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HomeMy WebLinkAboutVALHALLA BLK 2 LT 6Valhalla Block 2 Lot 6 #015-212-30 Municipality of Anchorage Page / of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Name: ~~ ~ ~/d~ ~5~ Wastewater System:~~ ~ Upgrade ~ ~,¢~ ~. 5~/~ ~ ~/~ ABSORPTION FIELD ¢ ~ /~ U Deep Trench ~ Shallow Trench ~Bed aMo~nd Uether LEGAL DESCRIPTION Soil R~ting: Total Bept" from original grade: GPD/Sq. Ft. WE LL: ~x*~ D New, ~ Upgrade 6r,ve~ depth: Ft. Number of lines; D~s~ance between line, t:' Classification (Private. A.B.C): Total Depth; Cased To: Total absorption area: Pipe material: Ft. FL SQ. FL Driller: Date Drilled; StalicWater Level: installer: , ~ Yield: GPM Pump Set al: Fl. Casing He[ghlAbove Ground: .~. TANK SEPARATION DISTANCES ~ s.pt~c ~o~g ~ S,T,S,., TO Septic Absorption Lift Hold~ng Pubfic/PHvate Manufaclurer: Capacity [n gallons; Msterial: ~ Number of C~partmenls: Surface w~t~ ~ ~ ~ ~ ~ LIFT STATION Lot / / Size in gallons: ~ Manufacturer: ENGINEER'S SEAL ~ OF AL.~ Department °f Health and. Hqma~Services appr°val Reviewed and approved by: ~ ~ Y~_ Date:~-/-~ ~'~ONAL~::~ 72-013 (t/9~) MOA~5 Permit No. Le al Description: SW930274 2 2 Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVIOES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone 3¢5-4744 On-Site Wastewater Dispo.al System and/or Well Inspection Report LOT 6, BLOCK 2, VALHALLA SUBD. SECTION 22, T12N, R3W 01521230 PID No.: PLAN 1"= 40' PROFILE OF ELEVATI~)N TEST HOLE fiTABLE OF_REFERENCE OJNT ~OEB~ ELEVATION DISTANCES REMARKS INVERT EL. NLET INVERT EL. 6" CLEANOUT ALARM SENSOR MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930274 DESIGN ENGINEER:BRUST AND ASSOCIATES OWNER NAME:MAZZEO ROCKY & MADELINE OWNER ADDRESS:5208 38TH AVE. SEATTLE, WA 98105 DATE ISSUED: 8/10/93 EXPIRATION DATE: 8/10/94 PARCEL ID:01521230 LEGAL DESCRIPTION: VALHALLA BLK 2 LT 6 LOT SIZE: 20000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: HOLDING TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 2 3 4 THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: BRUST & ASSOCIATES Engineers - Planners - Surveyors 1610 Dimond Drive Anchorage, Alaska 99507 (907) 562-7878 August 4, 1993 Municipality of Anchorage Department of Health and Human Services On-site Services 825 "L" Street Anchorage, Alaska RE: Lot 6, Block 2, Valhalla Subdivision This letter and attachments is to accompany a permit application for an on- site waste disposal system at Lot 6, Block 2, Valhalla Subdivision. The following are attached. 1. Drawing of proposed on-site system, and separation distances. 2. Soils log. This lot is served by a private well, which is adequate. I logged a test hole on 7/17/93, and found the existing soil to be unsuitable for a soil absorption system. There is very little area on the lot which is not covered by the 100' protected well radii of the adjacent wells. The soil is a hard impermeable sandy silt, overlain by 2.5' of organic material. Water was encountered at -5.3'. This would preclude use of a deep or shallow trench, or a bed system. There is not enough available area for a mound system. There is little probability of public sewer to this subdivision in the near future. I see no option other than a holding tank. Development on adjacent properties will not be adversely impacted by construction of the proposed system as distances to adjacent features would be in compliance with applicable requirements. Separation distances will be actually increased by abandonment of the existing soil absorption system. The existing septic tank encroaches on the protected well radius by 3' The proposed system will remove that encroachment. slopes on this lot are moderate, and average about 5%. Drainage is to the south west. It is recommended that a permit for the on-site system be issued. Sincerely, ~tan/ley Brust, P.E. ~ -- J ~LL 0 / / \ / ~ , ~J /, ~ co co/v~ ~ ~, ~ ~L~I , I ~ ~ ~ J ~O0'R(T~)--- ~ ' ~ ~J / ~ · NOTES: ~.....~ ............ ~,....~.~.....~ ~**~"~' ~" BRUST · ASSOCIATES ON-SITE SYSTEM DETAILS DA~: 7/~ 8/93 ENgINEERS-PLANNERS-SURVEYORS SOALE~ ¢-~00' 1610 DIMOND DRIVE (907)562-7878 ANCHORASE, ALASKA 99507 LOT 6, BLOCK 2 ;oB NU~O[R~ ~0 VALHALLA SUBD. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 PERFORMED FOR: f~ ~' ~ ~ ~ ~ i LEGAL DESCRIPTION: Township, Range, Section: 7-/Z.,/ SLOPE 81T'E PLAN t/t,,..-_.,, ,,, 1 2 3 4 5 6 7 8 9 10 11 WAS GROUND WATER ENCOUNTERED? IF ~S, AT WHAT DEPTH? ' Gross Net Depth to Net Reading Date Time Time Water Drop I I 14- 15- 16- 17- 18- 19- 20- ~ PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BE~W~,,EN ~ FT AND FT COMMENTS .4'o,/ /.,- /,,;p~.,,,t~',.'~' ,~-~.,..¢ ~r,,o,,:/~., PERFORMED BY: ¢, ~t./¢~- I %' /~¢~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4~85) ) MUNICIPALITY OF ANCHORAGE ( ~1~ , 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 L~ NEW MAILING ADDRESS LEGAL DESCRIPTION Well ] Absorption area Dwelling ¢ / PERMITNO. ~ Z Manufacturer Material No. of compartments ~ Liq. capacity in gallons ,FHOME~DE: Insidolength~ /h Width , /~ Liquid depth ~,~ [ X'~>O 5e~ Dwelling PERMIT NO. %_~O Z < anufacturer ~ [~ Material ~ Liquid ~pacity in gallons ~ Well Foundation ~ ~ PERMIT NO. ~ DISTANCE TO: %O~~ , '~q Noarostlotline ~,~, inches "o. of I,.es Length of each line~(~ ~ -- ~ ~ Total length of lines ~Trench width Distance between lines ~ ~of til0 to finish grade ~ Material beneatb tile ~ Total effective absorption area Length Width Depth PERMIT NO. ~ Type of crib ri diameter Crib depth Total effective absorption area ~ e Building foundation Nearest lot line ~ DISTANCE TO: ~lass ~ Depth Driller Distance to lot line PERM[~ NO. ~ DISTANCE TO', Building foundation Sewer line Septic tank Absorption area(s) OTHER 72-013 (Rev, U78) !l!!: i l!:i",!(i"l'l I FI'I!: GI:;:!:)II!,![:, !:::i!'~![:;' "iili~: I!?,(:)T'i()H 0!::: TI!Ii: li::::',l::::l:i',~,'l:::ll :!iON (:L?',I Fl_ii;E!) l' i !Iii!:;:!::] t ! Ii:i 111",! [:' '! :!' I:::!!'! l::i:::!!'1:!! IfF!l:;;: l,ll"[ll l l'll~; !:;?.i]iiOtti[?!::Hl]~_!"/'!:!i; I:::(1)F;i: O?',!':il;):'l'lll :i~!~l'.I~i]~;::; i::ff',!D i'll~i]! I.:ii; ~:'::::: July 29, 1977 R&M NO. 751206 Rocky Mazzio SRA Box 1579-D Anchorage, Alaska 99507 Subject: Soil Investigation for Sanitary Sewer System, Lot 6, ~lock 2, Valhalla Subdivision, Anchorage, Alaska Dear Mr. Mazzio: At your request of July 28, 1977, we conducted a subsurface soils investi- gation at the proposed location of the sanitary sewer system on the subject lot. The investigation complied with those procedures required by the Municipality of Anchorage, Department of Health and Environmental Protection. This investigation, which was accomplished on July 29, 1977, consisted of a test hole drilled to a depth of 18 feet below the existing ground surface. The test hole was sited according to your instructions and its location is shown in attached Drawing A-01. Drilling was accomplished with a rotary drill rig using continuous flight solid-stem auger with an outside diameter of 6 inches. A sample was taken at the depths shown on the soils log in Drawing A-01. The sample will be held in storage at our lab for approximately six months. In addition, all material brought to the surface by the augers was continuously monitored by an experienced engineering geologist. The topography at the drilling site is generally horizontal. At the time of the investigation the site had original vegetation consisLing o£ devil's club and low brush. The top of the test hole was located at original ground surface. The soils encountered in the bore hole are shown in the test hole log in Drawing A-01. The symbols used in Drawing A-01 are explained in Drawings B-01, and B-02. This log displays specific conditions encountered at the test location. However, subsurface conditions may vary in other parts of the lot without any apparent surficial evidence of the change. Groundwater was not encountered. Bedrock was not encountered. At the time the hole was drilled seasonal frost was not present. A percolation test was performed within the bore hole at the depth shown in the attached Table 1. All depths were measured from the top of the hole. The data in Table 1 show average infiltration from the depths indicated to the bottom of the hole. The measured percolation rate was 5.1 minutes per inch. July 29, 1977 Mr. Mazzio: Page -2- We appreciate this opportunity to be of service to you. Please contact us if you have any questions concerning this letter or if we can be of additional service. Very truly yours, R & M CONSULTANTS, INC. Stephanie Hoag Staff Geologist Jim McCaslin Brown, Ph.D. Head, Earth Science Department gld Attachments: Drawings A-01, B-01, B-02, Table 1 LOCATION SKETCH Lot 6 50' ~T.H. 1 Lot 6, Block 2, Valhalla Subd. Anchorage, Alaska Not to Scale Distances shown are approximate and have not been measured by surveying methods. A TEST HOLE LOG Scale: 1"=3~ ORGANIC MATERIAL SILT w/ SO[,~ SAND, CLAY AND GF~VEL (ML) Interlayered with SAND w/ SO~ GRAVEL 1-3' Layers Brown, Moist 2I TRACE (sP) 1 __10.5' GI~AVELLY SILT w/ SO~ SAND, TRACE CLAY (GM) Lenses of sandier material and of gravel 18'T.D. Groundwater was not encountered. This log depicts subsurface soils observed within the test hole at the location shown. See Drawings B-01 and B-02 for explanation of symbols. ~SMH I DAT E:--'~-~29 - 7~ [SCALE:see above LOCATION SKETCH AMD TEST HOLE LOG ROCKY ~ZZIO FB. PERCOLATION TEST Rocky Mazzio R & M NO. 751206 TI~E 10:16 10:17 10:18 10:19 10:20 10:21 10:22 10:23 10:24 10:25 10:26 ]0:31 10:36 10:41 10:46 10:56 11:06 11:16 ELAPSED TIHE 1 2 3 4 5 6 ? 8 9 10 ].5 20 25 30 40 50 6,9 FEET 35 375 4 4 45 45 45 o475 o5 .575 .65 .75 .85 1,0 1.15 1.325 DROP IN FEET 0 0 0 .025 .025 0 .05 0 0 .025 .025 .075 .075 .].5 .15 · ].75 TOTAL DROP 0.975 FEET {11.7 INCHES) IN 60 MINUTES 5.1 MINUTES PER INCH Well Log .. .......... ........... ........................................ For Y Location..~~...7...~ ........ ~..~....., . .~, ,~¢W~..~-,¢.,....~,..Z~,..,. .......... Date comple,ed ....... ~.~,,~.../.,~....~.,,..,~.,. .......................................... Size of casing ................................................. Distance to water ......... j,4'..~ ............................................................... Distance to water while pumping.......~_ .~.....~ ................. at rate of ...... j..4...~....i .......................... gallons per hour. .I iI Formation I from I to I Driller DELTA DRILLING COMPANY SRA BOX 394 B ANCHORAGE, ALASKA 99507 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box .066 o *.chorage, ^K gg 9- 6 0 ~.ci.anchomge.a~us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. GENERAL INFORMATION Complete legal description Lo'(- (~ ~2~:~C1~- ~" Location (site address or directions) Current Property owner(s) ...~"O~-/,3 Mailing address ~'~-~.O { Lending agency Expiration Date: Day phone :::~l~--_~ ~... Day phone Mailing address Real Estate Agent Day phone Mailing Address Un/ess otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: _~ 3. TYPE OF WATER SUPPLY: · Individual Well Individual Water Storage Community Class Well Public Water System 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 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 beb~veen 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 fcr properties served by a pdvate or C:ass C well and may be reissued with new water sample results. (Certificates may be reissued for a pedod of up to one year with valid water samples.) Certificates are valid for one year for properties served by C~ass 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. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 infqrmation obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(ara) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Engineer's Printed Name ~ ~- ~'~T,~ Date 5. DSD SIGNATURE tJ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with t Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: Mtmicipn!!ty of A cborage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Soulh Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-7g04 Legal Description: HEALTH AUTHORITY APPROVAL CHECKLIST WELL DATA Well type ~l~.-l~f~"~ If A, B, or C provide PWSID # Date completed ._.~7~T~ Sanimy seal (Y/N) ~ Total depth ~zLft. Cased to ~ It. ~ FROMWE~LOG Well Log (Y/N) Wires property protected (Y/N) Casing height (above ground) ~ in. AT INSPECTION Staac water leve~ ~- ~ ff. Well produc~on ~ g.p.m. WATER SAMPLE RESULTS: Coliform ~:~ colonias/100 mi. Arsenic: mg,/L B. &-'~,~TANK DATA Nitrate ~),~ mgJI. TankType/Matarial i{~~~''' '"1'"~d~---"~ Tank size Z.~OIPO gal. Number of Compartments Foundation c~eanout (Y/N)?~ Depression over tank (Y/N) Other bacteria ~ colonias/100 mi. Date of pumping C. ABSORPTION FIELD DATA Date installed 4::~/.-~/~-~ Cleanouts (Y/N) High water alarm (Y/N) Pumper ~',*[OI~:~-"C~L.~'t,,J,C) ~,,~,M.~J~-~ Date"D~e n~alled Soil rating (g.p.d./ff2 or ~/bdrm) System type T~~prassion over field. -- Date of edeq~~ail) ~ For __ bedrooms ~,~~'~atment (past 12 mo.) (Y/N & type) If yes, D~IFTSTA~ON Data installed 'Pump on' level at in. Datum SEPARATION DISTANCES Size in gallons 'Pump off' levL' Cycles tasted Manhole/Access (Y/N) - High watar alarm level at in. Meet~ alamt & clrcu~ SEPARATION DISTANCES FROM WELL ON LOT TO: ,~'~t~c tenl~iR ~tatisa on lot Absorption field on lot Public sewer main ~*'~l,,.[ ~- .,,~*lseptlc service line ~ I On adjacent lots ,,'v I I~' / On adjacent lets ~ I lO I Public sewer manhole/cieanout Holding tank SEPARATION DISTANCES FROM C~-~"T;,~w~_~OLDING~.ANK ON LOT TO: Building foundation ~.~._ t Property line JO ! Absorption field Watar main l~J ~ t,.-tg' watar service line '"~' ~"~C)1 surPace watar Wells on adjacent lets ~ J ~) I ~CPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line a.ilding foundation Watar main Fe Watar Service line C~ur~n d,~r COMMENTS Sur~ce water Wells on adjacent lots - ~'"ay. parking/vehicle storage G, ENGINEER'S CERTIFICATION I certify ~at I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Data HAA Fee Data of Payment Receipt Number (Rev. 12/0t) ~'~$ · '"" Waiver Fee $ Data of Payment '%~ Receipt Number  'K CT&EE~lmnm~t~l ~rvlces Inc. 1024312001 All Date~Thn~ are Aln~a Standard Time Eaton, Btcnt Priattd Date. rflme 07/16/2002 10:15 12201 Shenandoah Pi Colle~ed Date/Iln~ 07/12/2002 12:40 12201 Shenandoah PI Re,dyed Date/Ilme 07/1272002 15:30 Tedmknl ~or 0 Released By 4 0.950 I~L U~Iu M~.hoa ~ . Dam Date Init 0200 m~/L EPA 300.0 f<lO) ~//12/02 ~T · 2 OB, No Coli co~/lOOmL SMI$ 9222B O7112/O2 BAG Wt..IICM O0 NOT A.°P~R C~ T~F' R£~ED S~JBI~Ofl PLAT. UN~ NO C:IK:~dSTN4~'~ S~:XJ~D AH ~BUILT B~ ~ ~ COCSTRU~IIO¢ OR F~ ~'TA~U~IO BOUI~A.'~y OR I~4~ ~ Lm ~ SURVEY T~E NO'[[: Prepared by Johns, Jr.. & Assoc. Professional Land Surveyors REJ HLJ 2736 96-068 VALI1ALLA SUBDIVISION 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 ParcelI.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 6; Block 2; Valhalla Subdivision Location (site address or directions) 12201 Shenandoah Anchorage, AK Property owner Mailing address Lending agency Mailing address Agent Address Morrison Mechanical P.O. Box 91260 Anchorage, Day phone 272-4806 AK 99510 Day phone Kevin Olfrink/ Key Properties Day phone 345-4535 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 '~ 3, TYPE OF WATER SUPPLY: Individual well xxx NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site H0iding tank: Community on-site Public sewer Community well Pubtic water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 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 I 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 verifythat 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 regulatLoz~s in effect on the date of this inspection. ~ & $ ENG NEERING Name of Firm 17034 Eagle River Loo~ Road Id~,. _e_n,/. Phone ¢0 c,/~/_ ;~¢/ 7 c~ EagJe River~ Alaska 99577 Address , ! ~, /4/~,, Engineer's signature ~"~/~~--', /~4.,-~. Date ~//I/0/7 DHHS SIGNATURE Approved for edrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments ' ,'" ?he Muhicipality of Anchorage Department of Health and Human Services (DHHS) issues Health Aut ority -'Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. Tt~e 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 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, I]NViRONM~NT^L 81~RVIC~,S DI-~I~ON Municipality of Anchorage FEB DEPARTMENT OF HEALTH & HUMAN SERVICES J~ ~' C Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: ~-c~- (~ ~'~L~c:~ ,3_ y/jlJ/y,~.z.~ 4 ParcelI.D,: A. WELL DATA Log present (~/N) Total depth San tary seal ~/N). Date completed Cased to If A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected (~N) FROM WELL LOG AT INSPECTION Date of test '~/ / ~ ~ / ~7 ,~ ,~ ,,] / ~, / Static water level Well production '~" g,p.m. g.p,m. WATER SAMPLE RESULTS: Coliform © Nitrate Date of sample: ;:Z//~ /~¢ '? B. SEPTIC H~I~TANK DATA Date installed ~ / 3 $/'¢ 5 Tanksize ~7' Od Collected by: ~'~umber of Compartments __ Foundation cleanout t~j?N) Y/2 J Depression (Y/._~)~ ,~/o High water a arm (~/N). Date of Pumping. t / ~ 7 Pumper Other bacteria C~ $ & $ ENGINEERING ~7G~4 Eagie i{Jver Loop Road No, 204 Eagle River Alaska 99577 C eanouts ~¥)/N), Y4* -¢ C. ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Soil rating (g.p.d./ft2 or fF/bdrm) System type Gravel thickness below pipe ...~-~-~i'ota depth Monitoring Tub~(¥¢ ")N~/'EePression¢ over field (Y/N)_ Date of adequacy test Results-(Pa~'ss/Fail) For bedrooms Fluid depth in absorption field~befo erererererererererS~est (in,); Immediately after gal. water added (in,): Fluid depth //(ins) Minutes later: Absorption rate = g,p,d, ¢~Pef~oxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" lev~J~at~ "Pump off" eve at*. High water alarm level at* .~/*Datum Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septid~b¢ld~in~g~tank on lot / ~ O Absorption field on lot /~ / ,4- On adjacent lots On adjacent lots Public sewer main / //,' Public sewer manhole/cleanout Sewer/septic service line ? o -/- Lift station SEPARATION DISTANCES FROM SEPTIC~O~LDII~ITANK ON LOT TO: Foundation ~O Property line /o ¢ Absorption field Water main/service line ,~¢*o .]- Surface water/drainage /o ~ ¢~ Wells on adjacent lots / O o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Gu rtairrdCaTn Building foundation Wate r.~j3oain/se rvicel~ e'fi~ .... .... --~'-~-D~r~eway, parking/vehicle storage area Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review in conformance with M~A/ HA,¢~ guidelines in effect on this date. Signature Engineer's Name S are HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $. Date of Payment Receipt Number Zt~l, I~T&E Environmental Servleea Inc. CT&E Ref.# 970639002 Client Name S & S Engineering Project Name/# N/A Client Sample ID Lot 6, Blk 2 Valimlla S/D Matrix Drinking Water Ordered By PWSID 0 Smnple Reanarl~: Client PO# Printed Date/Time 02/13/97 10:15 Collected Date/Time 02/10/97 10:00 Received Date/Time 02/10/97 14:05 Technical Director: Stephen C. Erie Released By -~'/~" Re*uLt* 0.880 0 0.100 mg/L $~1B 6500-UO3F 10 max co[/lOOmL $M18 9gg~O 02/10/97 ,JBL 02/10t97 RAM Parcel I.D. # 1, 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 GENERAL INFORMATION Complete legal description /- / Location (site address or directions) Property owner ,,~/Z_.? Mailing address ,.-'~-'~',~'~" Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF I~EDROOMS: '-~ ~I' TYPE OF WATER SUPPLY: individual well 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: 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. 72-025 (Rev. 1t91) Front MOA #21 = 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 inspectiom Name of Firm ~'/~4,',~7 Address //~;/0 .)~/>-~.~'~d' Engineeds signature- DHHS SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. Phone Date 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 Pending 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. 72~25 {Rev. 1/91) Baok MOAt21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number ...... Date completed ,, * Driller .~¢/Tz~-z-~ Z~/-7/ b ,*, Cased to '~¢ Casing height ~/~ ¢ FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /Y2 y / Absorption field on lot ~ /~ ') Public sewer main Sewer service line WATER SAMPLE RESULTS: Wires properly protected (Y/N) g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots ~ / Public sewer manhole/cleanout Petroleum tank Date of sample: Nitrate ~~:~'~ Other bacteria Collected by: B.' SEPTIC~/I~0LDING TANK~DATA Date ~nstalled Cleanouts (Y/N) High water alarm (Y/N) Foundation cleanout (Y/N) Date of pumping Compartments ./ Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~/~:)~ On adjacent lets ? To property line /.?- Absorption field Surtace water/drainage ~------ Foundation 72-026 (3~93)° Front CONTINUE D ON BACK PAGE C. LIFT STATION /~.~,' ~ Date installed Size in galtons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA 4X~,~/,~ Date installed Length Total absorption area Date of adequacy test Width Soil rating (GPD/Ft~) Gravel thickness Cleanout present (Y/N) Results (pass/fail) Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION .System type Total depth Depression over field (Y/N) for After test .If yes, give date On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area Bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number RECEIVED . Two ( '] Fiw: ]~NDIVII)LVxLI ' :, [ IACI] ','l'{ I t I OG, A well Joy is lequiled for all ?,0ils N(Yi'I:: Till: IN,~P[{(i'i'I()['~ I;{[' MLIf;'I ACCOMIL,',.F]Y E,,",CIi i]l{(]/ ES I' I?EF()RE PItOCI{,~SING (:A~] BI] IFil'il ': ' r, ,LR !~LJPPL~ F.DIV DL ,(.MML NI ; itl(.' J] LI1¥