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HomeMy WebLinkAboutNORTH WOODS BLK 3 LT 27Northwood Block 3 Lot 27 #051-731-55 Municipality of Anchorage Page ~, of '-z._. 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 Permit Number: 'c~[c='~c~'''~ PIDNumber: ~t ~ ~ Name~ ~, ~.~. Wastewater System: D New ~pgrade Address: ~ ~, ~ ~~. ~o~ ABSORPTION FIELD Phone: ~[ __ ,~ INo. of Bedr°°ms: ~S ~ D Deep Trench hallow Trench D Bed D Mound D Other LEGAL DESCRIPTION Sol, Rating: ~ ~ GPD/Sq. Ft. Total Depths.from ~°dginal' grade: Block: Subdivisign: Depth to pipe boltom from original grade: Gravel depth beneath pipe Range:~ Section: Fill added above o[[ginal grad~: Gravel length: ~ TOW~~ ~-~ ~' ~ ~ ~ ~ Ft. ' ~ ~ Ft. Gravel ~ Number of tines: Dislance between lines: WELL: ~ New ~ Upgrade ~t~ ~ Ft. ~ [~ Ft. Classification~~(Private, A,B,C)X~ Total Depth: Ft. Cased To: Ft. Total absorption are~ ~ SQ. Et. ~ipe material:~~ ~ ~.~ Driller: Date Drilled: Stalic Water Level: ~e: Date installed: Yield: GPM IPump Sot at: Ft. ICasing Height AbOve GrOund:Ft. TANK DISTANCES ~ Septio ~ Ho~i,~ ~.T.~.P. SEPARATION To Septic Absorption L i fl Ho,ding =ublic/Private M~ ~ Capacity iR gallo~s: From Tank Field Station Tank Sewer Lines{ '1~ ' ' t~ [~ ~ Material: Number of Compartments: Well ~ ~1~ ~1~ ~ ~ ~~ ~ Surface Water ~+ t~+ i~ ~ ~ LIFT STATION Lot ~t Siz~n~ ~ Manufacture~ , , I Foundation ~1 ~ ~ / / l~vel at: "P~ f a,:o ~ ~.~ ~ '% ~-~al I ns pect ion s pe do r m ~d by: ' ~J~ Remarks: ~t~ ~~ ~~ .?~7/ ?'.""." ,~ ~:~. -- ~q: *. ':¢" ,~* ,A C ;'-. :( ;'~*';'7 *~' ENGINEER'S SEAL S & S ENGINEERING ., . :~ J4'~ ~:. .~ ~. Inspections performed bv17034 Eagle R~L~p R~dNo,~tes: 1st ~-~ ~ * ~' ' ~ ~'~;" ' ~ "' -~agle River, Alaska ~5~ - 2nd ~- ~ -~ I ~ ................. '' ' Department of He es ap ~~~4~? Reviewed and approved by: Date / '~~ 72-013 fllgt) MOA 25 Permit No. '~ I ~C:> '~--'~'~ Page ~" of ~ Municipality of Anchorage 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 I I 72-013 A (2/91) MOA 25 PAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET. ROOM 502 ANCHORAGE. ALASKA 99519-6650 ON-SITE tdASTEtdATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:S~910023 DESIGN ENGINEER:S & S ENGINEERS OkINER NAME:ALASKA HOUSING FINANCE CORP OUNER ADDRESS:520 E.34tb ANCHORAGE, AK 99503 DATE ISSUED: 2/14/91 EXPIRATION DATE: 2/14/92 PARCEL ID:05173155 LEGAL DESCRIPTION: NORTH tdOODS BLK 3 LT 27 LOT SIZE: 20046 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE UlTH: THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA YASTEYATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING YATER REGULATIONS (18AACBO). THE FOLLOI,;ING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ;yHEsDBI~A~ix!,FIEL~E INSTALLEB ,~)H~bJi".l OI',l ~T 3 o+" 3 SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN o be only 5ft. from the existing seepage ~red loft. This lesser separation is ,~,~u~,L5 ~o~ r~L~ ~ro~ng trench ha~ not failed due to bio-mat build-up, and there will still be the mi~mum 4ft. separation distance before sewage will reach the existing trench causing it to conduit into the groundwater. If you require additional information for your review, please contact us. S/gm 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 7 8 9 10 12 13 14 17 18 2O DATE PERFORME~ :(~ Township, Range, Section.~"p ,. ~....~. L~.-~ ~-'"~r::~. ':~ SLOPE SITE PLAN ENCOUNTERED? IF ES. AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ~'. i~' - · ---- PERCOLATION RATE ,.... .., TEST RUN BETWEEN '~ ~ AND ~ FT [Rev. 4/85) Oel~th to Water Alter_ Monitoring? ~o-~'~* ~J 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 ADDRESS LEGAL DESCRIPTION LOCATION J Well~ Absorption ~a DISTANCE TO: ¢~_~/~.~/~S~,~ I Manufacturer Liq.. )acity in gallons IF HOMEMADE: Inside length Well Dwelling DISTANCE TO: wel~4 DISTANCE TO: No. ,of lines/ Length o~e~cc~ling' Top of tile to finish grade¢ / Length ' Wi~tth Foundation ~ ~// f Total length of lines Material beneath tile Depth Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Driller Building foundation Sewer line DISTANCE TO: OTHER .PHON E ~ ~,~9~/ Eli UPGRADE Materi~ Width Material Nearest lot line/f~.~ /'.f_ Trench ~.~d~h inches inches NO. OF BEDR~.~MS No. of c¢~.~tm_ eh'tS' Liquid depth PERMIT NO, Liquid capacity in gallons PERMIT NO 7 (~ (~.,~~ ~¢ ,stance ;; t; I~ f; eCN Oi~e~% t i o n area Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Sept c tank Absorpt on area(s) PIPE MATERIALS SOl L TEST RATING [ NST~-~.ER REMARKS /~ · DATE 72-013 ~ev. 3/781 ~ · - ~ LEGAL [.',EF'FIF.'TMENT ",-,...: HEFtLTH FIN[:, EN',,,'IRONMENTRL ]..F:OTECTION ; :d?.'5 ' L' !..:,1F..EET., ldNL. HURMLJE., . HI' .... ':¢L-c.....,ld.lL , ~ ;.'-.".: 64 - 47 ;-2 ,Z, F'EF.:M!T N_'] ,' . -- RPF'LICRNT STEVEN L. SKRGG'E PO E,O:::: [:, C:HLIGIRK RK LOCRTION PETERS CREEK LEGRL L27 B3: NORTHWOODS S/D LOT SIZE TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MRXIMUM NUMBER OF BEDROOMS SOIL. RBTING <SD FT?BR)= 278 THE REQUIRED SIZE 0F THE SOIL ABSORPTION SYSTEM IS: 23:000 SQLIRRE FEET F:, E F' T ~'4 := 1:'!_ L_ E Nr_3 T~-t = 7,-Z, 13 F-: R"...' E L. E:. E F'-iF H == ";~ THE LENGTH DIMENSION IS THE LENGTH ,::IN FEET) OF THE TRENCH OR DRRINFIEL. D. THE DEPTH OF R TRENCH OR PIT IS THE DISTFINCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCFIVRTION (IN FEET). 'THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN ]'HE OUTFAL..L PIPE: AND THE BOTTOM OF THE E',:.~CFtVA'FION (IN FEET). PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE tNSTRLLRTION INSPECTIONS OF RNY WELLS RDJACENT TO THIS PROPERTY RND THE NLIMBER OF RESIDENCES THRT THE WELL WILL SERVE. T ff--~ [) ( 2 ) ][ ~g ?-'-; F' E C: T I C, ~-.~ S R F-: E F: E L---~. L..~ I F-: .E-2 [: BRCKFILLING OF RNY SYSTEM WITHOLIT FINF~L INSPECTION FIN[:, RPPROVRL BY THIS DEF'RRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND RNY ON-SITE SEWRGE DISPOSAL :SYSTEM IS ±00 FEET FOR R PRIVBTE WELL OR 150 TO 200 FEET FROM R PUBLIC HELL. DEPENDING UPON THE TYPE OF PUBLIC P.IELL MINIMUM DISTANCE FROM Ft PRIVRTE WELL TO A PF.'.IVATE SEWER LINE IS 25 FEET FIN[) TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RPPLY. SPECIFICATIONS RND CONSTRUCTION DIF4GRRMS ARE RVRILABI_E TO INSURE PROPER INSTRLLATION. F'EF-"~"'I ."[ ]- E.%<F' ]] F--:ES [:,F..:E:E~"'IE:EF~ 2:::1... I C:ERTIFY THRT · it: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPALITY OF FtNCHORRGE. f=IF'PL I C:F4NT /' _¢b.',,'}lzt 1 *-'1 :~I¢'":H~OS -- / ~ IF 'T'HE V4. 0 O & E EN~-NEERING & DEVELO~-,MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name: SOIL LOG '~ ~'"~' k"Z~ ~/~ -~d~. ~ Tel. No Earl Ellis 688-2280 Mailing Address: LegalDescription: L_OT- -~-~7/ /~O6/~' ~/ /~/'~7-/¢1/v/60~ .~-U~. Depth (feet) 0 Soft Characteristics A/iL ~L.r '77~'~ %~zz~ 6~ 7__ 8 9~ 11__ PLOT PLAN 12~ 13__ 14~ 15 PERC. TEST 16__ Ground Water Encountered; Yes.__ Proposed Installation: Seepage Pit Comments: No V If yes, what depth Drain Field Performed by: Date: Munic. i ' a!ity~ of,Anchorage ueve!opment ~e.,rvlce$ uepgnment~ .,. '. ' Building' Safe~ Divisi6n On-Site water and Waste~ater P~mm 4700 Sou~ Bmgaw St. Parcel I.D. 051-73.i55 i. G~.~ER~L INFOR~a. IION · ? Complete legal description · P.O. Box .196650 -' Ah'~hbr~ge,,AK. 99519-6650 .,,:: ~ .v , .-.www ci anchoraoe ak.us" --'-, ~.-. ~ - ·" . (907) '343-7904' ' ' ' ' · CERTIFICATE OF HEALTH Au:i'HoRITY. APEROVAb ". ...~ FOR ASING[E, :FAMILYi"D'WELLII~Gi, · ~. . '-'- ':.~':.. ' ""'" '"'. ..... ... ,.,;-'~i.': '[7'. ..... · ,.: : .' . ..:",.'H,~#'::'.'/:/'l::l~.:'~l;OlCl R.; .: ; '" .E?pira~6n.Date: ;. ::. ,~r~..,, North Woods 8/I), Block 3, Lot 27; --. .'. ' Location {site address ordireefions} '22821 N6rthwoods Driv," · ·., · ' · · " Current Property owher{s), patty 811ss Day ph~6ne :'$88-7524- - . ' ' .... Mailing address 22821 Northwoods Ddt; I k, AK 99 ' .' . . Lending agency - -, Dayphone' . · . Mailing address Real Estate Agent Alnslle Phillips Day phoh9 ,273.7242 Mailing Address Prudential Vista Real Estate 4241 B Street. Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBEROFBEDROOMS: 3 3. TYPE OF.WATER SUPPLY: Individual Well Individual Water Storage ... Community Class _A Well Public Water System TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] · [] Individual Holding tank [] ~ Community On-site [] [] Public Sewer [] The Municip~ii~"(~f ~nchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The 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 here{o and .as of the 'validation date shown below, I verify that my investigation, based on procedures Outlined in the Health. Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(am) safe. functional and adequate fo~' 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of Installation. Name of Firm KND En~qlneerlnq Address 20441 Ptarmlqan Blvd., Eagle RiveG AK 99577 Engineer's Pdnted Name Kenneth M. Duffus DSD ~.I~NATURE ~ · ~ Approved for ~ Disapproved. -Conditionai approval for Phone 696.6111 Date 05/071200f bedrooms. __. bedrooms, with the following stipulations: Additional Comments Attachments: I-IAA Checklist Septic System Advisory Well Flow.Advisory Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: .~'-'-//- 0 ~/ (Rev. . Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bmgaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak, ue (g07) 343.79O4 HEALTH AUTHORITY .APPROVAL CHECKLIST Legal Oesoflpben: North woods. Block 3. Lot 27 Parcel ID: 051.73.t55 A. WELL DATA We, type Community If A, B, or C provide PWSID # 2t300~/N~'--/ Total depth ~-~--''""~Casod to · Casing height (above ground) FROM WELL LOG AT INSPECTION Date of test Static water level Wall production Fluid depth in absorption field bofom test ~ in. Elapsed Time: 360 min. Final fluid depth ~ in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Water added 450 gal. New depth t4.5 in. Absorption rate >= 450 g.p.d. 1~9 If yes, give date Coliform colonies/lO0 mi. Nitrate Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Anchoraae Tank - Steel Date installed ~/31tlg91 Tank size t250 gal. Number of Compartments Cleanoute vee Foundation cleanout vee Depression over tank noHigh.water alarmves Date of pumping 5/3f200t Pumper C. ABSORPTION FIELD DATA Date installed ~/31/91 Soil rating (g.p.d./ff~ or ~/IxIrm) Length ~ tt Width f ft. Gravel below pipe 2.S ft. Total depth 4.5 fL Eft. absorption area 765 ~ Monitoring tube yea Depression over field no Date of adequacy test srJ/2001 Results (Pass/Fall) bess* For ~1 bedrooms Other bacteria__ colonies/lOOml System type ~h~llow Trench D. UFT STATION Data installed 6/3/9t 'Pump on' level et ,,41 in. Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WGLL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main 8~ze in gallons 1250 Manhole/Access (Y/N) yes 'Pump off" level at 28 In. High water ala~n level at ~ Cycles tasted :~ Meets alarm & drcult requirements? yes On adjacent lots  Holding tank C/HOLDING TANK ON LOT TO: Building foundation ~'+ Property line ~'+ Absorption field ~'+ Water main lQ'+ Water sewice line lQ'+ Surface water 1gQ'+ Walls on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 1<)'* Building foundation 1~'+ Water main Water Service line lg'+ Surface Water 11~'+ Driveway, pa~Jng/vehlc~e storage Curtain drain 50'+/none knorr) Wells on adjacent lots 200'+ F. COMMENT~ in. 'The 35' ~eflcfl is ocefa0na at its umer reaches. The eoera~no level of Ihs 63' I~nch Is at o. E"OI"EE.'S CE.TIF,C^TIO, I cerUfy that I have determined through field in,~pect/ons end g~t-"Z/;,~-,..q~~' -&'~l,, revtew of Municipal record, that the above systems em in , ,, o... . ... conformance with MOA HAA guidelines in effect on this date. *'* * ' '"" ~ Engineer's P~lntad Name Kenneth M. Ouffus ~:~_ .:~.~,~ HAA Fee $300 Data of Payment 05/07/2001 Receipt Number ~'~' Waiver Fee $ Data of Payment Receipt Number ParcelI.D. # · MUNIC PAL TY OF ANCHORAGE ~ DEPARTMENT OF HEALTH &'HUMAN SERVICES_!: ' D iv i s ~r~ ;fi tEe n~ ~c~; ~t;~ t~;~vices P.O. Box 196650 . Anchorage,'Alaska 99519-66~0 343-4744 3- ~i:~ :i ._ CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner~)~u~ ,~ ~--)51'~- ~::)~rw~<~ T-~C) Day phone Mailing address ~.~. ~-~- I~,~ t ~"¥,'~--'~' ~A~h~' Lending agency Day phone Mailing address Agent ~, Address Day phone B Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site ~ Holding tank ' Community on-site If community well System, provide written confirmation from State',~DEC at,est-: .,;. -.~.~ -,,. --.. NOTE: 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#2~ 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance .with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm David R. Dayton P.E. Address C.J~giak, Alaska 99567 DHHS SIGNATURE ~ Approved for --~ / Disapproved. Conditional approval for Phone Date bedrooms. bedrooms, with the following stipulations: .Additi6h~l Comments - By:"-':' '/'~ Date .The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before'a certificate Is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72025 (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 /~ ~b c/c- 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 Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main _g.p.m. ATINSPECTION Sewer service ne · ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout g.p.m. Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~'/-~./~ / Y Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) Compartments ?-~ Depression (Y/N) /V/ Alarm tested (Y/N) ~ Pumper ~'~'~-~'~/ ~'~--'---~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /,J /r~ To property line z~ 5 '-*-- Sudaoe water/drainage On adjacent lots Absorption field 72-026 (3/93)* F~o~t Foundation ~" / Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) ?' "Pump on" level at Manufacturer / Manhole/Access (Y/N)_, '--.5-~"~" "Pump off" Level at High water alarm level ~ '- ,~., Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed ~,/.5,/9! Length .. ~' ,:9' Width Total absorption area Date of adequacy test Cycles tested 4 -/- On adjacent lots '~/~- Surface water Soil rating (GPD/FF) ~' ~ System type 5~ Gravel thickness ~-, ~ Total depth '7 d~_~-- Cleanout present (Y/N) "'/ Depression over field (Y/N) /'~/z_%/~,_/ Results (pass/fail) ,P,~ for -~ Bedrooms Water level in absorption field before test --~,o,-~- -~,z~,~,~,~- Peroxide treatment (past 12 months) (Y/N) /'-rZ' After test SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Sudace water If yes, give date Curtain drain Driveway, parking/vehicle storage area On adjacent lots /,-~///'-)- Property line To existing or abandoned system on lot Cutbank ,'~,//J-- Water main/service line E. ENGINEER'S CERTIFICATION I cerlffy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the ,d,~Le of this inspection David R. Dayton P.E. 20210 Dona]a~ St. Signature Chuglak, Alaska ~g567 ,, z.~,~T,~ ~-~ ~, ,.~ ,. Engineers Name Date /~/~ HAA Fee $ Date of Payment Receipt Number 72-026 (3'93)* Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 27; Bloc~ 3; North Woods Subdivision; Location (site address or directions 7538 North Woods Driv~ Property owner Mailing address Lending agency Mailing address A.H.F.C..# 111368 Day phone 520 East 34th Avenue, Anchorage, Alaska 99503 Day phone Agent Kathq G~ra~i GREATLAND REALTY Day phone Address 11411 (~H C,£~,n HJgbw~y: Eagle. Riv~; A~aska 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDRO~)MS: 3 TYPE OF WATER SUPPLY: NOTE: 694-9125 Individual well Community well Xx Public water If community well system, provide written confirmation from State ADEC attesf- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: 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 MOAt~21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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. Phone 7034 Eagle RiYer Loop Road No 204 Name of Firm Address Engineer's signature DHHS SIGNATURE ~ Approved for Disapproved. Conditional approval for ~-'~__~J~"~O~/) b e d r o o m s. 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~I Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST % A. WELL DATA Well type 7~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: ADEC water system number Driller Casing height. Wires properly protected (Y/N) g.p.m. AT INSPECTION ; On adjacent lots r'Jl ~ ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~:~-"~-'~. \ Cleanouts~CTN) High water alarm~N) Date of pumping Tank size \'~--~"~-~ %"~¢:::~ Compartments '7_.--- Foundation cleanout::~) V Depression (Y(~l:> r~ Alarm tested (Y/N) Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot c> ~ On adjacentlots Foundation To property line ~ ~1 Jr'' Absorption field Water main/service line I 72-026 (Rev, 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent ~N) y High water alarm level Manufacturer ''~'~('-~ ~/'~ Manhole/Acces¢) y "Pump on" level at ~t~l "Pump off" level at ~::~ ut Cycles tested ~ ~ Meets MOA electrical codesd~)N) V SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot I~ ~ ~ On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed (.,¢ ~'~2 ~ ~ Length ¢'~ ~;;~' Width ~" Total absorption area Depression over field (Y~ Results (pass/fail) \ Peroxide treatment (past 12 months) (Y/J_N~:> ~ Soil rating Gravel thickness '~-' Cleanouts presentQC~N) Date of adequacy test for ~'~ ,-/ bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot 1~ E;~¢.~ To building foundation On adjacent lots Surface water \ ~ I .~_ Curtain drain_[~ On adjacent lots .-~::,¢~1 ~ Propertyline '~'"~2~ To existing or abandoned system on lot Cutbank I~ ~r-~ Water main/service line Driveway, parking/vehicle storage area ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on th his inspeetjpn. Signature 'i Eaqle Engineer's Name 72-026 (Rev. 3/91) Bac~ MOA 21 Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 June 5, 1991 WALTER J. HICKEL, GOVERNOR 563-6775 FOR: S & S Engineering Ray PWSID 213001 My review of the records on file in this office reveals that the Chugiak Utilities, Northwood Subdivision Class A Public Water System, is in compliance with the provisions of 18 AAC 80.060, State of Alaska Drinking Water Regulations. Sincerely, Keven K. Kleweno Lead Engineer *~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR tdl ilxJH~.r~!L~\ OF ,",NCl '.ORACE MUNICIPALITY OF ANCHORAGE DEPT. OF F!E.,qL'.rH & FNVIRONMENTAL PX©TECTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 LStreet-Anchorage, Alaska 99501 MJ~Y ~L 8 ~81 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 R E C E l V E D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. '~'"'~ I PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE MAILING ADDRESS 4. REALTOR/AGENT [ PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION ~_~ 'z- ~-7 '-~ ~ ;~ STREET LOCATION 6. TYPE OF RESIDENCE [~NGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four I~]-'""~wo [] Five [] Three [] Six [] Other 7. WATER SUPPLY [] INDIVIDUAL* [~'"~COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~"'"~D I V I DUA L/O N-SIT E** (~/ [] PU.UC UTI,,TY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS I~] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSQRPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~f/~PPROV ED FOR 7 BEDROOMS [~ CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ~'~ 72-010 (Rev. 6/79)