Loading...
HomeMy WebLinkAboutBROADWATER HEIGHTS TR B1 roadv a'l'¢r' Troct B1 #050-131-78 Municipality of Anchorage P.ge DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage. Alaska 99519-6650 · Telephone: 343-4744 On-Sile Wastewater DiSposal System and/or Well Inspection Report Permit Number: ~O0'~'c~ PIDNumber: Name: V,~ j~ ~,~ ~ fi¢,.~ /~ Waslewaler Syslem: U New ~Upgrade ¢~ ~15 ¢,1/~-~¢~ Dr,~4~¢,w ~Ef¢*&BSORPTION FIELD Ph°ne:~--~f~'5 IN°'°fBedr°°ms:q ~Deeplrench ..hallowTrenoh .Bed .Mound UOther folal Depth from original gradej~ LEGAL DESCRIPTION S°ifRaling: Oe~% ¢PD/Sq. Ft. ' ~O ~ Numberollines: Oisl~ncebelweealine~: ~j~ ~j ~~ : Tolelabsorptionarea: Pipema/eri SEPARATION DISTANCES ~Septic U Holding O S.T.E.P. lOOkl¢'+ LIFT STATION Remarks: ~¢v~ R~q¢~7~4 ~o4 s~¢,~4~,,,~ BENCH MARK ~." S & S ENGINEERING . .~ ~ ~.,...~ 17034 Eagle River Leop Roa~, No. 204 Inspeclions performed by: E,:!e ~!~,r. ~l,~- ~s77 Dates:~ndlSl ~-t(~¢o~j~ D,partmont o[ H,allh ~ Human uome,s approval Reviewed and approved by ~ ~' ate: ~00 '~' "' ..... ~- 72-013 (Rev. 9/9t) MOA 25 PERMIT NO SW000352 PAGE 2 OF 3 D ........ ~u n~i%iBg~ti~ 7~o~ ~ Anchor~oe I~PAI~HIFtI~N~ ©P IHILbAL~HI ANO HUB'AN SERVICES ENVIRONNENTAL SERVICES DIVISION P,B, }3ox ]96650 eanchor'o, ge, Mo, sko. 99519-6650©Tetephone~ 343 4744 ON=S~¥E WASTEWATER D~SPOSAL S¥SYEH AND/OR WELL INSPEC¥~ON REPORT LEGAL TRACT 91, BROADWATER HEIGHIS P.i.D. NO. 050-131-78 3A LOT 4 LOT 4A DY LOT 5A EXISTING BEDROOM HOUSE LOT B PERMIT NO SW000352 PAGE 3 OF 3 iVtunicip, o, ti% o~' anchono, qe DEPARTIVlENT OF HEALTHAND HUIWAN SERVICES ENVlRONPIENTAL SERVICES DIVISION P.D. Box 196650 OAncho~age, Atask~ 99519-6650®Tetephone: 343 4744 ON=SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL TRACT B1, BROADWATER HEIGHTS P.I.D. NO. 050-131-78 FINAL tfifNAL GRADE ST1 ST2 .~97.7' " INSULATION 94'8~4.6' CO1 =9?.9' C02=95.8' A B FCO 29.0' 11.0' ST1 22.5' 55.5' ST2 26.0' 55.0' DBL1 29.0' 56.5' DBL2 50.0' 37.0' DV ,52.0' ,57.0' C01 22.5' ,24.5' MT1 25.5' 25.0' C02 10,3.0' 83.5' MT2 93.0' 74.0' CO1 =93.5' C02=93.5' MT1 =85.5' MT2=85.5' A NO WATER FOUND 79.5' ]3.0.H. N T.S Muulclpal!ly ~! Attchotage bEPAFr[rMENT oF HEALTH A HUMAN SE~VlOES 825 "L" 81reet, Al!chorag~, Alaska 99502-065~ soiLs LOG -- PERCOLATION TEsT 10¸ 14 16 18 20 COMMEN1S SLOPE wAs GROUNIJ WA'i'ER IF YES. AT WIIAT bEPlt'll? i~ptll t0 WaleL~J~' , SITE PLAN PE~COLA110N RAI E 17034 Eaale River Loop Road No. 204 ACCORDANCE WlIH/L~g~l[~, I~,~I~c~,I2~UIDI~LINEs IN ~FFEOt oN 1 Is DA~E. 12.008 {~ev. 4/851 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519~6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Sep 05, 2000 Expiration Date: Sep 05, 2001 Permit Number: SW000352 Legal Description: BROADWATER HEIGHTS TR B1 Design Engineer: 0003 S & S Engineering Owner Name: Byron & Virginia Kohfield Owner Address: 18315 Stillwater Dr. Eagle River, AK 99577- Parcel ID: 050-I31-78 Site Address: 018315 STILLWATER DR Lot Size: 66528 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field J~] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. AIl requirements specified in Anchorage Municipal Code Chapters I5.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. AT THE TIME OF CONSTRUCTION THE ENGINEER SHALL PERFORM AN ADDITIONAL SOILS TEST AND WATER MONITOR IN THE VICINITY OF THE PROPOSED UPGRADE. THIS SOILS TEST SHALL BE SUBMt%I'ED WITH THE AS-BUILT INSPECTION REPORT. MECHANICAL INSPECTIONS oNSITE WAS~'EWATE R ROBERT C. COWAN, P.E. August 17, 2000 CIVIL ENGINEERS (g07) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Tract B-l, Broadwater Heights It is requested that you issue a permit to upgrade a septic system to serve the existing four bedroom dwelling on the referenced property. One test hole was excavated and a percolation test was performed on 7/9/78. Ground water was monitored and after seven days the hole was dry as shown on the attached soils logs. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. P. CC/bjj Enclosure 17034 NORTH EAGLE RIVER LooP 4 SUITE 204 ', EAGLE RIVER. ALASKA 99577 SITE-PLAN DESIGN ~ i / / / ~ 33' SECTION LINE EASEMENT SITE-PLAN DESIGN 1" = 40' SCALE 0'7 ©© BLM 33' SECTION LINE EASEMENT .0 liE Rossoll 694-2774 Soils E~ Foundations Gg~.~CHNICAL 8' DEV~-~PMENT Box 90, Davis St,, Eagle River, Alaska 99577 694-2774 or 688-2280 CO. Earl Ellis 68~-22~ LOG Land Development Performed for: Name: .~ ~Y~4~-~ /~-'~=,~/ Tel, Ho, Mailing Address: ~c-~ ~-z- ~ 7 Y=-~_.~"'~=--~z Legal Description: ~--F- ~/ ~z~)~.~zJ-r~-~_ Depth (feet), Soil Characteristics o 10__ 11 Ground Water Encountered: Proposed Installation: Seepage Pit__~ Drain Field ~..i Comments: ~-"~/~___ ~..~.~ ~.~ ~ ~,~_~..-~ ~L.~_~ Yes No ~ If yes, what depth Performed by= ~~ ~/~'~-~--'~-- Date:'~----T-'~ ~, ROBERT C. coWAN, P.E. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-i 21 i ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Tract B-l, Broadwater Heights August 17, 2000 GENERAL: The scope of this project includes the installation of a Premier 1300 gallon HDPE septic tank, and upgrade of the existing trench to serve the existing four bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems mhst also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. t7034 ~o~i'~ ~Li= hlUE(q LUO~ i §U~'I~ 204 ~ ~EAGLIE RIVER, ALASKA 99577 Page 2 Tract B-l, Broadwater Heights August 17, 2000 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. ~om the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt ban/er covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Page 3 Tract B-t, Broadwater Heights August 1~', 2000 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated .Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couphngs (Caulder, Femco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. Page 4 Tract B-l, Broadwater Heights August 17, 2000 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR / INSTALLER  MUNICIPALITY OF ANCHORAGE '"-7"~'~:'-~)c:. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~-~ ENVIRONMENTAL ENGINEERING DIVISION ~~ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT P~O~E / ~EW LEGAL DESCRIPTION ~~ ~o. o~ ~OOMS UOC~TI O ~ ~~ ~r~ ~ DISTANCE TO: 1~ 6 ~ ' ~ ~~  Material No. of compartments Manufacturer ~ ~ ~~ Liq. capacity in gallons Inside length Width Liquid depth ~ ~ IF HOME~DE: ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ ~ ~ Manufacturer Material Liquid capacity in gallons Q Well Four, on Near~t; ~= D~STA.CE TO: //~ ~ o} ~in. Pe~T NO. ~ N°'°flines / Length°feach~'line Total4en6hoflines TrenchwiOth~ inches Distance between lines ~ ~ ~ Top of tile 't6finish grade Material benRath tile z~ ~ Total effective absorption area Length Width Depth PERMIT NO. ~ w Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line m DISTANCE TO: ~ Class ~ Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER MATER I ALS SOl L TEST RATING 2 ~ R E~KS -F APPROVED DATE LEGAL 913 (Rev. 3/78) PERMIT NO. DEPRR'FMENT OF HEALTH AND ENVIRONMENTAL F'~...:OTEC:TION 825 '" L"' STF.:'.EET., RNCHORFtGE, AK. 264-4?20 I-..1 E< L_ L_ R 1"-4 [:, ¢') I"-.i --- '.'5 I -F E ."'~"; E£ ~,..1 F~ I:~." F:' E: F:-:.". I".1 I '"'IF' < ?G06:?.'1. ) APF'L I CAN'T LOCRT I ON LEGAL CHARLES FERRIN STILLWRTER DF.: TRACT E:'I 8RORDWATER S,.'"[:' PO BO'..'-'-; ~.27 EAGLE RIVER LOT SIZE 688 26S~0 70000 SQUARE FEET TYF'E OF' SOIL ABSORBTION SYSTEM IS: TRENCH ,' ..... ,,, , '-" .'-' '-- .=,,,., ItH,=':,].M_I1 NLItlE, EF.. ~'"~F E, EE.,F..uurl=, = 4 ;:,uIL RFIT'ING ,:"-- 'T'HE REG!LIIRE[:, SIZE L-IF" '-C~ -"-'F~ ' ' - '-'"- . THE _-._IL ME,=,.RFTIUN -;,T"';~bE~ IS [:. IF£C F' l'" I--I = :.1.. 2 /_ E;-.C I%! 13 -r t..-t = ~-'1- ~Ti F"J." F! "...' Ev' I._ THE LENGTH DIMENSION I:5 THE LENGTH (IN FEET:..' OF THE TRENCH OR DRAINF'IELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SLIRFRC:E OF 'T'HE GROUN[:, AND 7'FIE BOTTOM OF THE E>:;CAVRTION (IN F'EET). "FHERE IS NO SE"r' WIDTH FOR TF.'.ENCHES. THE GRR',,,'EL DEPTH IS THE MINIMUM DEPTH OF GF.:RVEL BETWEEN THE: OLITFALL F'IF'E AND THE BOTTOM OF:' THE EXCAVATION ,::IN FEET). PERMI7' APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING 'T'HE INSTF~L. LRTICfN ~NSPECTIONS OF RNY WELLS A[:,..IACENT TO THIS PROPERT"r' AN[) THE' NUME:ER OF RE:SI[)ENCES TNFIT THE: WELL WILL. SERVE. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION RNE:, RF'PROVRL B'T' THIS DEPFIRTr,IENT t.4It. L BE SUBJECT TO PROSECLrl'ION. MINIMUM [.',ISTRNCE BETWEEN A WELL AND ANY ON-.SITE SEWAGE [)ISPOSRL SYSTEM IS :'L00 FEET FOR A PRIVATE NELL.; OR :L50 7'0 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF F'LIBLIC WELt .... WELL LOGS ARE REQUIRE[:, AND MUST BE RE7'LIRNED '1"O THE DEPARTMENT WITHIN ],~:O DFtYS OF' 7'HE NELL COMPLETION. OTHER RE6~.UIREMENT'..-"B MR"r' APPLY. SPECIFICATIONS AN[:, CONS7'RLICTION DIAGRAMS FIRE. AVAILABLE TO INSLIRE PROPER INSTRLL. ATION. I CERTIFY THAT Z: I FIM FAMILIAR WITH 'THE REtT.!UIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET F'ORTH BY THE MUNIC'IPAI_ITY OF' ANCHORAGE. 2: I WILL INSTALl_ THE SYSTEM IN ACCOR[:,ANCE WITH THE CODES. 2:: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REG!UIRE ENLARGEMENT IF' "f'HE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. S I GNE[:, ' _.~~~ r,,,,~ ~' ' , ~'-/ '-- ISSUE[:, E,_~__~ ............... [: FIT'E .......... ...C.__L_~Z_ ..... ',,,'] '2~ O Er E GEO i'ECHNICAL Er DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 S0I L LOG res-22s0 Soils ~ Foundations Land Development Performed for: Legal Description:, Depth (feet) 0 J Sotl Charactertstlc~ 2 8 ZO , Ground Water Encountered: Yes~ No~ Proposed Installation: Seepage Pit Comments: ~~-- /~ ~ ~ ~~ ., ;// If yes, what depth Drain Field /r Performed by: ( erlifie riili g DRILLING COmPaNY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE694-2588 OWNER OF LAND ADDRESS LEGAL DESCRIPTION PERMIT NUMBER DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. ,-~ / GALS. PER HR / 3%-::) KIND OF CASING KIND OF FORMATION: Ft. to ;, Ft. O c~-~7/,~ dV~/.3~- ~,' From Ft. to /i Ft. '~ ~~- ,~<l~ From~ Ft. to ) (~ Ft. 4~~z-~ [~ ~' ~O~& From Ft. to ~; Ft. .d)t- ,~OC, Z~ From From From From From From From :!i, Ft. to ; ,J c; Ft. d~,d::d2-~6.:-a/~'' From ' ?.~; ,~ ',, T~-','~- l:7~J From From. , Ft. to ..... Ft. ~/~,~&%wL~ z .,~ .... ,~ From~Ft. to Ft. )// G:~a~'~'~? ~:} ~2 t:' r~>'~ From From ~' ~ Ft. to /; '3 Ft. ~{ e,:~,r, ~' <-"o m/,-. From From '; ~ Ft. to i ~., . Ft. Df:.~,~,~ ,::~,-'. ~,rZ'., /:/d~c~tz29. From From Ft. to Ft. ~[" (~o -4-,q~T~&. From__ From :' Ft. to ,~ ', Ft. From From Ft. to Ft From From Ft. to Ft From__ From Ft. to__Ft. From From__Ft. to__Ft. From From Ft. to.__Ft. From__ Ft. to Ft. to._ Ft._ __Ft. to Ft. __Ft. to__Ft. __Ft. to__Ft __Ft. to__Ft. __Ft. to Ft. Ft. to .Ft. __Ft. to Ft. Ft. to.__Ft. Ft. to Ft Ft. to Ft Ft. to Ft Ft. to Ft __Ft. to__Ft. __Ft. to___Ft. Ft. to__Ft MISCL. INFORMATION: DRILLER'S NAME MunicipalitY of Anchorage Development Services DePartment Building Safety Division On-Site Water and WaStewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wwwlci.anchorage, ak.us (907) 343-7904 Parcel I.D. 050-131-78 GENERAL INFORMATION .C~mplete legal description ;Location (site address or directions) C~i'rent Property'0wn~r(s) Mailin. g address .~ Lending agency Mailing address Real Estate Agent Ann · -i. ?'Mailing Address CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING -- HAA# Exp!ration Date: Tract B-l; Broadwater Heights Subdivision 18315 Stillwater Dr. D.ay phone 7z, R-~.rlsq Day phone Rober'ts / Prudential Day phohe 244-3392 , - Unless otherwise 'requested, HAA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: 4 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 " [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Cedificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. 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. (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 syste, m. 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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm S & S Engineering Address 17034 N. Eagle RiVer Loop St.e. Engineer's Printed Name Robert C. Cowan DSD SIGNATURE ~ Approved for £]/' bedrooms. Disapproved. Conditional approval for Phone · 694-2979 204 ,Eagle River, AK.99577 Date (~/'3"2"//0 ~' bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date:' ~J, - ~.- 9 ' O/'7/ (Rev. 01/02) i! MUnicipality of Anchorage ,,, Devei0pment services DePartment ! i :' ' ~ Building Safety DivisiOn . I On-Site Water & Wastewater Program · '; 4700 South' Bragaw St. , '[ P.O.'B6~'196650 Anchorage, AK 99519-6650 (907) 343-7904 ~ . HE~,LTH AuTHORITY APpROvAL UHECKLIST- . Legal De~ scription: A. WELL !DATA I 1 P~rce! ' ! Well type ~'~'~' t : If A;-B. or C pr0~,i~l'e PWSID # '-- Well Log (Y/N) .'"7/ Date completed .'7--//:::~ San,taryseal (Y/N) Wires proper y protected (Y/N) " ; ; ,' ',. i :;" : .'~.. ~ '.' ':h' ; ~ . Total depth:/~ft. ~~ Casing heigh (above ground) :.- .. ,~ , ' FROM WELL.LOG · . .~ ~ , I" i; ;' : [ ' ' i I~'. I : . - , / Date of test ' · ,, ~//~/~ ,: . ..,/ /,O~ .' Static water level . . ~ ' j . , ~ ..~ ;, . ~' ', . - Well production' ~ ~~ ' ~ [g:p.'m:. .. ' -" ~ ~, ~ ~ g.p.m.~ WATER SAMPLE RESULTS: ". '," '1 ' ., Co ,form O, ,co o,ies/100m .... mrate m-/ . ' . ... .--, . . .~ .... . . ~ ,'.~" SEPT~C/HOLmN~ANK:DATA ": ." i*]!~:'l . Tank TypelMaterial:'~l ~ Tank s~ze /-~ fi. ga[. '~ "., Number ofCom)adments ~ ' - Foundabon pleanout (Y/N) ~ .~ ':: Depression o?er tank (Y/N) .~. Date or P.mpiCg',: ~72~;O~ ,Pumpor ~.' ', U~*S '.' :. · A SORPTION.FIELD DATA . . :. , , ..... Date ,nstalled~; ~//Z/O~. ~.SoU~n~p~ ' ~;~ '<','. ,"'~,,xff': ' · ' ~,ll':. . ~.. ' . ' :, : . !,~ ~' 2 ~ . Total d~pth ~ I~ Date'o[ adequacy teSt Fired depth m absorpbon field before test ~, m. ,~ Water adde~ gal.- Elapsed Time~ ~O min. :.~ ;, - Final fluid de )th ~Oin. Absorption 0 colonies/lO0 mi. De~pJ'ession over field /",J ' i !~, For '~ bedrooms !=:' I New depth~J in. '~atL, ~>:: ~ ¢'o g.p.d. If y~s, give date Sys : pe /~),'/'"'-'~~/'/' ~G avelbelow pipe ' ~ ft. Any reju. genation treatment. (past 12 mo.) (Y/N tyl~e)//i,,/~,,V'~- D. LIFT STATION ,~pa~eminStailed /t~///~ pon level at~/_~_ in. Datum / E. SEPARATION DISTANCES Size in gallons "Pump off'. level at ~ Cycles tested Manhole/Access (Y/N) in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots "'Public sewer manhole/cleanout '"'] Holding tank . ~J / Septic ~ank/li~n on lot Absorption field on lot Public sewer main Sewer/septic service line SEPARATION DISTANCES FROM SEPTIC/HQL-BfNG TANK ON LOT TO: SEPARATION DISTANCES FROM WELL ON LOT TO: (oo %-' fo0 Building foundation ~" ' '+'- . ~ ProPerty line ~" ~ Water main /']~/ '~ ' Water service line' Wells on adjacent lots ~, ~ 1~,_.. Absorption field ~- !+"' surface water [ OO 14- SEPARATION DISTANCE FROM ABsoRPTION FIELD ON LOT TO: Property line 'l ~:~ ~ Building foundation / ~ [ CO ~-- Water main , ),,,J.//~3~ Water Service line I 0 t.+_ : . : . : Surface water 'l OO tw-' ' Driveway, parking/vehicle storage' Curtain drainJ~rJ~' ~"~ 03d~Wells on adjacent lots' I ~0 ~ ,' in. F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field 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 //~ Date ~ /~' ~'/0 HAA Fee $ Date of Payment Receipt Number (Rev. 12/01) Waiver,Fee $ Date of Payment Receipt Number ..... , .. -;~ · · ~. :: ¢:';:,~i."', ' ~;.,, . ,.. .... · .... : .: ,. . , . .?, ,~ .. · .. ~ . ,, ,,.,.... :""~ ~' "' ~-':,~';'. ;~ '""' ' ~'"";'" :' ", 7, ~.~ :' ' ' ~: .... ' ' ' . '. :. '.. '. I '"' '"; '.' :i,-:" '~ .: : : ' '/' :'' ~.. . .; ..' .;.. _: '.. .. I · h,~ ., '.'.'.'-k' ,: I. ;. ' · . . ':~' · ', .' ~.o 1 .. '~ '" I,,.;- ---y." ' ' " :. .'" ~ '~" 14.,, - .. ,.-- .... · · i~'~ i ' '.. . I~,:/?~: .... '~'1~" '":.~-".'..,,, ,. ~ ~'"" "' ~" '-~' ~-h~" ' '; " " "? . ' '..., .~,~./.....' i ' ' . .;~ . ... .' _.,,..:' . . : _' r ,i." -. ' '.~,~ . .. "-~,> .... ' "-,, ' · ~.';~" '...":"',. '' " · ~,. ""4.~ '-. I ' ..,~i ' .'~": -. . : . .: ..: · I · ; , ~; . ~ '[ '4' Z Z..,/ ' ~ ,~,". ' I A r.q. ' '-"]':' " ~.,.,,,/;.,..(. z ,.,?,., .--,~ ' -- ."'~. ·., i,'-'."'-L.,!" ' '"':':"~:; ~ r F-~/'¢,..,~.,..,. ,. . ' · .,,,, . : . . :. ' "' "x, ['. "; "' .AS-BUIlT ~ ;i:, . "" I hei'eby'certlly that i-have surveyed '." .... describe~ property: 7'"/-~'~ ~;--! ~ '~, ' .. " : .: '., .: ~-~l~.'~r- p.,~l~ ~-'.~o~t; .,.~ ..... . ~--~.~ ~, 'r,¢~ ,~, %~,... · '" ' ": Anchorage Becordlng Prednct, Alaska, and that the :' ::;'~ . ~ ' i ..improvemezlts sltttnted thereon are within the.pt-operty ~, ... ,._..y,,.t..,~.~,,%,. . ... i linel and.do .not overlap or.encroach on th6. property ,.. · c · -,. * ' --.~-"{'1~. ' I lying adjncel~t thereto, that Ilo improvements oli pkop- , ,.. '.. ,a :, l.~s' ,'~..,. :;; 'i .. -:.. · . ',:','.c. ,,~:.4,,.' *,~.i'}t , '.[ erty lyln~ adla~ez, t thereto encroach.on the bremlses In' ~." -. '" .' "~ "; -7 .- ". '~i', *~"°',. :~' "°'~. -'-I~i [ que.~tton and that fi, ere are no roadways, trnn.q~hL~qlon lines or other visible easements oh said property, ex'cept,. , . i: ;~i'~"F~t~t!~ i],lq~k. ~.,.'~ ~11.] ..... '., ' . . . ,.' . ,," ' ' ... ..:., - ; ~' '.. :: ' ...,',,~ ',l,~n.~ '~ -~?'.;.*? I~ISCALE.; :,~,. · : Ile~cistcred Land Surve.¥or No. · " .;';-".'..;.~.;,.."~ "' :".' ~;:~,.';.~ [ 1" ;--.~-gpt :' ,' .Box 450, Eagle River, Alaska' ... .' ' "' ,' '~'i':, ' . ' ':,,'.'-', 'e / '- '.'. Phone liD4-2543 .... ~.,__~- '. I ._._.~ ............. . · ,'.'.'.-;-~l-C.:." .~'~ .. . · /,..: . SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1043154001 S & S Engineering TR, B 1, Broadwater His TR, BI, Broadwater Hts Drinking Water Sample Remnr~: All Dates/Times are Alaska Standard Time PrintedDate/Time 06/11/2004 9:25 Collected Date/Time 06/07/2004 14:44 Received Date/Time 06/07/2004 15:47 Technlcnl Director "Stephew(5. Ede Allowable Prep Analysis Parameter Results PQL Units Melhod Container ID Limits Date Date Inlt Waters Department ' Nitrnte-N 4.89 0.100 mgrL EPA 300.0 B (<=10} 06/07/04 JJB Microbiology Laboratory Total Coliform 0 col/100mL SM18 9222B A (<=1) 06/07/04 DKC Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343~4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. Ot'7 o :- · ~'b ~ - 7¢ 1. GENERAL INFORMATION Complete legal description HAA# O rD rD /"'/ ~, ~ Expiration Date: Location (site address or directions) \~:~"~\~- -~,~'~-~,~,-,~,~-- ~.'~- Current Properly owner(s)~q¢~.2 ~ ~ ¢c~,~>~ t~ ~Day phone Mailing address ~%~ %~c~.~ ~'~, Lending agency Day phone Mailing address Real Estate Agent \~L,,/~'-,\~,~, Or ~¢~,,~ f-~.,~E Dayphone ~c~-~oo Mailing Address ~ ~o~,t~' ' ~"~' ~ , Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: )//~ ~ NUMBER OF BEDROOMS: ~ ~ ~/¢~ 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 [] Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health 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 old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The iVlunicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72 025 ~Rev 01 901' 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval application show that the on-site water supply and /or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verity that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address $ 8, S ENGINEERING 170-'~4 F,~91~- Rive~' Loo,oJ~ond Eagle Rivet', Alaska 99577 DHHS SIGNATURE 1,--'"' Approved for LC Disapproved. Conditional approval for Phone / Date . ~ ¢' ~ 'k ~,, bedrooms. bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: Original Certificate Date: ~ ~ o.~..~'- Oo Reissue Date: Municipality of Anchorage R E C E I V E Department of Health and Human Services Division of Environmental Services SEP 2 2 Z000 On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak.us MUNICIPALITY OF ANCHORAGE (907) 343-4744 ENVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ""~ '~-[, "~¢~A-i>¢,v~ce_ lJrf'5 A. WELL DATA Well type Date completed Total depth I~,DI ft If A, B, or C provide PWSID # __ Sanitary seal Cased to ~) ~,'~ FROM WELL LOG Date of test q -~'~ --/~, Static water level '~ '7 ' ff Well production ~. ,5' g.p.m WATER SAMPLE RESULTS: Coliform ~) colonies/100 mi Nitrate ~5-4, mg/I Date of sample: ~/~ ~ co Collected by: Well Log Wires pro'perly protected Casing height (above ground) J~ in. AT INSPECTION 5-~~ ft B. SEPTIC/HOLDING TANK DATA Tank'TyP~/Material ...<~ ?/'-7~ ~ ('"i Daieihstalled ~-/,~.oo Tanksize J.~oo gal Cleanouts ~ Foundation cleanout ~ Depression over tank __ Date of pumping 'z'~/4- -- /%/E-~ Pumper C,. ABSORPTION FIELD DATA Date installed ~-/~ ~ ~ Soil rating (g.p.d./ft2 or ft2/bdrm) ~,¢~- Length ~¢~ ft Width ,2,~ ft Gravel below pipe ~x fit Total depth /~,~-Ift Effective absorption area/.~Y'~/ft2 Monitoring tube 7 Date of adequacy test ~J/4 /~,¢~ Results (Pass/Fail) ~ Fluid depth in absorption field before test '--'-' in Water added Elapsed Time: ---"---' rain Final fluid depth ----- in Any rejuvenation treatment (past 12 mo.) (YIN & type) ~,)o Other bacteria ~) colonies/100 mi S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River~ Alaska 99577 Number of Compartments ;~ AJ High water alarm System type . Depression over field For ¢ bedrooms .1 . gal. New depth in. Absorption rate >= ~ ' g.p.d. If yes, give date 72-026 (Rev. 01/00)* Do LIFT STATION Date installed "Pump on" level at Datum Cycles te~ted ' in E. SEPARATION DISTANCES Manhole/Access High water alarm level at in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot J o~ t~ Absorption field on lot ~ cz:;) U¢ Public sewer main ~J/k Sewer/sepiic service line .2~ J ~ On adjacent lots On adjacent lots \ Public sewer manhole/cleanout Holding tank SEPARATI(~'~ DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ ~1 Property line ~ o ~4-- Absorption field Water main t'~/J~ Water service line ~,~4- Surface water Drainage C/A- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line [O \¥ Building foundation 't k~ Water main Water Service line Curtain drain Surface water \ c,c, ~'- Driveway, parking/vehicle storage Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field 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 t'~08~-.'~;'-- C". Date c~/- ~,/~ o HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* MUNiCiPALiTY OF ANCHORAGE M E M O R A N D U H WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. 000 ~L~ During a recent Health Authority Approval on-site '~= and test of the potable water supply well on Lot productivity was determined to be ~.~ gallons per minute. .... ~ ~=d by this Deuartment The minimum well proeuctzv~n¥ _=qu (~MC .... ~) for a - per minu%e. ALthough ~ne subject well curreneLy ~.{~as minimum ..... ~ m ~t aL! parties concerned are advised that the production caDaci%v oE the weAL may fAuctuate. Res%riction Lawns and gardens maF be recuzrea. This aav~sorv mu..~ be attacnee eo ail copLes of the sublect Heai%h AuthoritF ApprcvaA. ROBEH[ C. COWAH, P.E. I1OBERrA. SI IAFER, EE. WELL RECOVERY TEST DATA WELL LOCATION (legal): TEST DATE: WELL DEPTH: /~O CASING DEPTIt: CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-121 F TESTED ElY: WELL DRILLER: '"~ DATE DRILLED: ?-/'7 - ?,.~ TEST PROCEDURE: MISC DATA: 1) Draw waler down Fo pemp. Caslag Ilelght: 2) ShuF pump oFF 15-60 min. Sanitary Seal? -record Ume Wires le Conduit? ~record meier readlH~ Grading O.t(.? 3) Tara pumpou. Drawdown. PumpDeplh: 4) She[ pump off, Samples -record Ume Dale: 5) Calcnlale gal,lmla, recovery. /1:~ ~ ~o,~ ~ ~ //,'~7 TEsT DATA: START TIME: STATIC WA]ER LEVEL: TRIAL II PU P II TIME II II AL, U,N. OFF OFF /~ ,' 05~ ~o . o OFF OFF OFF ~,'oo OFF ~2~,~ ~/,~- ' OFF 4 ON OFF ~q, gO B~.O ~ / OFF 0 F F 3 RESULTS: WELL CURRENTLY PRODUCES: / FLOW RATE NOT GUARANTEED--SUEISEQUENT VARIATIONS CAN OCCUR. 17034 HOR111 EAGLE tlIVEB I COP - 81JI[ E 204 · EAGI.E [lIVER. Al ASKA 99577 09-19-00 09:00 FROM-CTE ENVIRON~NTAL ,~ CT&E Environmerttal Services Inc. 5615901 T-937 P.O~/03 F-828 1005509001 S & S Engineering TR B1 Broadwater Hts TR B1 Broadwater ~Its Drinking Water CT&E Ref.# Client POt/ Client Name Printed Dace/Time 09/18/2000 15:33 Pro]est Name/# Colleetefl I)ate/Tlme 09/12/2000 lh00 Ctient Sample ID Received Date/Time 09/13/2000 12:45 Matrix Technical ~reetor~ Stephen C. E_de. ,, PWsIDOrdered By 0 Released~ ~ Sample Remarks: A~lowal~l¢ Pr~ Analysis parameter Results PQL Un/ts Method Limits Date Date Init W~ers Depar~ent Nitrate-N 4.56 0.500 mg/L BPA 3000 10 max 09/13/00 SCL Microbiology Laboragory Total Coliform col/100mL SM18 9222B 09/13/00 MU..C,PA.TY OF ^.CHOR^GE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION Application Date ... ~'~ Legal Description (include tot. block, subdivision, section, township, range) Location (address or directions) Applicant Name Applicant Address ~.~ ~ ~\~J~ (b) V-c~t'~:~F~Telephone: Home (~ - ~ t ~ Business [c~l~'"~O (c) Applicant is (check one): Lending Institution []; OwnerJ. bui+der~f--; Buyer []; Other [] (explain); (d) Lending Institution d..<~/,4~,c~.3~,..~'T~ ~ Telephone Address (e) Real Estate Company and Agent Address ~~ ~~ ~ ~ ~ ~ Telephone ~- (f) ~ the HAA to the following address: S & S ENGINEERING SRB 196X ~GLE RIVER, AK 99577 TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well'l~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, SEWAGE DISPOSAL Onsite [~ 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. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Healtt~* Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ _g_ _~ I~NGINEERING Telephone ~' ~;;;~Z,.-?_.. ~- ~ ~- Address SRB ~96X Date EAGLE RIVER, AK 99577 Approved'f~r ' ~ ¢ bedrooms by / , Approved ~ ' "~' Disapproved Terms of Conditional Appr, oyal Conditional Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 {11/84) ~,~c~O.'-' '-~' MUNICIPALITY OF ANCHORAGE (MOAi .,C\?~,L','~{~g~,~.~c[\O~HEALTH AUTHORITY APPROVAL (HAA) ~ ~?~ ~ _ CHECKLIST - FEBRUARY 1984 ~O~~ 264-4720 Legal Doscr~~ WELL DATA ~c~ ~ Well Classification Well Log Present~;3~N) Total Depth ~, ~ t Static Water Level Casing Height Above Ground Electrical Wiring in Conduit~J'N) Separation Distances from Well: · To :Septic/bletdfi3g Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line pi Cleanout/Manhole / '~ *'~. If A, B, C, D.E.C. APproved (Y/N) Date Completed ~ - ~,"1 - "I ~:~ Yield Cased to '~c~ ~ Depth of Grouting '----- ~-'~ / ~ ~ Pump Set At ~) ~ ~l~,~' Sanitary Seal on Casing~N) Depression Around Wellhead ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by ~-~ Water Sample T.,~s.t Results Comments ~'~~ ~-~ 1 B. SEPTIC/~ TANK DATA Date Installed Standpipes~'N) Air-tight Caps Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N) j ~ ,-//~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/~=leldm~ Tank: Size I'Z~5'7~ No. of Compartments ~ Foundation Cleanout (Y~[~ Date Last Pumped I'Z-~?--''~ ~ , for "" Temporary Hotdin~ lank Permit (Y/~) ~ I~-~''~ To Building Foundation ~'~ /'~: / To Disposal Field ~' To Water-Supply Well To Property Line To Water Main/Service Line Course Comments To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~'~/=/t~,'¢~ Type of System Design Date Installed ~ ~.~1 ~'~ Width of Field '~L~ Gravel Bed Thickness Square Feet of Absorption Area ~[o~:.~ t?~ Standpipes Presentd~N) Fto~6et~ $~4,~F~If ~ Date of Last Adequacy Test Depression over Field ~ I$- :~ -,l'& _ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ! To Building Foundation Lot To Water Main/Service Line \ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots :~,1-1L- To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S& S ENGINEERING. S,gned SI( I~ 196X Date / ,,~O/0C' ~ Compan ................. ~,---'oo ..~ ~GLI:: KIVI:K, ~Y~I~ MOA No. Receipt No. Z~~/~ Date of Payment /~/~//~ Amount: $ ~--~ Page 2 of 2 72-026 (11/84) MUNICIPALITY OF AI'~CHOi~AGE &4UNICIPALITY OF ANCHORAGE ~,~;¢ DEPAfi'lrMENT OF HEAi.'('[1 ~.:~ E:B'V ,qf')Nf,..'iEF,~TAi PHt)TECTION DEPT. OF HEALTH & .,~...~,~,~.,.... %,,~ 8'~5~. L SLi ~x¢ · ik m:h~,,'a,?. AJ,~';k a t9 ,'~-n,~.,., t ENVIRONMENTAL PF, OTECTION "aEQUEST FOR APPROVAL OF iNDIVIDUAL WAT E~::,, AND SEWE~IE,6,[tt~[ D EH~'U;:C '[i~)k:U: Con'~ph;te ~di pairs on paq0 1, Incomt'~lete req~osts witI not [x~p~oco~;sed. Pie;~se allow ,n (10) days [or processing. ~ Bryon/Virginia Kohfield ~ 694-9555 S~a= Rouee 2 ~ox 7338 99577 CL!'Fi;;~ I PHONE Byron/v ir.g_~n.a._K0..h~_i _e._Zd L~67_~.~-~9 5_ .5_~ ............. Same PHON E State of Alaska, Veteran's Administration ~[ 274-7555 907 West Northern Lights Boulevard 99503 .i. i U:.;'. i.'i O I~/AG EN¥ PHONE Virginia Kohfield % Area Realtors . ~. C-:..% L Tract B-1 Broadwater Heights Subdivision ii! i:i' Meet Virgina at Area office, she will take you up. ~XX <~ ,GLL FAMILY ~;~ One ~'X ~:'Om .... , Otn~,r ,_~ MU[.,TI!:~LE FAMILY [ ]} 'Fhn:e [- ~ Six 1,'?' '[ ' ['~ XX INDIVIDUAL~ * ATTACH WELL LOG. A w(fil loft is ~equire(' for ali wells drilled ' ~ COMMLIN!TY ¢il,c~:ju]: I()~5. Forwcllschiiied l:xhx'1:oti~a[d:it~ give we!! [] PUBLIC UTILITY depd~ (alack h~n if availa:¢le.) Well lo~ : ................................................. attached. ':::~L?A(.,~ ?dSPOSAL SYSTEM ' ~ '¢ individuc, l,.on .si[e, a ye installath)n d,xL¢ zg? 8 X~ iNDIVII)LIAL/ON-SITE ..... " - . If syi;t(Hll i~ ovor i'WO (2) yea s old ;:~i~ aduqmlic':y test h; leqt h J,. L. IC .J'llLll 1 INSPECTION FEE MUST ACCOMPANY EACH REQUEST ~3E,-ORE PROCESSING CAN BE INITIATED. THIS SIDE t:OI:'t OFFICIAL d~ c, ~'[:'' ONLY D A ~i E [1 li!C E I V E D INolECItON APPOINTMItN!S ~ [ ,.,~: DAlE DA ~ ~.: ', L. ~.'R NSPECTOR IN~;PEC'i-()R ~':, ~ ~,,. : OF RESIDENCE SIN 3t.E F/\MiLY . ?,,riL,I L'T I P L E FAMILY 2~ :*",' A i' E R S l,J P P L Y : iNDI\/IDUAL : CO?,,,iMU N ITY NUMBER OF BEDROOMS ~'~.i ONE iTS'J THREE r ~ !_; FIVE [~.q OTHER [.~J TWO 1-2] FO U R EJ]J $ t X PERMi'F NUMBER :' ~:'LiC UTILITY Cc~ll ~oction \/etifie(:l ....................... LOG RECEIVED :;. :: ;%AGE DISPOSAL SYSTEM Pf;RMIT NUMBER ~,mr ;u<:dr:,l~ Verified ..................... '~ : n.:h:'i'mqkor E;]HoMingTank :: .:: ~ ~ ....... tf Tank is homemade '~: ~ ~ ; 'lANK MANUFACTUREFI ,::)' ABSOF~P-FION,~,.,.~.~ :~ *' MATERIAL WEt,L TO: Lot Line CCdX,IDIT!OIq,~,L APPROVAL (Iott,u nlu!,l i( c,)mlmIW ~:r!~ tific~m:) DISAPPROVED REALTORS® '4. REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES Type of Inspection: CMRO VA ~: FHA Property Owner: ~v/Po~ , [~/~,~/~a~ ~ ~ ~'/~ Mailing Address: ~/~ ~ ~ ~~ Day. Phone Name of Buyer: _~y~- ,~~J~ ~~/~' Mailing Address: ~~ ~t ~a~ Name of Lending Institution: ~~ ~'~- CONV Day Phone ~/- Mailing Address: Name of Realtor or Agent: ~/~~z~ _;~~/~/~/ Mailing Address: ~/~ .~',ee'~., ~t~... ~-~? Phone Phone Legal Description: Location: Type of Facility to be inspected: / Water Supply Type of Supply: Public Utility ~ I _ If Individual, number of dwellings presently served If Individual, depth of well Individual / Sewage Disposal System Type of System: Public Utility ~ If Individual, date of installation: Individual No. Bdrms. g/ (on-site) [B REALTOR AREA, INC. REALTORS Anchorage "C" St. Office 3300 C Street (,qQ71 77R-2525 [] East Anchorage [] Eagle River Eastgate Office Parkgate Office 5437 E. Northern Lights P.O. Box 249 (907) 278-2525 (9071 69&9555