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HomeMy WebLinkAboutDENALI VIEW BLK 2 LT 6Denali View Lot 6 Block 2 #015-461-13 GREA I ANCHORAGE AREA BOR( ",H Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME , MAILINGADDRESS S K- PHONE t-4 > LOCATION GAL DESCRIPTION SEPTIC TANK: DISTANCE ��v / NUMBER OF FROM WELL! MANUFACTURER 'L- MATERIAL COMPARTMENTS INSIDE LENGTH A# INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY ALLONS. TILE DRAIN FIELD: �`,,t�i TOTAL LENGTH DISTANCE FROM WELL �Q� FOUNDATION/_NEAREST LOT LINE_ OF LINES r NUMBER OF LINES f DISTANCE BFTW EN LINES TRENCH WIDTH IN. TOTAL EFFECTIVE ABSORPTION AREA/� SQ. T. LENGTH OF EACH LINE / DEPTH OF FILTER !Ae DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE �-2 IN. ABOVE TILE y_G IN. WELL: A 'w"p , *.Gv TYPE— A'AAAIAt __� t O UCTION BUILDING NEAREST NEAREST SEPTIC FOUNDATION—,LOT LINE , SEWER LINE , TANK_ CESSPOOL APPROVED DISTANCES: OTHER SOURCES DISAPPROVED —REMARKS INSTALLED BY:"Z?17le- ! • ��' SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: / i �LJ�� i 3 Form EQ -032 DEPTH DISTANCE FROM: SEEPAGE SYSTEM_ PI�DIAGRAM OF SYSTEM ' �j10r'0r 5 f E NAME OF APPLICANT �L INSTALLATION LOCATION LEGAL DESCRIPTION — GREA .:z ANCHORAGE AREA BORGH ct.1w Is I: z 0 PERMIT NO. DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 27r44-4561 /if- WL SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT INSTALLATION OF: SEPTIC TANK T TYPE AND SIZE OF FACILITY TO BE SERVED MAILING ADDRESS Wy * SEEPAGE PIT DRAIN V 34/x- %p PHONE ER FINANCED THROUGH -T BE INSTALLED BY " SOIL TEST RESULTS a�G M 1 N � Baa l,�m NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE� — TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEEPAGE A SEPTIC TANK . SEEPAGE PIT , DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK 6 SEEPAGE PIT DRAIN FIELD _�I'Aloov ALSO CONSIDER AREA WELLS, WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD SEPTIC TANK, , SEEPAGE PIT , DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING/INSTALLATION. V G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORNCE WITH SAID CODE. DATE —2 � APPLICANT'S SIGNATURE FORM NO. EQ -01 6 Greater Anchorage 3330 "C" Street Anchorage, Alaska Gentlemen: Anchorage, Alaska September 2, 1975 Area Borough 99503 The enclosed test boring log accurately represents soils beneath the planned sewage effluent disposal area of Lot 6, Block 2 of the Denali View Subdivision. I understand that this information, together with the in-place percolation test, will be used to determine leach field (or trench) require- ments for an on-site sewage disposal system. TJT:If Enclosures Plot Plan Boring Log Gradation Curve Very truly yours, DAMES & MOORE illl,96 Thomas J. Tepper Soils Engineer .►`�F. ®F .ACS Ip iCD ce: !40 71H e 0 eo�ee oom eemc u3 oeHse ayes • eoe00e•o • ..�, 6 /(J vims__ Thomas Tepper s 11Q ®® �•m NO. 3785-E fi �� �PROFESS0�+® 946.1 R FILE SUBJECT jt ��r�,._ ,;1-i =' --- SHEET OF! i 4�i=� G -►-b- pY tinL(-I l _.._ _ Stow^ so-. ,i G, 4 L*,,4. w -Jet, 6yYa,.fE 1 CSM' M1'� f141 (yh1 — ML-) . K � ^ � r - 20 r r� MAMEM s Q400MfW 6 o 'a t; � W CL �¢ CQ N W a t♦,.) z r=LLJ 4x 0 Municipality of Anchorage ' Development Services Department Building Safety Division „ , r, On -Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-461-13 HAA# ()W� 3 1. GENERAL INFORMATION Expiration Date: 12J 42�/ Complete legal description DENALI VIEW SUBDIVISION: LOT 6. BLOCK 2 Location (site address or directions) 8901 SULTANA DRIVE * ANCHORAGE. AK * 99516 Current Property owner(s) JAN SCHULTZ Day phone 770-1963 Mailing address __8901 SULTANA DRIVE * ANCHORAGE. AK * 99516 Lending agency Mailing address Day phone Real Estate Agent CLAIR RAMSEY w/ DYNAMIC PROPERTIES Day phone Mailing address 3111 "C" STREET * ANCHORAGE, AK * 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 261-7552 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site 0 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 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 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. Note: Alaska Water and Wastewater Consultants, Inc. shag be paid $ at, or prior to closing for the engineering services provided. 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 riles 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, AKWWC, Inc. 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. AKW WC, Inc. 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 otherperson or party is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. with the fllowing Phone 337-6179 Date 1r 117 D HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other By:Original Certificate Date: 1112! L°? (Rev. 1210 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: DENALI VIEW SUBDIVISION; LOT 6, BLOCK 2 Parcel ID: 015-461-13 A. WELL DATA. Well type MATE If A, B, or C provide PWSID# N/A Date completed 12/11/1975 Sanitary sea[ (Y/N) YES Total depth 118 ft. Cased to 40+ ft. r FROM WELL LOG Date of test 12/1/1975 Static water level 30 ft. Well production 4-6 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 1.82 mg./L. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 24 in. AT INSPECTION 10/23/2003 29 ft. 2.64 g.p.m. Other bacteria 0 colonies/100 ml. Arsenic: N/A mg./L. Date of sample: 10/23/200 Collected by: AKWWC, INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 9/5/1975 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 10/23/2003 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA BELOW EXISTING CRAOE Date installed 9/5/1975 Soil rating Ep>r ft=/bdrm) 220 System type DEEP TRENCH Length I $8 ft. Width 3 ft. Gravel below pipe 12 ft. Total depth *15.75 ft. Eff. absorption area 912 ft' Monitoring tube YES Depression over field NO Date of adequacy test 10/23/2003 Results (Pass/Fail) PASS For 4 bedr00%140m Fluid depth in absorption field before test 116 in. Water added *668 gal. New deptfi 1"49•5in. ii I Elapsed Time: 1035 min. Final fluid depth 134.5 in. Absorption rate >= 600+d. 9-P• Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — **LAST' 516 GALLON CAUSED A RISE OF ONLY 14.5 INCHES. r LAQoie LE:%JCL 1•q-1% etLeo (r1IeR.-r a Grew.doo-r Az Gac.lr 'Ot of TK -v". D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lofs 100'+ Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line *5' foundation 10'+ Water main N/A Building Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ *LOT LINE WAIVER REQUESTED F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that t 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 Pri ted ame JEFFREY A. GARNESS Date ,7 a; Driveway, parking/vehicle storage 10'+ i I#mO• •lAv15MA frAl_ C* mess,* —7953 mf ,.• �c G A � 4O�c� Pro f e s sioo�4o HAA Fee $ Waiver Fee $ I I<; Date of Payment 1 Date of Payment' l Receipt Number Receipt Number ` f TT— (Rev. 12/01) ALASKA WATER & WASTEWATER CONSULTANTS, INC. November 17, 2003 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref Lot Line Waiver for Lot 6, Block 2; Denali View Subdivision. To whom it may concern: We request that your department issue a 5 foot lot line waiver from the west property line to the existing drainfield. I am unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assiltAt ce. P.E., M.S. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507 Ph: (907) 337-6179 • Fax: (907) 338-3246 * Website: akwwc.com Municipality of Anchorage Mttrk- Begich, M(iyor Building SZfct.y Division P.O. I3ae 196650 • 4700 Bragaw Street Anchorage, Alaska 99519.6650 • (907) 343.8301 • Par (907) 343-8200 h ltp://tt�tle.mun i.nr�; November 18, 2003 Jeff Garness, PE Alaska Water & Wastewater Consultants, Inc. 3701 E. Tudor Road, Suite 101 Anchorage, Alaska 99507 Subject: Waiver Request for Denali View Block 2 Lot 6 Waiver Request # WR030106 PID #015-461-13 Dear Mr. Garness: Your request for waiver of the required 10 feet horizontal separation from a property line to a wastewater absorption field has been approved. The approved separation distance is 5 feet from the West Property Line to the existing Drainfield. This waiver approval applies to the existing on-site wastewater disposal system to property line separation only. Any future upgrade to the on-site wastewater disposal system will required all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343- 7904. Sincerely, Jeffrey Poet Engineering Technician On -Site Water & Wastewater Program Municipality of Anchorage Development Services Department • ""� Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 w•ww. c i. ancho ragc.ak. us (907)343-7904 Waiver Review Worksheet WR#: 030106 PID#:015-461.13 HAM 030583 Permit#: Date Received: 11/17/03 Legal Description: Denali View Block 2 Lot 6 Engineer: Alaska Water & Wastewater 3701 E. Tudor Road Suite 101 Applicant: Jan Schultz Waiver Requested: 5 foot Lot Line waiver from the West Property Line to the existing Drainfieid Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ..0.00aaa6a08880..aw0a000000..090...a0a0aaaaaa0w■ 0 M M a M a a a 00 M 9 ................ a. Waiver is Granted: Waiver is not Granted: List Conditions or Reasons for above: Date: By. a Reviewer ........................................ ..................................... Rec#: 44649 Amount: $150.00 Date Paid: 1111712003 r�•Icg z; o m= NIA v0•+�` '•.Tq,Ao U21 •D-1 -I�n m r•I,�rIK •~ Q� n• : 00 OP <S� NA r0 N 'pN� qK 0-^� m�>�l � Ao ��K 0a0 2��r'1 NKA= 0o C' �' '•^Q r• i g �r-F�i� Qti p y o" c•„ cO v' > �>Ny T 44440 rOf. .fid �0 fn O��n0�00 •G Z�-Day bl rO-A 1 1 O 1'1N r'I �+ z� m oK D � A 3AIc\JQ JkiNH co W Ln CrIt Ln m w 0 0 W 00 y rn N Cn Ay,n = U< - Z. > Z CO nnK N NtiC Ntin � OCti A � A Ads Z =CZpp Am p zmm ^N 00, K ? Oy c>o m IZ'1OZ K ..A O 1.1 j C y x r C Z y rr=i O R o c H p A O 3EA Ornr N x z ^P o _ n Wxo> z DD _1 D K n D A w -1 O z .Ziy N SSD OJ CD C z ' v,,, = n y 0tzn r'1 = a o n n0O O S a > m m r mm p y y- Pm y m r,t1z m n mF Don -1 C Z O n0 rrn r�'IyZ l7 CJy+r p 00 -a rn > .,z yzb< r= O A0 3 C3 _ X n F Z 8� H 1n S N K A IC Z n O n _ z ^m OO'n A M r�•Icg z; o m= NIA v0•+�` '•.Tq,Ao U21 •D-1 -I�n m r•I,�rIK •~ Q� n• : 00 OP <S� NA r0 N 'pN� qK 0-^� m�>�l � Ao ��K 0a0 2��r'1 NKA= 0o C' �' '•^Q r• i g �r-F�i� Qti p y o" c•„ cO v' > �>Ny T 44440 rOf. .fid �0 fn O��n0�00 •G Z�-Day bl rO-A 1 1 O 1'1N r'I �+ z� m oK D � A 3AIc\JQ JkiNH co W Ln CrIt Ln m w 0 0 W 00 O MUNICIPALITY 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. # I - L �1' ) —' HAA # 1. GENERAL INFORMATION Complete// le//gal description 4 ° f 6- Location (site address or directions) 5Z' If o' , ,- Z -21 -- Property owner/nay f Dn z'/s r �Or Ne/ oh Day phone Mailing address 1172`1v DY. • 121 r' -IL-2,;- 1-2 Pl- 1-1/k- Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. l 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well r/ 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 NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Re, 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 regulations in effect on the date of this inspection. Name of Firm / c 9 /� Y /� 'r. �� > Phone Address Engineer's signature 6. DHHS SIGNATURE I Approved for 4 bedrooms. Disapproved. Conditional approval for Additional Comments M Date _&Lv 2 `T. bedrooms, with the following stipulations: Date /--/ - 3 - C; o 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 orderto 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. 72-0P (Rev. 1911 R CX MOA 121 •�v�—r v Q Li NOV 0 2 2000 Municipality of Anchorage — DEPARTMENT OF HEALTH & HUMAN S�AH�ABVhWEjTyOFANCHORAGE Environmental Services DivisiAVIRONMENTAL SERVICES DIVISIO 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: I&e-l- 4, B E. �, /J e'/ 1 / .Su d Parcel l.D.: A. WELL DATA Well typee/� If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed Total depth %� P Cased to 'yam V- Crr, Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) Y Date of test Static water level Well production FROM WELL LOG 5e ye?6 WATER SAMPLE RESULTS: AT INSPECTION /� 8/d0 �7--�. y 11 g.p.m. �>Z — g -p.m - Coliform 6 Nitrate /• 'Y _- _ Other bacteria Date of sample: //��o'r 9�Dd Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ? �76 Tank size S D Number of Compartments Cleanouts (Y/N)--�—/ Foundation cleanout (Y/N) Al Depression (Y/N) A/ High water alarm (Y/N) 4114 Date of Pumping r6%-2/Pe Pumper Af ilovne Seru, ��s C. ABSORPTION FIELD DATA Date installed 2/5-A - Soil rating (g.p.d./f[2orft2/bdrm) -UD Systemtype f�ch�h Length �Width 3 Gravel thickness below pipe /a Total depth /6 .z Effective absorption area Monitoring Tube present (YIN)-Z—Depression over field (Y/N) /V /,Rt- 1v 1Flee Date of adequacy test dnd _ 1060/au Results (Pass/Fail) D� s s For L/ bedrooms Fluid depth in absorption field before test (in.); mmediately atter_ gal. water added (in.): /a. 1,z_ e / et- 300 Fluid depth'2" e' /2 F'6_ (ins) Minutes later:,P1 �qO Absorption rate =awe • 690 f c.p.d. Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* If yes, give date /f/A D. LIFT STATION Date installed Manhole/Access(Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO at* Septic/holding tank on lot / 3D 7 On adjacent lots Absorption field on lot / �/D f On adjacent lots_... -- Public sewer main Nei/ Public sewer manhole/cleanout Sewer /septic service line c13 Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 9% 11 Property line /D / Absorotion field _ Water main/service line b'f Surface water/drainage /D° f Wells on adjacent lots _ /� ° �.../ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation / 9 Water main/service line Surface water Driveway, parking/vehicle storage area --Ed— Curtain Ea Curtain drain 1!/e1ne Wells on adjacent lots F. ENGINEER'S CERTIFICATION l certify that l have determined thru field inspections and review of Municipal in conformance with MOA HAA. guidelines in effect on this date. Signature Engineer's Name f.' ,7�e� Date HAA Fee Date of Payment141, �l Receipt Number .. 10 Y 614 D 3 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number JD of the aGbve'systekbe are ..� .E. 1 a ' 'rr 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 Parcell.D.# �i�J"���13 HAA# 1A914 a(o(% 1. GENERAL (NFQRMATION' r Comp(et 4e6ai description'__ Location (site (site address or directions) Property owner "llyz E Day phone A1,24L 9.480 Mailing .address.9'oi Lending agency` Day phone Mailing address Agent _ Address r. Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: e- 3. 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 systema 4. 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 BYENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal.system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm !'m�.��.4.r !''`Jy Phone Address Engineer' 6. DHHS SIGNATURE Approved for Disapproved. By •= OF •A.<4 it, 00 , 4H o ' DOU LAST.1(6LEY "" CE 8176 ., r �! bedrooms. 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 orderto 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-M (Rev. 1/91) Beck MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Parcel I.D. A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC wat1epstem number Log present (Y/N) y Date completed do -c • Driller C ! L. 4 / Total depth F I�4 Cased to _AQ A. « Casing height Sanitary seal (Y/N) Date of test Static water level Well flow Pump levels Y Wires properly protected (Y/N) 10 FROM WELL LOG AT INSPECTION Owe • /� > `� 75" I1 J i /TT_ m r _ r7l G:> 'i g.p.m. S g.p.m. tD SEPARATION DISTANCES FROM WELL TO: Septictholding tank on lot /.moo ,`"',4�4 ; On adjacent lots /.00 `Fr` Absorption field on lot If 'V '` F'� ; On adjacent lots kv Public sewer main '-/-g Public sewer manhole/cleanout Sewer service line 90 f" Petroleum tank ''��� WATER SAMPLE RESULTS: Coliform Nitrate 9 Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 9 Ar- Tank size Z.5"0 Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) AJ _Depression //(Y/N) '-) High water alarm (Y/N) T X1.4 Alarm tested (Y/N) 'yam Date of pumping, " Pumper,' -r SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots /ow Foundation 97"4f. To property line /o �F/-/• Absorption field /Z Water main/service line Surface water/drainage A/-� C: rn �9r to O M M <7 m �- N C N G: 0 ff Z 72-026 i3W>• Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE -MOM LIFT STATION TO: lot On adjacent lots D. ABSORPTION FIELD DATA Manufacturer —Manhole/Access (Y/N) "Pump off" _ �Cvy ed R Surface water Date installed -S�Pr `�7-6"— Soil rating (GPD/Ft2) 2zo Length --P Width ` Gravel thickness Total absorption area q "g ,C'' 4 System type Total depth Cleanout present (Y/N) i Depression over field (Y/N) AJ Date of adequacy test�0� /, / 9g Results (pass/fail) ��ss for =5 Bedrooms Water level in absorption field before test �/ owf rm) G� After test $(t 7 £e� Peroxide treatment (past 12 months) (Y/N) If yes, give date Ad �� 6Z -I `I` SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot _eo 1,4�4" To building foundation On adjacent lots ioa "• / Property line ass<� To existing or abandoned system on lot A/)1V On adjacent lots �o «, Cutbank ^�/,v Water main/service line til Surface water oo 1`. 74 Curtain drain AJ14 E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area 1 certify that 1 have checked, verified, or conformed to al! MOA and HAA guidelines in, " jof this inspection. A: 49TH ., Signature" ' ' " " ",. "� r. • • :;iii.. •', ,�. K,.�( $.: Engineer's Name ���:' 'gyp t;' •' r a' ?�•. CE G#76 •' Date ��• "'� • °�`� F . •Z�:�. t -- HAA Fee $ 3C -n I O -D Date of Payment Receipt Number s L-7 7 st 72-026 (3193)• Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVALL��Jn_ l 1� OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date —ST 1. GENERAL INFORMATION (MUST BIS COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) "Ir 6 &e def 2 1_i Vitµl iz.f 2. Location (address or directions) r9o/ sao-wW,4. (b) Property Owner, 8/� �>/cE Telephone: Home 34k-330 Business Mailing Address idz (c) 'Lending Institution Mailing Address (d) Real Estate Company and Agent Aririracc Telephone tc? Telephone (e) Mail the HAA to the following address: or: Check here ❑, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single -Family. Number of Bedrooms _ 3 3. WATER SUPPLY Individual Well Community ❑ Public['] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite It 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 tRpv 8/86) Front ZA a=- UAWAci ✓iE.t) - 5. 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 Health 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 ^EGf Telephone S� SO e/a Address W i3._J Adr.. far TE a G✓. C i 9s�3 Date -L/,8r 6. DHHS APPROVAL Approved for J ? bedrooms by Approved Disapproved Conditional _ Terms of Conditional Approval CAUTION Date 7' _26_98 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. Page 2 of 2 72-025 (Rev 8/86) Back MUNICIPALITY OF ANCHORAGE (MOP%l MUNICIPALITY (REMC(HORITY APPROVAL (HAA) ENVIRONMENTAL SERVlCOESHJIIC(WLgyT _ FEBRUARY 1984 APR 2 1264-4720 1988 DoT G iX�' Z �Ei✓.9t/Ecs Legal Description: A. WELL DATA RECEIVED _r�tAt R10 iEtL4 Well Classification /''R/✓ATE If A, B, C, D.E.C. Approved (Y/N) WIA Well Log Present�N) Date Completed �Z —/-7S Yield ® ybw 6ph i Total Depth /Af Cased to 50"t Depth of Grouting Static Water Level & 3O.Z' Pump Set At Casing Height Above Ground Sanitary Seal on Casing 191N) Electrical Wiring in Conduit ©N) Depression Around Wellhead (Y&I Separation Distances from Well: i To Septic/Holding Tank on Lot On Adjoining Lots /Oa *- To Nearest Edge of Absorption Field on //Lot ���' �"' ; On Adjoining Lots �� + To Nearest Public Sewer Line Af4 To Nearest Public Sewer Cleanout/Manhole A) To Nearest Sewer Service Line on of Water Sample Collected by AEcS W/ �I ; Date ' -0 0 Water Sample Test Results BAe 7— A117_.4 07 -1-S Z - Comments Is AlELL )c;, ► 7e-rr /5= Afd /.fCemao uli4TR baa✓E ito B. SEPTIC/HOLDING TANK DATA Date Installed Size �t� No. of Compartments Standpipes ON) Air -tight Caps�N) Foundation Cleanout (Yo Depression over Tank (Yo Date Last Pumped ?',Z-41'7 Rona ,L�anTue Pumping/Maintenance Contract on File (Y/N) A11A ; for !�/x Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Al154 Separation Distances from Septic/Holding Tank: •9� To Water -Supply Well /a4 To Building Foundation r r To Property Line /0 t To Disposal Field /Z To Water Main/Service Line /d 4- i Course A&V Comments Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major Drainage L.(, ,aL )&ZAI-/ ✓W0 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Z " Type of System Design 7�c� i Date Installed 9�s�7s Length of Field 38 Width of Field 3 I Depth of Field r Square Feet of Absorption Area Depression over Field (Y/v('�j - Results of Last Adequacy Test Gravel Bed Thickness 917— Standpipes Present6N) Date of Last Adequacy Test fj�F�uA-T`E Separation Distance from Absorption Field: i To Water -Supply Well /00 To Property Line /S i To Building Foundation 4.4 119 To Existing or Abandoned System on Lot ; On Adjoining Lots Z --,r-,0" To Water Main/Service Line �� 'f To Cutbank (if present) r To Stream/Pond/Lake/or Major Drainage Course /0 '0& To Driveway, Parking Area, or Vehicle Storage Area /0 Comments D. LIFT STATION "*"a stalled Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) mping Cycles during Adequacy Test. Meets MOA I certify that I hav the ked, v ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed A� L- Date Company AECf MOA No. 8"dL Receipt No. //o 3 _/ Date of Payment '2L Amount: $ 7� d Page 2 of 2 72-026 (11/84) 'r e » wlr t• too €n is SP��°,r pose . , • •eee it ... 0 ;� OY C. REID, J e4.t 'sp CE - 2251 odo