HomeMy WebLinkAboutMEADOW RIDGE ESTATES BLK 2 LT 4Meadow Ridge
Est.
Block 2
Lot 4
#051-4/) 1 - 18
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
NAME
MAI LING A D D,~,~SS
__..0,
LEGAL DESCRIPTION
LOCATION
Well I Absorption area/
¢,ons I.OMEMADE:
Manufacturer
of eac
No. of lines I Length
Top of tile to finish grade
Length /~ / Width /? ~
Foundation
Total length of lines
Material beneath tile
Dept~/ / D~r~-P
IMaterial
Nearest lot line
Trench width
NO. OF BEDROOMb
W dt~ Liquid__deptl~ ~_.~
PERMIT NO,
Liquid capacity in gallons
PERMIT NO,
inches
Tota~r effective absorption area~.~-,-~ ~
Nearest lot line Z~- /~
Typic of crib
I DISTANCE TO:
Class .
D STANCE TO:
Crib diamet,~ ~!
Depth
Crib d e p.t~_
Building
Drille~_.
Sewe~h~ne
Distance to lot line
~S e'~t ic tank
PERMIT NO,
Absorpt on area(s)
OTHER
PIPE M/ZTERIA LS
SOIL TEST RATING /
REMARKS
DATE LEGAL
Department ~ Health and Environmental 'rotection
825 Street, Anchorage, AK. ;501
264-4720
* * * HANDWRITTEN PERMIT *
Location: . Phone Nu~er:
Type of Soil ~sorption System Is:
Trench: Drainfield: Seepage Bed: HOlding
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
DEPTH
The Required Size of the Soil Absorption System Is:
LENGTH / ~/
GRAVEL DEPTH ~' /
__ ' WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimu/n depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HGL-DA-NG) TANK SIZE = /~,O~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are Yequired
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I a_m familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
.th~residence is remodeled to include more that 3 bedroomS.
i e~ ~ ~'~/ ~' ~.-/~/~/ ~ '~- .... ~ * ~ Issued by'
App¢ -'-lic~n¢C~-- --/-'/ -
SWP/024(1/81)
r'~.SOILS LOG
MUNICIPALITY OF ANCHORAGE
[~ PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SITE PLAN __
SLOPE
2
8
9
WAS GROUND WATER
11 ENCOUNTERED?
IF YES, ATWHAT
Gross Net Depth to Net
Reading Date Time Time Water Drop
14
,;, ,. ., . ;~: "/?./,
· i-,~ :>~.-.~.., , ,:,?:%,~4',,, PERCOLATION RATE {minutes/inch)
COMMENTS " / -'~ /Y~ -
PERFORMED BY: ; ' '~
,- ~ I1, ~u~w..~ -
72-008 (6/79)
Parcel I.D.
Municipality of Anchorage \ .
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program //~"~
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
w,,vw.ci.anchorage.ak.us
{go?) g43-Tg04
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
051-461-18
1. GENERAL INFORMATION
Complete legal description
.xpira,ion Da,e:
Lot 4, Block 2, Meadow Ridge Estates
Location (site address or directions) 21008 CountrTview Drive
Current Propertyowner(s)Thomas & Jann Vanderhoof
Mailing address
21008 Couatryview Drive
Lending agency
Dayphone (907) 688-2010
Chugiak, Alaska 99567
Day phone
Mailing address
Real Estate Agent
Mailing Address
Terri Davis
Next Home Real Estate
Dayphone(90?) 727-5130
~QO0 Spenard Road #5
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
Anchorage, Ak 99503
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Cotnmunity Class A
Public Water System
Well
[]
[]
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Deparb'nent (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 A~aska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties sewed by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HA. As upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or e public
water system. The Munic!pality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I 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(are) safe, functional and adequat~.[oElhe.number of
bedrooms an(:~l~pe of structure indicated here n further verify that based on the informatior~o~{?n'ed from the
Mun cpa. t~:ef'"A~chora,, ge files and from my. investigation and nspection the on-site wate~'supply~n~/o,~...
wastewateri~[~posal system is(are) in comphance w~th all applicable Mumc~pal and State codes,
and regulations in effect at the time of installation.
Se
Ha'me of Firm Pinard Engineering
Address PO Box 871347 Wasilla, Alaska
Engineers Pdnted Name Paul E. Pinard'
DSD SIGNATURE
~ Approved for 3
Disapproved.
Conditional approval for
Phone (907) 357-3647
99687
Date 6121
· ,'-",2,%"' "'*"!..-~--~'.-~ ·
..f,~r'.~-. · ~'-e~U;~ .' ~'~,'
bedrooms, ~ ~"~'/~ *--* * * · * · * ;-~-%- L--~'
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~;/~ ~/~ 2,
Legal Description:
WELL DATA
Well type A
Date completed
Total depth
Municipality of Anchorage
Development Services Department
Building Safety Division
On-~lte Water & Wastewater Program
4700 South Bmgaw St.
P,O. Box 196650 Anchorage, AK 99519-6650
www.cLanc~rage,ak.us
(~0Z) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Lot ~ Block 2~ Headow Ridge Eetateis ParcallD: 051-&61-18
If A, B, or C provide PWSID # ~..1./Jk;31 Wall Log (Y/N)
· Sanitary seal (Y/N) N/A Wires property protected (Y/N)
Cased to R/& f. Casing height (above ground)
AT INSPECTION
FROM WELL LOG
Date of test N/A
Static water level R/A It.
Well production R/A g.p.m.
WATER SAMPLE RESULTS: R/A
Coliform colonies/100 mL Nitrate rng./I.
Date of sample: Collected by:.
SEPTIC/HOLDING TANK DATA
Tank Type/Material Sept, to/Steel
Tank size 1000 gal, Number of Compartments
Foundation cleanout (Y/N) Z
2
Depression over tank (Y/N) R
R/A
R/A fl.
R/A g.p.m.
Other bacteria
S/A in.
Date installed 8/18/8.3
Cleanouts (Y/N) Z
Date of pumping 9/19/01
C. ABSORPTION FIELD DATA
Pumper
High water alarm (Y/N) R/A
JR*is Septic Pumping
colonies/100 mi.
Dateinstelled 8/18/83 Soilrating (g.p.d./~er~/bdrm) I~Q isf/t~ystem type Seepage Pit,
Length 1 c) It. Width lC) ff. Gravel below pipe 6
Total depth 11 ft. Eft. absorption area 4~i6 · Monitoring tube · Depression over field N
Date of adequacy test 6/19/02 Results (Pass/Fall) Pa. isa
Fluid depth in absorption field before test 10 · 8~. Water added 600 gal.
Elapsed Time: C)0 min. Final fluid depthlc)
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
For ~} bedrooms
New depth 26 in.
in. Absorption rate >= 500+ g.p.d.
N If yes, give date
D. UFT STATION
Date installed
'Pump on" level at
Datum
E.
SEPARATION DISTANCES
Size in gallons
'Pump off' level at in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lilt station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?.
Building foundation 5 ~ +
Water main 10 ~ +
Wells on adjacent lots 200 ~ +
Ii'/&
On adjacent lots
On adjacent lots
Public sewer manhole/cieanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Absorption field ~ ~ +
Surface water 1 O0 ~ +
Preperty line, 10t+
Water service I~e 10 t +
Property line
Water Service line
Curtain drain
F. COMMENTS
Water main 10" +
D~my, paddng/vehide storage ;~0; :1:
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
10 ~ + Building foundation 10 ~ +
10" + Surface water 100 ~ +
N/& Wells on adjacent lots 200 ~ +
in.
.
.view of Municipal record, that the abov~ ~~.
conformance with MOA HAA -uidellnea
Engineer's Printed Name Pe. al E. Ptnard
'...
ete
HAAFee $ "~7~ WatverFee$
Date of Payment /j/~2.Zt/C:) '~, Date of Payment
Receipt Number ;C3~./"7Z/~:) -' ~,/'7~(~' Receipt Number
PINARD ENGINEERING
P.O. Box 87134~
Wasilla, AK 99687
(907) 357-ENGR (3647)
ADEQUACY TEST
LOCATION: Lot 4, Block 2, Meadow Ridge Estates
APPUCANT: Thomas & dann Vanderhoof
21008 Country, law Drive
Chuglak, Alaska 99567
SEPTIC TANK TYPE~tZE: Steel/lO00 gallons, per MOA Records
ABSORPTION SYSTEM: Seepage Pit, per MOA Records
DAILY FLOW:
3 BEDROOMS x 150 GAI./~R = 450 gallons
TEST DATA
JOB NUMBER: 02-t05
DATE OF TEST: 6/19/02
FIELD STAFF: P.J. Pinard
NUMBER OF BEDROOMS: 3
SCUM: 0.0' SLUDGE: Minimal
NEEDS TO BE PUMPED: Yes
CURRENTLY tN USE: Yes XX
No XX
No
Time Flow Volume Cumulative Septic Tank Septic Soil Absorption System Comments
Rate Volume Tank
PM (GPM) (GALs) (GALs) I. Jquid Level ° A Level Monito~ A SAS Monitor A SAS
Tu~e 1' Level Tu~e 2' Level
4:30 6.7 4.0' 0.9' Start Test- Mctcr 328480
4:45 6.7 100 ]00 4.1' 0.1' 1.1' 0.2' 328580
5:00 6.7 100 200 4.1' 0.0' 1.4' 0.3' 328680
5:15 6.7 100 300 4.1' 0.0' 2.1' 0.7' 328780
5:30 6.7 100 400 4.1' 0.0' 2.1' 0.0' 328880
5:45 6.7 100 ~00 4.1' 0.0' 2.1' 0.0' 328980
6:00 100 600 4.1' 0.0' 2.2' 0.1' Stop Test 329080
RECOVERY 'ALL MEASUREMENTS IN FT.
Date Time ST MT! SAS MT2
6/19 , 6~.0 4.07-0.1' 1.67-0.6'
PM
TEST: PASSED XXX FAILED
COMMENTS: There was 0.9' of measurable liquid in the SAS prior to beginning the test. With the addition
of 600 gallons to the system during the test (mom than the design daily flow), the level rose 1.3', leaving
mom than 3' still available. Recovery was rapid, with the level dropping 0.6' 20 minutes after stopping
the flow.
Reviewed by: Paul Pinard
Date: 6/21~2
/
/
!
/
AS.BUILT NO CORNERS SET THIS DA'I:E
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON.
I hereby Certily that I have performed a Mortgagee's inspection
of the following described property; /..o'r' 4-~
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines and
do not overlap or encroach on the property lying adjacent
thereto, that no improvements on property lying adjacent thereto
encroach on the premises In question and that there are no
roadways, transmission lineS or other visible easements on said
property except as indicated hereon.
Dated at Anchorage, Alaska
this ~"J day of 3"L.'~J6 20 O ~--
FRED WALATKA & A.SSOClATES
(907) 248-1666 Engineers and Surveyors
~: DE~RTMENT OF HEALTH,,.HUMAN SERViCES-~i,,~!.(~,~.~!?~ '! , ,~ ~,,~:;
Division of Environmental Services ~ ,,.,,
...... ~.. ............ , , On-Site Services Sebtion~.,,i,":',';: .... ,.
,.,,~-..,.,:, ........... P,O. Box 196650 ..Anchorage, Alaska'.;',99519-6650 "' "' '" ' ' -
..... CERTIFICATE OF HEALTH AUTHORITY :.,, .~,, .,~ .,.....
-:: · :': ....... "APPROVAL FOR ASINGLE FAMILY DWELLING
:,.:.:.?,: Complete.legal, description .......
'.'~ "' "~:~: .:' Location (s te add'reSs or directions) ......
. . ~ ~ ~, ..,,,. . , . .,,- . , :, .~.,~:~.: · _
Day p none · ·
NOTE: -*: If commumty waSteWater system, prowde 'wrttten conhrmat~on fro ,=:ADEC
As certified by my seal affixed her~t0 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 forthe num bet of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files anC from my investi~]atio-'~.~nd inspection, the on-site water
supply and/or waste-water disposal System is in comp ~ance with all Municipal and state codes,
· ordinances~ and regulations in effect on the date of th~s ~nspect on ~'-~&~"~..-'-:',.. ":
.L ~ .... 'L~ ..../~-~. ·
Name of Firm .', ' KND Engineering
20441 Ptarmigan Blvd. _, , -
Address':.~:-- ' Eac]. le River 99577.8736 '
. , AK' ~, '. -. . ..,~,.~:; ,,; ;,,, ~.;,...:. ,.. ;, ._
Engineer's Signature
Konrlelh
Department of Health"and Hum'A~: Services (DHHS~:'~;~~ Hea th Auth,,, *,,
~po~n: t~e r..e..p, re~ent.a, bons g,ven ,n pa~ag~-aPhh5.[~b0~?..b~)' an independent
~ me ~tate o~ AlasKa. Tne DH HS does this as ~ c(~u r~e~ ~O'p~Jrchasers of homes
and ih~i~'il~h'~Jng ~nstitUtions in order to satisfy certain federal and state requirements. Employees of: DHHS do not
conduct inspections or analyze' ~ata before a certificate is .issued. The.,,Mu~ cipa i~:~of~Anchorage is not
responsible'for errors or omissions in the p'r0~essional eng'i'~e~r's w0rk~
?~_~.. - ..~ , ,. -, .....
Health Authority Approval Checklist
Legat Description: /..,,.~/z/ i¢]~ ,~¢e'/t/~u).~,~l" ¢, .~.-5/ Parcel I.D.:
A. WELL DATA
Well type
Municipality of Anchorage
DEPARTMENT OF~HEALTH & HUMAN
Envimnm'ental:Services Division
825"L" Street, Room 502. Anchorage, Alaska 99501. (907)
A lfA, B, orC, attach ADEC letter. ADEC water system number ¢.!!
Log present (Y/N) / Date completed ~
Total depth J Casedto /,/./' Casing height (above ground) j
Sanitary seal (Y/N)~ ' // Wires properly protected (Y/N) ~
FROM WELL LOG
AT INSPECTION
Static water level
Well production _ g.p.m. J
WATER SAMPLE RESULTS:
Cotiform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date ofPulnpmg (4~//// /~O~
/'/
C. ABSORPTION FIELD DATA
Date installed ~//~j~'~
Length /q / Width
Nitrate ~
¢~ted by:
Other bacteria
Date installed ~'?/~/ff.~. Tank size /l)tO(~ Number of Compamnents r~ Cleanouts(Y~) _
Foundation oleanout (Y~ /' Depression (V~) ff High xvater alarm
Soil rating (g.p.d./fl~ or fl2/bdrm) [~Oy[~[/,~t Systeln type
/? / Gravel thickness below pipe ~ / Total depth
Effective absorption area z/,5-~ 5/Monitoring Tube present(Y/N) / Depression over field (Y/N) /(,/
Dateofadequacytestff/////f/:3~Results(Pass/Fail)~ For ~.~ bedrooms
Fluid depth in absorption field before test (ill.): ~7..,~~ 'q hnmediately afterff/~ gal. water added (in.):
Fluiddepth ~-90t Minutes later: r~,5~/' (in.) Absorption rate = .5-/~ /t g.pxL
Peroxide treatment (past 12 months) (Y/N) t&// If yes, give date
'5'
D. LIlgF STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested /
/
E. SEPARATION DISTANCES
Size ill gallons
"P u mp,oDnlt lut~el at * //"Pump off level at*
/
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ~ [)dT) ~ '"t' ' On adjacent lots
Absorption field on lot ,e~ d7-D ' 4- ; On adjacent lots
/'
Public sewer main /[(~q- Public sewer manhole/cleanout
Sewer/septic service line A/~/ Lift station /[]/~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation _~ / '-P Properly line /15) t l~
Absorption field
Water main/service line /~ /d' Surfacewater/drainage /~TO~ 4- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
Cultain drain
Water main/sen, ice line
Driveway, parking/vehicle storage area
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
! certify that I have detern,ined thrufield inspections and review of Municipal
in conformance w~th X[OA HZ4 guidelines in effect on this
Signature
, ' '
.......................................................................
HAA Fee $ ~ ' d~
Date of Payment g~ '~/c.~ ~ 3
Receipt Number ,,/ff. g3q ~""~ ~3,~r'~
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
' ~UILI~ MJRT. IhC~.
M0.~36 ~.~
ASBUILT-NO CORNERS SET THIS DATE.
I HEREBY GF.r~ilFy .THAT I HAVE SURVEYED THE SCALE~ ,, ·
FOLLOWING DESCRIBED PROPERTYt
..,', .."'
AND THAT NO ENCROACHIdENT$ EXIST E~C~rrr AS ,e.~_A,~..* _/L~ ".¥*~'4
VISION PI.~I', UNDERHO ClRCUM~'~CE$
~ DATA H~ ~ ~
ARY LINES. ~w~..
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
1. GENERAL INFORMATION
Complete legal description
Lot 4; Block 2; Meadow Ridge Estates
Location (site address or directions) 21008 Country View Drive
Property'bwner Con~:~'.~. T. T~remas Day phone
Mailing ~res~": '~176 Oeean'Park Drive 32 Anchorage, Alaska
Lending agency
Mailing address
Day phone
Agent Hal Jack, on HERITAGE REAL ESTATE 18850 Eagle Riv~ Road
Address Ea~le Riv~r,?Al~ka 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
Day phone '694-4994
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XX
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
X×
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev. 1191) 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 furtherverifythatbasedontheinformationobtainedfrom
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.
S & S ENGINEERING
Name of Firm ........ ,- ,.= .... Lcc~ e~ k~...~ Phone
Address Eagle River, Alaska 9")577
Engineer's signature
DHHS SIGNATURE
Approved for 7" Z_.)bedrooms
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 th is 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. 119~) Back MOA ~21
Municipality of Anchorage /~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter.
ADEC water system number '7---/, \ ~"~\
Legal Description:
A. WELL DATA
Well type A
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date completed Driller
Cased to Casing height
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
Sewer service line
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B.
SEPTIC/HOLDING TANK, I~TA
Date installed Tank size .~ ~or~p~artments
Cleanouts~/N) ~,/ _Foundation cleanout~.~N) .__~./ Depression (Y~[~
High water alarm (Y~[~ ~'-~ Alarm tested (Y/N)
Date of pumping -'~ ¢cl 'Z~ Pumper
Well(s) on lot
To property line \c~
Surface water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
¢--~o ~'P On adjacent lots
Absorption field 5"' ~ 4--
Foundation
Water main/service line
72-0'26 (Rev. 7/9D Fronl CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets,MOA electrical codes (Y/N) ~
SEPARA~CE FROM LIFT STATION TO:
..~¢/.e4+-d~ lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
Surface water
D. ABSORPTION FIELD DATA
Date installed ~'~
Length I.~ Width
Total absorption area
Depression over field (YN~
R es u It s.__~p a(~-~f a i I) ~--~
Peroxide treatment (past 12 months)
Soil rating I ~"~P
Gravel thickness
Cleanouts present ~:¢N)
Date of adequacy test
for '"['"'~ ¢-P..~ ~"~')
[Z~o~[~ If yes, give date
System type ~¢-¢-P~(4C-
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots '¢2
Surface water
Curtain drain
On adjacentlots ~kl,~ Propertyline / ~ 4¢
To existing or abandoned system on lot
Cutbank ~//x.. Water main/service line \c~ t 4-
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & S ENGINEERING ,,,~'~'~, Oi' ¢~ ~.~,
Si-nature 17034 Eagle River' Loop Road NO. 204 ~,~:;¢°'¢°'~~ ;~¢?~,
Engineer's .ame~ ~~:~-. :~.t~.
HAA Fee $ ~-'l(.-~ ·
Date of Payment -')
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
WALTER J. H/CKEL, GOVERNOR
SOUTHCENTRAL REGIONAL OFFICE
3601 C STREEt, SUITE 1334
ANCHORAGE, ALASKA 99503
July 7, 1992
(907) 583.6529
Mr. Hal Jackson
Heritage Real Estate
18550 Eagle River Rd,
Eagle River, AK 99577
SUBJECT: Monitoring Status for Dawn Water Co.
PWSID#: 211431
Dear Mr. Jaoksof~;
As requested, the following is the current monitoring status for Dawn Water Co, (PWSID#
211431);
coliform sampling: 6/10/92. last sample date
inorganic sampling: 10/@/90 .. last sample
As a class A public w~ter system supplied by ground water, this system is required to
sample fo( total ootif.3rm contamination monthly and for inorganic chemical contsm[¢~ation
every three years.
Please contact r'ne if you have 8ny further questions,
Sincerely,
Marie P. Fried
Drinking Water Program Manager
MPF~ji (SCRO-dw)dawn.let
ce: Keven Kleweno, ADEC/SCRO/ADO-Anchorsge
