67(i° V MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES M Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 34313744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # 020-091-72 HAA # 1(11/CC6)61 f 1. GENERAL INFORMATION Location (site address or directions) 4620 VIRGO AVENUE ANCHORAGE. AK 99516 Property owner FRANK BLODGE17 AND SHARON COLDWELL Day phone (907) 345-8425 Mailing address 4620 VIRGO AVENUE ANCHORAGE AK 99516 Lending agency Day phone Mailing address Agent DAVE BROCK w/PRUDENTIAL VISTA Day phone (907) 727-8555 Address 4241 "R" STREET ANCHORAGE AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding Tank Community on-site Public sewer xxx NOTE: If community wastewater system, provide written confirmation from State ADEC ing to the legality and status of system. 72-025 (Rev. 1191) Front MOA #21 Computer Version Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $800.00 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, 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/Ahe on-site water supply and/or wastewater disposal system is in compliance with all Municipal �an to codes, ordinances, and regulations in effect on the date of this inspection. f n / A ' Name of Firm Phone (907)337-6179 Engineer's Signature U nate_ o W In conducting this evaluation, AWWC, Inc. a pt to provid a borough, conscientious engineering nalysis of the system in accordance with ADEC and MO1D HSS� p�idelines & Regulations. The reported results described the performance of the system under the conditions encduntered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate during the year, and the water 000�opp usage of the family being served by the system. These conditions are outside the control of o F i A 40� the evaluator of the system. Satisfactory test results do not guarantee future performance o 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 O L7; 4 fH 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 other person or party is not authorized, • • • • • • • • . / nor will it confer any legal right whatsoever. �O m J reY . Garnt<S5• P ' 6. DHHS SIGNATURE QO sf E 795 co Pio • ....... • •' F,o�o I/ Approved for 3 bedrooms ��4pdP erass%O �OO000� Disapproved Conditional approval for bedrooms, with the following stipulations: Additional Comments By:Date '7- 3 / - D o a� 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. 1191) Back MOA #21 Computer Version Municipality of Anchorage JUL 21 2000 DEPARTMENT OF HEALTH & HUMAN SERVE E In�.fl�lury *IV GE Environmental Services Division °^^MFNrA�i'_. 825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 3 f47ej 2000 ,..,,. , , ;t hwCHORAGE Health Authority Approval Checklist 1VIALSI-RViCUSDIVI"- Legal Description: MINDYER MANOR S/D; LOT 5, BLOCK 2 Parcel I.D.: 020-091-72 A. WELL DATA Well Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A Log present (Y/N) YES Date completed 9/29/81 Total depth 246' S Cased to 40' Casing height (above ground) 13" r� Sanitary seal (Y/N)/e5 �6 Wires properly protected (Y/N) YES FROM WELL LOG Date of test 9/28/81 Static water level GROUND LEVEL Well production 1.5 g.p.m. AT INSPECTION 7/14/2000 45' 1.6 g.p.m. WATER SAMPLE RESU TS: Coliform Nitrate �' 5' Other bacteria Date of sample: 7/17/2000 Collected by: A.W.W.C., INC. B. SEPTIC/HOLDING TANK DATA Date installed Tank Foundation cleanout (Y/N) Date of Pumoin Pumper Number of C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) Length Effective absorption Date of adequacy test Width Gravel thickness below Fluid depth in absorption field Monitoring Tube present Fluid depth T(ins) Minutes later: _Feraxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)• Computer Version (Y/N) High water alarm (Y/N) System over field (Y/N) (Fail) For Bedrooms Immediately after gal. water added (in.): _Absorption rate = If yes, give date D. LIFT STATION Date installed Manhole/Access High water alarm Size level at* "Pump off' level at* *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: adjacent lots N/A Septic/holding tank on lot N/A On ad 1 Absorption field on lot N/A On adjacent lots N/A Public sewer main Sewer/septic service Public sewer manhole/cleanout 100'+ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation Water main field water/drainage Wells on adjacent lots SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property Surface water F. ENGINEER'S 1 certify that I I of Municipalr with MOA HA Signature Engineer's OD HAA Fee $ Building foundation Driveway, parking/vehicle storage area Wells on adjacent lots inspections and review stems Q�p 1 stems are in conformance this date.44 0 ESS Date of Payment Receipt Number a 61 6�( a ©�� 72-026 (Rev. 3/98)' Computer Version Waiver Fee Date of Payment Receipt Number �ey Gayness; C 7953 : • �G ...•' �cAdO prof assiovdo 07-20-00 16:53 FROM -CTE ENVIRONMENTAL CT✓ZE Environmental Services Inc. AL. CT&E Refs/ 1003575001 Client Name AK Water & Wastewater Consultants Inc. Project Nament N/A Client Sample ID Mindyer Manor Loi 5, B2 Matrix Drinking Warm Ordered By PWSD) 0 Sample Remarks: 5615301 T-675 P.02/05 F-227 Client PO# Printed Date/Time Collected Date/Time Received Date/Time Technical Director Released By .yy, 07/20/2000 15:01 07/17/2000 14:30 07/ 17/2000 16:45 Stephen C. Ede . i /Ov% , /, Allowable Prep Analysis Parameter Resolts PQL Units Method Limits Date Daze Init Waters D@1J2ar1=0v1t Nitrate -N 0.500 U 0.500 mg/L EPA 300.0 10 max Microba.ology Laboratory Total Coliform 0 coUl00mL SMIS 922213 07/17/00 SCL 07/17/00 KAP -'ttmE -✓ Time - e �I l �j 611Q�y Date Date Date Inspector Inspector Inspector Comments _ E_ l�l�("ln Gn Conditional A— - -' Co.._ nay s C040 w n ah ffn - PLJU w6l-<� Date Sewer Installed Permit N61 Septic Tank Size 2 Y CU 9 — (9 1 / b �- ( � Holding Tank Size Soils Rating Well TQ Absorption Area S7 w Well Log Received 50 Well to Tank /v APPLICANT FILLS OUT LOWER HALF ONLY Property Owner Mailing Address 77 /45&t4 / Phone _ Buyer Address Lending Institution / ?� yj , c, ��-Lf Phone.-'-,(,/'es Address Realty Co. & Agent Phone Address Legal Description Street Location 6 D Type 9LR6sidence Single Family I a S�Z� C� f-RD-A ❑ Multiple Family No. of Bedrooms ❑ Ot er Wate pply Individual ATTACH WELL LOG. A well log is required for all wells drilled since June ❑ Community 1975. For wells drilled prior to that date, give well depth (attach log if ❑ P blit Utility available. SewQ6 Disposal ❑ Individual Year Individual Installed: ` / l ❑ Public Utility When Connected to Public ❑ Holding Tank Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. N 83 u no 2L,, 19 0 7Gt.rl IPIIS).e>11 p. ):soy 1.0-21-37 ,N-)jc'nora(jc Y AK 99F` 1, 1 c 2 n t ,()t 5, ,j.ock 2e �L and WatOl- annot- Ap--)'COvcAI for indivIch-la-L -on coMI)dC'-fic" I- b granted up.ti'l th, Kulloy-ing bn- tor our L - d to b well loq sur !,--e e v i -ow lould it ZS 111h 10 top of til.. W eil Ca- ter tigh'. -te th bC F;U!)-�)iL, d UO r y-; i s CG)Ofol_ f,)U The wat 'tree t -for will need to b,. Ile o-1 v-- the si,( y - zhe se, a -e later ciralns awav surf stallT "IApa to tile SeNjer S Y t", t Q, TI cops oil �A-!.-n the e(_ j�y this as p lie there arc allY not J- ancien, corr,.�cted. (U-screy . _Ive I)e(--n at 264-4720. p 3'ease ca,l this ()ffice furthur c1l'u';"�t-ions, p 0 z"-Brelyf C C) -C V I C'J 12 / c i -YN