HomeMy WebLinkAboutHANSEN SAND LAKE ADDITION LT 12A1MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
MUNICIPALITY F ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval -r_
Parcel I. D. 012-153-92-000
Expiration Date: _87 3
Legal description HANSEN SAND LAKE ADDITION LT 12A1
Site address 3730 W 74TH AVE Anchorage AK 99502
Current property owner(s) GUNAWAN TRISTIANA LIVING TRUST
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 5/26/2023
.This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory x
Other
COSA Approval_June 2022
MUNICIPALITY F ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 012-153-92-000
Expiration Date: 8/26/2023
Legal description HANSEN SAND LAKE ADDITION LT 12A1
Site address 3730 W 74TH AVE Anchorage AK 99502
Current property owner(s) GUNAWAN TRISTIANA LIVING TRUST
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 5/26/2023
,This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory x
Other
COSA ApprovaLkne 2022
MCIPAUTY OF ANCHORAGE
Development Services Departments Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 012-153-92
Complete legal description HANSEN SAND LAKE ADDITION; LOT 12A1
Location (site address) 3730 WEST 74TH AVE *ANCHORAGE, AK
Current property owner(s)
TRISTIANA GUNAWAN
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone 907-245-1658
3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank X Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age n/a - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench N Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $. 12850 Waiver Fee $
Date of Payment Szz4A '
COSA # Ci S C' I f
Date of Payment y��z SA -5
Waiver # 0-5 V 2 3 10 2�6
COSA AppllcaUon June 2022
IA
COSA Checklist
Legal Description: HANSEN SAND LAKE ADDITION; LOT 12A1
$zr,—`d' S cd'
O"j 00
Parcel ID: 012-153-92
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 19660) Total depth 73.2+ ft
Cased to LINK ft
X Sanitary seal is functioning correctly
X Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 4/17/2023
Static water level at beginning of test 66.8 ft.
Comments
B. TANK DATA
Measured operating fluid level in
Date of pumping
❑ Required ance completed, if AWWTS
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective. -0000
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant o�dnot sed for more
than 30 days prior to d f test)
Gallons introdu gallons date
Any rejuve n treatment (past 12 months)
enter date
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 5.4+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑Q No
M Coliform bacteria is Negative
Nitrate mg/L N Nitrate less than MRL (ND)
Arsenic 5.53 ug/L ❑ Arsenic less than MRL (ND)
Collected by uCu
Date 4/17/2023
C. LIFT STATION
❑ Required maintenance c
Age of lift station years
Lift stationWeroial
Adequacy test date
Results ❑ Pass
Fluid depth prior, st in
Water ad gal
Ne uid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
V7
E. SEPARATION DISTANCES Lac f
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) /
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
Yes if No NSA ft [Eyes if No ft
Neighboring Tank > 100' ❑o Yes if No ft
Absorption Field on Lot > 100' ❑ Yes if No NSA ft
Private Sewer/Septic Line > 25' []Yes if No * eft
Holding Tank > 100' QYes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' Q Yes if No ft
❑i Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑- Yes if No ft Q Yes if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No ft Surface Water >�O0'Jam, If No ft
Tank to Property Line > 5' ❑ Yes if No ft Wells on :
Field to Property Line > 10' ❑ Yes if No t"''� Private Wells > 100' ❑ Yes if No ft
Water Main > 10' „.�'f'�s if No ft Community Wells > 200' E] Yes if No ft
Water Ine > 10' ❑ Yes if No ft If tank or field is under driveway com ent belo
23
F': EN'GINEER'S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Garness Engineering Group, LTD. (GEG)
Engineer's Printed Name Jeffrey A. Garness
Phone 907-337-6179
Date
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in
accordance with the guidelines and regulations established by the Municipality of Anchorage and industry
practices. The reported results describe the condition of the system/s on the date/s of the evaluation.
Separation distances were measured to readily identifiable features. Hidden defects or encroachments may
exist that were not identified during the evaluation. The operational life of all wells and septic systems depend
upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate
during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing
the systems. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not
Guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding
the future performance of the well or septic system. GEG makes no representation whether an alternative well
or septic system can be installed on the property in the event either of the current systems fail to perform
adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG
to perform the evaluation. Reliance upon the information provided in this report by any other person or party
(including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever.
COSA Checklist—June 2022
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Municipality of Anchorage, dent S
��' 1)rpartment
P.O. Box 196650 0 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV231025
PID#: 012-153-92
COSA#:OSC231137 Permit#:
Legal Description: HANSEN SAND LAKE ADDITION LT 12A1
Engineer: Garness Engineering Group
Your request for a waiver of the required 25 feet horizontal separation from the sewer service line
to the private well has been approved. The approved separation distance is 23.0 feet.
This waiver approval applies to the existing sewer service line only. Any future upgrade to the
on-site wastewater disposal system will require all separation distances be met or another approval
from this department.
.............................................. 0 ■ ............................. ■ 1
Waiver is Granted: X Waiver is not Granted:
Date:�Z 3�Z?, Approved by: ��p
Name of R�e.r. ....... ■ ............................................. 1
**** VARIANCE/WAIVER REVIEW ****
May 22nd, 2023
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Hansen Sand Lake; Lot 12A1
To whom it may concern:
The subject lot is served by a private well and public sewer. The neighbor's driveway is adjacent
to the subject lot and their private sewer line runs parallel to the lot line. The exact separation
distance from the well head to the sewer line is unknown. Per MOA records for lot 12A2, the
well (for lot Al) was shown on the design drawings (for the well permit of lot 12A2) and the
private sewer line was proposed 25'+ from the well head. Per GEG inspection, the well head
appears to be about 24 feet from the centerline of the sewer cleanouts in the driveway. It is
unknown if the sewer line is a "straight line" between the two cleanouts. In short, the well head
may be 25 feet from the private sewer line, however, we are requesting a variance down to 23
feet. Water samples were pulled on 4/17/2023 and the nitrates were non-detectable. The sewer
line does not appear to have compromised the water quality and may meet the required 25'
separation distance.
If you have any questions, please contact us at 337-6179. Thank you for your assistance
Sincerely, 4, A
JeffreyGarness P.E. M.S. ,�, #; 9TH ';,r
Presid ' /.
• P.. .....
f A.•Garness •: �/
' • E-7953 • �`�/
"ROFESStONP`r"`
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3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
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M U N � C � P A L J 7{Y OF ;C\ HICM0G AG
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
907-343-7904
"{ Fax: 343-7997
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC231137
Subdivision: Hansen Sand Lake Addition, Block: , Lot: 12A1
A water sample revealed an arsenic concentration of 5.53 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
Municipality of Anchorage
Development Services Department
Building Safety Dlvlslon
On-Site Water & Wastewater Program
~-4700 South Bragaw SL
,' P.O. Box 196650 Anchorage, AK 99519-6650
-. - www.cl.anchorage.ak.us
'. (907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL.
FOR'A SINGLE FAHILY DWELLING ':-
Parcel I.D. 012-155- 61
1. GENERAL INFORMATION
OlO'o ¢/'
Expiration Cate: '.5'-° -,,O, ~ - O' I
Complete legal description HANSEN SAND LAKE SUBDIVSION; LOT 12A,
Location (site address or directions) 3750 WEST 74TH AVENUE ANCHORAGE, AK g9503
Cu~ent Property owner(s) DOUG & OLGA BORLAND Day phone ' 248-'5360
Mailing address
Lending agency
.3750 WEST 74TH AVENUE
ANCHORAGE~. AK 99502
Day phone '. "'"
Mailing address
Real Estate Agent
Mailing address
KEV1N TAYLOR W/ PRUDENTIAL VISTA Day phone.
4241 "B' STREET ANCHORAGE, AK 99503
273-7223
Unless otherwise requested, HAA will be held by DSD for plckup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Indivldual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Ind!vidual On-site
Ind~vtdua! Holding tank
The Municipality of Anchorage Development Servlces Department (DSD) Issues Certit3cetes of Health Authority
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for praperUes served by a slngle family on-sita 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 fram 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 eld. (Certificates may be reissued for a period cf
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
weIIs or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the
professional engineer's work.
Note:Alaska Water and Wastawater Consultants, Ina shall be pald $8OO. OO at, or prior ]
to closing for the engineering servfcas pro~fded.
I
4. STATEMENT OF INSPECTION BY ENGINEER
As ce~fied by my seal affixed hereto and as of th ~ validation date shown below, I varify that my
Investigation, based on procedures outlined In the Health Authori~ Approval Guidelines for this application,
shows that the on-site water supply and/or wastawater disposal system is(are) safe, functional and adequate
for the number of bedrooms and type of stnJcture Indicated herein. I further verify that based on the
information obtained from the Munidpatity of Anchorage files and from my investigation and insl:~ction, the
on-site water aupp~' and/or v~stewatar disposal system is(are) In compliance w~th all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of Installation.
Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS. INC.
Address 6901 DEBARR ROAD, SUiTE 2B * ANCHORAGE, AK 99504-
Engineer's Printed Name JEFFREY A. CARNESS. P.E.
Engineer's Comments:
In conducfing this evaluation, AWWC, inc. attempted to proy~do a thorough,
consdentious engineering ena~ls of the system in accordance w~ ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readi¥ Identifiable features. The operational life of all walls and
septic systems depend on the local sozTs condition, groundwater levels that may
fluctuate dudng the year, and the water usage of the family being served by the s~,stem.
These conditions are outdo the control of the eva]uator of the system. Satisfacteo/ test
results do not guarantee fun're ped~nance of the system, nor do they guarantee that
there are no hidden def~ts or encroachments. AWWC, Inc. can therefore not provide
any v,~a'ran~y or future estimate of how long the s3,stam will continue to m~et the
operational requirements of the ADEC or MOA DSD. The content of ~is report Is for
the sole benefit of the owner listed abey~. A~y re/lance ulx~ or use of this report by any
Phone~ 337-6179
5. DSD SIGNATURE
~ Approved for
other person or party ls not authotfzed, nor wfll it confer any fagal rlght whatseever.
Y
,,~
L~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the fllowing stipulatio~_.:~A'...
· ~, ~. · '
Attachments:
HAA Checldist
Septic System Advisory
Well Flow Advisory
Manltenance Agreements
Supplemental Engineer's P, eort
Other
. Original Certificate Date:
Municipality of Anchorage
Development Services Department
· BulMlng Safety Olvlslon
On. Site Water & Wastewater Program
4700 6oulb 6mgaw St.
P.O. Box 196850 Anchom0e, AK 09610-8850
Legal Da~rlptton:
A. WELL DATA
Well ~ P~IVAT[
HEALTH ,AUTHORITY ,APPROVAL CHECKLIST
HANS£N SAND LAKE S/D; LOT 12~ Parcel ID:
ifA, B, otC provide PWSID~ N/A
Date completed *APPRX. lg72 ~lllltery eeal (Y/N) YES
Total depth 74+ ft. C8~ ti) 40+ fl.
FROM WFI I LOG
Date of last ~
W.~Jl.pro~ucllofl g.p.m.
WATER ~MPLE RESULTS:
Coltfo~n 0 colonlsa/100 mi.
Date of sample: 1/29/01
B. SEPTICJltOLDIN$ TANK DATA
012-153-61
NO
YES
*P M A. R
Well Log
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
M29/Ol
67 .It.
6.64 g.p.m.
12'+ I~.
Nllrate 0.5 mgJL. Other bacteda
Collected by: AWWC, INC.
PUBLIC SEWER
Tank Type/Mala~l Date installed __
Tank slze~gal, Number of Com~
FoUr lank (Y/N) High water alarm (Y/N)
D . Pumper
C. ABSORPTION FIELD DATA
0 colunles/100 mi.
Date Installed Soil ral~ng (g.p.dJff'or ~/1xlfm) System ~ / /
Length It. Width IL ~ . fl.
Tolal deplh ff. Eft, absorpllon area ft" M~ Daprsasl_on over ~eld.
Date of,dequacy test ~~=all) .... ~.or . .~bedrooms
Reid depth In .bsor~~~dd~A g,~-,~ -- >. New dep~ in.
Elapsad ~..,.wd~l:"~ Final fluid deplh In. . Absoq~on ..rote >-, .. g.p.d.
nation treatment (pest 12 mo.) (Y/N & type) If yes, give dala ·
D. UFT STATION
D. ate installed Size In gallons ~
Pump on' level at in. "Pump o . High water alarm level at In.
~ Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~eptlc tank/lilt station on lot N/A
Abso~tlon field on lot N/A
Public sewer main 75'+
Sewer/sepUc service line 25'+
On adjacent lots. 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout
Holding tank N/A
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Pmperb/line Absorpfion field ~
Water main ~
Wel~s
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundatlon Water main
Water sewloe line Surface water ~tomge
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I cerfffy that I have determined ~hrough ~eld inspec~s end
review of Municipal records that ~e ebove s/stems ere In
conformance wlJh MOA I-IAA guldellnee in effect on ~hl$ date,
//
HAA Fee $
Date of Payment
Receipt Number,
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date Au:Bust 28~ 1986
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 12A Hansen Sand Lake Addition Subd., Sec 2~ T12N, R4W, Grid 2126
Location (address or directions)
3750 West 74th Avenue, Anchorage 99502
Applicant Name Douglas Borland Telephone: Home 243-5825 Business 243-1975
Applicant Address 37~0 West 74th Ave., Anchorage, Alaska 99502
Applicant is (check one): Lending Institution I-1; Owner/builder IX1; Buyer []; Other [] (explain);
(b)
(c)
(d)
Lending InstitutionUnited Bank Alaska
Address 645 G Street
Telephone
276-1911
(e) Real Estate Company and Agent N/A
Address
Telephone
(f) Mailthe HAAtothefollowingaddress:
Doug Borland
3750 West 74th Avenue
Anchorage, Alaska 99502
TYPE OF RESIDENCE
Single-Family:7/~ Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
Individual Well []( Community [] Public []
Note: If community well system, must have written conf rmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [~ Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
'5.
ENGINEERING FIRM PROVIDINg. ,4SPECTIONS, TESTS, FILE SEARCH, DA'I,.. 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
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 Ted Forsi & Associates, Inc. Telephone (907) 274-9517
Address 810 East Ninth Ave, Suite 200, Anchorage; Alaska 99501
Date August 28, 1986
Engineer's Seal
DHEP APPROVAL
Approved for ,, . /J?bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality 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 not responsible for errors or omissions in the
professional engineer's work,
Page 2 of 2
72-025 (11/84)
WELL DATA
Well Classification ~C-, , ,<, /~ .
Well Log Present (Y/N) No Date Completed Clrca 1972 Yield
MUNICIPALITY OF ANCHORAGE (MOA)
...~? HEALTH AUTHORITY APPROVAL (HAA)
;~':: CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: Lot 12A, Hansen Sand Lake AHd~tion
SuBd., Sec 2, T12N, R4W, Grid 2126
~ :, If A, B, C, D.E.C. Approved (Y/N) --
120 gph ~'
100~ Cased to 90'+
Depth of Grouting [ 0 Pump Set At 90+
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots N/A
...... ; On Adjoining Lots N/A
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot 50+
; Date 8/27/86 /
Total Depth
Static Water Level --
Casing Height Above Ground 2 ~w ~
Electrical Wiring in Conduit (Y/N) Yes
Separation Distances from Well:
To Septic/Holding Tank on Lot .......
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line 120 4-
Cleanout/Manhole 125+-
Water Sample Collected by N. Lindholm
Water Sample Test Results Attached
Yes
*Nine-foot deep reinforced concrete structure with wood-framed roof houses
Comments
casing and conduit. Top of casing 2' above surrounding ground.
concrete structure is drained.
SEPTIC/HOLDING TANK DATA
PUBLIC SEWER ~
Size No. of Compartments
Air-tight Caps (Y/N)
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Casing is welded and
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
PUBLZC SEWBR
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
PUBLIC SEWER
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have.,checke¢, verifie)¢, o~' conformed to all M DA and HAA guidelines in effect on the date of this inspection.
Signed ~ Date 8/28/86
Company Ted Forsi & Assoc. ,InMOA No.
Receipt No. \~ -- ~ ~
Date of Payment ~[~[~7~
Amount: $ ~-O~ , ~ b
Page 2 of 2
72-026 (11/84}
APPLI(-"NT FILLS OUT UPPER HAI" ~ONLY
.
Buyer
Address Zip Code
Lfinding [gstitutionz' .,~ ~/j~ ~, /,,,/. ~ .~/ Phone
Realty Co. & Agent Phone
Address ~ Zip Oode ,,
J
Type of Residence /
~ Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~ I~.di~l~~ A~ACH WELL LOG. A w~l log is required for ~11 wells drilled since June 1975.
~Communi~ ~ For wells drilled prior to that date, give well depth (attach log if available).
Sewer Disposal ~/, }-¢ j ~ /
~lndividual ' ' ............. Year Individual Installed: '~/~OX
: Public Utility ............. ~ When Connected to Public Ut~y: ~/[,,.(,
NOTE: THE INSPECTrON FEE MUST AOOOMPA~ EAOH RE~EST BEFORE ~OCESSING CAN BE INITIATED.'
Time Time Time Time
Date Date Date Date
Inspector : Inspector Inspector : .. Inspector
Field Notes:
~ ~ ~..-/~.,~ ..~.~- ~, ~. ',
(~,~) APPROVED BEDROOMS ~CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) 00 N DIT~OD NAL~APPROVA L*
Soils Rating Date Sewer Installed W~_tion Area ~~- Well Log Received
Well to Tank Septic Tank Size