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HomeMy WebLinkAboutALPINE WOODS BLK 2 LT 6Alpin Woods Block 2 Lot 6 #015-234-13 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L' Street. Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES ,D~'5/&A/5 /IV IA/OdD ~_ TO SEPTIC ABSORPTION Address FROM ~ TANK FIELD WELL Phonets} Perm,t No iN° °l Bedrooms WELL ~- ~O/q ~E~ ~DESC.,.~.O./d ~-- ~ LOT LINE Lot j Bloc Subdiwson ~I ~ ~/~ (~o0~ FOUNDATION , Townsh,p, Range, Sect,on AS-BUILT DIAGRA~ IShow location ol well sepac system property hnes, loundahon, S Z ~ Ti~ ~t ~ ~ d ...... ay water bcd,es, etc TANKS ~ i Malerml~¢¢~ No. of Compa~ments~ TYPE OF SYSTEM ong'nalgfadeDeptht°pipeb°tt°mfr°m ~--~ FT ~}°taldepthfr°m°rlgtnalgrade ~-, FT Fdl added above original grade Gravel depth beneath pipe ~ Total absorpt,on area ,¢j Distance between hnes ~ g& SO FT ~ FT I WELLS ~ PRIVATE ~ OTHER (Identifv) ~J~ss~f~c~tlo~ (A,~.O) ~ot~l Depth Cased to ~O.~U~T~t ~iEC~ FT ET [nstalle~ ] Dale Installed I REMARKS: Scale: /"= /¢0' ~61~L Municipal and Stale guidelines in eflect on Ihis date: // ~ Health Depadmenl Approval: ~ _ Date: 72-013 (3/85) M U N I C I P A L I T Y 0 F A N C H 0 R A G E Depar'tment of Health & Human Set'vices 825 L Stpeet, Anchopage, Alaska 995(}1 343-472('.) 0 N - S I T E S E W E R P E R M I T F'e~mit. Number.: 880145 Date Issued: 07/29/88 Engineep Designed Owner. Name: DESIGNS IN WOOD Owner' Addr'ess: 89].1 JULIANA STREET ANCHORAGE, AK 99502Z-5564 Day Phone: 349-8014 Section: 23 '['ownship~ 1;~:N Ran,:;]e: 3W Lot Size 46144 (sq,,{"t:.,, or' acr'es) Max Bedr'ooms: 'This Per. mit: 4 'f'otat Capacity: 4 ~::)I::F' t I:C, .... I~,,NI" .... ": M:i.r'~imum total septic: tank ,:::apac it,'y. 1. '"'=" qal... Ion Each sept:it 'Lank must have at least 2 compartments. Depth ?..o t.c,p of septic tank(s) < 4.() feet r. equir, es ir'/su].a~..~.or'~ oveP ._.=~nk(s) INFORI*I D.H.H.S. F:'RtOR TO :LST & 2ND INSPE:C'TIONS BY ENGINEER, AF"I'E:R C.)I:::'F'IE;E HOURS, CAI....[... 343-4681 AND LEAVE A MESSAGE. CONSTtRUCT PER IEI',IGINEERS A'f'I"A[]I~IED AF:'F'ROVED DESIGN. P E R FI I 1" E X P I R E S 12 / 3,1./[38. PERMIT VALID FOR A SINGLE: FAMILY Fi'.ESIDENCE ONL. Y. IF I CERTIFY 'THAT: I, I am familiar' with the ~"equirement. s for' on-s:i, te sewer's ancl wells as set ~:or'f.h by the Murlicipa!ity of Anchorage (MOA) and the State o¢ A].asl.,:a. ;~,, I will instal], the system in accor'dar~ce with all MOA codes and regular:ions, anti in compliance wit. h the design criteria oF this permit. 3, I w:i.].], adher'e to all MOA and State of Alaska requirements for' the set back distances ¢Pom any existing well, wastewat, er disposal system of public sewer'age svstem on this or an~' adjac:ent or nearby lot. 4., I ur~,:::ler, stand t. hat this per, mi'L~zs valid ['op a maximum of 4 bedr'ooms. I also under'stand that. 'the cap~itv o¢ the total system :i.s 4 bedPooms and X/ PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage. Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: 2 3 4 5 6 7 8 9 10 11 12 Township, Range, Section: SITE PLAN SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Reading Date Gross Net Deoth to Net Time Time Water Drol~ / -//8/~ ~ 0 cO :. o -, ~ ~5 lo ~,&" t. ~" 13 14 15 16 17 18 19 20 COMMENTS Z.> :-: ,/~>/~/ 7.'g~ 7:g5 PERCOLATION RATE ~. ~ (m~nutes~ncl3) PERC HOLE DIAMETER TEST RUN BETWEEN ~' FT AND ~ FT PERFORMED BY: [L)~?/~. ~'/~ ~.7"~ ~ ~7/,,J I/Y/f/C/''/~jgZ--- -~- //"/~JJ}~'"J~OIJCERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE W,T..LL STATE ANO MUN,C,PAL G~,DE~I.ES,. E~FECT O. TH,S D^TE. DATE~ 72-008 (Rev. 4/85) 070 5F ?.~ Ac. 5 085Ac. 7-u~ - 5 /?: :" 5- ~4 558 SF O. 79 Ac. 588°pO'qS,,£ Municipality of Anchorage Development Services Department Building Safe~ DMsion On~ite Water & Wastewater Program 4700 Sou~ Bmgaw SL P.O. Box 196650 ~chomge, AK 99519~650 ~.ci.anchorage.ak.us (907) ~3-79~ CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAHILY DWELLING ParcelED. 0 5-234-13 1. GENERAL INFORMATION Expiration Date: Completelegaldescription ALPINE WOODS SUBDIVISION; LOT 6, BLOCK 2 Location (site address or directions) 6451 DOWNEY FINCH * ANCHORAGE, AK Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JOHN BUCG Dayphone 764-2708 3301C STREET SUITE 400 * ANCHORAGE, AK 99503 Day phone SUSAN BICKMAN W/ DYNAMIC PROPERTIES Dayphone 261--7600 3111C .~TRFF'T * ANCHORACF AK q9503 Unlessothe~ise~quested, HAAwillbeheldbyDSD~rpick~. 2. NUMBER OFBEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well B Individual On-site Individual Water Storage Individual Holding tank Community Class A Well [] Community On-site Public Water System [] Public Sewer The Municipality of Anchorage Development Sen/ices Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties sen/ed 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 sen/ed by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties sen/ed by Class A er B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note:Alaska Water and Wastewater Consultants, Inc. ahall be paid $ c~Z.~'"-at, or pdor I to closing for the engineering services provided. I 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(am) safe, functional and adequate for the number of bedrooms and type of structure indicated heroin. 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(am) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. NameofFirm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179 Address 6901 DEBARR ROAD, SUITE 2B * ANCHOEAGE. AK 99504. Engineer's Printed Name JEFFREY A. GAENESS, P.E. Date' "/[~ ~/O ~-' Engineer's Commehts: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identitiab/e features. The operational life of ail we/is and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions ara outside the control of the eva/uator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is f~r the sole benefit of the owner listed above. Any ra/iance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for ~7~ bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the tllowing stipulations: ON-SITE ;. WASTEWATER ~ ' PPOGRAM Manitenance ~reement~ ~ ~ ~ Supplemental Engineers Reo~ Other (Rev. 12,,01) Original Certificate Date: Municipality of Anchorage Development Sen/ices Department Building Safety Division On-Site Water & Wastewafer Program 4700 South Bragaw St. P.O. Box lg6650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907) 343-79o4 0 Legal Description: A. WEII DATA Well type CLASS Date completed Total de~th ,'t. HEALTH AUTHORITY APPROVAL CHECKLIST ALPINE WOODS, LOT 6, BLOCK 2 Parcel ID: 015-2.14-13 COMMUNITY WATER SYSTEM If A, B, or C provide PWSlD# 21..1598 Well Log (Y/N) Sanita~/seal (Y/N) Cased to It. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: ~olif~rm colonies/100 mi. B. SEPTIC/HOLDING TANK DATA g.I).m. Nitrate mg./L. Date of sample: Tank Type/Material STEEL Tank size 1250 gal. Number of Compements Foundation cleanout (Y/N) YES Date of pumping 7/5/2002 C. ABSORPTION FIELD DATA Date installed 11/4/1588 Length 75 ft. 2 Depression over tank (Y/N) NO Pumper pBELOW EXlS'rlNO GI~4D~I Soil rating (g.p.dJft~o~'~ 140 Width 5' lt. W:.,s propedy protected (Y/N) . Casing height (above ground) AT INSPECTION in. Other Collected by: colomes/100 mi. Date installed 11/4./1988 Cleanouts (Y/N) YES High water alarm (Y/N) N/A ISSAC'S PUMPING Total depth ,6.1,1 .lt. Eft. absorption area 646 fi= Monitoring tube YES Date of adequacy test 7/10/2002 Results (Pass/Fail) PASS Fluid depth in absorption field before test 0 in. Water added 1002gal. Elapsed 'r~rne: 0 min. Final fluid depth 0 in. Absorj:)tJon rate >- Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN System type SHALLOW TRENCH Grovel below pipe 3,0 It. Depression over field NO For 4 bedrooms New depth 0 in. 600 g.p.d. If yes, give date - D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off' I~=~/I et Cycles tested In. COMMUNITY SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lilt station on lot Absorption field on lot Public sewer main _ .~'~/er Ioup-C service line Manhole/Acc-<- (Y/tO High water alarm level at Meets alarm & circuit requirements?. WATER SYSTEM On adJacem lots On adJ~,'~nt Public sewer manhole/ctaanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Pmparty line 5'+ Absorption field Water main 10'+ Water sewice line 25'+ Surface water Wells on adjacent lots 200'+ 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Curtain drain NONE KNOWN Building foundation 10'+ Surface water 100'+ Wells on adjacent lots 200'+ Water main 10'+ Driveway, parking/vehicle storage 25'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal reconts that the above systems ere in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed N~me Date JEFFREY A. GARNESS Date o,.a..e.t . (Rev. 12/01 ) Waiver Fee $ Date of Payment Receipt Number in. LOT 6 " LO'I 5 EXIS]INC HOUSE 24. 1~ ~ ,,,/,~ ALPINE WOODS SUBDIVISIOi.~ 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 015-234-13 HAA #fei GENERAL INFORMATION Complete'legal description Alpine Woods Lot 6, BLock 2 HA970023 Location (site address or directions) 6451 Downey Finch Drive Property owner Karl..Boesenberg Mailing address Day phone Lending agency Mailing address Day phone Agent Jack White / Bonnie Mehner Day phone Address '3201 'C' Street, Suite 200~ Anchorage, AK 9950323994 Unless otherwise requested, HAA will be held for pickup. 4 NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well x Community well Public water NOTE: 762-3111 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: x 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 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 Municipality of Anchorage, DHHS Phone 907-343-4744 Address 825 L Street, Suite 502 Engineer's signature Date DHHS SIGNATURE Approved for -~c~--- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Addition~ Comments Septic tank pumped by A+ Home Services May 6~ 1998 This certificate is re-issued based on data received for a certificate issued on 1-23-97. By: 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. /2,-0~5(Pa~.1/91) Back MOAti21 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 Location (site address or directions) ~z~ ~ ~ '~ ~.=~/ t5~'o~:~ _~ ~~ ~ ' ' Day phone Prope~y owner ~ Mailing address ~~ ~ o~ ~~ C~ Lending agency I,,J ~ Mailing address Day phone ~J [/~ Agent Address ~_c,t C C--T, Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well l'~-----t"L~ ~-~2'- D ay phone ) o 3 - ,7c/4- Public water NOTE: 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. 72-025 (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. 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. A~aska Water Name of Firm Was,ewater Sarvir~ Phone ~ 7-'~/7~ 8471 8rootCd.c~i/Dr.[ Engineer's signature ~~y'~ Date DHHS SIGNATURE ~ Approved for 4 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 'BY.:: --' ",/r.':" " Date//- 23-'77 &PProwl C~'~ifi~"~ only upon the Bpr~en~tions given in ~rag~ph 5 above by an independent prof~i~n~ engiB~r ~i~erd in the State of Alaska. Th~ DHMS do~ this a8 and their lending institutiCn8 in Crier to ~tis~ e~lin fdeBI and s~te ~uireBen~. E~plCy~ of BHHS do not ~ndu~ ini~ion8 or t~ll~e datt before t Ce~ificate is i~ud. The ~unioi~li? of AnohoBge is not P~ponsible for e~o~ or oBi~iCns in the prof~ional engin~8 72-1325(Rev. 1/91) Back MOAi~E1 MUNICIPALITY O~ AN~JHg!~I~ ENVIRONMENTAl- SERVICES 0IV!SION Municipality of AnchorageJAN 1" 1997 DEPARTMENT OF HEALTH & HUMAN SERVICESR E C E iV E Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744 Health Authority Approval Checklist Legal Description: Lo-r- (=,_~ i~ Z) ~-~PtN~ c~c~'~Parcel I.D.: A. WELL DATA Well type ~_.~c~ I1~, or C, attach ADEC letter. ADEC water system number L~) .... Date completed ~°tal depthanitary seal (y/N)~-,,,,,,,,~- Cased t° -- --~ir~saling height (ab°~roperly pro~ed (y/N FRO~ ~ION Date of test __"~~ __ Static water level ~ Well production _ ~ g.p.m. ~ B. SEPTIC/HOLDINGTANK DATA Date installed tl/~ Tank size Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed ~ ~ / ~ ~ Length -'7 ~'1 Width Depression (Y/N) ~ C) ~'High water alarm (Y/N) Soil rating .(g.p.~fF or ft~/bdrm) ~Z~FC:) ~' / Gravel thickness below pipe Effective absorption area ~z~ Monitoring Tube present (Y/N) '~ Date of adequacy test I 'z./z~ ~/¢/~ Results(Pass/Fail) [3~--~ ~. Fluid depth in absorption field before test (in.); ~, '~'--~ Immediately after Fluid depth //- ~'' -~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) System type '/-~--~~ Total depth Depression over field (Y/N) I~ o ~ - For ~ bedrooms ji~'! __ gal. water added (in.):- 7_ _~. ~ "~- ( ~ 0 ~" Absorption rate = ~o,,~-- V-,~c~O~lf yes, give date .g.p.d. 72-026 (Rev. 3/96)* F. LIFT ~ ~ Date installed ~ Size in gallons~~ Manhole/Access (Y/N) ~ "Pump off" level at* SEPARATION DISTANCES SEPA~ROM WELL ON LOT TO: Septic/olh dingtank on lot ~ On adjacent lots /'~'~'~ Absorption field on lot Public sewer main ~ Pub~ Se~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~ ~ ~/~,~6 Foundation ~ t ~¢~..~.P~'Property line ,~/4- Absorption field Water main/service line ~ 1 o / Surface water/drainage ~'lO~3 / Wells on adjacent lots SEPARATION DISTANCE FI~IOM ABSORPTION FIELD ON LOT TO: Property line t~'~ (~_c~ !~-gu' ~uilding foundation ~lc~ ~-' Water main/service line Surface water ~'toO ~ Driveway, parking/vehicle storage area "7 · Curtain drain No~ [~.~ ~J ~ Wells on adjacent lots ~- 7--~0 ENGINEER'S CERTIFICATI~ ' '~?~.:~'~%'~% ,~{ I cedi~ that I h~et~i~d t~ru field inspections and review of Municipal records~.~e~o~e~y~ re Engineer's Name ~ ~ ~ ~ ~-;: ~//J~~~~;~' Date / ~30 ~ ~ ~'~" '~/~~> HAA Fee $ ,'~ D'-L5 , ~'~ Date of Payment ///~/~ 7 Receipt Number ~_5-"~2 ~/'~ ? 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number Parcel I.D. # 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 Corn plete legal description HAA# H clSO1 I I Lot 6; Block-2: Alpine Woods Loc~{i~n ~site address or directions) · ::i;;i'~Property oWner.'' P~p & Ginq~,~ : .: :!~:-,Mailing address' C/0 REAL ESTATE SUPPORT SRVC ~;~aii!ng address,' ~_. Agent - ...... - ~ "Address 6451 Downey Finch Drive Anchorage. AK Day phone, -34,5-84~;7 8200 Humboldt Ave. South Suit~ 204 Minnea~oZ,~, MN 55451 Day phone Day phone -: NOTE: Individual well ...... ~ ~-'0 ~', .: Community well XXX --. ~, ~ '~"~. ' Public water ~ ~. ".~, ~ F .... ..~,~ ~ ~? , If communi~ well system, provide wfi~en confirmation from State A~a~est- lng to the legafi~ and status of system. 4. TYPE OF :WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system,'prOvidelwritten confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) 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 invest.~ation 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 ~aTg1034 Eagle River I'°~P Roa-cl N'e~ EngineeCs signature Phone Date SIGNATURE , Approved' for Conditional approvar;for:(1''~'' ' ":? *': b~ro°ms, 'with the following stipulations:~'~:~}}-. Additional Comments , L-x[,''' By: 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. 72-~'25 (Rev. 1/91i t~ck MOA ~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data///'~ Well type L.r~4',4/t~NlTt/ If A, B, or C, attach ADEC letter. ADEC water system number / , / Log present (Y/N) /'~///~ Date completed ,'?~ Driller Total depth ./~//~ Cased to /~/~ Casing height Sanitary seal (Y/N) /b///~ Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well flow ?~///~ g.p.m. ~r Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot bOO "/ Absorption field on lot ~00 ''/ Public sewer main ~/~ Sewer service line ~,'/,,'~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform / Date of sample: /~/~ Nitrate Collected by: Other bacteria B. SEPTIC/bI~IL~ TANK DATA Date installed Cleanouts (~N) High water alarm (Y/N) Date of pumping Tanksize /~.~© 5,,~c Compartments Foundation cleanout {~N) YE~- Depression (Y/~ I'~/~ Alarm tested (Y/I~ ~II I~( Pumper ¥~)70 SEPARATION DISTANCES FROM SEPTIC/J~I~Ei~I~G TANK TO: Well(s) on lot /'J/A To property line 16 -k Surface water/drainage On adjacent lots Absorption field Foundation _~ Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE Date installed Width Length / C. LIFT STATION / Date in~~.~ Manufacturer Size in gallons ~ Manhole/Access (Y/N) ( I "level at "Pump off" Level at Vent .Y/N. -- · ~ High water alarm level ~._ 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 /~//~/~ Soil rating (GPD/Ft2) ~/z/O _t F,F~/,_ System type Total absorption area Gravel thickness ~ Total depth Cleanout present (~N) Y~' Depression over field (Y/J~J Results(pass/fail) ~?-~ for /~ ~ If yes, give date ~ Bedrooms Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot f0/~ On adjacent lots ~-2,O0 '~ Property line (~ /~/' ! To building foundation ! 0 /- To existing or abandoned system on lot On adjacent lots ~ ',~ Cutbank ~,/A Water main/service line /O ' Sudace water 1Od ''~ Driveway, parking/vehicle storage area /d '-/- Curtain drain [~) OrJ¢-~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date HAA Fee $ ~ I ~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back MUNICIPALITY 0f ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-66~- 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # GENERAL INFORMATION Complete legal description Location (site address or directions) 6,751 Downy F.incf~ DrJve. Property owner Mailing address Day phone Lending agency Mailing address Day phone Address 320i C $~.¢ee.,., Anclwrage, A~.asEa 99503 Day phone 56,~-~5o0 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: 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 NOTE: X Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER Sm 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 DHHS SIGNATURE ~' Approved for S & S ENGINEERING 17034 Ea.qle Ri,vet Loop Road No. 204 Eagle River, Alaska 995T~. bedrooms. Phone Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date///- z~F -/6;~/ 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. 72-025 (Rev. 1/91) Back MOA i¢21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKUST Legal Description: .Z~ ~ 'i ~.~. _nr_~'_2_ )/~/pj~ b.)~r~d ~ Parcel I.D. A. WELL DATA Well type ~zJ~l~'lf A, B, or C, attach ADEC letter. Log present (Y/N) Date completed ADEC water system number Driller Total depth Cased to Casing height Sanitary seal (Y/N) Date of test FROM WELL LOG Wires properly protected (Y/N) MUNICIPALITY OF ANCHORAQE AT INSPECTIOIr~INVIRONMENTAL SERVICES DIVISION Static water level Well flow g.p.m. RECEIVED g.p.m. Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Z ~ 'f Absorption field on lot ~__ cOO '¢ Public sewer main '~l ¢~ Sewer service line ~_ ~-~ Jr WATER SAMPLE RESULTS: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ./0 0 t,.)C, 'H-acked ppmv [ Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~,,- I ~- ~ Cleanouts (Y/N) L~ High water alarm (Y/N) Date of pumping Tank size l 2 ~--0 ~ ~[/o~j% Compartments Z Foundation cleanout (Y/N) u[ Depression (Y/N) P~ Alarm tested (Y/N) ~/I~ - ~ '~ - '~' I Pumper ~ + /'~J'e~(= _~_~r SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ¢J / I~ On adjacent lots To property line ,/O Surface water/drainage Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date i'~ed Manufacturer Manhole/Access (Y/N) Size in gall _ ,, Vent (Y/N) %, ./% Pump on" level at . "Pump off" level at High water alarum lev~ .... Cycles tested Meets MOA electrical co%Y/N) _____ SEPARATION DISTANCE FRO~FT STATION TO: Well on lot %djacent lots Surface water D, ABSORPTION FIELD DATA Date installed ~/' - I~'.- ~:~4 Soil rating / O0 ,c~/~ ~ System type Length ~ ~ Width I ~ Gravel thickness ! 2. Total depth Total absorption area ~ _~0 ¢ Depression over field (Y/N) ¢ Results (pass/fail) ~ ~ ~ -~ Peroxide treatment (past 12 months) (Y/N) Cleanouts present (Y/N) Date of adequacy test for ~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots .:2 cOO f- Property line t -f' To existing or abandoned system on lot Cutbank _/~-TO Y- Water main/service line Driveway, parking/vehicle storage area I / 0 '-t- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect Signature Engineer's Name Date S & $ ENGINEERING 17034 Eaqle Ri,ver Lo~p Road No. ~lz ¢,~gle River, Alaska 995~7 ~ ~late~qf this inspection. ii' ~.~¢ '~' · ¢-~-_ ~,~ , .~,. HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Parcel I.D. # MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ["~./~'"_ ~_~.?'Z/'-/'~,~ HAA # ~g\ g~.- '~L_x,.-~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LoT' /~ ~_oc~ 7_ ,4£p/,~ I~ocD~' ~ Z..:5 'TI~/~i Location (address or directions) e, ./-/._¢ / ,O O L ~.' ~ ~-- ~ ~ l ~d c ~4 lc)re:, (b) Propertyowner DF__.5~G,~5 /xf I/dOoD Telephone'(home) Business 5~/'~ - ,do i ~/ Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family~ Number of bedrooms WATER SUPPLY Individual Well [] Community ~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site'[~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /~/'/~J L~-r/_.-~ o Address PO- -~0 Y" Date Telephone 3'S'7- 836 7 / Engineer's Seal 6. DHHS APPROVAL Approved for '/7/' bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: L 4~ ~Z. .~/A~,,,~: A. WELL DATA Well Classification Well Log Present (Y/N) __ Total Depth Cased to __ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Date Completed Depth of Grouting If A, B, C, D.E.C. Approved (Y/N) Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~F__. ~ AT'TAd H E-f'~ · On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ;Date B. SEPTIC/HOLDING TANK DATA Date Installed /oJ/$.j,~ Size Standpipes (Y/N) ')/ Depression over Tank (Y/N) IZ~O Air-tight Caps (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) /./,/4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~O.~.~u,~,r? ~.'~Z.z_. To Building Foundation To Property Line -~'O' To Disposal Field To Water Main/Service Line 5/~' No. of Compartments ~/ Foundation Cleanout (Y/N) y Date Last Pumped ~J~/ ~,,, .~, ,~UCTiO~J ;for Temporary Holding Tank Permit (Y/N) Comments To Stream, Pond, Lake or Major Drainage Course ~©~z_ ¢~ A ~_:,~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /~ '-/$ - ~E Width of Field Type of System Design Length of Field "/:~ Depth of Field 2'-~ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test Y SEPARATION DISTANCE FROM ABSORPTION FIELD: ToWater-SupplyWell /~,om. mu~, r-L/ To Building Foundation ~©' Lot ~J~'~ o ^~ LoT To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ,4/~,~/~z)T~J ~,~ ~TE~ / b · To Property Line ; On Adjoining Lots To Existing or Abandoned System on To Cutback (if present) '"'"'D~J.FT STATION . Date I ns~a~.......~ _ ,Size in Gallons ~ Pump On" Level at -'"'""'""~~ High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ,~..........~ Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA inspection. Company Date MOA No. Receipt No. Date of Payment //-- ~"~-,/" Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 idelines in effect on the date of this Engineer's Seal MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH A~JTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section~ township, range) Location (address or directions) (b) Applicants Name_~?~,~.~ ~?_ z~/=/~.:m~ Telephone - Home 2 ~/g ~ ~u~ess Applicants .... ~ ..... , . ~dress ~Zp,5~ ~/a/a C~;~~-~ ~ (c) Applicant is (check one) Lending Institution ~ ; ~er/builder ~ ; Buyer ~ ; Other ~ (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent "- Address Telephone (f) Mail the ~kA to the following address: 2. Type of Residence $ingle-Family~ Number of Bedrooms Multi-Famil y :~ Other (describe) 3. Water Su~ Individual, Wel!~ Community ~ Public~ Note: If community well system, must have w~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Onsite ["~ Public Community Holding Tank~ Note: If community well system, must have v~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] Engineering Firm Providiny__in_~s~ections, Tests~__File Search~ Data and Information As certified by my seal affixed hereto and as of the validation date shotra below, i verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal, system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify based on ~'~ info~vaation " ~ .... oota~.ned from the Mmnicipality of Anchorage files and from investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with e_l! Municipal and State codes, ordinances, and reguia-- tions in effect on the date of this inspection° Name of Firm Address DHEP A~_p r oval Approved for ,i> bedrooms Approved ~' ' .: Disapproved Terms of Conditional Approval CAUTION THE L~bq,~ICIPALITY OF ANCHORAGE DEPAR%%lEN~f OF ~ALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SO~LY UPON THE REPRESENT- ATIONS GIVEN iN PARAGI~kPH 5 ABOVE BY AzN INDEPE~DENT PROFESSIO~i~L ENGIN~EER REGISTERED IN THE, STATE OF AI=%SKA. TILE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. ~PLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. T}~ MUNICIPALITY OF ~u~CHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK~ (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7 -I 9-84 Well Classification ~,tUNICIPALITY OF ANCI-IOI~QI~ DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (~{OA)£NVIRONMENTAL PROTECTION PP OV n FEB CHECKLIST - FEBRUARY 1984 Legal Description: Cased to Well Log Present (Y/N) Total Depth Static Water Level ;~ ~ Casing Height Above Ground If ~ B, C~ C, D.E.C. A provea(g /N) Date Completed Pump Set At Electrical Wiring in Conduit (Y/N) Separation Distances f~cm Well: , To Septic/Holding Tank on Lot '7_ ~ o ~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 2 dOt ' ; On Adjoining Lots TO Nearest Public Sewer ~ T l/- C Yield i~.. Depth of Grouting Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Nearest Public Sewer Line C leancut/Manhole Water Sample Collected By 'Water Sample Test Results C~u~nts To Nearest Sewer Service Line on Lot ; Date '~ ~ B. SEPTIC/HOLDING TANK DATA Date Installed [{l''c l~ %'J Size Sta~i~s ~) ~/ Air-ti~t ~ps (~) ~ession o~r Ta~ (Y~,)) I~ ~te ~st P~d t~' A P~ing~inte~n~ ~n~a~ on File (Y~)~A ; for ~'~ Holding Ta~ High-Water ~a~ (Y~) ~ ~r~ Holdi~ Ta~ ~r~t (Y~)~ ~p~ation Distan~s ~ ~ptic~olding Ta~: To Water-Supply ~11 ~ ~' To ~ildi~ F~ndaticn , TO Property Line To Water MairJService Line Course ! o o % To Disposal Field ~ To Stream, Pond, Lake, cr Major Drainage Receipt ~ Date Paid: Amo un t: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD BATA Soils Rating in Absorption Strata Date Ir~talled ~f% ~ ~ ) ?~ Width of Field i ~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field '~ Depth of Field ~- Gravel ,Bed Thickness ~ ~?~ Standpipes .Pr~esent (Y/N) Date of Last Ax~equacy Test Separation Distance from Absorption Field: To Wihter-Supply Well ~co-~ To Property Line / TO Building Foundation [ ~' To Existing or Al~ndor~d System on Lot ~7 ~ ; ~ Adjoining Lots / TO Water Main/Service Line ~;~m [c'~ TO Cutbank(if present) /vA To Stream/Pond/Lake/or Majo~ Draipmge Course ,~ c TO Driveway, Parking Area~ cr Vehicle Storage Area I D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dir~e~s ions ~A MarJ~ole/Access (Y/N) ~"'~ "Pump ~f" ~1 at ~ Vent (Y~) ~ ~ing Cycles ~ing Adeq~ ~st. .~ee ts Mf)A Ccnm~nts Signed KB1/d5/s [Page 2 of 2] ** Check Permitted Bedroom Rati~3 Against HAA Request I certify that i have checked, verified, or oonforn~d to all MOA HAA Guidelines in effect on the date of this inspection. [ Date MOA No. 2-15-84