HomeMy WebLinkAboutFALLING WATER BLK 2 LT 4Falling Water
Block 2
Lot 4
#050 -772 -OS
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�/JPHONNE
XNEW
/f`!/r•�/� 6 J.MP'GE'Tp�
c�
6O`3L./0
❑UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
Lor 41
LOCATION
NO. OF BEDROOMS
3
Uy
DISTANCE TO:
Well`a 3
Absorption ar �
Dwelling ,
PER I� O 3
WQ
Manufacturer i• ��
CJ
Ma6r7-��L
No. of compartments
yF
Liq. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
�U
�
OZ
DISTANCE TO:
Well
Dwelling
PERMIT NO.
_ F
Manufacturer
Material
Liquid capacity in gallons
O
J
=
DISTANCE TO:
Well /
/S
Foundatio ,
�z
Nearest lot line
Xz0
PERM NO. ��//
764
JW u. Z
No. of lines
Length of eachine
Total length of lines
Trench width
Distance betwe n lines
F Z W
nches
Imo.
Top of tile to finish grade
Material eneath tile
Total effecti a absorption area
ZO 7501 Fr.
O
SL`Prx- �o •'�N-0
48 inches
Length
Width
Depth
PERMIT NO.
W
g F
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
W
W
to
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
PIPE MATERIALS
PVC P1_,q- T/c
SOIL TEST RATING
INSTALLER
ERIC'/<Son/'� ',4eK/��
o
REMARKS
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n
LTJ£ 7-e3 L � y0 -'_P CEA
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Aw da•��
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Earl P. Ellis
:•
4tNO 17A5.r
®4` , �•�•....•••.• •ams
�� d
APPROVE DATE LEGAL
d'e Z07 �, LScvc_
7Lir4LC-/�1�L� #W_
Ole
72-013 (fiev. 3/78)
(ter
by
DOC Co. dba
SULLMN WATER WELLS
P.O. 80X 272, CHUGIAK, ALASKA 99567 a TELEPHONE 688-2759
i
)WNER OF LANDrr1 r; 4'r 7` ,_.l-- _. DEPTH OF WELL
STATIC LEVEL OF WATER FT. / r� `'-'
ADDRESS -
/__;DRAW DOWN FT. -
.EGAL DESCRIPTION-
)ATE
ESCRIPTIOI\)ATE - Started —Ended �' ' =' GALS. PER HR
'ERMIT NUMBER -
KIND OF CASING
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MISCL. INFORMATION:
DRILLER'S NAME •= ...u°--
Plur4 I C_- I F -it- I -F'-e IZIF=
DEPARTMENT Or HEALTH AND ENVIRONMENTAL F'ROTECTION
:z:125 'L,' STREET, ANCHORAGE, AK. 99501
264-4720
PERMIT NO. 800374 )
APPLICANT MIKE GUMBLETON SR B:•-.'. 9030 CHUG IAK 688-3290
LOCATION ER
LEGAL. LOT SIZE 86000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATI14G (SQ FT/BR)= 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DF=7F-w-FH_—. 0.� I aN0_rlA= a OR~al CHEF -r H = --
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT 15 THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE 15 NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
FED DD U I F."FE C- -'-- a I`r I C _r Fl N K :H5 I =- E="= -0 "- k2N 0 n 1 1 C-1 "!=-'
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.
— — -r 14 0 -. ::2 > I F=* F= i::: -r 10 F--1 F:P FE F -Z E: C,! U I F;,I 1= C.,
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.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
is 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSND THAT THE OpljSITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE ItREMOV�_ED Tr-,/IOC41DE MORE THAN 3 BEDROOMS.
S I GNED:--------------
ISSUED BY
V4. 0
0 & E GEO-, ;CHNI CAL Et DEVEL 'WENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Soils Et Foundations Land Development
Performed for: Name: Tel. No.
Mailing Address:
Legal Description:
Depth (feet)
-
0
1
E
3
4
5
6
7
8
9,
10
11,
Soil Characteristics
12 R7
13 ® sa.sm oaoa4
•a
1U_ 7 o co p
® e uDp DD Y f
�5 pAQOC e9f f�i 03 "�'dJL ( iD DBfl B°fid .,V
Wc/J .(.°D .y�.................. FPp •
17
16 /A(� Russell L. Oy5}Cr s rj
w04 6, to No. 4236-E •"(0�`
0.
4�e' IV*.PfA DU09CDq\ �/\ f•
%%ROFESSO V4W
Ground Water Encountered: Yes—_ NoIf yes, what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
Performed by: Date:
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVR!!'H
Parcel I.D. 050-772-05
1. GENERAL INFORMATION
Expiration Date:
Complete legal description Falling Water Block 2 Lot 4
Location (site address) 3025 Mistv Mtn Rd, Eagle River, AK
Current Property owner(s) Monis Day phone 622-5518
Mailing address same
Real Estate Agent David Schade Day phone 622-5518
2. TYPE OF DWELLING:
M Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class C Well
Public Water System
3
TYPE OF WASTEWATER DISPOSAL:
M
Individual
M
❑
Holding Tank
❑
❑
Community
❑
❑
Public Sewer
❑
Received by. '' Date / v
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 1696
Date of Payment��/y
Receipt Number 0/5 05�
COSA # 6W 14 %43J
Date:
Date of Payment
Receipt Number
Waiver
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,
based.,on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the 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 NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng
6. DSD SIGNATURE
zSystem #1 Approved for 3 bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By: (Ci i Original Certificate Date: 2 ( /
The MunicipalityAnchorage Devlopment Services Division (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSAbluesheei 9-1-12doe
X Nitrate Advisory
Arsenic Advisory
Other
H more than 1 septic system is on the lot:
. COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: /,44411V6 I, 4-re,Q R Ltj Parcel ID:OSO-7%2—OS
A. WELL DATA
Well type If A, B, or C provide PWSID # Well Log (YIN)
Date completed 81J_118 (7 Sanitary seal (Y/N) T _ Y Wires properly protected (Y/N) TY
Total depth �ft. Cased to Z ss ft. Casing height (above ground) Ino n.
FROM WELL LOG AT INSPECTION
Date of test 4ZZ H , y
Static water level /Q S ft, /Q 7 ft.
Well production /4 g.p.m. $ g.p.m.
WATER SAMPLE RESULTS:
Coliform __0 colonies/100 mL Nitrate 3. mg/L
Arsenic 0. 230 ug/L Date of sample: LZ7 Collected by: Allelr%. ?5;lr._
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material 5FP 1 le -/S T-/,= EL Date installed O �G
Tank size /2/I0 gal. Number of Compartments Z Cieanouts (Y/N)
Foundation cleanout (Y/N) Ir Depression over tank (YIN) V High water alarm (Y/N) N
p S
Date of pumping 3 Pumper
C. ABSORPTION FIELD DATA
Date installed /o 0 Soil rating (g.p.d./ft2 orftz/bdrm) /D'O System type h e o Z&_ -,.e4
Length _-7 ft. Width 3 ft. Gravel below pipe 15� ft.
Total depth ft. Eff. absorption area 376 ft, Monitoring tube T Depression over field A
Date of adequacy test Z / Results (Pass/Fail) ?a SS For 3 bedrooms
Fluid depth in absorption field before test 3 6 in. Water added / SG gal. New depth 3 F in.
Elapsed Time: 60 min. Final fluid depth 36 in. Absorption rate >= - d.
�g•P
Any rejuvenation treatment (past 12 mo.) (Y/N & type) if yes, give date
D. LIFT STATION IVA
Date installed
"Pump on" level at
Datum
Size in gallons
in. "Pump off" level at
E. SEPARATION DISTANCES
WELL ON LOT TO:
Cycles tested
Septic tank/lift station on lot-10.L—If-
Absorption
ot10tT /If -
Absorption field on lot /66 1,&
Public sewer main A/fl
r
Sewer /septic service line
Animal containment areas 5 ��
SEPTIC/HOLDING TANK ON LOT TO:
I
Property line !`Q �` Absorption field S
Water service line 4 �t. Surface water �� f
ManholetAccess (YIN) _
in. High water alarm level
Meets alarm & circuit requirements?
On adjacent lots /D d et
On adjacent lots f O 6 '¢
Public sewer manholeldeanout All+
Holding tank NA
Manure/animal excrete storage areas / oo f7'
i
Building foundation /d fi
Water main A/,
Wells on adjacent lotsAGO
if
ABSORPTION FIELD ON LOT TO:
Property line t'6 �'14 Building foundation /40 Water main
Water Service line /d il- Surface water Driveway, parking/vehicle storage
Curtain drain 4ZX4ff= Wells on adjacent lots�'f
F. COMMENTS
G. ENGINEER'S CERTIFICATION
J certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name
Date _24/
COSA brown sheet_10-10-12.doc
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES }•
Division of Environmental Services
_—
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519.5650
.(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
Parcel I.D. # 050-772-05 HAA # 0100/a
1. GENERAL INFORMATION
Location (site address or directions) 3025 MISTY MOUNTAIN ROAD EAQ1 F RNR AK
Mailing address - c/o WENDY STEVENS w/ DYNAMIC PROPERTIFS
Lending agency
Mailing address
Day phone
Agent_-WENDY STEVENS w/ DYNAMIC PROPERTIES Dayphone 261-7657
Address 3111 C STREET. SURE 100 • ANCHORAGE. AK 9050
Unless otherwise requested, HAA will be held forpickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site xxx
Holding Tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
Ing to the legality and status of system.
72-025 (Rev. 1181) Front 610A tl21 Computer Version
Note: Alaska Water and Wastewater Consultants, lnc. shall be paid $550.00 at,
or prior to closing for the engineering services provided.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, l 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. r
Name of Finn
Phone (907) 337-6179
Engineer's Signature nate
!n conducting this evaluation, AWWC, In a n ted to de a thorough, conscientious engin ring nalysis of the
system In accordance with ADEC and M A Guidelines & Regulations. The reported results described the
performance of the system under the conditions ncountered at the time of the test, and separation distances .
measured to readily identifiable features. The operationallife of ell wells and septic systems depend
on the local soils condition, ground water levels that may fluctuate during the year, and the water o�oo
usage of the family being served by the system. These conditions are outside the control of o00
the evaluator 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.. �P • '
AWV=, inc. can therefore not provide any warranty for future estimate of how long the (ij;
system will continue to meet the operational requirements of the ADEC or MOA DHHS. �.!.. % .
The content of this report is for the sole benefit of the ownor listed above. Any 0
reliance upon or use of this report by any other person or party Is not authorized, ....
nor will it confer any legal right whatsoever. �Q t'f y . Go ess,
3 ;
6. DHHS SIGNATURE CE—
�n'.'� .
Approved for—bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
a
Date L /0 - 0/
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. IM) Back MOA R21 Computer Version
Municipality of Anchorage
• v
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 "L' Street Rm 502 Anchorage, Alaska 99501 (907) 343-1744
Health Authority Approval Checklist
Legal Description: FALLING WATER S/D: LOT 4, BLOCK 2 Parcel I.D.: 050-772-05
A. WELL DATA
Won Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) YES Date completed 8/11/1980
Total depth 154'-9" Cased to 154'-9" Casing height (above ground) 18"+
Sanitary seal (Y/N) YES Wires property puled (Y/N) YES
FROM WELL LOG
Date of test 8/11/1980
static water level 105'
Weti production 10 G.P.M.
WATER SAMPLE RESULTS:
AT INSPECTION
1/3/2000
110'
3.0+ 9.p -m.
Coliform 10 Nilrate 0.6-00 e4q /r_ Other bacteria
Date of sample: 12/28/2000 Copected by. A.W.W.C.. INC.
B. SEPTIC/HOLDING TANK DATA "INSIDE CRAWLSPACE
"HOUSE HAS BEEN VACANT AND WINTERIZED FOR THE ENTIRE YEAR.
Date kuta0ed 8/10/1980 Tank size 1000 Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) 'YES Depression (Y/N) NO High water alarm (Y/N) N/A
Date of Pumping **1/10/2000 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
Data Installed 8/10/1980 Soil rating (g.p.dJlM of rtn 100 System type DEEP TRENCH
Length 47' Width 30" Gravel thidmess below pipe 4' Total depth 11.5'+/—
Effective absorption area 376 SOFT. Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
Date of adequacy test 1/3/2000 Resugs (PaSs/Fap PASSED For 3 Bedroom
Fluid depth In absorption field before test (In.); 0" Immediately alter 1513 gal. water added (in.): 22.5"
Fluid depth 4.5" (Ins) Minutes later. 30 Absorption rate = 450+
Permdde treatment (past 12 months) (Y/N) - NONE KNOWN K yes, give date —
?2-= Rw. &leer ComwW v@r"
D. LIFT STATION
Date installed Size In
Manhola/Access (YIN) 'Pump on'
High water alar level at' •Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
'Pump off" level at*
Septic/holding tank on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent kits 100'+
Public sewer main 100'+ Public sewer manhole/cleanout 100'+
Sewer/septic service One 25'+ U(t station 9S NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+
Property line
5'+
Absorption field
5'+
Water main/service One 10'+
Surface water/drainage
100'+
Welts on adjacent lots
100'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property One 10'+ Building foundation 10'+ Water mairrlservice One 10'+
Surface water 100'+ Driveway, parking/vehide storage area 5'+
Curtain
F. ENGINEER'S
I Certify Chet I
ormuntapain
with MOA HA
Engineer's
HAA Fee $ 3 FLD ,
Date of Payment
/-�r-::;,/
Id Inspections and review
stems are In conthrmance
this date.
Receipt Number 04 9 3 -
rz= (Rw. 3mr c= vuwvwww
on a
Waiver Fee
Date of Payment
Receipt Number
01-04-01 17:09 FROM -CTE ENVIRONIENTAL
CUE Environmental Services Inc.
CT&EReLN
1007934001
Cilent Name
AIC Water & Wastewater Consultants Inc.
Project Namem
Fallinit Water S/D
Client Sample ID
Lot 4 Blk 2
Matrix
Drinking Water
Ordered By
PWSID
0
Sample Remarks:
5615301 T-899 P.02/03 F-762
Client PON
Printed Date rime
Collected Date/time
Received Date/rime
Technical Director
Released By //�/,
01/04/2001 9:38
12/28/2000 8:45
12/28120oo 11:25
Stephen C. Ede
W/ ��
Pammeer Rewlts PQL Lrnits Mattwd Allowable Rep Analysis
Limits Data Date Init
Waters Department
Nitrate•N 0.500 U 0.500 mg/L EPA300.0 10 max
Microbiology Laboratory
Total Coliform 0 c0VI00mL SMIS9222B
12Q9/W GCP
12/28/00 SKW
MUNICIPALITY OF ANCHORAGE
DEPARTME. OF HEALTH AND ENVIRONMENTAL PA =CTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Ga
Application Date�-/- /Sy /7 n-
-,� - –
1: GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township,
N
Location (address or di
(b) Applicant Name/ Z2Kk
Applicant Address x71_ 4 "2
(c) Applicant is (check one): Lending Institution ❑
Telephone: Home ��� 3 �� .- Business —_
_3
W`; Buyer O ; Other D (explain);
yt� �•z�Tele hone _
(d) Lending Institution -:-–.— P
Address —_--._ — _"—"P ",
(e) Real Estate Company and Agent '1!f, - 'tegx'
Address _._-- _.— _ -- k' ---
�- - --- yy- �Z
,he HAA to the following address:
Y� � st6-se.CGhe->�b
47
TYPE OF RESIDENCE
Single -Family ot Multi -Family D
Number of Bedrooms — -3 __
3. WATER SUPPLY
Other
Individual Well �d Community D Public O
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite)l Public O Community O Holding Tank O
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
12-025 (11/84)
Page 1 of 2
5 ENGINEERING FIRM PROVIDING .tSPECTIONS, TESTS, FILE SEARCH, DA% AND INFORMATION
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 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
forthe 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— �;4F, gk
� Telephone
L
Address � :••., -1_-;
Date
6. DHEP APPROVAL
Approved foredrooms by _
Approved _—- Disapproved
Terms of Conditional Approval
Conditional
CAUTION
,. i
YtS
I. Robort •••^- • • .2, ., j
A. Shutur
Pte ••• No. 1457-f ��•„
• �.. ••\`Myr'
The Mur:rpabty 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. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is riot responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
-e,,,s.<
G'�
NCNpv
MSN\ o�QtMeN�P�
MUNICIPALITY OF ANCHORAGE (MOA1
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: L'►�r �iVK 2—
A. WELL DATA
S If A, B, C, D.E.C. Approved (Y/N)
Well Classification � PP
Well Log Present &N) Date Completed `a' 1t -042 Yield • 5 cm P" 't"
Total Depth 1 "IA1 a1 " Cased to tS41 01 " Depth of Grouting
Static Water Level tom , Pump Set At IL
Casing Height Above Ground �pN Sanitary Seal on Casing4�%)
Electrical Wiring in ConduitON) Depression Around Wellhead (Ya
Separation Distances from Well:
To Septic/44efdf 7g, Tank on Lot 1 per✓ On Adjoining Lots t a t t
To Nearest Edge of Absorption Field on Lot 1 1 S ; On Adjoining Lots \ t a
To Nearest Public Sewer Line rJ n To Nearest Public Sewer t
Cleanout/Manhole To Nearest Sewer Service Line on Lot ZS a -
Water Sample Collected by S�rS SSG �n3f�-etiX, ; Date f-3—Ig
Water Sample Test Results S/k1�15� 2�
Comments -
1;0%2 -t97 Jti ` 1 til 625L1SSs .4G 'G.- 4nrt-
B. SEPTIC/HOEMG TANK DATA
Date Installed 4�5 - 10-8Size L L-wt� No. of Compartments A-
Standpipes&N) Air -tight Caps ON) Foundation Cleanout (YAM
Depression over Tank (Y/2 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) A for
Holding Tank High -Water Alarm (Y/N) a Temporary Holding Tank Permit (Y/N)
'J A
Separation Distances from Septic/HoMiN Tank:
To Water -Supply Well l o'i✓ To Building Foundation
To Property Line L C> 1 k To Disposal Field —
To Water Main/Service Lin
Course
Comments
Page 1 of 2
72-026(11/84)
I o I -4- To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata + I FmL_ Type of System Design 071 2�114
Date Installed G -10 - 8 01
Length of Field W7
u _
Width of Field 3a Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area ?2 2-c;, If Standpipes Present®N)
Depression over Field (Y)&)
Date of Last Adequacy Test 0-7,1-85-
Results
-Zt-8SResults of Last Adequacy Test S�Tv
Separation Distance from Absorption Field:
To Water -Supply Well 1 1= To Property Line A --o
To Building Foundation 5Z
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
To Existing or Abandoned System on
1
;On Adjoining Lots -
a
To Cutbank (if present)
41-13Y.,
t
Dimensions
Manhole/Access (Y/N)
"Pump On" Level at "Pump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
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.
Signed 8 & f ENGINE -RING Date S-Z7�-43J�
,i�ra
Company,' 'I_E RiVEIR, Ai,r''10KA ;''11377MOA No.
Receipt No. M'Z—I (o!S
Date of Payment TT $ OF
l�•�V
Amount: $ +" "�" " jSeat"`
Page 2 of 2
72-028 (11/84)
Time
APPLIC'- NT FILLS
OUT UPPER HALT ONLY
Time
eQ
Property Owner
-
Date
Phone
Date
Inspector
Inspector
Inspector
Inspector
Mailing A'Icress
Zip Code
j-9—t S
Buy,8r
MUNICIPALITY OF ANCHOMGE
- vt�c (au �p�a Z S- f'EPT. OF
V ENVIi�OIJ,`,1=MAL PR❑r.CTlON
�,V`�-"-" C'_ C� S? . CN"�e� I�O.�-�
Address
r�. M Ilr l
Zip Code
�4�„
L L
AA,4
Lending Institution
DISAPPROVED
Phone
Address
Zip Code
Soils Rating
Realty Co. &Agent
�Ic)
Phone
Septic Tank Size /(j 0 0
Address � _
,/
� �ti . `;7 .�J C!
Zip Code
Legal Description
jl /
Street Location
/
- O 1JJ/%/d/���.- %/07
i/
Type of Residence
X --Single Family
[I Multiple Family
-j
No. of Bedrooms__
L] Other
Water Supply
A.Individual
ATTACH WELL LOG. A well log Is required for all wells drilled
since
June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log
If available).
❑ Public Utility
Sewer Disposal
/ (
W 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.
Time
Time
Time
Time
eQ
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
j-9—t S
Field Notes: (2-N(CC' • U
0�vw:k
MUNICIPALITY OF ANCHOMGE
- vt�c (au �p�a Z S- f'EPT. OF
V ENVIi�OIJ,`,1=MAL PR❑r.CTlON
�,V`�-"-" C'_ C� S? . CN"�e� I�O.�-�
C.tl•►'�oA.Mw7l' / .....
r�. M Ilr l
R
EIVED
�4�„
L L
AA,4
---- c�
( ) APPROVED BEDROOMS �L� 'CONDITIONS OF APPROVAL
DISAPPROVED
( ) CONDITIONAL APPROVAL -
DATE
Soils Rating
Date Sewer Installed
Well To Absorption Area f S
Well Log Received
Septic Tank Size /(j 0 0
Q) -- ( o -- 8 (0
Well to Tank / O .3
72023 (3182)
L Lap
1
i3OS
iuoveinber 30, 1983
?4iko Guiableton
subject: Lot 4, Block 2, Falling tdater Subdivision
Approval for the individual sewer and water facilities cannot
bo, granted until the following items have been completed:
° A well log submitted to this office for our files and
review.
`-2!(r ° The top of the well casiny should be sealed so that it is
Nst:t>aAs- water ti;.3ht.
Exposed electrical wires to the weld head are in violation
(P.c f the Hunicipality of Anchorage codes and must be encased
n conduit.
N ���rTTTT Phe septic tank pumped with a receipt submitted to this
department.
° The depression over th4<„sewer >yat.c:a;:t will need to be filled
so that surface water drains away from the sewer system.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 164-4720.
t; i nc..ercly r
Cory Willis, R.S.
Acting sewer & water
Program Manager
Ct•75`7/e�/i:l
1
6. LEGAL DESCRIPTION
DATE RECEIVED
INSPECTION APPOINT E T
TIME
33
TIME
TIME
DATE
DATE
DATE
El One ❑ Four ❑ Other
SINGLE FAMILY
❑ Two ❑ Five
INSPECTOR
INSPECTOR
INSPECT
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF H -ALT► i &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PF11M MENTAL ,' FLCTION
825 L Street - Anchorage, Alaska 99501
JAN 2 i 1981
0*
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720 R E E V E D
AND SEWWA�CfCITIES
REQUEST FOR APPROVAL OF INDIVIDUAL WATER
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PR ERTYOWNER
PHONE
Gta r "flea- / h
MAI G ADDRESS ....,
PROPERTY RESIDENT (If different from above)
HONE
sIg
/-/- 3
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
6. LEGAL DESCRIPTION
Je�
7 rte
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
El One ❑ Four ❑ Other
SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER SUPPLY
XD INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
l y o YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
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
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: )DOC) If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL n
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
APROVEDFOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE \
BY
72-010 (Rev. 6/79)