HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 3 LT 17A /"~)WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 8 Geophysical Surveys
I~l-IsO,OUgh S,bdlvl,ton~ Lot Block I~-~1~I I/4qtre. Section No. TownlhlPNrlJ__ Re.go ED Merldla,
~DISTANCE ANO~IRECTION FROM ROAO INTERSECTIONS 3. OWNER OF WELL:
~,*,~ *~. ~o~ Bo.o. ~ "'
~.~.~ ~ ~ 6. ~Cobt. tool ~Rolary ~Orivin ~Dug
~.~ ~ ~ 7/ 8. c~s,.~: OThr...d O'W..d.d
lO, STATIC WATER LEVEL: ~ ft.
0
~11~ 4 0 ~non
REr trn ,....o..,.o ..,,o,.,..,
~ ~' ~ ~ Materiol: ~ NIQI Cemlnl ~ Other:
15. Woflr Temperature o ~ F ~ C
PERMIT I'.tO. (
MUN Z C Z ~, .=IL I T'I-" OF
DEPARTMENT OF HEALTH R,'.,ID ENVIRONMENTAL PROTECTION
825 'L' STREET, ANCHORAGE, AK. 9B50i
264-4?20
i.4ELL PERI'"'I I T
820140 )
APPLICANT
LOCATION
LEGAL
C&E ENT.
LI?R B~ CAMPBELL HTS
PO BOX 10-991
LOT SIZE
8732 SQUARE FEET
MINIMUM DISTANCE BETI4EEN R ~ELL AND ANY ON-SITE SElqRGE DISPOSAL SYSTEM IS
i00 FEET FOR R PRIVATE I.IELL OR 158 TO 200 FEET FROM R PUBLIC NELL DEPEHDING
UPON THE TYPE OF PUBLIC 14ELL
MINIMUM DISTANCE FROM R PRIYRTE 14ELL TO R PRIVATE SENER LINE IS 25 FEET AND
TO R COMMUNITY SEI4ER LINE IS 75 FEET.
NELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT blITHIN ~0 DRYS
OF THE 14ELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER IHSTRLLRTION.
PERM I T E×P I I:;;: E--C; DECEI"IBER 3'-i.. :2982
I CERTIFY THAT
l: I AM FAMILIAR I.IITH THE REQUIREMENTS FOR ON-SITE SEI.IERS AND ~IELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I 14ILL INSTALL THE SYSTEM IN ACCORDANCE 14ITH THE CODES.
SIGNED:
APPLICANT C~,E ENT.
V4. 0
~.RT ]F'Y 'IHF:I
~J Ftrt F'P..I,1]L,IRF: 14]lFI 11-;L' ~;EOLITF.'EI'II-J!l.~. I:U~: CR-I-:-.:! .gl-' =--,E.I.!L'I-.'S, Fir-if, HELI.~, A.c. -'.~:1
' iF! ¢:%' ll-lr I. illl.llC]f-'fjj. ]T~, I';l" f!l.lf.l, lORf~f'.
~..'l): __ .~~ ..............
· FIr-lr'L .1C'F~Itl l'..~':t, t'~'.Q. . ftC'
07 8 9 70
MUNICIPALITY OF ANCHORAG - R �k.: ;
s ..i.•:.�"e� _ rid ,.,
Development Services Department Ph.ovl �07-39'14
On-Site Water & Wastewater Section Fa' z*0 3 997
Certificate of On-Site Systems Approval
Parcel I.D. 014-072-44 Expiration Date: 7- L - t
1. GENERAL INFORMATION
Complete legal description Campbell Heights, Block 3, Lot 17A
Location (site address) 4021 E 67th Avenue Anchorage, AK 99507
Current property owner(s) Jesse W. Glosser Day phone 244-5222
Mailing address 4021 E 67th Ave. Anchorage, AK 99507
Real estate agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well Private Septic ❑
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer X
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5_56 Waiver Fee $
Date of Payment 3/,R6/iq Date of Payment
Receipt Number O5 OiO Receipt Number
COSA# O 3e /Q 1 U 7 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 Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 3/6/19
tom, ''• ♦i
.4 / 49th '' - H♦.
• W1, ,H HMH0
6. DSD SIGNATURE , d.,H � ,...0
=IMMH�tMH...t...HH/O��H••H��it�.
�\ System #1 Approved for 3 bedrooms •����0�,f;mICHAEI E. ANDERSON :j
♦♦�-J,'a. No. CE-4381
System#2 Approved for bedrooms ♦j�fF� .3/6/19., .,.��'+•
ir
Disapproved ♦♦44PR ;;;�+�
Conditional approval for bedrooms, with the following stipulations:
`\l lott((((((((/(r
te
ON-SITE '%
W
ATEH AND
o WASTEWATER
PROGRAM
J �
O `\
04,,
4i6- •StRv\G��`�
R\1\-
,04,„ St
By: � %10Original Certificate Date: q ^�
The Municipality of Anchorage Development 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 X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: Campbell Heights Block 3 Lot 17A Parcel ID: 014-07244
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA •
❑■ Well log is filed with Onsite (or attached) Well production at time of test 6.2 gpm
Date drilled 5/26/82 Water storage tank volume N/A gallons
Total depth 73 ft Well disinfected for coliform test? ❑ Yes ❑� No
Cased to 73 ft ❑■ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑■ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑� Arsenic less than MRL (ND)
Casing height(above ground) 18 in. Collected by Forge Engineering
Date of flow test for COSA 2/28119 Date of Sample 5!1/19
Static water level at beginning of test 32 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) N/A years ❑ Required maintenance completed
Tank type/material N/A Age of lift station N/A years
Measured operating fluid level in septic tank N/A Lift station material N/A
❑ Standpipes/foundation cleanout per record drawing Comments: Public Sewer
Date of pumping N/A
D. ABSORPTION FIELD DATA Public Sewer
Which system tested (date installed) Adequacy test date
[' ALL standpipes present per record drawing Results ❑Pass For bedrooms
Total measured depth from grade ft (max) Fluid depth prior to test in
Measured depth to pipe invert from grade ft(min) Water added gal
❑ N/A—pressurized field
New depth in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time min
depth into effective
E=1 Code-required soil cover over field Final fluid depth in
ElSystem presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout> 100'
❑Yes if No NSA ft E Yes if No ft
Neighboring Tank > 100' ❑Yes if No N/A ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft
Absorption Field on Lot > 100' ❑Yes if No N/A ft Holding Tank> 100' ❑✓ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment> 50' [' Yes if No ft
❑✓ Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ✓❑ Yes if No ft 0 Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑Yes if No N/A ft Surface Water> 100' ❑Yes if No N/A ft
Property Line > 5' ❑ Yes if No N/A ft Wells on Adjacent Lots:
Absorption Field > 5' ❑ Yes if No N/A ft Private Wells > 100' El Yes if No N/A ft
Water Main > 10' ❑ Yes if No N/A ft Community Wells > 200' El Yes if No N/A ft
Water Service Line > 10' ❑Yes if No N/A ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ❑ Yes if No N/A ft If absorption field is under driveway comment below
Property Line > 10' El Yes if No N/A ft Wells on Adjacent Lots:
Water Main > 10' ❑ Yes if No N/A ft Private Wells > 100' ❑ Yes if No N/A ft
Water Service Line > 10' El Yes if No N/A ft Community Wells > 200' ❑ Yes if No N/A ft
Surface Water> 100' ❑ Yes if No N/A ft
F. ENGINEER'S COMMENTS
Property is served by AWWU Sewer.
G. ENGINEER'S CERTIFICATION ,���� 44
�•,,�P....* ft% 6>L5•7*.i
I certify that/have determined through field inspections and review `�� �'•.•
of Municipal records that the above systems are in conformance with a ' 49th �� 0. * •
MOA COSA guidelines in effect on this date. ;•, �_� ���• .,.. ,�
0 •
1 VA MICHAEL E. ANDERSON ;
• .. _Ji
• .•. No. CE-4381
• � . . . .- 7
�.\�
V
COSA Checklist yellow sheet v (.4) *. FQ�� 3/6/19 ••................. ... 0.
•
* '*': .. DEPARTMENT OF HEALTH & HUMAN SERVICES. ' .' * .
.... . · ' Division of Environmental Services - .,. -..: ....
,-. - *~.~-: -. ;...:...... * On-Site Services Section :....--': . .. ' ...... - .;
· ..' . .. P.O. Box 196650 Anchoragei'AlaskH 99519-6650,
-- - ; : , .- .- . . 343-4744 .
":"' ': * ' CERTIFICATE OF HEALTH AuTHORITY
'-~"-,= , ': .... '".APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # el q- 0'7 ~'- ~ ,AA #
1. GENERAL INFORMATION .... "
........_ . C~-~plet~-Ie'gal. . description , L~ F t-/ ,~ '[~loC~ ,?._
· '. Location (slte address or directions) . ~/o¢/ ~.. ~'?~
Mailing addiess ,-(o z I E'.
Lending agency. ~-~w ,~ C -
........ Mailing address ~'o ~t.O.
Day phone
Day phone ~'z- z./,5 ,,
. '..-... '-:5i'Agent :H~ {H r' ~tn~tf~'~'O~'/ -- ERJ.~'Cram~r~L:'ff.e.Dayphone "¢~ ¢'~¢~ z - -' -
· :- -;:'~':Addr~'~Z30'-'~ ~'~'- ~: - -A~'~ "~ ~ '~'~'~'~ ~'~;'.~; ~.:.~;~L' ...
· - ~ 7~'~ ':*~20~le~i~e~,se~u~ste III hed rnnk,,n',:.:=".?.-.:= '.'.:~ ¢:~:,~"..;:*; "'~ :"
~ : ".;:';:,. 2.~: : NUMBER OF BEDROOMS: ;"-' :'3 "'.. -.'., ' .' . ~ -: ~'~'" :.'.;:.'"-.':.~';;.'...,,;;;:.~..-~ ~.'./-. :.-";.' ~ ~'
3. : , ~PE OF WATER SUPPLy: · ' : '. , ·
. ~= . ' ' ;- ' Individual well : ~ ..... .- - ..'-t-.'.": ...... .. ' · ·
'' ) '
· - Public water - . .... ~. -' . ' ...
-..NOTE: If ¢ommunl~ well system, provide walden ¢onfi~ation from State ADEC a~est-
.... ~ ........ lng to the lega/i~ and status of system. ' ............ '. - ,,,.,;".", ';, ;';':' -
Ind~wdualon-site - . , , ,~ --] . ,::~ . .
.: . . Communi~ on-rote ...... ~ ~',, ,4. ,..".-,~.~ ~ '.. · -
- - . '-= Publcsewer · ~-.,, ~. ~ - . ......- · '~.,,~.~ ~ .... , ~. +
......... ,..,, . .. - .... ,,, ..,:)..
--.. ~ NOTE: .If communl~ wastewater s~tem, provide wri~en confi~ation from State ADEC ..
a~esting to the legali~ and status of s~tem. "' -' · . ~ ' ~. '- · ..'
STATEMENT OF INSPECTION 'BY ENGINEER' '- '~" ' "~ *
As certified by r~, seal affixed hereto and as of the validatio~ date shown below, I verify that my
Investigation o~ this Heal!~.A~ uthdrity.Appi'0~al application shows that the on-site wate? supply
and/or wastewater disposal system Is saf .e, f. unctional 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 fi!es 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. .
_'~_ -._:-: . . '_. ~'__ '. . :: .-. "~:- .:-- ..... ... - _,'* , . .- ............. ..
· :..,. .... '__~ ;~ * . - . -.,...; -....· -
..-..-~: .-:-:--:~:-.....-. :~i~...:-::::: _... :.-:, .,-. ........ :-..-: _ ... _ . .~p..:.:.:-:~:....
· .-..: .... .-,, ,,.
"" '' ::':': -:':' ......... ' ..... "2- :"' '"-":': '::; -'::" ':':' 't.'. ",-...... - --,'~,,,~...~.-.,-.":~g~'i:' :">::':":::':-".:: :'..:
~ .. - ',..'.~' ~ '-, ..,-~-:~ot;~:,~.~ . :~'.,.T~" ."i-""' ."
' ', :.'- ': ~t nl. lu~ ~II~.I~JA"~IIR~ .... "- . .... : .... : ' ',~ -*TH~-OOOR~ I=. MO(:~E.'": ' E:': ' :- ' :';' ~- ;' ,'":: -t-
.... -: ............ ........... :P ............. '~,~'-d .. * .'..~..... m .....=..r:=.,,~.--._, ..... -,.
.... '.. ',...~.'~" :approved for,- · - .;bedrooms...~--~:,- ,~:7~.:.o.. .... .
-> :-: ':, .-.~. > ......~ ~ond~tiona .~pprova for ,- ............ ,l~lrooms ;w~th the following
..... · ..... ~ .,. . . - ~,. ~.::.?!-',..~._: -- -. , . .
...... ' . ,~ ,,., ' ' ','.. ·',,,- ' .... :,': -'
"": AdditionalComments.' ' . ....... ' ' ' '
· . :_: ,.-.,~.: ~ ~:?:*?.:~.:::.-...-::~:...=.:-..:. ----~ .... -..--- -... ........... ._,= ..-:..~. ,.::.:
.,... ,...,, .. ......... '".:."-'.:..
,., ,,~t,,v.:~ ,,~..,:,') : .... . ~,,,,,.~. :, :_:..:.:..
· .~,%x~',, ~ ~',/zf~' Date
· . ~'.. . ..,- .,.,..,... _- . ::::~ ':. :; '---.-~.".,:.,~.--
.. to, . .,, ,. . :_'.. ..:' .~ - .:.... .. ....... .
'~.'.....- ,, ~ u~ . . .,,, . * . ', ::- ~.gC :.,.:,_ ~ ': '
Municipality of Anchorage
Department of Heal!h. and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LogalDescripticn: L. 174j ~IH..~, ('~/~l;,el/ ltt-.J ParcelI.D.
A. Well Data
Well type J~ u' /
Log present (Y/N) 'r'
Total depth '73 ' Cased to
Sanitary seal (Y/N) Y'
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 5' / ~ ~' / ~ ~ Driller ~ I?
7 3" Casing height
Wires.,pmPedY ,protected (Y/N)
AT INSPECTION
FROM WELL LOG
Date of test
Static water level
Well Ilow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
g.p.m.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
-~ ~o.., ~...~ ; On adjacent lots
N. /~'. ; On adjacent lots N. A,
R.3' -+ Public sewer manhole/cleanout ';> Ioo '
Petroleum tank No~,
WATER SAMPLE RESULTS:
Coliform 43 I c ~ Nitrate
Dale of sample: 3 / 7/9,5'
Collected by:
B. SEPTIC/HOLDING TANK DATA N,,~.. (.../t Ix.,, t.~,c4
Date installed
Cleanouts (Y/N)
High water alarm (Y/N).
Tank size
.Foundation cleanout (Y/N)
.Compartments
Depression (Y/N)
.Alarm tested (Y/N)
Date of pumping
Pumper,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Suflace water/drainage
.On adjacent lots
Absorption field .. ,'-
Foundation
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION N. ~4.
Date Installed
Size In gallons
Vent (Y/N) 'Pump on' level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot i" On adjacent ~s '
D. ABSORPTION FIELD DATA N,
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at,
Cycles tested
,Surface water.`
Date Installed
Soil rating (GPD/FF)
Gravel thickness
System type
,Total depth
Depression over field (Y/N)
.Cleanout present (Y/N)
Length Width
Total absorption area
Date of adequacy test
Water level in absorption lleid before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
To building foundation
On adjacent lots
Results (pass/fa~)
Surface water
for
Nter test
If yes, give date '
Well on lot On adjacent lots , Property line
To existing or abandoned system on lot
Cutbank Water main/sewice line
Driveway, perking/vehicle storage area
Bedrooms
Curtain drain
E. ENGINEER°S CERTIFICATION
I cer~fy that I have checked, vedfied, or conformed to all MOA and HAA guidelines in ef~e.c~.~..~..e...clate_ - ..._ of this inspecEon.
=,,-ineefs Name -F,~o ,~o,'.~ ~.. ~oo~'~ - ~ -~;
~_ ,,,.) ~0,,,,,- . - ',,,;-,,°-o CE-3537
HAA Fee $ $~<3 ,~-~'~ Waiver Fee $
Date Of Payment "~,~'~/~'- Date of Payment
Receip Number t//t> 7- Receipt Number.
.. 03xl1~95 14:11 (~3Ft'IERC I AL
CT&E Environmental Services Inc.
Laboratory Division ---
Laboratory Analysis Report
Il
200 W. Po,er Drive. Anchorage, AK 99618-1605 -- Tel: (907) 562.2343 Fex: (907) 561-5301
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
014-072-44 HAA # ~
GENERALINFORMATION
Complete legal description
Cempbel~ Heights, ~ot 17A, Block 3
Location (site address or directions)
4021 E. 67~h Avenue
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Scott Hurlbert/Andrea Dickson
4021 E. 67th Avenue~ Anchorage, AK
N/A
Day phone 263-4523
99507
Day phone
Vista Real Estate/Jim Smith Day phone 562-6464
3000 C Street, Suite 101, Anchroage, AK 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 N
TYPE OF WATER SUPPLY:
X
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legafity and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
x
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 Eagle River Eagineering Services
Address P.O. Box 773294, Eagle River, AK
Engineer's signature ~z'~~''~'-
Phone 694-5195
99577
Date
DHHS SIGNATURE
)< Approved for ~
Disapproved.
Conditional approval for
bedrooms.
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 .DH HSd oes this as a courtesy to purchasers of ho m es
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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /..o1" /7/I./ ,~l.~ $ Parcel I.D. ~/~-
A. WELL DATA
well type
Log present (Y/N)
Total depth
Sanitary seal (WN)
If A0 B, or C, attach ADEC letter. ADEC water system number ,,~///~-
Date completed ,5"-,/~ ~'/~'z. Driller
7,-~ I Casedto '~ ~ ~ Casing height =~'.~'
Wires properly protected (Y/N) ~Y
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level '
g.p.m.
AT INSPECTION ~
MUNICl, AtrrY OF ANCHO~,OE
~.-- .~-~,-- ~" ~F. NVIRONMENTAL SERVICES DIVISION
.Z.? ' . 0 7 19 3
' EIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line ~ ~ 2-5"1
; On adjacent lots "~'/,~
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ,~'~/~'
WATER SAMPLE RESULTS:
Coliform
Date of sample: ~'~/~
Nitrate ~"/'~//n..~/L.-- Other bacteria
Collected by: ~/&//'/~:&;/~
B. SEPTIC/I~;Y=i;~4Q TANK DATA
Date installed Tank size Com~.~3tY
Cleanouts (Y/N) Foundation cleanout (Y/N) ~....~epre. Tion (Y/N) _ T
High water alarm (Y/N) ~33~/N) ; ~__., _ . _
Date of pumping ~-~ , " ','.._ .~. ~
SEPARATION DISTANCES FR~TfC/HOLDING TANK TO: '
Well(s) on lot ~ On adjacent lots ~Foundation
To propertyline .-.~'""~ ' Absorption field Water main/service line.
rainage '
~1'2-02~ (Re~. ~/91)F~i MOA ;$ CONTINUED ON BACK PAGE
C. LIFT STATION , ' ' ' .,.'
"' nsta,,ed . : '
Size ih,~ons ....... Manhole/Ac, cess (Y/N) '
Vent iY/N)~,. "Pump on" level at _ '[Pump off" level at _
High water a. lar~e! · Cycles tested
MeetsMOAe~ectric~s(Y/N)--~ . - . : . :,
SEpARATIO~ DIS~N~M 'LI~ STATION TO:' '
Well on ~ot . O~ adjacent Iot. s ~ Su~ace water~
Dst; insi;il;d":~; ~ ' --~ating ~ System ~pe __
Lengt~ Width ' ~ . Gr~hickness Total depth
Total absorption, area · ~anouts present (Y/N) _
Depr~;;,;'. ~e; 'i~,~ (Y/N) ' ; .~, adequacy test
Results (pass/fail) for
V e ' ,
Peroxide treatment (past.12 months) {Y/N) date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ~ . .
Wellonlot On adjacentlots.
To building foundation To existing or aband~ed ~s~m
On adjacent lots Cutbank__ .Water ma~n/se~ice line
Surface water
Curtain drain
bedrooms
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HA~ guidelines in effect on. .the date o3 this inspection.
· _, .. . . .
Date
, ~. ~ ... , . ~ k~o~ESS~ , .
HAA Fee $ / ")/-']
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
JU~ 04 '93 ~9:~ ~ORTH~t TESTIS, PHCHORAC~
Eagle ~lver Engineering
P.OJ Box 7T3294
Eagle ~i~er ~K 99577
AttA~ ~Ou/a ~utera
NORTHERN TESTING LABORATORIES, INC.
tNDUSTRIAL AVENUE FAIRSANK'A, ALASKA g$701 (907) 45~,311~ ~. FA~
FAIRBANKS STREET ANCHORAGF-, ALASKA 996M ~071277,.83~* FAX
Ou=;Lab ~: AI23T35
Location/Project: -
You~ Sample.ID: Campbail 1T A/3
Commented,
Lab ~
Date Arrived:
Date
Time Sampled~
Collected
o6/oli 3.
l~O0
MD .
* Definitions *
B - Below ~egulator~ Nl~,'
H e Above ReguLatory ~, ..
E - Estimated Value
~ - Hatrix Interference
D ~ Lost to Dilution .
NDL - Hethod DetectiO~. Limit
Nu~be~l H~thOd Parame~e~ Units ~esult * HDL Pre~:meed &nal~zed
'1
Reported By: 'Susan C. ~lfenta[
Hlcrobiology Supervisor
,lt~ate-, m~/1 <F, DL 0.1 06/0~/93
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
(") I q - (~ ~ -~-t ~'~ HAA# ~ ~-~t \ IC)Lt
1. GENERAL INFORMATION
Complete legal description
Lo~. 17Al Block
Location (site address or directions)
4021 East 67~h Ave~u~
e
Property owner
Mailing address
Lending agency
Mailing address
Agent SZM HILL
Day phone
40~I Ec.6t 67~. Aue.nu.~., Anchorage, Ak.
MAP. STOW REAL ESTATE
Day phone
349-1477
Day phone ~48-2804
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ,~
TYPE OF WATER SUPPLY:
Xx
Individual well
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.
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 waste~,ter 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 PhOne,
S & S ENGINEERING
Address 17034 Eaqle River Loop Roa~ Ne. ~ ....
Eagle River, Alaska 99577
Engineer's signature ~ Date <~- ~:~ -~ /
Se
DHHS SIGNATURE
/~ Approved for
Disapproved. . .
Conditional approval for
bedrooms,
Iwith the following stipulationsi
Additional 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 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 errom or omissions in the professional engineer's work.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Be
Well type ~lf A, B, or C, attach ADEC letter.
Log present (Y/N) C~
Total depth ~ .~
Sanitary seal (Y/N)
ADEC water system number
Date completed ~'-.PA-~2 Driller' AI,~;~ b,;,ll;
Casedto -'~-. '~ Caslng height [-~'
t~ Wires properly pr?tected (Y/N)
FROM WELL LOG AT INSPECTION
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:
Co,,orm
Date of sample:
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
'"~ ~ ~ Petroleum tank
Nitrate -.~,~'~l~'~-~-~c.'~r~ ~'/'J. -~.'~, Other bacteria
~' ~- °1 I Collected by: ~ %L .~
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping.
out(Y/N)
Depression (Y/N)
(Y/N) ' ' -: '~ · '
SEPARATION DISTANCES FROM
TANK TO:
Well(s) on lot
On ad ~t lots
Foundation
To property
.Water main/service line
Surface water/drainage
~'~(n~,.~i~=t ao^3~ CONTINUED ON BACK PAGE
C. LIFT
Dat~
Size in g
Vent (Y/N)
High water alarm level
Meets MOA electrical COd
SEPARATION
Well on-lot
D. ABSORPTION FIELD DATA
7 Date installed"
p on" level at
Manufacturer -
Manhole/Access .(Y/N) ,,
· "Pump off" level at
DM DN TO:
Surface water
Cycles tested
· On adjacent lots
Surface water
Curtain drair~
g System type
;~Lengt~~ " __Width Gravel thickness Total depth
t~T:-~t al ~so~.t i(~-~ a rea '- Cleanouts present (Y/N)
DepresSion o..ve'Xr~d (Y/N) ; .... Date of adequacy test
Results (pas~/f~il) ~ ~ for .
Peroxide treat~ (pa~nths)(Y/N) If yes, give date
SEPARATION DISTANC~ FRO~SORPTION FIELD TO: .
To building foundation ~ To existing or abandoned system :on lot
Cutban~ ' Water maln/se~ice line
Dr arking/vehicle storage area
bedrooms
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
E. ENGINEER'S CERTIFICATION
HAA Fee $ //70,~0 Waiver Fee: $
Date of Payment ?/~0 /~/ Date of Payment
Receipt Number ~.~0 ~ -- f'77_~'[ Receipt Number
CttEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5~33 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FAX: (907)
$.]~ tOpO~tl tO:
Jm[y,t, Co~lit,~ :10~ 30 91
[,~ozitozy Sup~vtoor-.:$TE?~g C. ZDE
Non. ~.tett.~ "~.t ~0 ~OM:~I J~OVl
lot imtyZ'~ ET.Efts Thn, OT-Ozeater T~n
EAST 67TH AVE/~
Till lifOl~ATlOil I~ii~OII II 1(i TNI US! Of LE#OING
IIIilIIUTIONI iI~J(:IIIC/~Ly 10 l#Od IUi¥ I:~lifLlCTS
I~tldJl# J~illtlJG ITItUCTUItII ~ PLATTJD LOT LIN[S
OI I,~lJ#J#TI AIlO II NOT 10 gl USEI) F~II POSITI~ING
THAN T~OS[ SHO~IIOIi T~
30'
AS'SUILT SUrVeY aN3 CO~NER$ SET THIS DATJ)
I hlrlbx certify thee i hart I~rformCd ~
~acrl~Fr~rtyL
LOT 1ZA, IL~K 3, ~GELL
that the Iq~'o¥(3~te lltumtad
Ire klthI~ the pro~trty
lyl~ ~Jmc~t thereto, that
I~l~c~her~. Dit~mt~horAge,
-' ;LF D.I.
--~IS':I'EME
-- . APPLIC'-'~AT FILLs OUT UPPER HAL..ONLY := .' ~ .
Address Zip ~e
~ Other
~ ~mm~lty ~ For wells ~ill~ prior to Iha date, gtve well depth (attach I~ If available).
D Public Utility
Sewer Disposal ~_*~
~ Indlvld~l ~ Year Indlv~ual InstallS:
NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~ESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector (~ ~,~.~ .-
MUNICIPALI~ OF AN~ORAOE
AU8 1 8 1082
RECEIVED
( ~ APPROVED ~DR~MS *CONDITIONS OF APPROVAL
( ) DISAP~OVED
{ ) ~NDIT~NAL APPROVAL*