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Home My WebLink AboutHILLSIDE NORTH #5 BLK 3 LT 4Hillsid North Block 3 Lot 4 #041-031-91 Municipality of Anchorage Page I ' DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL'SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ,,~/ ~ ~ '?~ ~ PID Number: ~:3 I¥,/--O ,~ ~, - Cf ;~ Name: Address: Phone: F--t'-\bCLh:W/ ~ P-.,I~ ~, LEGA, DESCRiPTiON Lot: Block: Township: Range: WELL: ~Z New Classification (Private, A,8,C): Driller: Yield: Section: [] Upgrade Total Depth: Cased To: Date Drilled: I Static Water Level: From Well- Surface Water Lot Line Foundation Curtain Drain Pump Set at:, Casing Height Above Ground: SEPARATION DISTANCES 70 o Remarks: Inspections performed by: Wastewater System: [~New [] Upgrade ABSORPTION FIELD ?,~Deep Trench [] Shallow Trench [] Bed [] Mound [] Other Soil Rating; /r ~ GPD/Sq. Ft. ,Dep h o p pe bottom from original grade: Fill added above original, grade: Gravel width: Total absorption area: E;¢o SQ. Ft. Total Depth from original grade: Gravel depth beneath pipe '7' Ft, Ft, Gravel length: ¢~.~ Ft. Ft. Number of/lines: Distance bet.~ween lines:Ft. Pipe material; Date installed;/,0,/~ TANK ~¢..Septic [] Holding [] S.T.E.P. Manufacturer: A'-Nc TA.- Material: ~ ¢~..t¢.~/ Capacity ii ~'c~s:~.~ Number of Co,~.~rtments: 7e-013 (Rev 9/91) MOA 25 Department of Health and Human Services approval Reviewed and approved by: _~cc~c"t/~"c~,-- ¢~ Date' ~'1~-.¢~ Location and Description: Size in gallons; Manufacturer: "Pump on" leve~ at: "Pump off" level at; High water alarm at: Pump Make & Model Electrical Inspections performed by: BENCH MARK LIFT STATION SWINO TIES: AB 20 FT AC 55 BC 5,4 AD 67 £D 66 AE 84 BE 79 AF 72 BF 77 TTANDARD TRENCH OTAL DEPTH lOFT i~ , FFECT/VEROCK REPLACEMENT TRENCH ~)- WeI1 $0 75 SCALE: /" -- $0 FL 49~h I00 ]3BEN SPURKLAND No, CE-2225 125 1_50 I I / / / TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ANCH. AK. 9950/ (907) 279-5916 ]HILLSIDE NORTH/rS, BK 8, MIDDLEROCK ROAD GRE$$ ENDSLEY LOT DATE: DEC, 15, ~997 SHEET; 2/3' '~: GRID: 2145 PER'MIT # SW970356 PI9 # 041-051-91 HSNO304i,?~6 PRIMARY TRENCH S tonctorcl ?reDches: 40' L on9 10' ~eep ZO' Sewer rock 3' Cover REPLACEWENF FRENCH SCALE Cleonouts 3' Cover 88.5:' 1£50 90{ Septic tank Foundotlon Cleon out 91i /E 84.7 77.5 7,0 Pt oF £ept/~ Woc~< 7Z5 IE 84. /E 85.90 TBBBEN SPURKLAN~ P,E, ~03 W15%h Ave Anchorage Ak 99501 NORTH/zS, BK 3, GRE$$ ENDSLEY LOT 4 SEPTIC SYSTEM",'~S .BUILT' D~T£: DEC.~$, 1997 PERMIT// SW970556 PARCEL ID // 041-051-91 HSNOJO45. DWG Fro~ : ALF'INE DRILL 9~,~ 345 02'~2 Dec. 15, 199'7 10:35 PH P01 STATE OF ALASKA D;EPARTMENT OF NATURAL RESOURCES DIVISION OF MINING & WATER MGMT WATER WELL RECORD WELL BOFIOUQH 6UBDWleION~..~k.,/~, , ~ LOT BLOCK 81EOYION QTflS 8ECTION TOWN~HIk~N [OCA~iON/SK~CH~ WELl_ OWNER: ' Mated~l T~pe and Color F~om CAS NG STIC~;U~ ~ft. Diem: ~{n. t~ft WELl. INTAKE opENING TYP~; I.: ......... ~ perforated ~'open hole Depths of openings; _ _ SCREEN TYPE: Dlam: ............ in. Slot/Mesh Size: Length: . GRAVEL PACK TYP~: Volume u~ed' __ Depth GROUT TYPE~, ~r" ....... Depth: from ft t~ ~, _ ft .... ....... ~ D~VELOPMENT M~HOD: PUMPIN~ LEVEL AND YI~LD= ' PUMP INTAKE DEPTH: , -- ft'~r~po~': PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970356 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:ENDSLEY GREGORY C OWNER ADDRESS:9620 BURNING BUSH DRIVE ANCHORAGE, AK 99507 DATE ISSUED:10/08/97 EXPIRATION DATE:10/08/98 PARCEL ID:04103191 LEGAL DESCRIPTION: HILLSIDE NORTH %5 BLK 3 LT 4 LOT SIZE: 100188 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18kAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ~.~;LR~_T~RE~LOCATING THE DRAIN FIELD, CONTACT THIS WITH ADDITIONAL SOIL TEST RESULTS~ ISSUED BY: - \ DATE 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN HILLSIDE NORTH #5, BLOCK 3, LOT 4 GREGG ENDSLEY Municipality of Anchorage September 27, 1997 Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 We are submitting an application for the installation of a well and septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 16 f. Use Standard Trench Soil Rating. < 1 min/in = 1.2 gal per sq.ft/day See Sieve analysis No. of Bedrooms 4 Required Areaper Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 4 x 125 = 500 sq.ft Testhole depth 16 feet Bottom Rock At 10 feet Top Rock At 3 feet Rock Depth 7 feet Total Trench Length 500 / 14 = 35.7 ft SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 40 FT TOTAL WIDTH 2 FT TOTAL DEPTH 10 FT ROCK DEPTH 7 FT COVER 3 FT SEPTIC TANK 1250 GAL MUNICIPALITY OF ANCHORAGE ENVIRONI¢,ENTAL SERVICES DIVISION SEP 2 9 1997 RECEIVED The installation of this septic system will not prevent wells from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. / / LL~? 3 i:!:!:!:!:!::: \ T(T~S < 25~ ~ LEVEL _. ~ -- ..::? N/ 50 0 50 100 150 PO0 850 300 SCALE; i" = I_00 VT, TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ARCH. AK. 9950! (907) 279-$916 ]HILLSIDE NORTH//5, BK 3, LOT MIDDLE£OCK t~OAD GREGO ENDSLEY SEPtiC SYSTEM DESIGN DATE: SEPT. 26, 1997 SHEET: 1/5 GRID: 2145 PEEk/IT ii PID l! HSNO304Lgk/6 TOTAL ~E,T~ ,0 ~T X~ //~ // ~ /I 1 ~'~'~:'7" ... EFFECTIVE ,~0CI¢ Z FTn ~ ~ ~ II ~ // ~ /I I ~H<:':<.~:,:.~ - ~ // /i ~ ~ ~ u ~ Il ~~ ~ ~el] ? I //~ // ~/////~////~ ~ J ' // rR[~c~ mr ~E ~OW¢ CLOS~ rD ~ ~ / / I ~ ~ 49~h ~ ' .,~ ~.~..~ ............ .;-~. ....... ~$ TD~EN SPURKLAND ~?£AL£: ~ = ~0 FT. TOBBEN SPURKLAND P.E. 205 W 15TN. AVENUE ARCH. AK. 99501 (907) 279-$916 SEPTIC SYSTEM DES/ON DATE: SEPT. 26, 1997 SHEET: 2/3 GRID: 2143 PE£ivlfT # PfD fl HSNO3041,DIV5 PRIMARY TRENCH Monitor Cleon Out Cleon ZTu? £' W/de 40' L on9 15' Deep 7,0' Sewer rook ~' Covem ~4 ft REPLACEWENT TRENCH SCALE Monltom ~ -- Co vet ?oundotion Cleon out lL~50 901 Septic tank bauble C[eon ZTu?s Ex/st, 6round klm Cover To nk 7,0 £~ o£ Septic Rock Effective NO SCALE 1£50 goL septic tank BENCH MARK, TE]]~BEN SPURKLAN]~ P,E, ~03 WlSth Ave Anchor'age Ak 9950]. p79-3916 NORTH//5, BK 3, G£EGG ENDSLEY LOT SEPTIC SYSTEM DESIGN DATE~ SEPT. 26, ~997 SHEET~ GRID, ~9143 HSNOJO43. DWG PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEJ=R'S S E'~,L) DATE PERFORMED: 14 ILLgibi~ NO~'TH ~.~,'rownsh,p. ~n.e, Section: Lo'T ~, t'5~ ~ SLOPE S,TEP'AN WAS GROUND WATER · ~ ENCOUNTERED? l~'l O S L IF YES, AT WHAT O DEPTH? p i.E_. Oepth to Water Aller j J *' ~,~./~ ~ E Monitoring? ~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop DISCLAIMFR: Groundwater Past and future presence from these OO~Vatlons. PERFORMED BY: PERCOLATION RATE ~ (minuzes/inch) PERC HOLE DIAMETER ~ ~j TEST RUN BETWEEN ~ FT AND ~ ~ FT conditions indicated are for the dates shown only. and/or depth of groundwater can not be predicted CERTIFY THAT THIS TEST WAS PERFORMED IN ~ ACCORDANCE WITR ALL STATE AND MUNiCiPAL GuiDELiNES iN EFFECT ON THiS DATE. DATE'. ~ .~% i~'~ 72-008 (Rev. 4/85) I~ER~T OF I~TAININO MUNICIPALITY OF ANCHORAGE Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Parcel ID 041 -031-91 Certificate of On -Site Systems Approval OSC261093 Expiration Date: 7/8/2026 Legal description HILLSIDE NORTH #5 BLK 3 LT 4 Site address 10121 MIDDLEROCK RD Current property owner(s) CAMPBELL -NELSON LIVING TRUST X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: By: ` / --� �- C,•Original Certificate Date: 5/22/2026 Thi�s E6rtificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject syWtem(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service 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 submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory X Tank Age Advisory Arsenic Advisory Other COSA Checklist.docx COSA Checklist Legal Description: HILLSIDE NORTH #5 B3 L4 Parcel ID: 041-031-91 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 12/1/1997 Total depth 205 ft Cased to 111 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 36 in. Date of flow test for COSA 7/8/25 Static water level at beginning of test 104 ft. Well production at time of test 4 gpm Water storage tank volume None gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 5.31 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 7/9/2025 Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 50" Date of pumping 7/8/25 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 10/15/1997 ALL standpipes present per record drawing Total measured depth from grade 11.9 ft (max) Measured depth to pipe invert from grade 4.8 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective (ED). If not, state depth into effective 6.75' Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 7/8/25 Results Pass Fluid depth prior to test 1 in Water added 600 gal New fluid depth 4 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 600 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 84 in (MOA 7’ ED) Effective depth (ED) used 3 in (Missing ED + Final Fluid Depth) Effective depth remaining 81 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots & appears approximately 3” ED is missing – not measurable. Foundation clean out exists but is not shown on as-built survey. COSA Checklist.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10’ Yes if No ft Field to Foundation > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS Survey shows an old apparent test hole that is not part of the septic system. 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 FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 04/17/2026 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 04/17/26 11Y D I � • yip 1�,��; i . i � �i � ? � i� ! el;A�I Ar � w `Ir+ '— h `� '� 5� •fib �'� I� � >�� dl,� '�` iii h • 1 � 1 � `V � 1 I , V �,L� - �, - •.kms �;� �� . >, � jI9 9 i _ -.. zw ^"° = a.. • . . / . - % �' „�' '-\ i ��, - - -ice. 7 F Nitrate Advisory Certificate of On -Site Systems Approval # OSC261093 Subdivision: Hillside North #5, Block: 3, Lot: 4 A water sample revealed a nitrate concentration of 5.31 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/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. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. I Mailing Address: P. D. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org LOT 3 LOT 5 LOT 8 EXISTING HOUSEHILLSIDE NORTH ADDN. NO. 5 SUBDIVISION, BLOCK 3, LOT 4 RETAINING WALL, TYP. 2% PAVED DRIVE WAY 5/21/2026 ' MuNIcIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Envlmnmental Se~ces On-Site Services Section P,O, Box 196650 Anchorage. ~Jaska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # 041-031-91 ,. HAA# H/E)/ 1. GENERAL INFORMATION .Complete legal description H~L~SIDE NORTH SUBDM$;ON ';5'. ~OT 4. Bt_OCK 3.' Location (site address or directions) 10121 U~DOLEROCK ROAD ANCHORAC;. AK 99507 Property owner CREG FNDSI ~ Day phone (907) 384-7007 · 'Mailing address 10121 MIDDLFROCK ROAD ANCHORAGE. AK 99507 Lending ager~cy, Day phone Mailing address Agent RICHARD JORDAN w./ SUN PROPFRTIES Address. Dayphone (9o7'~ 248-0555 Unless otherwise requested, HAA will be held for pickup. · 2. NUMBER OF BEDROOMS: 4 3. 'TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide wdtten confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL= Individual on-site Holding Tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide w~ftten confirmation from State ADEC lng to the legality and sfatus of system. 72-025 (Rev. 1/91) Front MOA #21 Computer Version Note;Alaska. Water. and Wa~teWate;' Consu. lta~ts,'ln.c. Shall be paid $1110 oo at, I" ' ' or prtor to, ctosing for the englneerin~g services prov;~Yed..'. .: .::: i ' ' '" · I'-: 5. STATEMENT OF INSPECTION BY ENGINEE..R.: .~' i~, *[ * · As'ce~fi~l by my ~eal affixed hereto*and'a~)f't~ %;aiidat~on;data shown I~low. I verify that ~n~,' . Investigatioh of this Health Authori~ App .m..';;al application Sh(~ws that the on~slte water supply and/or*:~ Wastewater disposal system Is safe. functi0hel and ~Jde~a{~ fei. the nu'mbe~' of bedrooms and type of ~ structure Indicated hereln~,l further verify that ba,~KI Oh the informa.b.'on obtained fn~m"the Municipality of Anchorage files and from*my Invesfig~tio~ and In~pec~on~ the*0n-s~t6 water; supp,l~; and/o~wastewatar disposal system Is in COmplianCe ~th all Muhi~ipal ~,~1 State' Codes~ ordinances, and regulations In effect on the date ofthi~ln.specfion. .. ,.* ~' '~*~.~/c'I.. '~ .'. *',-* , .~ ~,~*, *~' ' ' *' ' .,'~'. penormanca of the system under the con~Yitions encountered at the time of the test, and separetio~ ~istan¢~ measured to rsadi~ identifiable features., Th~ opere~3~Ml life of'~ll wells alii septic systems'doped :,,~: · on the local soils condition, grot~nd water levels that may fluctu~ts d~drig the year, and the water usage of the fam~, be/ng =en~d ~y the ~/s~em.. rh~,e c~d~&~S ar~ outs/de the'co~tro; or - the evaluato;~ of the system. Satisfactory.test results do-not guarantee* future ~rlormance '-' Al/WI/C, 'lnc: can therefore .not P/~ide ;~ny ~;ab'~,~ future 'e~ffr~te'of I~v 'k~g 'the ~.* ". !-: The content of thls report ls for the sole beneflt of th~ owr~r'll~te~l ebove? Any ,: ' 'd'/.'// nor vvfll i~ cor~fer ant, legal ri~ht whatsoever~ . . .. 6. DHHS SIGNATURE " ' .... P'"' Approved for ~ . bedrooms, :.-. . . , .,.,.,..' '" '--'' ·., Disapproved " '"" Conditionalapprovalfor bedr°°ms'witht(ef(~ll°wings[i~:~.~"O'F'-A~'~.~... . .~,,~,x.x~.~-; . ... Additional C~mments ' '~ ~.. PROGRAM ~_~ '.... The Municipality of Anchorage Department of Health and Human Servlces (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 AJaska. 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. 1/91) Ba~ MOA #21 Computer Version Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental 8endces Divlelon 825 "L' $1~eet. Rm 502 Anchorage, Alaska 99501 (907) 343-4'/44 Health Authority Approval Checklist Legal Descrlplton: HILLSIDE NORTH S,/D 1~5; LOT 4, BLOCK 3, Parcel I.D.: A. I/V'EM. DATA Well Type PRNATE Log present (Y/N) Total depth San~aw ~ (Y/N) Date of test Stetlo water Imml Well prnductlon 041-051-91 ifA, B, or C, attach ADEC letter. ADEC water system number YES Date completed 12/1/1997 205' Cased to 111' Casing halght (above ground) YI~S Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 12/1/1997 1/2`3/Ol ~' 1 4.0 g.p.m. 5.0 +/- Date of sample: 1/2.3,/2001 Collected by: A.W.W.C. INC, B. SEPTIC/NOLDING TANK DATA Dateinstelled 10,/14-15/97 Tankalze 125o Number of Compartmente Foundal~on deanout (Y/N) YF.S Depression (Y/N) NO Date of Pumping 1/2`3/2001 Pumper C. ABSORPTION FIELD DATA Date Installed Effec~l~ al:~orptlon ama Date of adequacy test Ruld depth In abeoq)tlon I[eld before test (in.); Ruld deplh g' (Ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) 1 g.p.m. OLD MCDONALDS 2 Cleanoute (Y/N) High water abum (Y/N) N/A Soil ruling ~x)r fl2rrxlrm) 1 .~ System type TRENCH Width 2' Gravel thickness below pipe 7' Total deplh 11 560 SQ.FT, MonltoringTubepresent(y/N) Y~S Depresslenoverflald(y/N) NQ 1/23/2001 Results (Pass/Fa!l) pASSEO For 4- Bedrooms O' Immed~telyafter 764 gal, water added (In.): ~." 1,~ Absorption rate = 600+ NONE KNON If y~S, give date -- D. UFT STATION Date Installed Manhole/A~:'ess (Y/N) High water alarm level at* Size in gallons ofl" level *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100'+ Absorption tleld on lot lOO'+ Public eewer main N/A 6ewerlseptlc eendce line 25'+ SEPARATION DISTANCF..~ FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property llne 5'+ Water maln/seMce line 10'+ Surface water/drainage 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOTTO: Property line 10'+ Building foondatlon Surface water 100'+ Curtain drain NONE: KNOWN On adjacent lots 100'+ On adjacent lots. 100'+ Public tamer manhole/cleanout N/A U~ ~telJon N//A Absorptlon field .5% Wells on adjacent lots 100'+ 10'+ Water matn/sendce line 10'+ Driveway, perldng/vehlcle $lemge area 10'+ Wells on adjacent inte 100'+ Waiver Fee $, Dale of Payment Receipt Number HAAFee $ Date of Payment Receipt Number F. ENGINEER'~ CERTIFi,Cj~TIOJ~/~ of Municipal re~ord,~ tt~ th~ ~ve ~}y~ema ere in conformance wfth MOA HA/~ gu~e~t~/,~/O ~ct........°~ 'ls dale. ~glnee~s N?Ie~OARNESS 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 GENERAL INFORMATION CompLete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address b Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: V 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. 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, ordinances, and regulations in effect on the date of this inspection. NameofFirm 'l ~ J~/~'~ ~O-'~o~'~'~[~t"-~-~ ~ ~ Phone ~-~i~ Address ~ ~ ~ 1~ ~ Engineers signature ~ ~~~ Date ~/3~/~ ~ Sm 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 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. - M4JmCfPAUW OF APR O? 1998 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERViCESD~oriiirr~..~.~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist Parcel I.D.: Date of test Static water level Well production Y Cased to FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed I~-/! / ~ -~ Ill F.-b Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION WATER SAMPLE RESULTS: Coliform /~ Date of sample: ~///~l-'7 / Y g.p.m, g.p.m. B. SEPTIC/HOLDING TANK DATA Date installed / O/~///~/"7 Foundation cleanout (Y/N) Date of Pumping h//A- / Nitrate h '~- ~ 14.'[~/~. Other bacteria Collected by: '~'~"~ -~ Tank size i~- ~ 0 Number of Compartments ~ Cleanouts (Y/N) _ Depression (Y/N) ~ High water alarm (Y/N) ~ Pumper J'~/'h3c Soilrating (g.p.d./ft~e~f-~V~cl~-)- /,~ Systemtype r~- ~r'L-*- Gravel thickness below pipe 7 ~ Total depth c. A.SO.PT,O. P.E.D DATA Date installed I~/~ 5~/~ ~ Length qO ~"~ Width Effective absorption area b~{~ ~ ~-/~ Z Monitoring Tube present (Y/N) Date of adequacy test f'~//¥ Results (Pass/Fail) Fluid depth in absorption field before test (in.); L~ (ins) Minutes ater: b'/// Fluid depth _ Depression over field (Y/N) For Immediately after V/gal. water added (in.): cJ;p.d. ~/,Absorption rate = If yes, give date bedrooms Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons "Pump on" level at* *Datum "Pump off" level at* E. SEPARATION DISTANCES F. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/t'~,j~iia~tank on lot J L/Lo F Absorption field on lot I ~ ~ 'j' ~ Jo-- On adjacent lots On adjacent lots Public sewer main l'~/~ Sewer/septic service line ~ 10-69 Public sewer manhole/cleanout Lift station t'~//~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation :~ J::::"t['' Property line ""]O ~--~ Absorption field ~1 ~) Water main/service line Ith9 j:::-[~ Surface water/drainage ~ IO Wells on adjacent lots '~'~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line bO ~..~L.- Building foundation 7~-~q~ Water main/service line Su~3ce water ~ ~ O Driveway, parking/vehicle storage area ~ Cur~.. ~ drain ~ Wells on adjacent lots ~ / ~ ~ ENGINEER'S CERTIFICATION ~'~ ~ I ce~ify that I have determined thru field inspections and review of Municipal mc~rds that the~above in conformance with MOA HAA guidelines in effect on this date. J .'- ~ ' :: ~: Signature ~~ ~:~;~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number