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Home My WebLink AboutT15N R1W SEC 18 LT 91BTISN RIW · 18 Lot 9lB #051-172-51 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 O ,~ / - / 7 ~ -- ,,5- / ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT .am~,) DISTANCES ^dd,es~ I C'"~"~ ~' ~ ~d ~ ~ SEPTIC ABSORPTION ~. ~ ~ ~ -- ~1~ TANK FIELD WELL Phone(s) Permit NO. ~o o, ~.~,oom~ WELL ~ ~t ~.~.~...c,,..,o. LOT LINE ~f~ FOUNDATION ~ ~' Township, Range, Section TANKS Manufacturer Capacity m gallons Material No of Compadments TYPE OF SYSTEM w....,. Depth to pipe bottom from Total depth from Original grade originalgrade ~ FT ~.~T ~ ~~ Fifl added above o,[gina, grade Gravel depth beneath pipe ~ ~ -- ~ ~' Gravel length 3ravel width WELLS ~RIVATE ~ OTHER (Identify} ~ i~leI~A~~ REMARKS: ~ ~ '~ %[ S & S ENGINEERING I i/U~q ~ag;~ ~; ,~,' LOC; ~=2-J ~ZG. =~4 ~difY Ihst this Inspe~ion was pedormed according to all -- ''~' Date: 0 72-013 (3/85) 4o~ S~,a. rr/+ '"'"':: ' October 17, 1990 ROBERTSHAFER, P.E. ROGERSHAFER CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 91B, Sec. 18, T15N, RIW, S.M. PEFJ, IJIT REQUEST NARRATIFE SEWER&WATER RequeSt you issue a permit to upgrade the existing septic leachfie~d INSPECTION which has failed a septic adequacy tnt. The proposed upgrade is to the south of the existing leachfie~d in one ENGINEERINGSTUDIES of the areas available as an alternate site. This area should have no ANCREPOmS further impact on adjacent lots since it is in the same area as the existing leachfield. The lots in this area are generally large and the topography is WELLINSPECTION r~atively flat. With the leachfield in the proposed location there is &FLOWTEST still room on the property for further upgrades and upgrades to adja~e~ and septics. SITE PLANS~ ,~ ROADDESi.~ J.~"~ I/ROBERT~.- [ A. SHAFER, P.E. RJS/gm SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: LEGAL DESCRIPTION:/.~I '~"'i ~ec'l'~;TT'~Ji"'~l'J; ~'~T°wnship' Range, Section: 4 5 6 7 8 9 10 11 12 13 14 15 16- 17- 18- 19- 20- SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Aller ~ Moniloring? L"~_L"' (,4 Dale: Reading Date Gross Net Depth to Net Time Time Water Drop 2 to PERCOLATION RATE ~-- '~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~.-J)T AND ~ ~ FT COMMENTS PERFORME[~:3~4~Na~IieN~f~rN~G'~gp ~,ga¢~ ~o 2. 4~~ER]IFY THAT THiS TEST WAS PERFORMED iN 72-008 (Rev. 4/85) Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION!.~.3~" ~_ ! '~°'! ~¢_. IR:TT~.U;~. ~; ~.~Township, Range, Section: 1 2 3- 4 5 6 7 8 9 10, 11- 12- 13- 14- 15- 16- 17 18 19 20 SLOPE IOUND WATER SITE PLAN .! ? Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE , ~, ~[ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~T AND ~' ~ FT , GOMMENTS lNG ,, MUNICIPALITY OF ANCHORAGE ~t ON-SITE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION ~). 825 L Street- Anchorage, Alaska 99501 TeLephone 264-4720 SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORTL,o£~_ ~AME ~ ~' . PHONE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS [ /~ ~1/area , PER ITNO.%¢ Well ~ / Absorpti~ .. Dwelling ~ ~ DISTANCE TO: ~ /~ Z Manufacturer Material No.~', comp~ents Liq. capacity in gallons Inside length Width Liquid depth /¢~ IF HOME'DE: ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, O < Manufacturer I Material Liquid capacity in gallons n PER IT O. ~= DISTANCE TO: /~ ~ .~. ~ ~ ~ No. of lines Length of each e Total lenn,t~.~th of lines Trench widtb Distance bet~es ~ Q~ ~ Top of tile to finish grade~__ ~ Material~en,ath tile ~ inches Total effective absor~n area Length Width Depth PERMIT NO. ~ 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 PIPE MATERIALS ~"C,~, / ~'/ ~YC ~a*~ ~ SOIL T~ST RATING ~ u~ iNSTALLER --, :0' ~ REMARKS ~ Eori ~. [iil~ · 72-013 (Rev. 3/TB) /'~' /~ ' '~ -' ;Z~2 z ~ ~'~ ~(~7-~/ d¢<;* PERMIT NO. DEPf:tR1.rMENT I]F. ~EFtL..TH Ffi",ID E'NVIFIONMENTRL.. P'r<L,,EC:1.'ION 825 '"L'" S'FREE'1., F:INCHORRGE, RI.,::. 9950:t 264-4720 E.'T. L. It._ I:=ll 1"4 E:" 788628 ) AF'PL. I C:FINT LOCRT I ON LE:GRL CFtRL EDWSRDS F:IDRIFIN LANE (WEST) [..91 TISN RlI.,.I S:.'1..8 L:;"F RT BOX 695 CI'4LJGIRI< L, OT SIZE 688 2611:;;?. 47:..':80E~ E;r..]URRE I:::'EE'T' T'¢F'E OF' SOIL FtBSORBTION SYSTEM IS: TRENCH MRXIMLJM NUMBER OF BEDROOMS = 3: SOIL_ RATING (S6! F"r?E:R)=' ±50 TNE RE6.,UIRE[:, SIZE OF THE SOIL ABSORPTION SYSTEM IS: THE LENGTH DIMENSION IS THE L. Ei",IGTH (IN FEET) OF' THE TRENCH OFI DRRINFIEL..D. THE DEPTH OF R TFIENC':H OR PI1" IS THE DISTFINCE BETHEE]",I 1.'HE SOFIFF:ICE 01= 1.'HE: GROUND RND 1.'HE BOTTOM OF THE E',,4CFIVFr'rION (IN FEET). 1.'HERE IS NO SET WIE:,TH i=OR TRENCI-.IES. THE GRRVEL DEPTH IS THE MINIMUM [:,E:PTH OF' GRFIVEL. BE1.'HEEN THE OUTFRL..L.. PIPE: RN[) THE BOTTOM OF THE EXCSVFITION (IN FEE1.'). PEFIMI'I" RF:'PLICRNT HRS THE RESPONSIBIL. I]"'¢ TO INFSRH THIS DEPRRTMENT DLIFIIi'.,IG 1.'HE I NS1.'RLLFIT 1 ON INSPECT IONS OF' Fli",l"r' HELLS RD,..TFICENT TO TH 1:5 PFIOPEFI"f'~r' RND TI-rE NUblBER OF FIESIDENCES THRT THE HELL HILL SEFIVE. ..................... "IF I-.,.ll C':~ ':: 2 ::' I 1'4 S F=' E:.:' (:: 'T' ][ (31"-,I ':_.:; IFt IR E l;;-': lie C::I UI :[ I':;;: E: I[:::, ............................. BFICKFILLIN6 OF FIN¥ S'¢STEfl HZTHOU"r F'INRL INSF:'IECTION FIND RF'PFIC~VF:IL. B'.? THIL::!; DEPFIRTMENT HILL BE SUBJECT 1.'0 PFIOSECUTION. MINIMUM DISTRNCE BETHEEN FI HELL AND RNY ON.....SITE SEHFtGE DISF:'OSFtL S'-?STEH I'J.:!; ..1.r38 FEET FOR R F'RIVRTE HELL.~ OR 158 "ro 200 FEET FROM PI PUBLIC !4ELL DEPENDING UPON THE TYPE OF' PUBLIC: HELL .... HEL. L LOGS RFIE REL';!UIFIED RND MUST BE!: RETLIRNED TO THE DEPFIRTMENT HITHIN ]:0 [)R'¢S OF THE HELL. COMF'LE1.'ION. 01.'t.tER REQUIREMENTS MR"r' FIPPL'¢. SPECIFICRTIONS RND CONSTROCTION [)IFIORRM'.'S FIFIE RVFIILRBLE TO IN':SURE PFIOPEFI INSTFILLFITION PEEF;:r"I ][ "l~ E ::'-', F:' ][ ~L" EE."':~ [::,ECC EiPlE: E:Z R :7.~: :1.., I CERTIF"r' 1.'HR1.' 1: I F:IM FRMILIRR HITH THE REQUIREi"IE:NTS FOR ON-SITE SEHERS FIND HELL..S FIS SET F:ORTH BV TI-.IE MUNICIPRLIT¥ OF' RNC".HORRGE. 2: I HILL INSTRLL THE S'¢STEM IN RCCOFIDFINCE HI1.'H THE CODES. 3:: I UNDEFISTP'IND TMFrr THE ON-si'rE '.SEHEFI S'¢STEM i',lR'¢ FIEL::!UIFIE ENLFIFIGEME:N'T IF' 1.'HE FII!ESIDENCE IS FIEMODELE[:, 1.'0 Ii'.,ICLIJDE i',IOFIE: THF:IN S BEDFIOOMS. 2204 Cleveland Anchorage, Alaska 99503 I . . . L~eal Oe~crfnti~n: k o t_~ 1 o c k_,27~S u bdt v t S i o n~/~ ~P~~ This Korm Renorts Sotl~ Loo~ Percolation Test Penth Feet Soil Ch~ ra,,c,~?r i Q,t t c s Was 5round Water I~ Ye~, At wh~t De~th? Readinq Date Gr~ss Time Net Time Percolation Rate Hinute Prnnosed Inst~a-~,lom~'q: Seenaoe Pit Drain Field Test Performed By.~~~z~_ Data Certified DEPTH OF WELL OF WATER DRAW GAL~, PER HR Ffonl , ,, Ft, FL te~.. A & L DRILLING COMPANY BOX97, EAGLE RIVER,ALASKA99577 · TELEPHONE 694-2588 OWNER OF LAND ADDRESS . ,' ,'~ LEGAL DESCRIPTION DATE- Started Ended PERMIT NUMBER DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. < [ GALS. PER HR [ ,";: '.3 KIND OF FORMATION: From_ ~ Ft. to From '. Ft. to From ' Ft to.__ From , Ft. to From Ft. to.____ Ft. From .Ft. to Ft From___.Ft. to__Ft. From__ Ft. to.__Ft._ From__ Ft. to Ft. From .Ft to Ft. From Ft. to Ft. From Ft. to Ft. From__Ft. to.__Ft. From Ft. to.__Ft. From Ft to__Ft. From .Ft. to.__Ft. From Ft. to Ft. Ft. , ,',- ' t) ,. ',.. From Ft. to Ft. From Ft. to___.Ft From Ft. to__Ft -'/From Ft. to Ft, From Ft. to FL From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From__.Ft. to.__Ft. From Ft. to.__Ft, From Ft. to _Ft. From Ft. to Ft. From_ Ft. to__Ft, From __.Ft. to Ft. From__.Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME PERMIT NO. [:,EPF~R'TMENT uF' HEflLTH RND EN',~'IRONMENTRL PROTEC:TtOI",I 2~.;:1.6 E. TUDOR R[). 276-222J. ( 768¢38 ::, RF:'PL. ICRNT I~OUIE B EDWRR[? '.:-]RR BO',,',', 695 CHUGIRK L. OCRT ZON F~[:,R ~ ~N LRNE L. E6RL L9t %EC 18 "f':~SN R:LW LOT SZZE FEET MINIMUM DI'.=JTRNCE BETWEEN R WELL RNE:, RNY ON-SITE SE[,.IRGE [:,I':.'-;PO'-:.;RL SY':'~"FEM IS 10E~ FEET FOR IR PRIVFFf'E WELL OR 2EtC4 FEE"r FOR R F'UBLIC WELl._ WELL LOGS RRE REQUIRED RND MI..IST BE RETURNE[:, TO THE DEPRRTMENT I.,.ll'THIIq ]!:El DFI'.r':":_:; OF THE WELL COMPLETION. ::.:.;PECIFICRTIONS AND CONSTRUCTION DIRGRRMS RREE R",,'RIL. FtBL. E "FO INSURE PROPER I NSTRL. LRT I ON. I CER'T'IF~r' THWF ±: I RM FRMILIRR WITH THE REQIJIREMENT!E; F'OR OI".I-SITE SEI.,IERS RN[:' ].,IEL. I....'.E; F:IS SET FORTH B"r' THE MUNICIPFILITM OF' RNCHORI"aGE. · '.;~: I WZLL ZNSTRLL THE $~'$TEM ZN RCCORDRNCE WZ"rH THE ¢_:; I GNE[:,: _'~_..l;~..,..~2~_~,.~ RF:'PLICRNT LOUIE B EDWRRD .[ .r.',.: ,I.IE [ ............... [:'FIT E ..... ( erlifieh rilling by A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588 OWNER OF LAND ADDRESS LEGALDESCRiPTiON~/. ¢41 5'.~.~ /~ ~/~t~ ~/~ DRAWI)OWNFT. DATE-Started ~/3 o/EG Ended PERMIT NUMBER '~ ~:13~~ /~ '"'>., _ KIND OF FORMATION: ~' // '>d From ~Y Ft to~ /~" O-,~f~'.¢~i~ / ~From~Ft. to~.Ft /_ ~om / Ft. to)~ ~t. / F~om~/, ~t. to_~.Ft C From 'z~~ Ft. to ')~' Ft. .)~vo~.... g ~oC~:. ~ From . Ft. to Ft From ,;;STM Ft. From //'t~) Ft. to From Ft. top__ Ft From.__Ft. to___Ft. From Ft. to___ Fl From Ft. to Ft: From. Ft. to___Ft. DEPTH OF WELL 4.~,~.t. ~. ,/ STATIC LEVEL OF WATER Fr. 3 :/- Ft. (Sk ~ t' e'~/// 6 ~/]~c'q-T-(- From Ft. to____Ft ~,~o/:/ ~/(~Zf',Mff.,~. ¢ ~'"/~ Z'C~gFrom Ft. to Ft. From FI. to Ft. From Ft. to___ . Ft. From__Ft. to Ft. From__Ft. to_ Ft. From__FI. to Ft. From Ft. to__ Ft From.__Ft. to Ft. From__.Ft. to__ Ft. From Ft. to __Ft. From Ft. to__Ft. From__Ft.t~.' Ft. From Ft. to Ft From_ Ft. to_--Ft From__Ft. to Ft. From__Ft. to Ft. From Ft. to Ft. From Ft. to__Ft. From__.Ft. to Ft. From Ft. to Ft MISCL. INFORMATION: DRILLER'S NAME ": '" '~ ~ ' ( erlifiei [Irilliug A & L DI/ILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 69zl-2588 OWNER OF LAND ~', o~dt ~d _/_~ Z'Z)c~',q,~ O~~ DEPTH OF WELL _ / oo ADDRESS STATIC LEVEL OF WATER PT. LEGAL DESCRIPTION & ':[1 ~/ZQ I ~ ~-/~ ~ I ~ DRAW DOWN ET. From E~*~ Ft. to_ C~ ~~'~/ 5~~t. to-- Ft. () From /-) Ft. to ~6:' Ft. ~'3'//''',''~'y ~ 6'~,~,~dz, From__ Ft. to Ft From .?(~ Et. to q~) _.Ft. ~;~'--~ (9 From Ft. to~ Et From ,~L,,, Et. to ~ -' ' (-, -d ( ~ t~/~ ~,~ From ~ Ft. to_~ Ft. Fron~':~ Ft. to ~5c~ Ft. ~':/a ~ From Ft. to Ft From ~ Et. to /;:~'_Ft. /~LcYZ2' C'/-/~. Frmn Et. to__ Ft. From ~? ,~ Ft. to '7 ~" Ft. (,,~/4Vt~fd~t~Z-L From Ft. to~ Ft. From,/~ Et. to /c,., Ft. ,~'~/fiL~ From Et. to Ft. From Ft. to~ Ft. From Ft. to _Ft. From _Ft. to Et. From_ Ft. to_ Et. From ~ Ft. to Et. From_ Ft. to Ft. From Ft. to Ft. From Ft. to _Et. From Ft. to Ft. From~ Ft. to_. Et. From Ft. to Ft. From Ft. to Ft. Prom Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME Municipality of Anch,o.r,age Development Services Departh en: '" · Building Safety Division On-Site Water and Wastev~ater Pi:(~gr~n ': '~' - ' · 4700 South'Bragaw St..' ' · Parcel I.D. 051-172-51 ,1.' GENERAL INFORMATION c~)mpl i'd" ip etelega escr tion Lot 91B, Location (site at'dress or directions) ! 9407 Adrian Avenue James & Evelyn Morris Current Propedyo~ner(s) David & Teresa Schade "' PO Box 770864, Eagle River -... Mailing address , Lending agency Mailing address - P.O. ~ox 196650 A~drage, ~ 99519-6650. www ci anchorage akus ' ' ~ (907) 343-7904 :' ' - "' CERTIFICATE OF HEALTH AUfHORI~Y,AI~pROVA FOR A NGLE I-AMII'Y;DWELLING lo i .Expiration Date:. Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 .5'5- 0 / Section 18, T15N, R1W Dayphone688-5518 AK 99577 Day phone Craig Bennett/Prudential VislDayphone.689-6464 16635 Centerfield Drive, Eagle River, AK 99577 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System I TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding tank Community On-site [] 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 5 by an independent professional civil engineer registered in the State of Alaska. Certificates o[ 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 less than 30 days old. (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 t,,tunicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the v'alidation 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 end/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms end type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my Investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with at[ applicable Municipal and State codes, ordinances, and regulations in effectat the time of installation. $ &S ENGINEERING 17034 Eagle £;ver Loop Road No.204 Name of Firm Address Engineer's Printed Name_ bedrooms. 5. DSD SIGNATURE · JJ Approved for Disapproved. Phone Conditional approval for Additional Comments bedrooms, with the following stipulations: ~.-'.~' .' ., :' ~": WATER AND ... , PROGRAM By: Attachments: HAA Checklist Septic System Advisory _ Well Flow Advisory _ Maintenance Agreements Supplemental Engineer's Report Other , Original Certificate Date: (Rev, 12.,C0) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Soufft Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 w~v.cl.anct~-age.alL us (go7) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA FROM WELL LOG Date of test ~ Static water level ~ I fi. Well production ~' g.p.m. AT INSPECTION . ~,1 f~. ,q..2, ~.p.m. WATER SAMPLE RESULTS: Date of sample: "~/'1/0! Collected by: ~.,dg~, B. SEPTIC/HOLDING TANK DATA Tank Type/Material Other bacteria O colonies/100 mi. Tank size '/¢~;~ gal. Number of Compartments ' roundatio" c~ea~out (y~.) Date of pumping ~//~-/0 / Pumper ~'-,~" High water alarm (Y/N) Date installed Length ~'? ff. Width ,~ ft. Eft. absorption T°taldepth/~)'c~'ft' '¢~//3/0/ arae4~,.~ Monito~_...~e 7~ Date of adequacy test Results (Pass/Fail). ~.( Fluid depth in absorption tield before test / ~,~_~n. Water add~___~C~aJ. Elapsed Time:/4~nin. Final fluid depth f'in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) /~/l,/v~- ~'/'/4/~/ If yes, give date System type. / f~-'~/~ ~ Gravel below pipe ,-~-. 5" ff. Depression over field dO For -~ bedrooms ) # New depth~ ~. E~"~ g.p.d. O. LIFT STATION ED Size in gallons - 'Pump o~ level et Cycles tested Date installed 'Pump on" level at ~in. Datum /,/ SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift ;tatlon on lot. I OD /~- Absorption field on lot Public sewer main Sewer/septic sen~ce line ~. ~- '4- in* ManholeJAccess (Y/N) High water alarm level at Meets alarm & circuit requirements? In. On adjacent lots / o O ~.~ On adjacent lots /' oD / '*'- Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~- ~-- Property line ~ ~ Absorption field Water main ~'/~. Water sewice line Wells on adjacent lots /OO /~' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~;) /'~' Water Service line (/ Surface water /'o0 '+' Building foundation / O //- Water main N/~' Surface water / OD ~' ~' Driveway, parking/vehicle storage /'~::~/'*'' Curtain drain A/w~V.~: ~Vff.,f~/~ Wells on adjacent lots F. COMMENTS .... : - G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections end review of Municipal records that the above systems ara in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date ¥/, HAAFee $ '3 O0. Date of Payment H/I ,'1 / o t · Receipt Number O ~ "~ )- O ~ (Rev. 1~) 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 GENERAL INFORMATION Complete legal description Lot 918; S¢¢. 18; T15N, R/W, S.M. Location (site address or directions) Property owner Mailing address Lending agency Mailing address. Willie Rintoul Day phone 688-5931 2000 W. International Airport Rd. Suite A-10 Anchorage, AK.99502 Day phone Agent B~k Ma¢~n Day phone 564-2424 c/o Carr-Gottst~in Address A4fl! 4 q~o~ A~n~ga: A2~ska 99518 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: $ '-~ TYPE OF WATER SUPPLY: Individual well ×X NOTE: Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: X× Individual on-site Holding ta~k Community on-site Public sewer 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. Name of Firm Address Engineer's signature $ & S ENGINEERING 17034 EaRle River L~ol~ Road Eagle River, Alaska 99577 Phone DHHS SIGNATURE .Z~ _ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is continued suitability. Nitrate concentration is 7.9 mg/1. EPA 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. 72-025 (Rev. 1/91 ) Bac~ MOA fY21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type 1~'4 ADEC water system number Log present ~)~N) ~ Date completed ~C~-'1 -'J ~ Driller Total depth ~f[' ~" Cased to ~"l ~ ~"" Casing height Sanitary seal t(~N) '~ Wires properly protected If A, B, or C, attach ADEC letter. FROM WELL LOG Date of test ~o-"1 -"1 ~:~ I - 7-- ~ "ct Static water level "z~t ' ~ ' Well flow ~,~ g.p.m. ~.~' Pump level ~ ~ ~ t SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ ~' ; On adjacent lots Absorption field on lot ~ ~ ; On adjacent lots Public sewer main ~ Public sewer manhole/cleanout Sewer se~ice line ~ ~ Petroleum tank ATINSPECTION m WATER SAMPLE RESULTS: Coliform /,~ 4.,¢,~ /~oc,¢¢¢_~ Nitrate Date of sample: ~'~'c~l~ / I-~'/-~q? / Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (~/N) High water alarm (Y~ Date of pumping Other bacteria r--~ S & S ENGINEERING Eagle River, Alaska 99577 Tank size )c:c~c, ~,-u-- Compartments Foundation cleanout ~:;~N) *¢ Depression (Y~:~ Alarm ~ested (Y/N) ~ "~'PO -- ~ 2.- Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I c~c~ ~ To property line ~,~ Surface water/drainage On adjacent lots Absorption field Foundation "~ (~ ~ Water main/service line lo ~'~ 72-026 {Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Manufacturer Manhole/Access (Y/N) "Pump on" level at "-~crm--'~p off" level at ~sted Meets MOA electri~ NCE FROM LIFT STATION TO: On adjacent I(~ts Surface water D. ABSORPTION FIELD DATA Width Soil rating o (.o Gravel thickness Cleanouts present (~N) Date of adequacy test for Date installed Length c~ --zp~ Total absorption area ,¢'~'~)~' ~ Depression over field (Y,~ /'~ Results (pass/fail) ~'J/;~' Peroxide treatment (past 12 months) (Y/~) System type Total depth ¥ ~J/~ _ bedrooms If yes, give date "J/A. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I L¢~'~ On adjacent lots ~,C~°~'~ Property line To building foundation '-~' ~ To existing or abandoned system on lot On adjacent lots Surface water Curtain drain Cutbank ~l,~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in, date of this inspection. $ & $ ENGINEERING S ig natu re 17034 Ea_ale River Loop Road Eagle River, Alaska 99577 Engineer's Name Date ~_.~ ,."2-~ _,~ 'Z-- HAA Fee $ /7~ Date of Psyment .ecsipt N.mber 72-026 (Rev, 3/91) Sack MOA 21 Waiver Fee: $ Date of Payment Receipt Number DATE DATE DATE INSPECTOR INSPECTOR INSPE MUNICIPALITY OF ANCHORAGE MUN)CIPALITY OF ANCHORAGE ) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOND PT, O,F L ,,LTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL F,,Or~CTION ENV RONMENTALSAN TAT ON D V SION MAY 1 2 1980 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEtJ~E~'" ~'CI LV'I~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER MAILING ADDRESS PROPERTY RESIDENT (If different from above) *' PHONE 2. BUYER PHONE MAILING ADDRESS 3, LENDING INSTITUTION PHONE MAILING ADDRESS /~/~ ~-~r ~;~-T~ 4, REALTOR/AGENT '' PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPEOF RESIDENCE ~ING LE FAMILY ~ MULTIPLE FAMILY NUMBER OF~BEDROOMS ~ One [] Four '-1 Two ~ Five ~ Three [] Six [] Other 7, WATER SUP~PLY ~ INDIVIDUAL' [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM {3~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY * ATTACH WELL LOG. A well log ~s required for all wells drilled since June 1975. For wells dri led ~rior to that date, give wel depth (attach log if available.) YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72.010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DR I LLE D [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER E~JlNDtVIDUAL/ON -SITE DATE INSTALLED F-IPUBLIC UTI LITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank '~ ~_~_~-~ Size: ! ~}~ ~ If Tank is homemade SOILS RATING give dimensions: MANUFACTURER TYPE OF TANK TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line [ Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [~'"~APPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompa, a,a,a,a,a,a,a,a~rtificate) []DISAPPROVED 72-010 {Rev. 6/79)