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Home My WebLink AboutGARDENIA LT 168B MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [~UPGRADE MAILING ADDRESS LEGAL DESCRIPTION I L~.-r- {I,,,,,¢:,, ¢¢, .~-~:~=~.-. v~__-,"1"'i~,.-.~ , LOCATION Well t Absor ptio~.~ea/ Ov DISTANCE TO: I I~1~ I- Z Manufacturer ILiq.{ capacity~_(:::::~:::::~in gallons/I ~- ............. mu~=~=: Inside__length~ DISTANCE TO: IWell I D~IJ~ Manufacturer Well DISTANCE TO: No. of lines Length of each line Top of tile to finish grade Width Dwelling~r~.' ~ Widt~ Material Nearestlotline Trench width NO. OF BEDROOMS PERMIT NO. No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons of crib Crib diameter DISTANCE TO: DISTANCE TO: Building foundation Foundation PERMIT NO. Crib depth undat~on )tiller Sewer line of lines Distance between lines inches Total effective absorption area inches PERMIT NO. Total effective absorption area Nearest lot line Iotline PERMIT NO. Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING INSTALLER REMARKS LEGAL ~ Started PERMIT NUMBER KIND OF FORMATION! Froth50 Ft. to F, .~Ft. "00~/2 65,eia~'r.d_. .From V om / to G~LS. PER HR . ~. a ' ~- ~-'~ · KIND OF C~SING ~ Ft. to Ft. to Ft. to Ft.. '/ Ft.__ From" Ft. to Ft._ t/h' I X~-~'.'fl From '3' :_Fi. to From :~ -~ ' Ft. to '~(,' 'Ft~- · ' ' ' " Ft. to . From_' ~ Et. to ,Ft.~,ff~ I .~4oe~ ~/~m '~ From. · 'Ft. to ~ Ft. ~l~d": .... ~aF~-~'[~ From "~ Ft. to '~rom'?:' '~ Ft. to_ *~ Ft. !~ '..~, ;'~ From"" :'t Ft.'to_ 'Ft. From_ Ft. to , ' .Ft ' ), Prom f . Ft. to_ .Ft. · - From~Ft. to ) .' Ft. , ?,~'~?!,~ , . ~'. i, , ' · , -. ' From' ,,[.r¢ . Ft. t0~Et. r '.'. '.~Ft. to , ., Ft ' .Ft. ~. From .... ; Ft. to .- From '-'%Ft. to_ From "Ft. to_ From 'Fi. to- . -~wFro~ · .. _Ft. to_. ' LFt. From ' Ft. to. 'Ft. From - Ft. to / '"Ft] .Ft -Ft."" ' _Ft. Ft Ft '_Ft .... DATE l '~..'~:UED ~ 0"!/'02 .'"?F ADDRESSa F'.{3,. ~8X' 77E58 ADDRESS (VILLI,.Ahl A, SCHM!DT T..-,* ~.-- ~'IZE fRA{ S~ unicipa.tYof Anchorage PO U,...,4 6-650 ANCHORAGE. ALASKA 99502-0650 (907) 264-4111 TONY KNO~vLES MA YOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit ~: 840034 January 31, 1985 TO: Permit Applicant SUBJECT: T15N R1W Section 18 Lot 168 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new pe£mit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 i--1LIl'-.I I ~-: I F'RI I T'-r' 'DF I-II".iC:HORI-'IGE DEF'ARTMENT OF HEALTH FIN[:, ENVIRONMENTAL PROTECTION ,-::25 L STREET., FINF:HOF.:AGE, IRK 9950'~ 264-472E~ PERHi T NO: [:,RTE I SSLtE[:, - APF'L I iS:ANT - FIDDRESS · LEGAL [:,ESCRIP · LOT SIZE' LOT LOCATI"N- HFI;:--'; BEDROCd"IS: C~I'-,i--S I TE 'SEWER :-]40034 02:,"08,.-'84 H t LL i RI'! SF:HM I DT BOX EFIGLE R I ......... RI-::: SUBDIVISION: NB SECTICrN: i8 TOWNSHIP: 2. 5R ,::SL.--L FT. OR ACRES) MILE ±. 5 S. BIRCHNOOD 4 · -~: L4E L L F' ER f'l I~~~ cb,t.: LOT: t68 BLOCK: SM1/4 ~ 15N RANGE' LISTED BELOH ARE ,'r_-,.EM. CHL]OSE THE AF'TION THAT BEST FITS "r'OUR SITE. THE OF'TIF~NS R',,,'FIILRE:LE TO "r'OIJ IN DESIGNING "¢OLR SEPTIC [':" i-_' F'~ I I"-J 2.5 2.0. 4.5 · 5.0 7C~. 0 ':,' 2. 4 :.1.., 25E'L ~.":"~ '125 I=: E [:, DEPTH TO PIPE E:OTTOM '::FT. ) 4. 0 GRAVEL DEPTH ,::FT. ) 0. 5 TOTAL DEPTH (FT. :., 4. 5 GRAVEL WIDTH (FT.) 20. 0 GRR',,,'EL LENGTH ,::FT. ::, ]:8. 0 GRR',,,'EL VOLUHE ,::CU. YDS. ::, 28. '1 TANK SIZE <Gl'ILS) i., 250. 0 SOIL RATING <SI..--!. FT. ,'"BR) 125 :+::+: DEPTH TO PIPE E:OTTAM .::' 3. 5 FT. REL-]LIIRES INSULATION )~ :','::+: DEF'TH TO PIPE E:OTTFtH .C .4.. 0 FT. MR"r' REQUIRE R LIFT STATION :+:~: TANK MLIST HAVE RT LEAST TWn COMPARTMENTS ~F'F'L I CANT: W t LL t AM 'SCHM I [:,T I CERTIFY THRT: ! RM FAMILIAR WITH THE REQUIREMENTS FOE'. F~N-SITE SEWERS RN[:, WELLS RS SET FORTH B'¢ THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA. 2. I HILL INSTALL THE SgSTEM IN ACCORDANCE WITH ALL MOB CODES AND REGULATIONS., AND iN COMPLIANCE HiTH THE DESIGN CRITERIA OF THIS PERMIT. Z. i HiLL R[:,HERE TO ~LL MOB AND STATE OF RLRSKR RE6~UIREMENTS FOR THE SET BACK [:,ISTRNE:ES FROM ANY EXISTING HELL, WRSTEHRTER DISF'OSRL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR BN'¢ R[:,JRCENT OR NERRB'¢ LOT. 4. I UNDERSTRN[:, THAT THIS PERMIT IS ',,,'RLI[:, FOR R MAXIMUM OF 4 BEDROOMS AND RN'¢ ENLARGEMENT WILL REQUIRE RN R[:,[:,ITIONRL PERMIT. IF R LIFT STATION IS INSTRLLE[., IN RN RRER COVERED B'¢ MOA BUILDING CODES., THEN (i) RN ELECTRiC:AL PERi'lIT RN[:, INSPEC:TION MUST BE OE:TRINED.; (2) RS-BLIILTS · 4iLL NOT E',E RF'F'RO',.,'E[, WITHOUT RN ELEC:TRICRL INSPECTION REF'ORT.; RND (]) THE ELECTRICAL W3RK MUST BE [)ONE B'¢ R LICENSED ELECTRIC:IRN. ~c,~-~ .... ' ANCHORAGE. :--~ ~-~ ' - PERMIT NC'.. t, F .... MN, : WI~_~_~Mt~ SCHMI[:,T 1 ~.~ ,...~,~, · E:O::-:: ~RGL~ R · ,. EK., RK:~-'- --,.' ,- ~E.~,; '-'~',~ ["~'=--~ ........ - ='IF'=, .... t -,.,, - ~UE:DIVISIGN: NFl i-'lLil'~4.,_~ ,~ l"'"'"~'L T T'T' I_--~['i''- R I'-.I L--:_ I.-"-"~- R,.] E ,-,-..FH ..... ,=NT L,, HEALTH AND EN"/IRONMENTRL , ..0TECTION 82F, '"L'" STREET., ANC:HORRGE., RK ~95~3~ 6~4-.'--'~_-::± ' EAGLE RIVER · 5-'_- I--JELL PEF;;~:I-'I I T F'HONE: LOT SIZE 0 SQ. FT. TOWNSHIP: MAXIMUM NUMBER OF DEDROOMS = 4 SOIL RATING = ±25 125 125 (SQ. FT./BR) LISTED BELOW ARE TFIE OPTIONS AVAILABLE TO '¢OU IN DESIGNING ~OUR SEPTIC S~'5TEM. CHOOSE TIlE OPTION THAT BEST FITS 'T'OUR SITE. BLOCK: NB LOT RANGE: iW SECTION: WIDTH = LENGTH = TOTAL C, EPTII = GRAVEL DEPTH = GRAVEL VOLUME = [:, E "--; I ~--~ r-4 2Et 0 FT. 40. 0 FT. 4.5 FT. 0.5 FT. 29. 6 CU. ',-'[:,S. d ,,-.. SIZE = ±.. ;250 0 GALLONS ,::TNO COMPAF.:T,~-IENT ~-,- ..... · , HNk. l-,J i [:, E [:, F-: ~-~ I ,"' 4 F I E L [:, [:, E '--~ I ~31'-4 NtDTH = LENGTH = TOTAL DEPTH = GRAVEL DEPTH = GRAVEL VOLUME = TANK SIZE = 5.;] FT. 88. 0 FT. ! NF~TE ! - --::-,75 FT. REQUIRES TNI] TRENCHES "-' . -- ['lR'¢ RE¢~.UIRE LIFT STATION i CERTIFg' THAT: 1. I BM FAMILIAR NITH THE REI;~UIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH B'¢ THE MUNICIPRLIT'¢ OF ANCHORAGE AND THE STRTE OF ALASKA. 2. I WILL INSTALL ~ ~ '-".- ~ ,H~ =,~=,TE[', IN RCCOR[:,RNCE WITH THE CODEq AN[:, HAVE RECEIVED R F:F~p~, OF THE CODE SUMMRR'¢ c, r- - -- ,~ ..... DIAGRRM RTTRCHMENTS NHICH IS PRRT OF THIS PERM l T. ]-. I UNDERSTAND THAT THE ON-SITE SENER SVSTEM ~'I~Y REC~UIRE ENLARGEMENT IF THE RESIDENCE I5 REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. PERI'lIT APPLICANT HAS THE RESPONSIBILITY TO INFORM PERSONNEL DURING THE ,N_,T~,t,~L,N INSPECTIONS OF ANN WELLS RDJRCENT TO THIS PROPERT'¢ AND THE NUMBER OF RESIDENCES THAT THE NELL WILL SERVE. ZF R LIFT STATION 15 INSTALLED.. AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED. AS-BUILT5 CANNOT BE APPROVED WITHOUT RN ELECTRICAL INSPECTION REPORT. THE ELECTRICAL WORK MUST BE DONE Ag" R LICENSED ELECTRICIAN. I U,'~c.[.-. 9F'F'L I Ii:ANT [__'~c-I ~lEE'.- E, iT,, W ILL I AM "'-'~t~ T r.,m [)RTE' MUNICIPALITY OF ANCHORAGE · '. Department~-~ Health and Environmenta?-~otection · 825 - Street, Anchorage, AK. .:501 · . '-~" ' 264-4720 ~,~- Pe;-~,,it #,~' P, ~/,o ! ' ' ' HANDWRITTEN PERMIT ' * * "'---- W£LL AND/~ON-SITE SEWER PERMIT L~cation: ~egal Description: ~or/~ ~ Type of Soil Absorption System Is: Trench: Drainfield: X maximum Number of Bedrooms: ~ Phone Number: ~A/B/LU ElY LOt Size: Seepage Bed: __Holding Tank: Soil Rating(sq.ft/br) DEPTH The Required Size of the Soil Absorption System Is: ' LENGTH GRAVEL DEPTH ' WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(~LDiNG) TANK SIZE = /~s~O GALLONS * * ~e~it applicant has the responsibility to inform this department during the ~stallation inspections of any wells adjacent to this property and the number )f residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * ~ ~ackfilling of any system without final inspection and approval by this department ~ili be subject to prosecution. ~inimum distance between a well and any on-site sewage disposal system is 100 feet ~or a private well or 150 to 200 feet from a public well depending upon the type )f public well. Minimum distance from a private well to a private sewer line .s 25 feet and to a co,=~nity sewer line is 75 feet. Well logs are required ~nd must be returned to this department within 30 days of the well completion. )ther requirements may apply. Specifications and construction diagrams are ~vailable to insure proper installation. * * * PERMIT EXPIRES DECEMBER I certify that: (1) I am 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 codes. (3) I understand that the on-site sewer system may require enlargement if the residence is~re?deled to include more t~.~bedrT~.~ Applicant Date: SWP/024 (1/81) SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION cI PERCOLATION TEST 825 L. Street. An~, AJMk~ 99501 2E4. *.720 PERFORMED FOR= ~/OI L~ L. ,/~ ~'t~. ~C )L~/~f //2)~" ~_ DATE PERF(~RMED: B-- ~--g~ SITE P LA-'R'~ ~ SLOPE Gro~ / /Net Depth to Net ~%,. Date Tinge ,~/ Ti~ Water Or~ WAS WATER IF YES, ATWH ~ ' DEPTH? ' 5 6 7 8 9 10 11 12 13- 14- 15- 16 17 18 19 20 TEST RUN BETWEEN ~ FT AND ~ FT SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: ~'~J ~,L. LEGAL DESCRIPTION: ~'~"~'/'" 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17- 18- 19- 2O SLOPE SITE PLAN '~,~1~ WAS GROUND WATER ENCOUNTERED? [,~ ~-r~ ~-~--- DEPTH? No. 14..~7-E ,,' ../% J Gross Net Depth to Net Reading Date Time Time Water Drop ~ ~ (minutes/inch) PERCOLATION RATE PERFORMED BY:~Q CERTIFIE TEST RUN BETWEEN . FT AND . FT 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 A~PROVAL FOR A SINGLE FAMILY DWELLING O5-/-2 Z 7¢ 1. GENERAL INFORMATION Complete'legal description Location (site address or directions) ~R'~b'~V oWne~'-~ ~ ~ ~ ~."';E~dmg agency... _ ) Day fihone ~iling address · Address Day phone 4~l;~'~/"q/2~' 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for picku,p. NOTE: Individual well Community well Public Water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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-O25(Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority 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. Name0f Firm ?-&-?-E-NG!N-EERING Phone ~ ~ -'~-~ -79 l/u,~ =agra ~ver Loop Road No. 204 Address Eagle Rivert Alasl¢a 99577 Engineeds signature , , _ - Date <~ / 20 / ~q DHHS SIGNATURE J Approved for ?' / ~ __. Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of ·Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS 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 enginee¢s work, , -CEIVku Municipality of Anchorage AUG 6 DEPARTMENT OF HEALTH & HUMAN SERVIC~N~Qp^L~T¥ OF^NCHOi~, Environmental Services Division ENVIRONMENTALSERVICE$ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~--~?'- /~/¢~ ~'~-~'/'///~ ,~'/~ ParcelI.D.: A. WELL DATA Log presented)N) Total depth IfA, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~ -~- f FROM WELL LOG Casing height (above ground) Wires proPerly protected~/N) Date of test ~7'/~'~ Static water level / ~ / Well production ~ g.p.m. g.p.m. WATER SAMPLE RESULTS: -- Coliform 0 Nitrate Date of ~ample: ~/2~ B. SEPTIC/HOLDING TANK DATA Date installed ~//~/,,~"Tanksize.J~Z~__NumberofCompartmenJs ~-~ Clear~outsf~lN) ~ I Foundation cleanout I~) ~/~'-) Depression ('~ ,~/'(-,) High water alarm (Y/N) Date of pumicing ' ~/~-/'/~ Pumper ~'--~-, / C, ABsorPTIoN'FIELD DATA ' ~ Date'installed ~:~ll~' ,, Soilrating (g.p.d./fFor~ J~1-~ Systemtype ~"~.~-'~"~ Length ~-~ Width, :~:~-/ Gravel thickness below pipe ~/r~ Totaldepth ~ EffectiVe, absorption area /~)'~''~L j~ Monitoring Tube presen~h) ~:~, Depression over field (Y/~ '../ Date of ad~acy test ~) ~--"~- Results (Pass/Fail) ~-~,~. For /~::/' l/~--- bedrooms Fluid depth in absorption field before test (in.); :~// Immediately after-'~$~ gal. water added (in.): Fluid depth ~-/~- (ins) Minutes later: 2-~::~ I Absorption rate = ~ ~'/- g.p.d. Peroxide treatment (past 12 months) (Y/N) /t,/~¥,//~-~ /~'V'~t/~j If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) Size in gallons "P u rrjp.e~¢l~ *Datum High water alarm level at* Cycles teste d~¢./~/~- E, SEPARATION DISTANCES "Pump off" level at*_ Septic/holding tank on lot Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL ON LOT TO: I00 Sewer/septic service line On adjacent lots On adjacent lots Publio sewer manhole/cleanout Lift station ~///*~r- / SEPARATION DISTANCES FROM SEPTIC/HOLDiNG TANK ON LOT TO: Foundation ~ /"~- Property line ~ /'~- Absorption field '~/filL Water main/service line ~ I~/~ Surfac'ewater/drainage IO0~+ Wells on adjacent lots 1~/'¢-- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I ¢ /, Building foundation I 0 ~'~'/'- Water main/service line Surface water ) (~(~/,4- Driveway, parking/vehicle storage area Curtain drain ~/~t,..J(-- ~-.t,~wg 1'-..) Wells on adjacent lots iO~) r.~_ . HAA Fee $ Date of Payment Receipt Number ENGINEER'S CERTIFICATION ~ certify that ~ have determined thru ~e~d inspecti~ns and review ~f Municipa~ rec~rds t~e~ ,~, tems are in conformance with MO,4, HAA guid~elines in effect on this date. Signature ~// ~' Engineer's Name ~2~ ~' ~ Date ~/~40 /~ ~ ~¢~ Waiver Fee $ ~- ~ ~ ~ Date of Payment 72-026 (Rev. 3/96)* P:OFBox 1~ Anchomge:Al~ka ~51~0 ~: CER~FlCATE OE H~LTH AUTHORI~ . _ ; :..~, ~ APPROVA~EORA,$1NG~ FAMILY DWELLING 3.~TYPE OF WATER SUPPLY.-:~- Individual well ~NO~ l~commuq~l[~em~ ~:._.~: ~ .mg m the I~al~and~tus · '~2 ~'-~:-' NOTE:: :If communt~ ~te~s~te~eprovt~ attesting to the legality and Status of system. 5. STATEMENT OF INSPECTION BY ENGINEER. --~" . ..... .-~- --**- As certified by my seal'affixe(~ hereto ancFa~ofthevahdatiortdateshowr~below; I~verify that y +~ investigation, of. this Health Autho,ri..~ App~,v.a.i'.a, pph..ca..tlon shows that the'on-s~te water supp y and/or wastewater disposal system is safe, functional and adequate for the number of bedroc ms and type of structure indicated herein. I. further veri~ that based on the information obtained from the Municipality of Anchorage files and from my im/es_ti_.qation 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 c n the date of this inspection. Name of Firm"~ ~ :' $ & s ENGINEERING .... 17_034 £~gleRiver Loop Ro~,d No. 204 , ~..- ~ ?~e of Healt~ and Huma~ ~e~i~(DHHS~I~u~ -.,,.::, ', ~ :~ ~ppmval the mp~nmtions gi~:[n~ ~gmp~ve: by: an inde~ndent .... ~ ~ -,,,~, ~,~ = ~1 ',~ t ;~ a cou~ to pumh~ of hom~. "~'~' ~ce~n f~eml ~d sWte ~ul~~p oy~ of DHHS do '~ '?" .... , a:ce~ifi~te m i~u~. :~e Mumcipali~ o~:A~ho~ge ~s. not 72~25 (Rev, 1/91) Beck MOA e'21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~--c,,-' l ~ ~'~ (-~-~,'~ ~ ~ I~ % J~ Parcel I.D. A. Well Data Well type Cased to If A, B, or C, attach ADEC letter. ADEC water system number ,~' Date completed z-t/- ~ Driller ~ ~L.r.., /Z,I¢" Log present'N) ,_~ FROM WELL LOG Total depth ~/~-' Sanitary seal ~N) ,7/ Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I Absorption field on lot \ Public sewer main ~ ~,~ z7,'5" ' Casing height Wires properly protected (~1) y AT INSPECTION Sewer service line g.p.m. '7,? ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout ~ l ~' Petroleum tank ~-~o ~F~ WATER SAMPLE RESULTS: Coliforrn Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (~N) High water alarm (Y~ Date of pumping Nitrate Collected by: Other bacteda ~ S & S ENGINEERING ! lu..~e ~.agie River Leop ~ead r~e. 2o4 F..,~jle Ri~er, Alaska ~9577 Tank size /~-'~ Compartments Foundation cleanout ~N) / Depression (Y,~ Alarm tested (Y/N) Pum~r ~f~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /c~ ~ r On adjacent lots / To property line /~ t '~ Absorption field ~ / Sudace water/drainage Foundation Water main/service line /-/.- 72-026 (3,,93)° Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (y~ ~ SE~~ FROM LIFI STATION TO: Well on lot On adjacent lots Manufacturer Manhole/Access (Y/N) "~; Level at ~- ..~,ycles tested Surface water D. ABSORPTION FIELD DATA Date installed ~ - / L~ - ~ ~-- Length ~7- / Total abso6)tion area Date of adequacy test Width Water level in absorption field before test Peroxide treatment (past 12 months) Soil rating (GPD/Ft2) /~?~<~ ¢//~ System type Z ' Gravel thickness ~, ~ Total depth Cleanout present ~) / Depress~n over field (Y~ Resu~s ~ail) ~ for ~ Bedr~ms ~//~" Aftertest ~ ~ ~ If yes, gna date ~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /p ~ / On adjacent lots To building foundation 2~-o / On adjacent lots ~- ~ / ~ Cutbank H- Sudace water /o ~ Curfain drain ?~ / ~F Property line ,'/~ / To existing or abandoned system on lot Water main/service line / Driveway, parkingJvehicle storage area E. ENGINEER'S CERTIFICATION I ce~fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effec_.t..~4~.~.~.~ of this inspection. Signature Engineer's Name Date HA.& Fee $ c=~/'D, r_.~) Date of Payment Receipt Number ~.~-,¢¢ ('~,¢¢0¢'~'~) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P,O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~_ '"_~ ~ - ~ ~:~ --'~Ct HAA# t:', t-'~c~:~ '- "' "-' ~ GENERAL INFORMATION Complete legal description Lot 168B; SN~, Seczion 18; T15N; R1W; SM Location (site address or directions) 19013 Richne:, ,?.hugiak/ Alaska , Property owner Mailing address William Sc,hmidt Day phone P.O. Box 770682, Eagle Rive~, Alaska 99577 688-2018 Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below1 I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewater 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 Phone Address Engineer's signature Date DHHS SIGNATURE ~'~ Approved for/¢'~ r-~ ('/'~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~,~-,c.~ ~(~-r_x~. ,-~ ~- Date - The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Legal Description: A. WELL DATA Well type '~¢--\WN"¢~ Log present4C:i~N) Total depth ~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Sanitary sea~)N) Parcel I.D. If A, B, or C, attach ADEC letter· Date completed ADEC water system number '"'---- ~r /~.~ Driller '~,-~\ Cased to z::~ Casing height Wires properly protecteqld~gN) ,, Date of test Static water level Well flow Pump level FROM WELL LOG 4/¢5' AT INSPECTION R E CmE I V E D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ! Sewer service line '~-~'~- ~ · On adjacent lots ; On adjacent Pots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: ~ ~ '~-¢2 -<~ ~' B. SEPTIC/HOLDING TANK DATA Date installed '~ - ! ~ ~ '~ ~', Tank size Clean°utsd~N) y High water alarm (Y/N) Date of pumping '~ ~"~ ~'~J- Other bacteria Collected by: Foundation clea noul::~N) "/' ~: ;3-i. Fc,_qie River Loop Road No. 204 ~;: ~iver &!aska 99577 Compartments Depression ( Y/~_ Alarm tested (Y/N) Pumper '~--'~'}¢ '~'~'~f-~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I c:> "~. On adjacent lots To property line I ~ Absorption field Surface water/drainage / C;;q:pI Jm Foundation Water main/service line \~:~1 ..~ 72 326 ~Re~ 7 91 =-o"' CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at _ Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~ ~ [ ~ ~;~ Soil rating Length ~ ~ Width o-~ Total absorption area ~ c>'2_~ Depression over field (Y~ Results ~fail) Peroxide treatment (past 12 months) ~"~_._¢~ ='~'/¢z¢.~ System type ~ Gravel thickness ~:;~ Total depth ~-, ~ Cleanouts presentzC~N) ~-,~ Date of adequacy test "~ -'~--~ ~ _ for ._ -- ~-' _ bedrooms /,,,jc,,-.J~ /¢~z~t~/',J Ifyes, givedate -- " SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot t On adjacent lots ~.¢ '~ _ Property line To existing or abandoned system on lot Cutbank ~ //~ Water main/service line Driveway, parking/vehicle storage area To building foundation On adjacent lots '"~¢,~ Surface water Curtain drain E. ENGINEER'S CERTIFICATION Signature Engineer's Name Date I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this ¢nspection. ~ ¢: :'-~¢~ ~iver Loop Road No. 2~ '¢ ~ ,' 4;~'~ % '¢ ' HAA Fee $ , Waiver Fee: $ ..%. ~.; ) ... Date of Payment ~'~ ~' ' ' ,. Date of Payment Receipt Number . // Receipt Number