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HomeMy WebLinkAboutGLACIER VIEW HEIGHTS #4 BLK 2 LT 9 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 0 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Na~,~, I DISTANCES Add,ess I _ ~flOM ~ TANK FIELD Phoneis) Perm,, NO /No of Bedrooms L 37 WELL FOUNDATION AS-BUILT DIAGRAM (Show Iocat,on of Well. sephc syslem property I~nes, Iouudahon. dnveway. Ware( Dod~es. otc) /~ SEPTIC [] HOLDING TYPE OF SYSTEM "FRENCH [~ BED ~.DRAIN [~ OTHER or,g,mil grade '~ FI' ~ FT WELLS ~RIVATE E~ OTHER fldenlifv) j~otai Depth FI Cased to FT REMARKS: hlspectJons Pedormod by I ,~ & $ ~,NGINEERING ' Ihat this inspeclJon was pedorlllOd according to all Mu[iJcipal d ~ i ~ ne j~¢ Health D epaH.ent Approval: ~~_--fi ~~' D.,e / ~' ~-- ~7 ENGINEER'S SEAL SCALE 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION:~ ~ ~CI~ ~[~, ~,~Secti0R~ SLOPE SITE PLAN 8 9 10 WAS GROUND WATER 2./,:<g Oo ENCOUNTERED' :// IF YES, AT WHAT 12 11 DEPTH? E Deplh t° Waler Afler~'~ - ~"'- / /~ 13 Monitoring7 /~' ~ Dote: Gross Net Depth to Net Reading Date Time Time Water Drop z ' - 7) .* ;~ o ? . Z'l¢" 14 15 18 19 PERCOLATION RATE 'J"~/'"'~- (m,nutes/,nchI PERC HOLE DIAMETER COMMENTS ~-¢'¢'~"~/'~ /'/,,/j'-'~' ~'0 LZ~ ~ ~ .......... ~uuG ,., PERFORMED BY 17034 EaC' Ri,er L~p Road NO ~'"-2//% ~ " -- ¢ / :/ ~ CERqlFY THA~ ~HIS TEST WAS PERFORMED IN AuCORDANCE WITH ~LL STATE AND MUNICIPAL GUIDELIN DATE: ~ 72-008 (Rev. 4/85) DOC Co, WATER WELL P,O. BOX 272, CHUGiAK, ALASKA995G7 o TELEPHONE 688-2759 · ~MFn)m.~Ft. to Ft.~ Fmm~-- Ft. to Ft. Fr~_~Ft. to_ : Fromf.] ,:~Ft. to ...... Ft. . Fmm] ,~Ft, to ..Ft. Frorn .... Ft. to_ Ft. From ....... Ft. to ..... Ft. From ........ Ft. lo From ..... Ft. to From ..... Ft. to Frmn .......... Ft. to ....... Ft._ From ....... Fl. to ........ Ft. From Ft. to ..... Ft. From ..... Ft. to__ Ft. From__.__Ft. to .... Ft._ From ..... Ft. to ..... Ft. From ...... Ft,~gJNAC~ pALI'I'Y Fro, 0~ ~ .... n .... F ~N~N~NT~ pROT~CftO~ :rom ....... Ft. _ ..... From ....... Ft, to ...... 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 HEALTFI AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 9; Block 2; Glacier View H~ight~ #4 Location (site address or directions) NHN Eaglz Glao__Ze.r Loop Property owner Mailing address John H. & Mary E, Fras~ P.0.Box 770975 Eaql~ River, 696-1807 DayPwl~°,.n~52_3525 Alaska 99577 Lending agency Mailing address Day phone Agent Hal Jackson HERITAGE REAL ESTATE Address 18850 Eagl6 River Road E~cjlg. R~u~r~ Alask~ 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: Day phone 964-4994 Individual well XX 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 If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev, 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, lfurtherverifythat 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 Address Engineer's signature //~.HS SIGNATURE Approved for Disapproved. S & S ENGINEERING 17034 EagJe River Loop Road No. 204 bedrooms. Phone Conditional approval for 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 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 responsibre for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type ~¢.-',",¢ b.-~.. Log present (7.'~N) ~ Total depth \ 1:) Lc~ Sanitary seal(i~/N) _ Date of test Parcel I.D. IfA, B, orC, attach ADEC letter. ADEC water system number Date completed ~ - ¢~ Driller Cased to \ L~ L-~ Casing height Wires properly protected ~'N) FROM WELL LOG g.p.m. Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line AT INSPECTION ; On adjacent lots ; On adjacent lots _ Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ ~'"~ ~/~o ,v. JL. Nitrate Date of sample: ~ ~ o~ .. ~ B. SFPTIO/HOLDING TANK DATA Date installed 1"/.., ~'7,~, .-- ~¢, Tank size Cleanouts (~) ~ Foundation cieanout I~N) High water alarm (Y~-~ r'~ Date of pumping --] .~. \~ ~c~\ Collected by: Other bacteria S & S ENGINEEEING 17034 Eagle Rivet' Loop Road No. 204 Eagle River, Alaska 99577 Compartments ')/ Depression (Y,~ Alarm tested (Y/N) Pumper '~. ¢--~_ /-___-r:gc~g 9a~ ~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /© Lc~ On adjacent lots To property line ~,0 "~ Absorption field Surface water/drainage I ~::> Foundation Water main/service line. 72 026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DIS~ LIFT STATION TO: On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump Surface water D. ABSORPTION FIELD DATA Date installed \'~'~-~ ~ ~'~ Soil rating Length (.~"~ \ Width Total absorption area ~'~ '7 Depression over field (Y~:¢) Results4~:~il) Peroxide treatment (past 12 months)(Y.(~ System type Total depth Gravel thickness "~ ~ Cleanouts present Date of adequacy test for "'/-','~.'¢-~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot \\'D-\ To building foundation On adjacent lots Surface water Curtain drain On adjacent lots \t;:)~\ 'V' Property line To existing or abandoned system on lot Cutbank ~ //~..~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION / certify that / have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection. ~.~ ', S & $ ENGINEERING ,:-.~ . 17034 IEa.(ile River Loop Road No. :~04 Signature ;??:;p: r~;vc~r: AIc-s~.'a 99577 Engineer's Name Date HAA Fee $ \'q Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 9, l~lock 2, Glacier View Heights Location (address or directions) Eagle Glacier Loop Road (b) Property owner Laurel Crouse Gen. Conh. CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Telephone: (home). 69.4.--2529_ Business -694-4-200 Mailing Address (c) Lending Institution Mailing Address P.O. Box 770606)Eagle Riverf Alaska 99577 Telephone (d) (e) Real Estate Company and Agent Re./Hax Address ]6600 Cenherf&e]d Dr., Su. 201, Eagle River, Ak. 99577 Telephone 694-4200 Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: S ,R, S I;NC. INE. i;~IN _C. 7034 Eagle Ri~er I.oep Roa~ Ng~, 20~ Eagle River: Ala&~a 99R.7'~. 2. TYPE OF RESIDENCE Single-Family [~ Number of bedrooms 3 3. WATER SUPPLY Individual Well E~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site E~ Public. E] Community El. 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Va 'FiOld'¢t$ ~111=1 '$.L$~.L '$NOI.I.O~IdSNI 9NlalAO~ld IBII:II4 9NIld~ltNIgN~! .cj ~.~,.o~k MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 , O~ '~ 343-4744 ~7%~'/~. ~{¢~ ~ Legal Description: ~ Well Classification ~'"- ,, -~2 / Well Log Present CN)_¢ _Date Completed Total Depth ~ Casedto~ Depth of Grouting If A, B, C, D.E.C. Approved (Y/N) r4/A, Yield (,.~ ?~- ~-~¢,'~/~ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit ¢¢~:?N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot Pump Set At Sanitary Seal on Casing~N) ~,/ Depression Around Wellhead (Y/I~P ; On Adjoining Lots To Nearest Edge of Absorption Field o~ Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ¢~ ~:~ ~'-~1 Water Sample Test Results ~1~ Comments ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed ~.--- ~--¢-~t~_ ize ~ No. of Compartments Standpipes 4.d~N) 7 Air-tight Caps(C~N) Depression over Tank (Y/~) ~.--.'/ Pumping/Maintenance Contact on File (Y/N) . Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well / ~ To Building Foundation To Property Line I c)1 J¢~ To Disposal Field To Water Main/Service Line I ~ To Stream, Pond, Lake or Major Drainage Course \ '¢ Foundation Cleanoutd~'N) Date Last Pumped . ~ ; for Temporary Holding Tank Permit (Y/N) Comments 72-026 (Rev. 7/88} Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Instal led Width of Field Square Feet of Absortion Area Depression over Field (Y~ Results of Last Adequacy Test Type of System Design~ Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present~N) Date 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 ~ To Cutback (if present) Comments Installed Dimensions Size in Gallons ~ "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Manhole/Access (Y/N) ~'~'~Z~_ump Off" Level at Ve n t'~O'-/N-)- ~ PumpingC~c ~acyTest. **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. Signed $ & S ENGINEERING 17034 Eagle River Loop Road No. 204 Company -----EEC. ~ ,"dyer/. A!,'~s,ka 9957Y MOA No. ~ Receipt No. c:~// Date of Payment Amount: $ /?~- 72-026 (Rev 7/88} Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2