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Home My WebLink AboutLAKE HILL ACRES LT 4Lakehl'oll Acres Lot 4 #051-053-12 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME _ PHONE ❑ NEW / -. x` ke C:- UPGRADE MAILING ADDRESS- 'hF LEGAL DESCRIPTIO LOCATION/`� / l NO. OF BEDROOMS U y DISTANCE TO: WellJ f / Q� Absorption area Dwellin PERM NO. w ZQ Manufacturer /� �� / No. of compartments / Liq.pGity in gallons .� IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. Oz F Manufacturer Material Liquid capacity in gallons Well Foundation Nearest lot line PERMIT NO. w= DISTANCE TO: w LL v w No. of lines Len Trench width Distance between lines Z F G J inches FTop tile to finish Material beneath tile Total effective absorption area of grade p inches Length Width Depth PERMIT NO. Lu C7 Q F Type of crib Crib diameter rib d Total effective absorption area wa W rn Well BuioinqXoundation Nearest lot line DISTANCE TO: Class th rilye Distance to lot line PERMIT NO. LU DISTANCE TO: Building foundation nSewer line Septic tank Absorption area(s) OTHER X (� PIPE MATERIALS V SOIL TEST RATI N 9 ` INSTALLER Vaca IE 148 REMARKS r °a 'D Ij , - J $tin $a fie ,� • y a is V /l 1 1+1+1 APPROVED yy++ -seta 191 A_ ATE Jd-P A ` ^ ` ^ ��I��1�� |C�' �� ° DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 ^PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: 840723 UPGRADE 08/27/84 C/O S &S ENG'G BILL HICKEY SRB 196X EAGLE RIVER, AK 99577 694-2979 SUBDIVISION: LAKE HILL ACRES LOT: 4 BLOCK: NA SECTION: 3 TOWNSHIP: 15N RANGE: 11A 20000 (SQ,FT. OR ACRES)) I certify that: ` 1. I am familiar with the requirements ','or on-site sewers and wells as set Iforth by the Municipality of' Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of* this permit. 3" I will adhere to all MOA and State of Alaska requirements {or the set back distances f'rom any existing well, wastewater, disposal system or, public sewerage system on this or any adjacent or nearby lot" IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BEOBTAINED; (2) AS~BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WDRK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED DATE: �... ..... . �� APPLICANT: C/O S & S ENG/G BILL HICKEY ISSUED BY QATF: « PERNIT NO. ~"-lUdl'-.i 1" r: T F" .~-~L -I- D.EF'FIRTMENT E!' '-IEFtLTH FINE:, EN',,,'IRONMENTFtL t' ]TEC:TI¢IN ...... :325 :::'64 - 4 ,--'2g'~ C~ ~'-~"S. 1" TE S F [.-~ E F-." Id P ~3 F-."RE:. g F' E ~." D1 [ T ,' 8:-.':OEi5::_': ::, FIF'F'LiCRF,IT PHILLiP ,-~. C:YNTHIR HIC:I-:.'.E"~ SF:2 BL~.:,.7210]" I::HUGIRK 9956? L 0 C: FI T I 0 N LEGRL L4 LFIKE HILL FICF.'.ES LOT SIZE 99'99'9.'9 SQLiRRE FEET TYF'E OF SOIL RE;':;ORF'TIOF,I SYSTEM IS: TF.:EN,::H i',IFIXIHIJM NI_IME:ER OF EEr)ROEMS = -.:: S0tL RRTING THE F. tEL.]UIRED_-,'-IZE riF THE SOIL NE,--,UF..FTILN- "-- ' ' ' q '-'_-, T.:,TEI I"- ', I_-,"- ' 'THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS ]-HE DISTRNCE BETWEEN THE SURFRC:E OF THE Gi;;:OUi'.,I[:, RND THE BOTTOM OF THE E:e, CFiVFtTION (IN FEET). THERE IS NO SET 1.4!DTH. FOR TREF,ICHES. THE GRR',,,'EL [:,EF'TFI IS; THE MINIMUM DEP]"H OF GRFtVEL. BETWEEN THE OUTFFILL. PIPE FIN[:, ]"HE E:¢]TTOM f'lF THE EN'"R',,,'FIT.T:N (tN FEE]"). ./¢/7~/)"(} PERM! T RPF'LICFtNT HI I NS"I"RLLRT I OF~ I lq.:,F E ;'.,IL ME',E~' OF' RES I [:,ENC: ............... '-iF. ~...~ C~ ,::: E:FICKF Z L.I.. I NG OF FIN'T' g, EPFIRTMENT HILL BE MINIMUM DISTRNCE E ::LE1E1 FEE7' FOR FI PR] UPON THE ·TYPE OF F HINIHUM DISTFINCE F TO ICl COHMUNIT'-r' SE,~ OTHER REQUIREMENT':' FIVFIILFIBLE TO INSUf /(_ ..~,~_ ,-< .' '.' ETE [:, . rHIS ( . )( ,. : -q..A,. r / ~ rEM IS SPENDING FEET RND RFIMS 8RE F" F F: t"'t 1" T' E :-::T1--RP ::~ g-" r_. I CERTIFY THFIT ±: I FIM FRMILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS 8ND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORFIGE. :2: I WILL INSTRLL THE SYSTEM IN FtC:CORDRNCE WITH THE CODES. Z'.':: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLFIRGEMENT IF THE RESIDENCE iS REMODELED TO INCLUDE MORE THFIN ]:'BEDROOMS. NAME LOCATION GREA I ER ANCHORAGE AREA BORA. IGH =) Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ADDRESS LEGAL DESCRIPTION PHONE SEPTIC TANK: Pk C. 121n /Y DISTANCE /^ NUMBER OF FROM WELL MANUFACTURER ✓ �' " '�' TVTATERIAL � COMPARTMENTS —3 INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY /GALLONS. TILE DRAIN FIELD: r /a TOTAL LENGTH�� DISTANCE FROM WELL(��QQ'' OFOUNDATION �� NEAREST LOT LINE (y / OF LINES NUMBER OF LINES DISTANCE BETWEEN LINES / TRENCH WIDTH_��N. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE C DEPTH OF FILTER �'q DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE Tff ABOVE TILE IN. WELL: / TYPE— CONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL , OTHER SOURCES DEPTH NEAREST SEPTIC SEEPAGE SEWER LINE , TANK , SYSTEM_ APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY SEWER LINE DEPTH: PIPE MATERIAL LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM P o V DATE 5 _s 7 7 APPROVED ✓a G.A.A.B. DISTANCE FROM: '. .� d s f 71,5`/V STATEMENT FROM ACME DRILLING Star Route��ox X95— I Chugiak, Alaska 995_67 October 18 f9 76 Walt Corey - 333-2070 T0._----- ----- - - -- ------ i ADDRESS South Birchwood Loop Road I I rrDnAc W E L L L O G Well duller: 0 to soil feet -T-nd --5-�- 15 45 4.9 St Water to to. to tic — -soil- . --0 5 feet , gravel, 5 feet, - clay - - 9 feet - hard pan 51 feet - sand and water at level 4 foot ipproximately 4.0 gal pe � -- - ---- ---- so-so ---- and clay min'te ---- so-so --- _ - - - - --- --I - �------ --- -- - I Well duller: `��1 Cl 3_�I.- I I" l-, r -d C V`F F. °DEPHRTMENT "/ HEALTH AND ENVIRONMENTHL OTECTION ~ ° 2510 E TUDOR RD�/ 8NCHORHGE/ HK� 99507 ` 276�2221 ��E: 114 FE". IFR P1 I'Y PERMIT NO. ( 76]82 ) HPPLICHNT SAM COREY SRR BOX 1185--H CHUGIHK HK 688~]274 LOCHTION MI 2] GI-ENN HIGHWHY LEGAL. 1-4 LHKE HILL ACRES SUBD LOT SIZE ]1500 S(-XUHRE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MHXIMUM NUMBER OF BEDROOMS = ] SOIL RATING' FT/BR)= 280 THE REQUIRED SIZE 8F THE SOIL ABSORPTION SySTEM IS: �� -u --L �F`� o -el E_- I— ��" " F 91� � THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFHCE OF THE GROUND AND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRHYEL BETWEEN THE OUTFHLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). �C: F -i p F"E. ��r-.I'T- ��Lfi I E -E CA EITHER H CLASS I OR II NSF APPROVED PI. -ANT MAY BE INSTALLED. H CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF H MHINTENHNCE HGREEMENT IS NOT KEPT CURRENT Y0U NAY BE REQUIRED TO ENLARGE THE SOIL ABSORPTION SYSTEM HND/OR YOU MHY BE SUBJECT TO PROSECUTION. ' IF ` CLASS I SYSTEM IS USED THE LENGTH IS 50.0 FEET. IF H CLASS II SYSTEM IS USED THE LENGTH IS 64 0 FEET. BHCKFILLING OF ANY SYSTEM WITHOUT FINAL, INSPECTION AND APPROVAL. BY THIS MINIMUM DISTHNCE BETWEEN H WELL HND ANY ON --- SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL SPECIFICATIONS HND CONSTRUCTION DIAGRAMS ARE HVHILHBLE 4`8 INSURE PROPER INSTHLLHTION. �rl 1 'Y V F--� IL__ .1 F.*-- IF,:.-." Ce V_: ��IEE' �� F:7, F�?_ CH Irl I�-.:; � �� I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON ... SITE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE 2: I WILL INSTALL THE SYSTEM IN RCCORDHNCE WITH THE CODES. ]� I UNDERSTHND THHT THE ON-SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED� IF ISSUED BY DHTE u' ~� ~~~~~f��~-~�~----- �-~~~~~----�--~ / O Et E GEO', CHNI CAL Ef REVEL,. PMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 RusseN Oyster Earl Ellis 694-2774 SOIL LOG 688-2280 Soils Er Foundations Land Development Performed for: Name: �1 `C� `,�'�'�j Tel®. Mailing Address:�ra,�e Legal Description: 2-�—VUD Depth (feet) Soil Characterise 0 2 � , 3 4 5 7 B 9 .� to---- Ground Water Encountered: Yes No If yes what depth Proposed Installation: SeNage pit Drain Field Comments:._ die - ►- `� i T7'C �� - ` S fi'x DArfnvn.nd Govt Y\ �n '\ ),.�,�3)+"'1s+� Date: ' filar )IWlV-A— 12��.. 13 o 1-4 15 169 — -2p Awn Ground Water Encountered: Yes No If yes what depth Proposed Installation: SeNage pit Drain Field Comments:._ die - ►- `� i T7'C �� - ` S fi'x DArfnvn.nd Govt Y\ �n '\ ),.�,�3)+"'1s+� Date: ' filar )IWlV-A— NO �7, -/ SVA7E' OF A U11- U S98A BILL SHEFFIELD, GOVERNOR REPT. OF ENVIRONMENTAL CONSERVNI ON SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 274-2533 August 14, 1984 Robert Shafer, P. E. S & S Engineering SRB 196X Eagle River, Alaska 99577 SUBJECT: Horizontal Separation Waiver Between Well and Septic Tank, Lot 4, Lake Hill Acres S/D (8521 -WA -015) Dear Mr. Shafer: The department has reviewed the subject waiver request and cannot ap- prove the waiver because it was clearly not shown that the requestd distance would not contaminate the well. Sincerely, o Eickson District Engineer BEE/dd Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ek.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-053-12 1. GENERAL INFORMATION HAA # N/:%' O / 0 7 / !� Expiration Date: Complete legal description Lot 4, Lakehill Acres Subdivision Location (site address or directions) 24225 Sunnyside Drive Current Propertyowner(s) Angela Torgerson Dayphone406-752-2621 % Cheryl Burns Mailing address Prudential .lark Phira 12n1 r st /A Q— � 995CI Lending agency Mailing address Real Estate Agent Mailing Address Day phone Prudential Jack WhiteCheryl Burns 7 Day phone62-5897 3201 C Street, Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. Z 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-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 Alaska. 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 va!id for 90 days from 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 old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for cne year for properties served by Class A or B welts 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 the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority 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. S & S ENGINEERING Name of Firm 17034 Eagle River Loop Road No. 404 Phone Gly — 3 9 7 `i Eagle River, Alaska 99577 Address Engineer's Printed Name " Robert C. Cowan, P.E. Date s lis -/o l OF ROBERT C. COWAN 5. DSD SIGNATURE tj! �,.� CE -8801 ✓ Approved for bedrooms. CO Disapproved. Conditional approval for bedrooms, with the following stipulations: A itional Comments Note: a well for this pr . WATER AND PROGRAM Current nitrate concentration is 5.53 mgfI. EPA maximum concentration is 10.E Jjj/ }p1d�� infornrt ' • nr, a . Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other gy;Original Certificate Date: S i. 1- O (Re, 12. CC) Municipality of Anchorage • Development Services Department Budding Safety Division s • s t r On-Ske water & wastewater Program 4700 South Bragaw St. P.O. Bou 196650 Anchorage, AK 995196650 www.cl.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type at VR,fE If A. B, or C provide PWSID # Date completed -4(-W-4 Sanitary seal (YM) Total depth Jb 7 + ft. Cased to Jto{ ft. FROM WELL LOG Date of test Static water level rs ft. Well production 9 -p.m - WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Date of sample: B. SEPTIC/HOLDING TANK DATA Nitrate �5--F3 mgJ1. Parcello: Well Log (Y/N) A,10 Wires properly protected (Y/N) YES Casing height (above ground) I —41n. AT INSPECTION 5 /O of ft. ate' 3 g.p.m. Other bacteria D colonies/100 ml. Collected by: 514 --� ee�wb/nt Ec-.21.46- - Tank Type/Material t�lG Date installed 946 Tank size CC(7 gal. Number of Compartments v Geanouts (YIN) e'S Foundation cleanout&) .L Depression over tank (Y45 h/O-O- High water alarm (Y/N) ^/ Date of pumping / Pumper 1;PN rA-i l/ Hf'� ytS C. ABSORPTION FIELD DATA Date installed S Soil rating (g.p.dJfetP/bdr ) — System type Tec Length 6.11 ft. Width 3 ft. /Gravel below pipe ft. Total depth 1-'? ft. E8. abs rpti area q�g 11:2 Monitoring lube Depression over field n/O Date of adequacy test �' /D O / Results (Pass/Fail) �1 5e For 2 bedrooms Fluid depth in absorption field before test VA in. Water added_ gal. New depth in. Elapsed Time: LL min. Final fluid depth in.//!! Absorption rate >= tFOh g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) Ne^I- �.1/iZ(/A/ If yes, give date "— D. LIFT STATION Date installed Size in gallons Manhole/Access (YM) "Pump on" level at in. "Pump oft level at _ in. High water alarm level at in. Datum Cycles tested Meets alar ti circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtftAA lon on lot cn + Absorption Held on lot /00 /4 - Public sewer main r v A r /septic service line Z r � -J- On adjacent lots (co rr- On adjacent lots /nn 'r Public sewer manhole/cleanout /J A Holding tank Aet- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field 5 r � Water main r4 Water service line / t? 4- Surface water ( t7 CI 4 - Wells on adjacent lots r o 0 �4- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / n Building foundation / O �f Water main /A Water Service line / O r Surface water ICO r Driveway, parkinglvehicle storage Curtain drain **1AiiVA1 Wells on adjacent lots ono /' F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in . „• , '�' conformance with MOA FIM guidelines in effect on this date. Gil Engineer's Printed Name /` o 't i C' cow -4'w �4 �. ROBERT etE6j Date S �r S40/ l+ to% ;-`' CE :8801 HAA Fee $ 300. Date of Payment 1-//7/0 / Receipt Number OOyS3 (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number O MUNICIPALITY OF ANCHORAGE R4'Chry*0 Y • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section Sill o / qj P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING n Parcel I.D. # CN�4)\ - HAA # 1. GENERAL INFORMATION Complete legal description Lot 4, Lakehill Acres Location (site address or directions) 24225 Sunnsyside Drive Peters Creek AK P.ropertyowner F"irds Sheldon Dayphone 229-5593 Mailing address PO' Box 671087, Chugiak,AK 99567 Lending agency Gres tland Mortgage/John An4ersorbay phone 563-3889 Mailing address 3201' C Street, Suite 406, Anchorage, AK 99503 Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water _ NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. T2-025 )Aer. 1/91) Front MOA121 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. Name of Firm 5 & 5 ENGINEERING Phone 6 c1y — _-)- 9 79 17034 Eagle River Loop Road No. 20A Address E291e River, Alaska 99 7 / Engineer's signature � Date ( - / C G OF r p t ROBERT Cr COWAN i �? CE -8801 6. DHHS SIGNATURE L,-' Approved for _P49EE bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: .1, y/ k"I UITIC Date 1� " 9 ` q Cl 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 orderto 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-MOW.1M) Back MOAM a. ..� � �-� � ,o .3 �. Absorption field on lot )N DISTANCES FR /drainage Wells FIELD ON LOTTO: CE -8801 MUNICIPALITY OF ANCHORAGE AraL • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services IMEW On-Site Services Section crm P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel 1. D. # (�L�i - f ��'1 HAA # 1. GENERAL INFORMATION Complete legal description Lot 4, Lakehill Acres SID Location (site address or directions) 24225 Sunnyside Drive Pire.aS e-4,6'EK Property owner Nancy Magnuson Day phone 277-1923 Mailing address 11061 Boulder Circlet Anchorage AK 99516 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. fj 0 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. S & S ENGINEERING G Name of Firma. Phone Eagle River, Alaska 99577 Address Engineer's signature DHHS SIGNATURE Approved for Disapproved. 1: W6 bedrooms. Conditional approval for Additional Comments NuTln Date 11 / S— A ;� O F w jr * ` ._C--8801 f �fv bedrooms, with the following stipulations: Date % l - S__ % �? 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 orderto 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. 191) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907),W;,,�7g;4: Health Authority Approval Checklist Legal Description: Parcel I.D.: A. WELL DATA Well type P`" ' "/ 4-"- If A, B, or C, attach ADEC letter. ADEC water system number Log present (Ycq iv 4) Date completed "' / 9 7 G Total depth l � ��"" iti Cased to u 0 � Casing height (above ground) I � Sanitary seal &/N) Wires properly protected &N) FROM WELL ) OG Date of test Static water level Well production g.p.m. WATER SAMPLE RESULTS: AT INSPECTION (I/Y(q�( 01 / 70 Coliformy Nitrate a Other bacteria S & S ENGINEERING Date of sample: C1 `6 Collected by: t90-24 P_yi., Riyel. Loop Radd ias 20 Eagle River, Alaska 99577 B. SEPTIC/HOLDING/TANK DATA Date installed g l a `� Tank size Foundation cleanout 6VN) Y i✓S '01 =0 / 0 0 0 Number of Compartments a- Cleanoutso/N) Y¢ } Depression (YO^' 0 Date of Pumping 10 ( ),, I q '� Pumper j-& S High water alarm (YA N 0 C. ABSORPTION FIELD DATA Date installed � Soil rating (g.p.d./W or ft2/bdrm °� System type 7 Length 64 Width 3 Gravel thickness below pipe 6 Total depth r✓ 0 Effective absorption area F% i Monitoring Tube present ®'/N)W Depression over field (Y Date of adequacy test `t �� Results Pads/Fail) PlY5 S For bedrooms f Fluid depth in absorption field before test (in.); Immediately artery I o gal. water added (in.): i! Fluid depth /0 f (ins) Minutes later: I Absorption rate = 300 � a.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)' D. LIFT STATION Date installed Manhole/Access (Y/N) "Pump on" High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /00 / Absorption field on lot / Q o 4 - Public sewer main N (R Size in gallons On adjacent lots On adjacent lots "Pump off" level at* Public sewer manhole/cleanout N / 4 Sewer /septic service line a S -4- Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: r/ 14 Foundation y 0 Property line 3 0 Absorption field S Water main/service linep ��- Surface water/drainage o 0 i Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line a o / 4- Building foundation `/0 +� Water main/service line /0 �4 a Surface water / �0 Driveway, parking/vehicle storage area / Curtain drain N J P/ & K ° �^' +� Wells on adjacent lots > J 0 F. ENGINEER'S CERTIFICATION / certify that i have determined thru field inspections and review of Municipal in conformance withMO /H�j�` gyi eli�nes in effect on this date. Signature ��'��' "lyd✓a Engineer's Name /� 0Q�*ZT Coww Date + / 2 0 HAA Fee $ �� ' Waiver Fee $ _ Date of Payment �� ' jZ CP / ) Date of Payment Receipt Number / `'' ' C ��' Ls Receipt Number 72-026 (Rev. 3/96)* ROBERT;".C;"COWAN i @ �i •, CE - 8801 fes% tip: .._ ... are MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Application Date��/' 1. General Information (a) Legal Description ( lot, block, subdivi n, section, township, range) Location(�%ress or directions) _ _ (b) Applicants Name [:>jL Applicants Address Telephone - Home Business (c) Applicant is (check r —on --e) Lending Institution Owner/builder��; Buyer Other [:::I (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address /�/LAG-/�C�ri/`l R �'• Telephone :3 ,} r� �c `-1 (f) Mail the HAA to the following address: 2, Type of Residence Single -Family Number of Bedrooms 3. Water Supply Individual Well Multi -Family Community Other (describe Public I-�i Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public [::I Community E::] 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] I A• 5. Engineering Firm Providing Inspections, Tests, File Search, Data 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 regula- tions in effect on the date of this inspection. Name of Firm Address T Date ft 6. DHEP Approval motif (ENGINEER SEAL) Approved for 9 --bedrooms Approved Disapproved Terms of Conditional Approval CAUTION Telep,4.ne _ JL' jI� Conditional THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES EASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALIZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-•84 � M1oi ¢� ..�.e R 9• jti_77'� j •SAS 8 tri'"°'. ^.•' �``�' �El PROFF..15g��e, � (✓ 1!t e Conditional THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES EASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALIZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-•84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) ®3AID34 CHECKLIST - FEBRUARY 1984 N011D310dd 1V1N3WN081AN3 V H1JV3H d0 • d34 Legal Descriptior??eb �d1-�1NA!4 Well Classification <1 If A, B. or C. D.E.C. Approved(Y/N) Well Log Present dYY N) Date Conpleted �� G j r %�n Yield (7 4pry Total Depth -5-/ Cased to el L/) " �- Depth of Grouting Static Water Level Pump Set At 0-WV1eA1,9 ,v,K/ Casing Height Above Ground l ti Sanitary Seal on Casing Y ) Electrical Wiring in Conduitdy"N) Depression Around Wellhead OV9D Separation Distances from Well To Septic/UGIdIng Tank on Lot. �/0 ; On Adjoining Lots f d0 f To Nearest Edge of Absorption Field on Lot On Adjoining Lots To Nearest Public Sewer Line /114 To Nearest Public Sewer Cleancut/Manhole �A To Nearest Sewer Service Line on Lot SO Water Sample Collected By 5gS 4E��14R, ; Date -i -- ) S Water Sample Test Results / A-Ir79FP-k-c-7Z)a-AI- Cc ments B. SEPTIC/HA'TANK DATA Date Installed S - i 7 Size ) 2,0C) No. of Compartments Standpipes di'm Air -tight Caps ffN) Foundation Cleanout <:nN ) Depression over Tank (Y41q2 Date Last P d Pumping/Maintenance Contract on File (Y ) for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)^ / Separation Distances frau Septic/Holding Tank: To Water -Supply 411 S S- To Building Foundation fti To Property Lire p /'f To Disposal Field qS' i To Water Main/Service Line �/d To Stream, Pond, Lake, or Major Drainage Course Comments CIA/L,,2--7S P14r_'ZA676 P&,4Pe : C-61Vl/EX75-12 7-0 [Page 1 of 21 2-15-84 AUG 30`P C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �� 2Ei Type of System Design - Date Installed 2AZ-? `-? _ Length of Field Width of Field � Depth of Field C Gravel Bed Thickness �-7 Square Feet of Absorption Area /&f Standpipes Presentco/N) Depression over Field (YA9 Date of Last Adequacy 'lest Results of Last Adequacy Test � S e4•-T7S re i e, z- Separation Distance from Absorption Field: To Water -Supply We11 To Property Line i To Building Fobpdation CJ -r To Existing or.Abandoned System on Lot //4 On Ad'ining Lots To Water Main/Service Lires To Cutbank(if resent) `�_ 14 _ To St ream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Commnts D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes Dimansions Manhole/Access (YM) "Pump Off" Level at Vent .(YM) during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA on the date of this inspection. �ys Signed 9 9. Date Z Ca aHI 1rJ3 ' MOA No. KB1/d5/s [Page 2 of 21 Guy .tn in effect yy �,1� n .ase •�f�a4 Reberi /l. She • + '�`sk I TE aOG� OHoFrv, 2-15-84 4 CLA I 9 MUNI&ALITY OF ANI-rle r " '' fe-� / ' L G- U MUNICIPALITY OF ANCHORAGE DEPT O" i cCTION A DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTPRRQhl� ENTAL ❑ One ElFour EJOther 825 LStreet -Anchorage, Alaska 99501 EJTwo ❑ Five ® (SIA 7 7. WATER SUPPLY ENVIRONMENTAL ENGINEERING DIVISION *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY Telephone 264-4720 RECEIVER ❑ PUBLIC UTILITY REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES **If n DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. individual/on-site, give installation date 1. PROPERTY OWNER If system is over two (2) years old an adequacy test s required HONE by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MAILING ADDRESS 7 PROPERTY RESIDENT (If different from above) - PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE V -,P,7 MAILING ADDRESS REALTOR/AGENT 4 ON y / Com• L ti^�-& / c/w P_'ry MAI LING A D � SS 2- AA tpc�ctr C'I 5. LEGAL DESCRIPTION//� / / _ 0 1- � fe-� / ' L G- U STREET LOCATION 6. TYPE OF RESIDrENCE NUMBER OF BEDROOMS ❑ One ElFour EJOther 7 SINGLE FAMILY EJTwo ❑ Five ❑ MULTIPLE FAMILY I Three ❑ Six 7. WATER SUPPLY 0 INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) B. SEWAGE DISPOSAL SYSTEM **If n a' INDIVIDUAL/ON-SITE** individual/on-site, give installation date If system is over two (2) years old an adequacy test s required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified. PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: I If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTIh /) . TOTAL ABSORPTION AREA MATERIA�L,JI 4. DISTANCES WELL TO: Septic/I-Iolding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS L. APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompa ertificate) E]DISAPPROVED DATE BY (l'itle) LEGAL DESCRIPTION 72-010 (Rev. 3/78)