HomeMy WebLinkAboutHAMANN LT 4AHc monn
Lot 4A
#050-611-19
,~./ MUNICIPALITY OF ANCHORAGE ~._/
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
· 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING AD DR ESS.? ~--)'
LEGAL DESCRI~T>~N
LOCATION NO. OF
] Well . ~ Absorption area /
DISTANCE TO: c~ "
, ] I /a
~ Z I Manufacturer L~ - No. ~.~mpartments
~ ~cap IF HOMEMADE: Inside length -~. Width ~- Liquid~th
Well Dwelling PERMIT NO,
DISTANCE TO:
Manufacturer ~ _~ ~ ..... Mater~l~ ~ L~Nuj~a~it~ gallons
No, of lines ~ Length ~ eap~ ~ hre h~of lines Trench//width~/~ .~ Distance between lines
Top of tile to finish grade C~ Material beneath tile ~, ~ [~s Total effective r ea
Length Width Depth PERMIT NO,
Well foundatio~~¢ ~ Nearest Io~-Iin~
DISTANCE
TO:
D~pth Driller ~ Distance to lot line ~ PERMIT NO. ¢~ .~
Building foundation Sewer line I Septic tank I Absorption area(s)
DISTANCE
TO:
/
OTHER
PIPE MATERIALS
,/"D
SOIL TEST RATING
INSTALLER
REMARKS
APPROVED /,~ :
72-0'13 (R'~/v, 3/78) //I
DATE LEGAL
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759
OWNER OF LAND
ADDRESS ""/:"
LEGAL DESCRIPTION
DATE - Started -//
Ended ,, i
PERMIT NUMBER
DEPTH OF WELL '~ ~f f, L;
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
KIND OF FORMATION:
From ~' Ft. to ~ o _Ft.
From__ Ft. to Ft.
From i ,.~.~ Ft. to ·; / Ft.
From__ Ft. to Ft.
From ' / Ft. to /'3'::~ Ft.
From r~[ '~ Ft. to ~ '/ /,Ft.
From___Ft. to Ft.
From // ,' Ft. to, )1 ~ Ft.
From · · ' Ft. to !,, ~' Ft.
From__Ft. to Ft.
From 'i.~ Ft. to ,"-: ~ Ft.
From '~ ;: , Ft. to
' :--~ Ft.
From__Ft. to__Ft.
From ; ' · ~'': Ft. to '
From '~ '-~' -- .Ft. to ,,~": ;~ Ft.
From Ft. to_ Ft.
From ,--; ,:~' '~' Ft. to ,?:" :~ Ft.
'('"? "-"~9 ?" ~'~:~ ,;~//' ,' From--
f ~"-',.;z.!F~' From_
< :,~,'/,1 v f-A:" '/~,a~,:,,L .:::~ From__
/'[:: ~.~ tg::':C<,~ From
, ~?x~Z<:~.:' ', ~ '-. From ~
From
From
From
From
Ft. to Ft.
Ft. to Ft
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to Ft
Ft. to Ft
Ft. to Ft
Ft. to Ft.
Ft. to _Ft
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME
.~ ", E:,EF'FIR'T'MENT 6._~/HERLTH aND EN',/I F.: .' NMENTRL ~..?J/, r= _:T I ON
, 8.'...~z5 '"L"' STREET., RNCHORR. GE.. RK. '_:.~:~.501
, 264-4720
_ET D,:_ 2:.:~ S;._RRE FEET
LEGAL L4~ FIRMMRH ~
T'¢F'E nF ';I"'IZL IflESORF'TION S'¢STEM IS ~~-b[:,
....... ~ . .
MR::':: I MUM NUMBER OF BE}ROOMS = ~ ~ ~--x SOIL RRTING ;bb. FI,--'BF::,=
THE REQ_IRED SIZE OF THE SOIL FIEfE;ORF~~~(I Ib:~.~
THE LENGTH [',IMENCTFIN I'; THE LEN3TH (IN FEET::, OF THE T[ENCH
G~.OI..I[.~[: AN::THE BOTTOfl CF THE E,:.:,::fl,,fl'rZ]N ::!,.4 FEET::. ~
-KHE T~:E~-~C:H ~.,~ Z E:,Tt4 ~ ~ .~Z Zt. FEET.
THE GRR',,,'EL DEF'TH ~S THE M~4, ZMUM DEPTH OF GRFI'¢EL BETHEEN THE OLITFRLL P~F'E
RN[:, TF'E BOTTOM OF THE E,:.:,CR,,,RTION ,::IN FEET::,.
L N_, flN'¢ HEt. LS . -
INSTRLLRTIF~N IN=,FE_.II OF RE:,.TRF:ENT TO THIS PROF'ERT'¢ FINE:, THE
NUMBER OF RESIDENCES THRT THE HELL HILL SERVE.
BRE:KFILLING OF RN¥ SYSTEM HITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPRRTMENT HILL BE E;UBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN R HELL RND RN¥ ON-SITE SEHAGE DISPOSRL Sh.'STEM IS
:1_80 FEET FOR R PRIVRTE HELL OR t50 TO 200 FEET FROM R F'UBLIC HELL [.',EPEN[:,ING
UPON THE T'¢PE OF PUBLIC WELL
MINIMLIM [.',ISTFINCE FROM FI F'RIVRTE 14ELL TO R PRI',,,'RTE SEHER LINE iS 25 FEET FIN::,
TO R COftMUNIT¥ SEHER LINE IS 75 FEET.
HELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT HITHIN 3:8 DFI'¢S
OF THE HELL COMF'LETION.
OTHER RELqUIREMENTS MR¥ RPPL.'¢. SF'ECIF!E:R'~IONS RND CONSTRUCTION DIRGRRMS RRE
Ff',,,'RILRBLE TO INSUF..'E F'R. OPER INSTRLLFITION.
I CERTIFY THRT
! '! RM FRMIL. IFtR WITH THE RE~:.!IJIF, EHENF:, FOR ON-SITE =EI. LF..=, RN[:, HELl q RE; SET
FORTH B'¢ THE MUNICIPRLtT'¢ OF RNCHORRGE.
2: I HILL INSTRLL THE S'¢STEM IN FICCOR[.',RNCE HITH THE CODES.
3:: I UNDERSTFIND THRT THE ON-SITE SEWER S'¢STEM MR¥ REQUIRE ENLRRGEMENT IF' THE
RE':;IDENE:E IS REMO[."ELE[:, TO INCLUDE MORE THRN 4 BEDROOMS.
V4. 0
R-s.ell Oyster
694-2774
Performed for:
Legal Description:
Depth (feet)
0
9__
13__
14__
15__
O & E ENGINEERING & DEVELO"F--MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Name:. /~//~/~ ~'///L/~/~ L/-~ ~-
Soil Characteristics
Earl Ellis
688-2280
Tel. No ~z~- :~<~73~
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit__
~o
If yes, what depth
Drain Field
ertifiei Dd[[t.g
by
DOC Co, dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALAS KA 99567· TELEPHONE 688-2 ~pt.: Mumc~pal~tYHealth & Human°f Ano~ra~e3e~lces
ADDRESS, '- - ~ ')
LEGAL DESCRIPTION ~:~'i ..... d!.. /-) //,q,.17 /4/,,JD
DATE - Started Ended
PERMIT NUMBER
/
DEl'TH OF WELL <?(3 0
STATIC LEVEL OF WATER F'F (.7,, t ')
DRAW DOWN FT.
GALS. PER HR {,/ ,5
KIND OF CASING () ~:c;) (.)
KIND OF FORMATION:
From /) Ft. to-:- Ft. ,_;.ci:,;;,,'t~(~, ,(, T) C.rf ,r) /9 From.
From :>~. Ft. to .2.~ Ft. t ~ ..... &~,,v,-. ,1 -- ~- From
From ,-~., Ft. to ~}~ Ft. ~ From
Ft. to.
Ft. to
Ft. to
Ft. to
From~i~+r) Ft. to/'/O Ft.
From //]/0 Ft. to/St' .Ft. d';,":D,
From_/'('/ Ft. to /("~"0 Ft.
From / ('~ Ft. to~
From,J )2)" Ft. to ?/} <'
From
/
Ft. df.. ~/< .'~,:,~. JiO;,~,ts ~/~'<LC'fJ From
Ft. L') {:,:)/d,_~c:,.(~ · .. r+ i ~ 'f From
->-~ e )O;' Ft /~;&',:<<3-)Co/d "'9,~"
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.
Et
Ft.
Ft.
Ft.
Ft. to--Ft
Ft. to Ft.
__Ft. to Ft.
Ft. to Ft.
_Ft. to o*--- Ft.
From Ft. to Ft.
From__Ft. to__Ft.
From Ft. to Ft.
From Ft. to Ft.
From__Ft. to__Ft.
From FLto__Ft.
From Ft. to Ft.
From Ft. to Ft.
MISCL. INFORMATION:
!
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930450
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:BRAND JEFF I & JANET E
OWNER ADDRESS:HC 83 BOX 1626
EAGLE RIVER, ALASKA
99577
DATE ISSUED:10/26/93
EXPIRATION DATE:10/26/94
PARCEL ID:05061119
LEGAL DESCRIPTION: HAMANN LT 4A
LOT SIZE: 53227 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. 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).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. 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
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
1. EXISTING WELL MAY BE CONTINUED IN USE. IF CONTINUED USE
IS NOT DESIRED, WELL MUST BE PROPERLY ABANDONED.
2. NEW WELL MUST BE A MINIMUM OF 100' FROM ADJACENT SEWER
SYSTEMS.
PAGE 2 OF 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
3. SUBMIT WELL LOG WITHIN 30 DAYS OF COMPLETION OF WELL.
ISSUED BY: · ~ -'"'~z--~~ DATE:
~ ' . %,-.' . . ..' t "-.. . .': .
;"-~ \ ~_~-. '. -. ,,0'.. "-._. . ~: .
:, ~",, ',.. I/-". "1 ' - '"'..~ ' '
:'.. ~:,. "N~ t. '":'. :-~ .
AS-BUILT
[ hereby cert [3 t~at I hav~ surveyed thc fo lowing described
~ ?~y~ ~.,:. > ~'~ ~. ~z__~ ..............
~/~3, ,~ ~ ~ ·
merits si~te~ tbeteo~ ~e wit~ tb~ Etope~ ~nea and ~o
~o~ ove:~ap o: e~oac~ o~ the p~Pc~tY 1)'i~ aaJ~t there-
roadw~s, ~ansm~smn lines or other visible easemen~ on
said prope~y except as ~ndicated Eera:~n. .
~ntod at Ea'!e ~iver.' Alaska
",, . ' ~-~.;'/ Box asa, ~aa~c p.i¥~r, Alaska
1 ~ Phone (907)
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 'L' Street Room 502
RO. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. ~"~ -&//- / ~/
1. GENERAL INFORMATION
Complete legal description t, ot 4k,
24251 Hamann Road
Location (site address or directions)
Current Property owner(s) Chris Grasse
Expiration Date:
Eamann Subdivision
Dayphone 694-6~36
Mailing address
Lending agency
Mailing address
Day phone
Real Estate Agent Renax/kal:hi Olastead Day phone 694 -4200
Mailing Address 16630 Centerfteld Dr., Ste 201, Eagle River, AK 995.77
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: ~
' .l ~- )~ Ioo
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
....... Individual Water Storage
.... Community Class
..... ~ Public Water System
Well
3
TYPE OF WASTEWATER DISPOSAL:
m
D
[]
[]
Individual On-site
Individual Holding Tank
Community On-site
. Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given_in paragraph 5 by an independent
profes~i(~nal civil engineer registered in the State of Al~,ska. Cert!ficates. of, Health Authority Approval are
required.for, the transfer of title (except between spouses) on properties served by a single family on-site
wastewat~i; disl~osal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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 sampe resu ts ess than 30 days old. Certificates
are valid for one year for properties served by Class 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.
72-025 (Rev. 01.'00)' · ~
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date s~c~wn below. I verify tl';at my investigation
based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval
application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
S & S ENGINEERING
Name of Firm
17034-E~31e-R~ver--I-~o~ Ro--~_~.
Address Eaqle Rivert Alaska 99577
Engineer's Printed Name Robe:t C. Cowan
DHHS SIGNATURE
Approved for__
Disapproved.
Conditional approval for
Phone
Date I '&./I//Oo
bedrooms. ~) -~,, .... ,-, ~
bedrooms, with tho [ollowin~ stipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
· Expiration
Original Certificate Date:
Reissue Date:
72-025 (Rev. 01/00)'
Municipality of Anchorage
Department of Health and Human Senreer,, C
E I ¥ E D
Division of Environmental Services
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650 DEC 1 I Z000
. w~v.ci.anchorage.ak.us
(907) 343-4744 MUNICIPAUTY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ '~/ ~ ~ ~/~
Parcel I.D.:
A. WELL DATA
Well typaP/Z / (/.~'f~-
Date completed ~-
Totaldepth ~,~O ft
If A, B, or C provide PWSID #
Sanitary seal/~'5'
Casedto ft
Date of test
Static water level
Well production ~
WATER SAMPLE RESULTS:
Coliform O colonias/100 mi
Date of sample: / ~/:~/~
FROM WELL LOG
B. SEPTIC/HOLDING TANK DATA
g.p.m
Nitrate O, ~- mg/I
Collected by:
Ce
Well Log
Wires properly protected
Casing height (above ground)
AT INSPECTION
/ /
~'o ~' g.p.m
Other bacteria O colonies/100 mi
Tank Typa/Material
Date installed ~/,s~ ! Tank size / ~ gal
Cleanouts ~ Foundation cleanout tT/~ Depression
Date of pumping /~-/C./~/-) Pumper ~"7~
ENGINEERING
170~4 Eegle River Leap Read NO. 204
River, Alas~ca 925~
Number of Compartments ~
over tank ,&CO High water alarm
ABSORPTION FIELD DATA
Dat, installed ~/~/ Soil rating (g.p.d./lt2 or ~). ~" 5" ¢System type/
Le&~'~" ft / ' Width/~)-// ft Gravel below pipe ~ o,~
Total deptlY/~,:~", Effective absorption area :~'¢¢ft' Monitoring tube_~ Depression over field
Date of adequacy test /,~/-7/~ Results(Pass/Fail) ~3S For ~,~ bedrooms
Fluid depth in absorption field before test. / ~- ' in Water added ~ ~jal. New depth / ~
__ in.
Elapsed Time: '~ ~ rain Final fluid depth / '~' =
in Absorption rate > '~5"/~g.p.d.
Any rejuvenation treatment (past 12 mo.) (WN & type)/[/~,-v~--,~_~v'o-,,o,,,/ .If yes. give date __
72-(~6 (Rev. 01/00)'
D. LIFT STATION
"Pump on" level at f'~Y in
"Pump
level
at
.~,~/ Cycles tested
Datum
SEPARATION DISTANCES
in
Manhole/Access
High water alarm level at in
Meets alarm & cimuit requirements
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /Z:~:) ~'-
Absorption field on lot
On adjacent lots
On adjacent lots
Public sewer main /,,//^ Public sewer manhole/cleanout
Sewer/septic service line Z ~' './- Holding tank /~/,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~>~ "f-
Water main ~//,~-
Drainage /~ / A
/
Property line ~' /~-
Water service line ./~ /Y'
Wells on adjacent lots //~'~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water Service line
Curtain drain /-,/~/v~-
Absorption field
Surface water
Building foundation ~ ./':'~ Water main /v'//~-
Surface water / ~ /'*- Ddveway, parking/vehicle/storage
Wells on adjacent lots ~'0-~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 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
Date
HAA Fee $ ~IDO. oC:>
Date of Payment ,/,:,~.-//- 04:~
Receipt Number ~
Waiver Fee $
Date of Payment
Receipt Number
72.0~6 (R~v. 01/00)'
DEC-13-29~ iiFJ:39 Sg,S ENGIN~:~ING SOV 694 1211 P,02/93
Client
CT&R Ref.~ 1007547001 l, rin~ed Dat'erl'tmt 12/12/2000 14:42
Client l~ame S & S £ngiae~r~g Colle~-d Date~l'Ime 12/05/2000 1
pmje~ Nzme.~ L4A~ l~amann S/D Re~-~iv ed Ds. tu/'l'lme 12/06/2000 11:25
Cllen! SamPle ID ~4A Ha.zm~ ~/~ Technical D~rlor Stephen C.
~ Water
Sample l~,emarks;
0500 U 0.~00 mg~L EPA '~00.0
lOn'mx
SCL
To~l Coliform
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
050-611-19 HAA#
GENERAL INFORMATION
Complete legal description
Hamann Lot 4A
Location (site address or directions)
NHN Hamann Road
Property owner Jeff & Janet Br~d
Mailing address M~ R'~ F~× 1676._ P~91~ Riv~r, Ag:
No.est Mortgage/Don Presser
Lending agency
Mailing address
Agent
Address
Day phone
99577
Day phone
16635 Centerfield Drive, Eaqle River, AK 99577
ReMax of Eagle River/Audrey Mason
Day phone
16600 Centerfield Drive, Eagle River, AK 99577
694-3422
694-1144
694-4200
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 '~
TYPE OF WATER SUPPLY:
Individual well X
Community well
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
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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverifythatbased on the information obtained from
the tvlunicipality 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 Eagle River Enqineerinq Services
Address P_O. P¢~× 77t2q~-- P, Rc~I¢_ River, AK
Engineer's signature
99577
Phone 694-5195
Date
bedrooms.
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 ~1
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present (Y/N)
~7'/'/--/~/ Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 0 ~./?z./ Driller
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
~L~O J Cased to
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO: -~
Septic/hclding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
r/z./,p"
Nitrate
B. SEPTIC/HOLDING TANK DATA
Date installed ¢ ~]/~'/
,Z-/L~ / %0"
Casing height
Wires properly protected (Y/N)
g.p.m.
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
/ ? ,~/,. Other bacteria
Collected by: ~'~.--,-~-,,,-~-- ~./~,,
Tank size JO(PO Compartments
Cleanouts (Y/N) )/~ ..5 Foundation cleanout (Y/N) )/g 5 Depression (Y/N)
High water alarm (Y/N) ,/V//,g Alarm tested (Y/N) /"//'~
Date of pumping g)(~/g)?/'~ ~/ Pumper ~ J~-
SEPARATION DISTANCES FROM SEPTICiHOLI~Eq'G TANK TO:
Well(s) on lot ~-- / z./D ~ On adjacent lots
To property line 7'- .~ 5) Absorption field
Sudace water/drainage /'//~
-/'//2 D ~ Foundation
z~ ~ Water m~drrlservice line
72-026 (3/93)' Front ' CONTINUED ON BACK PAGE
C, LIFT STATION /,//Y~
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
.Cycles tested
Meets MOA electrical codes (Y/N). -
SEPARATION DISTA~OE~FRoM LIFT STATION TO:
Well on. lot ' On adjacent lots
D. ABSORPTION FIELD DATA ¢¢
Date installed 0
Length ¢¢ '/5~j ~-/P~/'Width /
Total absorption area -2 ?
Date of adequacy test 0~/
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) ~/¢' ~/"~,,~.
- /¢ / Gravelthickness ..~, 5
Cleanout present (Y/N)
Results (pass/fail)
Sudace water
System type
' Total depth ~',
~¢ 5 Depression over field (Y/N)
,P.4 %5 for ..~
After test
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 :/-/~ ' Property line / '~
~ ' To existing or abandoned system on lot ~//~)
Cutbank /'//~ Water r~aicVservice line -~/~ '
Driveway, parking/vehicle storage area '¢/~
E, ENGINEER'S CERTIFICATION
the date
I cer~fy that l have checked, verified, or conformed to all M~A an_.d~ HAA guidelines in effect on .~. of this inspection.
¢¢ $~o,,wP 0>1- ~o¢ rcEL. L.. 0~7'5/D~ /bo y/~,~-fEd-F/~ ?-~.P...LL~S../.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
Rece,pt Number
Waiver Fee $
Date of Payment
Receipt Number
CT&I~.Rel~O
Cficat ~{~xpl¢ ID
Malrix
Ordered By
· lh'ojcut Nurrto
pW$1D
Commercial Testing & Engineering Co.
Environmomal Laboratory Senrices ~'ae'~a~e'~~e~r~'~r~'~r~~~'~r4~'~
LABORATORY ANALYSIS REPORT
94.1656-1
IIA~.~tNN CA
WA'It~K
WORK Ci~cder 79011
EA~.E ~RENGffiE~-~G p~ht~ 9ate 06/071~
UA collect~l~ 06101194
Rcu~V~te ~/021~ ~ 12:30 h~.
HA TcdmicM Dh~et m' S Itt, P1J/EN C. E[ g
Sampl~ Remm:k,s:
L~'t. Anal
[late Ditto lult
t0 06/03194 CMR
i, So~, ~)eciat lnstn~tion.q Above HA = Not Anal, yze,'J-
** S~e .qmnpleRcmarks Abovc Ll'=L~la Trna
~ U=Un&tected~Rt~portedvatt~:i~tltcpra~lir"d°3mnt fit,,atluttlkalt- faT=Oeate, rqhm~
~ D=Secandaq, diMim~.
5633 n Street, Anchorage, AK 99518-1600 --Tel: (907} 502-2343 Fa~: {nO7) 561-§301
ENVIRONMENIAL FACILITIES IN AFLAS KJ~, COLORADO, FLORIDA. ILLINOi!I, MARYLAND, NEW JERSFY. OHIO, U'IAH, WEST ViRGINIA
GENERAL INFORMATION
(a)
(b)
(c)
~ MUNICIPALITY OF ANCHORAGE .,-~,'
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF iNSPECTION FOR .HEALTH AUTHORITY APPROVAL
OF ON-SIT.E SEWER AND WATER FACILITY
Application Date
Leg.al Description (include lot, block; subdivision, section, township, range) _.
Location (address or directions)
Cpplicant is (check ode): Lending institution ~; Owner/builder ~; Buyer ~; Other D (explain);
Business 2Gq-lqS'7 .~,~.
(d) L~dinglnstitution CL-,prC~I~R J~L'J-IA/~IA-g/~Ic Telephone
(e) Real Estate Company and Agent
. ',"{'Address '
. . { Telephone
(f) Mail the HAA to the following address:
...,. " is-c 5
' ,.:. ':.,'. :$.
~3 ;CWATER SUPPLY' ', .... ::. ,,~..;; .<
x.: ndividual Wel.l~ Community~ Public~
~oto: I[ community woll systom, must havo writton con~ rmation from tho Stato ~opartmont of [nvironmontal Consorvation
attesting
to
the
4"' SEWAGE DISPOSAL ' :';' '
.... - · ' .' :~- .... · . '- :; :,'-.5,. ' . · : ~: ' ''-?.'~?~-. ·
"qnsit~ p.~,c B Community B' Holdinfl Tank ~ ._,-"~ ~ :.% ":: ~' -'. ~;.;.}~:~?'/.~::~('~. . .~
Noto: If community woll systom, must havo writton confirmatio~ from tho Stato Dopartment o~ fi~vironmontal Consolation
:' ,:'. - ' . ',~t~;'. '4'. 2. :'.:'? -'~' - ;:;3."{::';;':; :'';k: - . ,,. ' -. ~
Page 1 of 2
2.- TYPE OF RESIDENCE ,. ' r'
Single-Family,l~' Multi-Family [] :i: Other
5. ENGINEERING FIRM PROVIDe, INSPECTIONS, TESTS, FILE SEARCH,
As certified by my seal affixed hereto, and as of the validation date shown below, I venfy that my ~nveshgabonof this Health
Abtho~'ity Approval shows that the on-site water su:pply and/or wastewater disposal systemi.s safe, function~_l and.adequate
· for the'nu rnber of bed~:0dmSand type of Structur~ indicated h~fein'..i f~l~,' v~rify that based on the inf0rm~i~ion~obtained:
' fro~ the Municipality of Anchorage files and from'my.investigation and~inspectionl the romsite Watef;~'u pply'and/or
wastewater disposal system is in compliance with ~tll Municipal and State codes, ordinances; and regulations in effect on
the date of this inspection ...... ',_. ~-,'.- ~-
-'""
Name of' Ficm -
S &5 Engineering'
Address '" ,,
Date Eagl~ qiver,"AIasEa <29~77 -~: (:,-:-:,: :'. . ~...',..--. z_.-'7_- ~¢' ~o ,'- -
DHEP APPROVAL
Approved for '¢'*~'~-'~) bedroomg by ~ '~' ~'~ Date
Approved ~'~' ' Disapproved . Conditional
Terms of Conditional Approval
" '-._ CAUTION ~'*
The Mbncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Em ployees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions ~n the
professional engineer's work.'
Page 2 of 2 . . .
72-025 (11/84) , - .
WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MO~7/'~ '
HEALTH AUTHORITY APPROVAL (HAA)
.... ~.~cipALITY OF ANc~:C~LIST - FEBRUARY 1984
mu'~"~:F. PT OF HEALTH & .... 264-4720
Legal Description:
Well Log Present ~_~
Total Depth Z. ~,c.~ ¢ Cased to ~'J~;) / 1/..
Static Water Level
Ii A, B, C, D.E,C, Approved (Y/N)
Casing Height Above Ground
Electrical Wiring in Conduit (:~N')~
Separation Distances from Well:
Date Completed ~'~ ~/' Yield
Depth of Grouting ~/~'
Pump Set At
~ ~ I ¢" Sanitary Seal on Casing~)/.N'~'
Depression Around Wellhead (.Y-~
To Septic/Holding Tank on Lot ~ L-3(-~ ~ ~'' ; On Adjoining Lots
To Nearest Edge of Absorption Field t~n¢~,~ ~Oc:~ ~' ~ ; On Adjoining Lots
To Nearest Public Sewer Line l,.(,i To Nearest Public Sewer
Cleanout/Manhole ~ To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ ~' ~ r~ ~['-J,i~'~'L~ ~ 6 ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
To Water-Supply Well
To Property Line
To Water'MeffT~Service Line
Course
Date Installed ti_ I I-~..~1
Standpipes~'.N')' Air-tight Caps ,~/-N~
Depression over Tank ~i
Pumping/Maintenance Contract on File (Y/N)
/
Holding Tank High-Water Alarm (Y/N) ~
Separation Distances from Septic/Holding Tank:
Size '[(-~ ~ No. of Compartments
Foundation Cleanout
Date Last Pumped
;for
Temporary Hotding Tank Permit
To Building Foundation [O ~'
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed c~ i\~:~
Width of Field ......~//
Square Feet of Absorption Area
Depression over Field (N~)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well [L_~ ( ~
To Building Foundation ~ ~
Lot ~'~ ~
/ ~-;~ ¢...-- Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present~
Date of Last Adequacy Test
To Water.M~kn/Service Line -'-~' ~'
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line '~--~O\ '~'
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons ~
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Company
Receipt No.
Date of Payment
Amount: $
Signed ~ ~, 5 i~gh~o;;~-l,.U Date
Sl:~¢i~ 'i9d4,, MOA No.
Page 2 of 2
72-026 (11/84)
Tir~e L:I Time ~
Date Date Date /
Inspector Inspector 0~'~0~02\~ ~ .I , Inspecto::
Comments ,:~ Conditional Approval
Date Sewer Installed Permit No, Septic Tank Size
,~/, Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY .
Property Owner ~ ~.: ' '~; ~ ~ ~' / ~ ~ Phone
Mailing Address ~, (~- ~:~'X ?~ ~/ ~_:-c~:,~ ~'~,~..t:~.~? ~,~t..(~ <~:~7
Buyer ~,, ~-/~, //~ ~':~ (~/~ ~
Address
Lending Institution ~ ~ /~ F-'¢-{- ~ 7",%T-/--- j~ F2 ,,~--~ Phone
Address
Realty Co, & Agent j-c/:_~-7-_,e.Y ~J2Tp/~'l T/4~IQ~&-7 Z-'M~.~ //-,~/..~,~'Z..~7o,~ Phone
Address /~--~/ ~')' ~""~J"-~) ~--~L-"-~-~Z ~'~-~
LegalDescription ,/-~o7- ~-/~)/ /-/,~ j~-~J AJ
.'C~' Single Family
[] Multiple Family ~o. of Bedrooms '~
[] Other
Wat~Supply
~ Individual ATTACH WELL LOG. A well Icg is required for all wells drilled since June
[] Community 1975, For wells drilled prior to that date, give well depth (attach Icg if
[] Public Utility available.)
Sewa..ge Disposal
~- Individual Year Individual Installed:
[] Public Utility When Connected to Public Utility:_
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.