HomeMy WebLinkAboutGLEN EAGLE BLK 4 LT 7Glen Eogl Block 4 LOt 7 #050-60! -24 Municipality of Anchorage ) Development Services Department Building Safety Division ',~ On-Site Water and Waslewater Program, 4700 S, Bragaw SI. P.O. Box t 96650 Anchorage. AK 99519-6650 Page www.d.anchotage, ak.u$ (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number:. 5 {J~ 0 1 0 .~ 0"7 PlO Number. "-: D,,,vid /-.hee=,~,- Was,ewa,erSystem: I--INew ~.Upgrade ~'~ E~. I¢ ~;~r ~d. Ea~l~ ~;v~r, i~J~ ~q57'7 ABSORPTION FIELD Well: [] New [] Upgrade e.,~.,,~ . ,._ c_ IO0g ''"- SEPARATION DISTANCES asep~ DHolding DS.T.E.P. SeptiC Absorption ti~ Holding Tank Field Slalion ~ank ~Un, e~f~/ ~ - IO5' I~0' ~ ~5~ HDPE ~w,,.J~ I~ ~ / LIFT STATION V E~Tt~C ~,'r~ ~ BENCHMARK S & S ENGINEERINe . 170~E,gleRIwrL~R~d,N~ 1. ~--~--0] Inspections pedormed oy:.., .... .,_,._ ~,w uams: ~'~'"' ......... 2~ E-~O-OI Develbpment Se~ices Depa~ment Approval * ,~vi~w~d ana ~pp*owa ~ / ~/. ~ D~te: ~ ' 3' O I ~', .'~"~---...*',~- ......... P£R.~IT NO, SW010207 PAG~ 2 OF ,-~ Municip. clti-t..__y_oF DEPARTHENT OF HEALTHAND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 eAnchor~ge, Alosk~ 99519-6650 · Te|eDhone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LECAL LOT 7, BLOCK 4, GLEN EAGLE S/D P.I.D. NO. 050-601--24 I PERMIT NO. SWO 10207 PAC~- 3 OF Municip. aH-t of' Anchor'o, e DEPARTMENT OI~ HEA~TH AND HU~/~N SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 ®Anchorage, Ataska 99519-6650·Tetephor~e: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LOT 7, BLOCK 4, GLEN EAGLE P.I.D. NO. 050-601--24 FINAL ST1 ST2 ~ 101.6' FINAL GRADE--/~ 2" INSULATION 98.0,~ 1000 GALLON , C02=99.3' C02=96.3' A B FCO 15.0' 25.5' ST1 56.5' 58,5' ST2 59.5' $9.0' DBL1 41.5' 59.0' DBL2 42.5' 59.5' DV 44.0' 59.5' :C01 48.5' 48.0' MT1 57,0' 49.5' 002 107.0' 80.0' MT2 105.0' 78.5' CO1 =102.2' MUNICIPALITY OF ANCHORAGE Development Services Depa~fment On-Sile Water & Wa$1ewaler Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (007) 343-7004 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jun 26, 2001 Expiration Date: Jun 26, 2002 Permit Number: SW010207 Legal Description: GLEN EAGLE BLK 4 LT 7 Design Engineer: 0003 S & S Engineering Owner Name: David Cheezam Owner Address: 1586 EAGLE RIVER RD EAGLE RIVER , AK 99577-0000 ParcellD: 050-601-24 Total Bedrooms: 3 Site Address: 023932 THE CLEARING DR Lot Size: 50321 SQ. FT. Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by cailing (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, Al( 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 ON-SITE SEWEP,/VVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. Permit Number sw_..~_L.0_.~,,._~ Property owner(s) ~ Ag ~ ~..B~:.~.~.,M Day phone Mailing address (1) ~,0, (~o~ ':t-~7-2-~'~ "~,,5'~.~,?- 7'~ Mailing address (2) ~.~G,t.,~.. ~\~J~P-.. : A.L. NSY-4~ ZipCode Legaldescription (Lot, Block&Sub'd.) ~o~ "3c . ~.oc~..'~c, ~ ' ' I.o , Legal description (Section, Township & Range) Lot Size ::L. ~0 ~ Number of Bedrooms THIS APPLICATION IS FOR: Sewer Only [] Well Only Sewer and Well [] Waler Storage Sewer Upgrade [] THIS PROPERTY CONTAINS: Hot Tub [] Jacuzzi Swimming Pool [] Water Sol'tening Unit Therapy Pool [] I cedify that the above information is correct. I fudher cedify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. - '~7o34 E,.gl. Rt',~r Lo4~ Reecl Ne. 2O4 (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) 0 0 5- GoJ"' Waiver Fees: Dale of Payment: Receipt Number: May 18, 2001 ROBERT C. COWANo P.E. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-121 $ MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7, Block 4, Glenn Eagle Subdivision It is requested that you issue a permit to upgrade a septic system to serve the existing three bedroom dwelling on the referenced property. One test hole was excavated and a percolation test was performed on 5/5/01. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was found. After monitoring ground water for seven days, water was found at 14' as shown on the attached soils logs. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. Ifyou require additional information, please contact us. Sincerely, cc/j Enclosure 17034 NORTH EAGLE RIVER LOOP · SUR'E 204 · EAGLE RNER. ALASKA 99577 DESIGN CRITERIA: .5 BDRM = 450 GPD SOILS = 0.45 GPD/SQ.FT. 450/0.45 = 1,000SQ.FT. REQ'D. TRENCH CRITERIA: 10' DEEP 7.5' EFFECTIVE 2.5' WIDE 67' LONG CONTRACTOR IS REQUIRED TO OBTAIN UTILITY LOCATES PRIOR TO ANY EXCAVATION WORK. ALL PORTIONS OF SYSTEM WITH LESS THAN 3.5' OF COVER REQUIRE INSULATION. l 17054 EAGLE RIVER LOOP ROAO ~&4~/ ~.~&~.. I - 77 LOT 7, BLOCK 4 ....... ~,,,~ o,~ I~-. ~o, 5A DESIGN CRITERIA: 5 BDRM = 450 GPO SOILS = 0.45 GPD/SQ.FT. 450/0.45 = 1,000SQ.FT. REQ'D. TRENCH CRITERIA: 1 O' DEEP 7.5' EFFECTIVE 2.5' WIDE 67' LONG I I I CONTRACTOR IS REQUIRED TO OBTAIN UTILITY LOCATES PRIOR TO ANY EXCAVATION WORK. ALL PORTIONS OF SYSTEM WITH LESS THAN 5.5' OF COVER REQUIRE INSULATION. EXISTING 1000 GALLON SEPTIC TANK (VERIFY INTEGRITY & REPLACE IF NECESSARY WITH NEW 1000 GALLON SEPTIC TANK DOUBLE CLEANOUT INSTALL EXISTING TRE :H II FUTURI LJ LIN, Z O' II II II ~1 5% II PROPOSED - TRENCH o° -- ,/,,,~\0 PHON[~ (907)694-2979 1o~ ~ ~eKrn ~ I~. I~rn. ~ (~o~)~,-,~,, r"'- ~."~-. r ..... -~.~.~. I-'-~-~-°, I--'~ o,~ I~. . ~o. DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Streel, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST SLOPE SITE PLAN 1 2 3 4 5 6- 7- II- 12- 13- 14- 17 18 lg 2O WAS GROUND WATER ENCOUNTERED~ COMMENTS Reading Date Gross Net Depth to Net ~o ?,c, G'/,?-' ~/~.' PERCOLATION RATE ~/~'~ (minuleumch) PEnc HOLE DIAMEIER ~ ~' TEST RUN BETWEEN ~ FT AND ~Z FT PERFORMED ~'& ~ I=NGINEEIilN~ I ~ CERIlIry THAT Tills 1EST WAS PERFORMED IN g . ro.a No. 2 c' .//r/n / Eqle River, AIIIKi YY~II · * - ' ROBERT C. COWAN. P.E. ClVlL ENGINEEP~ (9O7) 694-2979 FAX (907) 694-1211 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 7, Block 4, Glenn Eagle Subdivision May 18, 2001 GENERAL: The scope of this project includes the installation of a 1000 gallon septic tank and a new trench to serve the existng three bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed other,~5se, the property o~er shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their oam systems must also receive prior approval from the Municipal ltealth Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RNER, ALASKA 99577 Page 2 Lot 7, Block 4, Glenn Eagle 8/D May 18, 2001 All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than IO ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORIrrlON TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions sho~n on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced dovmward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the inve~ of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page 3 Lot 7, Block 4, Glenn Eagle 8/D M,y 18~ 2001 MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank pmpesed for installation must be constructed by a Municipal approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Cauldcr, Femco, or equal). A permeable nontoxic silt ban'ier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leach.field gravel layer and the native soil backfill. All leachficld gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVlRONMI:N'fAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME -~ P!IONE LEGAL DESCRIPTION UPGRADE LOCATION Well Absorption area DISTANCE TO: /~2~) · I- z Manufacturer ~ Inside length Li( . capacity in gallons D,STANCETO: LW__ o i t Well ~-r ] DISTANCE TO: I ' ~,~. { No. of lines I Length of each line ~ % ~ Crib diameter ~ TO: Well ~ [Cl~s Depth  [ DISTANCE TO: Buildisg foundation Dwellin~ ~.'~ / Wit t 1 Dweging Foundation ~_ '.~ / /Nearest IotLine/, Total ~ength of tine~ ~ Trench width ~ inch.s Material beneath tile Depth Crib depth Building foundation Driller Sewerline NO. OF BEDROOMS PERMIT NO. Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective abs~rplion area PERMIT NO. Nearest lot line Distance to lot lin[~ Septic tank PERMIT NO, Absorplion area(s) OTHER PIPE MATERIALS SOIL TEST RATING /?£ INSTALLER REMARKS DATE LEGAL Page 4 Lot 7, Block 4, Glenn Eagle $/D May 18, 2001 The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and befog the installation of any gravel. A septic tank may be set in place, but may not be backfilled befog this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but befog the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often them will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessray, a pre- construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any wa)' the contractors activities. The owner shall contract with the contractor to perform the ~vork outlined in these specifications and plans and in accordance with the attached M.O.A. permit. Them will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the oamefs representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the o~aaer and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to cam/ out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR / INSTALLER 0 Et E GEO, ECHNICAL Et DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694 2774 or 688-2280 Russell Oyster 694 2774 SOIL LOG Soils ~ Foundations Perfomed for: Name: H. tltng Address: Legal Description: ~'~ Depth (feet) Sot1 Char~cterl;tlc; Earl Ellis Land Development 7 8 9 lO 11 12 ~3 ~6 Ground Water Encountered: Yes Proposed Installation: Seepage Plt~ Con~nents: __ No If yes, whmt depth Drmtn Field / $ .'/'z.- Performed by: Oate: January 4, 1978 Ba~d Dickey Star Route Box 1613 Eagle River, Alaska 99577 Subject: Lot 7 Block 4 Glen Eagle Subdivision P¢-~it #77786 A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the pez%L, it, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If there are any further questions, please contact this office at 264-4720. 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Q O ra r-4 ra r-1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O N - d v1 O r-1 ul O �-1 C4 CJ O v1 nt C.1 Q 41 M i M Well Owner Location DRILLING, INC , DRILLING LOG Use of Well. (address of: Township, Range, Section, if known; or distance main road Size of casing_ Depth of Hole Static water level ft. (above) Screen ( ); Perforated ( feet Cased to feet (~lo~v) land surface. Finish of well (check one) open end ( ). Describe screen or perforation Well pumping test at gallons per (h~r) of drawdown from static level. Date of completion. (minute) for hours with WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness ); ft. .TO TO TO .TO. .TO. TO TO TO .TO. .TO __.TO. TO TO. .TO. .TO. .-W DRILLING, INC. DRILLING LOG Well Owner Use of Well Location (address of: Township, Range, Section, if known; or distance main road Size of casing Depth of Hole Static water level ft. (above) Screen ( ); Perforated ( feet Cased to feet (below) land surface. Finish of well (check one) open end ( ). Describe screen or perforation Well pumping test at__gallons per (hour) of drawdown from static level. Date of completion ); (minute) for hours with ft. 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' O I1 r � Q^ O E� V � Q Z � � a] O 06 co r E� 0- 0 > v) C)O 1= O (Cf U Q d Q (6 O L— CL CL Q U) N 4— U) i= O O N N IM, ON o CO OO LL Lo Z O in LU z v w (D Ii T Al TLO CY) V I L_ O LU C: JU(aaca ) U-DNCQN CGU)> OO 0W0LL�6 _0MO o NLO 70ca tc nf (1)oa O Q- :r CO oOm U � U En C D m C N 3 a N m C cn a) a) c6 > O El w m. O (Z 0❑ D � w J N �- a V/ V/ N W LU LL H O Lu z � O I— N M U ) O � (L � O >N _> N C O) O O E O N U � a) cn > > c ai ❑ � U M a) U) co cncm L ca 0 ■❑ U J 2:U) (° O °- a ❑ ❑ TO W Q W F- N LL LU a H Iq El (D U) ca 2) a) LL El ca a a) o N C O U -C ❑ N U O N � FL cn O r�N > VJ m ❑ 4) z H v N IL w Q N m ■❑ wil 11 a� cn a) tT W .> a� 0 a) CL x w T m 0 LL a) co a� a) U- 0 O c a) ca d O co in > 1 a Q CO O Glen Eagle Block 4 Lot 7 8/18/23 JRs N/A N/A N/A Benjamin Schiller, P.E. (907) 522-7773 CERTIFICATE OF HEALTH THORI'I?f., P,P. ROVAL .... FOR A SINGLE FAMILY:DWELLING:: [ ........ --' Parcel I.D. ' 050--601-24 ' 2.~.~,~...'C~r~pi~{~'le~3~l'~e~cfiption, Lot 7, l~lock~4, -Glen Bagle Subdivision ;. ' ....... [6~,~tion (s~te address or directions) 23932 The. Clearing, Dr'ive ............. ~' David Cheezem 694-2439 '~,.". Current Prope, rty.bg;ner(s) Day phone , · ';'-~.""".:.. Malhngaddres'"' *sPO Box 772243,--Eagle,RJ. ve~.~ ..... AK 99577-.,. I' ~'dir~,4'a'~ency Day ~hbn~ ...... Mailing address Real Estate Agent Remax/Kathi-Olmstead--: ......... Day phone 694-4200 Mailing..A.ddress 16601 Ce~-fi'61~t'D~;'-;-Ste'-20l~., · Eagle River, AK 99577 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual dh:site []  Individual Holding tank [~ Community On-site [] Public Sewer [] The Municipality of Anchorage 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 AJaska. 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 propedies served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may ~3e reissued for a period of up to one year with valid water samples.) Certificates ere 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 hereto and as.of th~ ~'alidation date shown below, I verity that my investigation · based o~.precedures outlined in th~ Health'Auth0rity' APproval Guidelines for this application, shews that the on-site ~ate~" supply and/or wastewater disp(~sal S~stem 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 m~' in,~esfigation 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 install?ion. · '$ & S ENGINEERING ' Name of Firm 17n34 r~?l,. IHv,.,. l',.,,,p ~,~,,,.I N~. ~__t~_ Address .E~gle River, Alaska g9577 . . Englneer'sPdntedName Robert C. Cowant P.E. L1L .b. edroo~ .m.~, 5. DSD SIGNATURE 1~ App~oved-f°r~ Disapproved. Conditional approval for Phone. Date !/,,~.~...'"" '".'...7~2~- 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: Municipality of Anchorage Development Services Department Building Safety DIvision On-Site Water & Wastewata. Program 4700 ,South Bregaw St. P.O. Box 196650 Anchorage, AK 99519-6650 vnwv.cl.anchorage.ak.u$ ( o7) 343.70.o4 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ' ' ~ ~ Parcel ID: ~ ' ~)1-~4 A. WELL DATA Well typ,~'~l V47'~ If A, B, ~ C provide PWSID # f Well Log (Y/N) ~ Datecompleted~.~/:~' Sanitary seal l~)N) "/ Wlrespmperlypmtected~IN) y~ TotalUepth./~O ". Cased to /~'? fl. Caslnahelght(abovegmund) /g '~n. Date of test Static water level · Well production WATER SAMPLE RESULTS: Coliform* O colonies/100 mL Nib"ate O. a"' regal. Date of Sample: B. SEPTIC/HOLDING TANK DATA Tank Type/MMeriel T';~k size '/0~) gal. Number of Compa.tments Foundation cleanout (Y/N) Date of pumping FROM WELL LOG AT INSPECTION .. ,Z?/' ~ g.p.m. ~"' ~'~ g.p.m. Other bacteria ~) coloniesll00 mi. Date installed ~, ~ o I Cleanouts (y/N) /~.r~' Depression ova' tank (y/N) /VP High water alarm (Y/N) ~ C. ABSORPTION FIELD DATA Dat*e installed / Soil rating ( ~fodrm) ~ System type / ~,~'"~/C Length ~ ~ r -ff. Width ~. ~ fl. Gravel below pipe ::~Z.. ~' ff. Total depth ! '1 ft. Eft. absorption area ~ Monitoring tube y~<~ Depression over field Date of adequacy test ~'~J Results (Pass/Fell) ~ For ~) bedrooms Fluid dep ' ' . Water added gal. New depth in. Elapsed Time: min. Final fluid depth in. ~~-~]s~ ~ g.p.d. Any rejuvenation b'eatment (past 12 mo.) (Y/N & type) ~ O If yes, give date. D. UFT STATION Date installed ~Size in gallons ~Pump on' level at /in. "Pump off level at. Datum / Cycles tested E. SEPARATION DISTANCES Manhele/~=cess (Y/N) High water alarm level at Meets ,,Imm & ctmult requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tentdll~t~n on lot Absorption field on lot / Public sewer main S~w~i:~lseptic service line Water main Wells on adjacent lots On adjacent lots On adjacent lots Public sewer manhole/deanout Holding tank SEPARATION DISTANCES FROM SEPTIC~ TANK ON LOT TO: Building foundation ~' '*' Property line ~'~'~ Absorption field Water service line ./~) ~'' Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / 0 ~' Building foundation / 0 ~' Water main /~/ /,~ Water Service line /0 /~' Surface water / b O / .4- Driveway, paddng/vehicle storage Curtain drain N;Nf" ~/~/J/JWells on adjacent lots /~)/~ ~- F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have deten~lned through field inspections and review of Municipal records that the above systems ere in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name //~/0'~,~2'' ~", CO Date -7//G / o ( HAA Fee $ Date of Payment Receipt Number (Rev. 12/0o) 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING '~0/- Z~iI~ HAA# GENERAL INFORMATION Complete legal description Location (site address or directions) m J Property owner Mailing address Day phone ~'~- .~///-/~ Lending agency Day phone Mailing address Agent Day phone ~,~'~/~ ~0~ Address /~ J'~ ..~_..~/~ ~""z2/~, ~5:~/,~'~/,'/'' Unless otherwise r~ue~ted, HAA will be held for picku~ NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: 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. 72-025 (Rev. 1/91) Front MOA #21 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, e ordinances, and regulations in effect on the date of this inspection. KND Engineering Phone Name of Firm ;C-~1 Plarmlgan ~va. Address Eagle_.~~ ~ Engineer's signatur~ ~-~~ Date DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date By: d*qun[qI 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 profe_~_ional 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-~(Rev. 1/91) Back MOAW~I RECEIVED Municipality of Anchorage MAY 1 DEPARTMENT OF HEALTH & HUMAN SERVICES_i~,UN ClPALI'[Y Environmental Services Division ~?~i;~NMENTAL,,...._ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type t~! ;~ Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist ~:2z~ ,~("V /-~/ ~' Parcel I.D.: i:~-.~) If A, B, or C, attach ADEC letter. ADEC water system number Date completed · ! Cased to /.,~'~ Casing height (above ground) FROM WELL LOG Date of test Static water level Well production Wires properly protected (Y/N) AT INSPECTION g.p.m. .~ ~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: /-~/-~'/~ B. SEPTIC/HOLDING TANK DATA Date installed /~/7~ Tank size / ~ ~),/~ Other bacteria / Collected by: Number of Compartments ~ Cleanouts (Y/N) ~ Foundation cleanout (Y/N) Y Date of Pumping · · C. ABSORPTION FIELD DATA Date installed ~,/~',-~ Depression (Y/N) /V/ High water alarm (Y/N) Pumper Soil rating (g.p.d./fF or fF/bdrm) Length ~,/_/t -~ Width ~'~ ,~'-~*-~-/ Gravel thickness below pipe Effective absorption area ~t~--~ Monitoring Tube present (Y/N) ~/ Date of adequacy test ~'/~o/~.~ Results (Pass/Fail) /~2 Fluid depth in absorption field before test (in.); ,~ Fluid depth ~-/, ~' (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* System type ~ ~' -~ Total depth -%.Z . Depression over field (Y/N) For ,,~ bedrooms Immediately after~..5~gal, water added (in.): Absorption rate = /7/~(~) + g.p.d. If yes, give date /(~/~ LIFT STATION Date installed / Size in gallons / Manhole/Access (Y/N) / "Pump on" level at* ,//"Pump off" level at* High water alarm level at*/ *Datum // Cycles tested . E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots /~)~--~ ¥ On adjacent lots Public sewer manhole/cleanout /(,//-~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: ! Foundation /~ '4 Property line /~) ~ Absorption field ./4:~ -/~ Water main/service line ~2~ ~ Surfacewater/drainage /D~ ~/ Wells on adjacent lots /to~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~) ~ Building foundation //--) ~ Water main/service line Surface water /tO tS~ 'P Driveway, parking/vehicle storage area Curtain drain //~_-.) % //V,,~¢ X~)~),n) Wells on adjacent lots /~)/'~ ''/'- F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records.U~ ~.]~i~.ystems are in conformance with~/ ,----,,MOA HAA guidelines in effect on this date. & -....~'ll,x- Signature Engineer's Name /)'~/7/2 ~ 7z,~/ ///~/'¢¢ /,~ J' ~. ,.~..[,r~r~ _ ..~.~...~.,~... ~, HAAFeo $ '~ ~ ' ~ ~x-¢ Receipt Number ~ ¢ U© (7 ) . ~.~ ~ceipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Ar.~,~or~ge, Alaska 89601 t ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTION~: Complete all parts on page 1. Incomplete requmt~ will not be proeelled. Please allow ten (10) dayl for processing. 1. PROPERTY OWNER Brad and Paula Dickey I $9239 I MAILINGADDRESS~t Rt Box 1813,Eagle River,Ak 99577 PROPERTY RESIDENT (If different from above) PHONE 2. BUYER Lisa 0'3rien and Theodore Johns Jr PHONE MAI LING ADDRESS 3. LENDING INSTITUTION Alaska l~ationa± Bank o~ th~ i~orthI PHONE at.on ~laudla Jonas 278-4581 MAILINGAODRESS Pouch 7-010,anch,Ak 99510 4. REALTOR/AGENT none I PHONE I MAI LING ADDRESE E, LEGAL DESCRIPTION Lot 7 Block 4 Glen Eagle Subd, STREET LOCATION Clearing Drive E. TYPE OF RESIDENCE [~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. EEl;I/AGE DISPO$AL SYSTEM INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY NUMBER OF ~DROOMS ~ One ~J [] Four [] Other [] Two [] Five [] Three [] Six ~le~se re~urn copy ~o ~r~.a * 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.) **If individual/on-site, give installation date June ' If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3178) MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION J U N P. ? 1978 RFCFIVFD THIS SIDE FOR OFFICIAL USE ONL'~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] 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 ~.~ ~- (,,~ -- ~ (0/' Connection Verified INSTALLER [~tic Tank or [] Holding Tank Size: ~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL .~_ . 0 4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area lSe,,er Line [ Naar.,, Lo, L.oe Absorption Area to nearest Lot Line 5. COMMENTS [[;~APP ROV ED FO R ,_._~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accom/l~certificate) / / [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev. 3/78) / / /// ,?? ° I / / g 0 · DTI000530 Z <E ~ o~qz. ~ 'x...../// 7 ~ // 0 / / >- n ///~ h--- ! ~,o - I / F,~ < / // / / / / / II / .. , ./L...h_ :47 / J / V.]t. ~ [i,r I/~ I II II '% I o~)® C, /