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HomeMy WebLinkAboutMARGUERITE HILLS LT 1A-1Marguerite Hills Lot 1A-1 #020-161-26 mo�ww`` � 1 �I 516- 1YotAl-fi/N y9sp6 V - I h • ! d- Ii Municipality of Anchorage Page of �-- DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 0 Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report od 5wq�omzo oLn -rL1 - 1.&Permit Number: tiw nr 004(0 rl.ti� PID Number: Name: 1-a V (4# • 0 n Wastewater System: New 0 Upgrade Address: Pod AUC,1/. ABSORPTION FIELD Phone: 21-45 S ?'aF I No. of Bedrooms: ILS Deep Trench C ShallOW Trench C 8ed C Mound C Other LEGAL DESCRIPTION Soil Rating: I Z Total Depth from original grade: GPDfS Ft I'D Lot: Block: Subdivlaion: Depth to pipe bottom from ongmal grade: Gravel depth beneathp♦�" 6rs/ 7 f Tr 11 Ft Ft Township: Range:Section: Fill added above onginal !Qrade: Gravel length: �j�� 6 / D F( T�j Ft WELL: 'Pew 0 Upgrade Gravel width: Number of lines: Oaunca oeh.een xn , F( F( Ft Classnwation [Private. A.B.C1: Total Depth: Cased To: Total absorption area: Pipe materiae PrtV. 3S";_ FI ZO Ft 6410 so. Ff -TC Driller' /r Oaa Ored:T SWer Inst Iter: Date installed: 2 G L SeFt G/� 0/ yield: 3.0 Pump Set at: Casing Height Above Gfouna: TANK GPM G111Cw Pw/e1 Ft. Z,0 Ft. SEPARATION DISTANCES ICsephc OHolding :1S.T.E.P. To semic Atnomoon Lip Holding Pmate Manufacturer. Capacity in gallons: From Tan. F.eid Station Onk Sew, Lines v%t A 'SO Welt /tib 1,4 /00a /fro 11L Material: CPeel Number of Compartments: 2 waie�e 100'1 /wf{ / /0014. LIFT STATION Lot X0,4 T y01� / /m/4_ Size in gallons. Manufacturer: Line Foundation L.1u / 'Pump on level at: -Pump ei at: High water alarm at: Curtain r/�A i Pump Mahe ei Electrical Inspections performed by: Drain fA Remarks: BENCH MARK Location and Descnl;.On: u � LA/C(( C 441 Assumed Elevation: d c. I%. OFA1 �gs,¢�tt^ GAP,.• j*•49THI ;* Inspections performed by: MW4r%/4.,h 1 er.aevt Dates: 1s a/ 2y o/ 2•••• •••••••• � OIL' 2nd '/ er rtt.o /. .• .... // >� ; MICHAEL N. ANDERSON e.4, Department of Health and Human Services approval �Ij r •, CE 94 g; •• ;�\� Reviewed and approved by: Date .;,4 ;- 77-013 (Rev. 9/911 MOA 25 Permit No. SW970020 S w D1 0'0 710 Page 2 of 2 Municipality of Anchorage 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 Legal Description: LOT 1A-1 MARGUERITE HILLS SUBDIVISION PID No.: 020-161-26 1 1 33' SECTION LINE EASEMENT - - - - - - - - - - - - - - - - - - - - - - - I I--- -I-Ft--- 1 SECONDARY I INI p I �I N 111 Iw o 111 w I Ipl 1', ON10K TMK _20_TELECOM AND ELECTRICAL EASEMENT _ V- p( OR�/ I i I I 1 1 ASBUIL SCALE: 1"=50 fA ✓� SM11 "J41( --100' WELL RADIUS aFMMEOUSE \\ WELL MARK SEPTIC FIELD 8 GRND. ELEV. / /� 1 C06 C05 A i, 12.6' C04 TCO2 101.1 i P(0 GALLON CO2 S PTC TANK / ,CO3 66.2' CO3 V- p( OR�/ I i I I 1 1 ASBUIL SCALE: 1"=50 fA ✓� SM11 "J41( --100' WELL RADIUS aFMMEOUSE \\ WELL MARK A 8 GRND. ELEV. PIPE ELEV. COi 12.6' 33.6' 101.1 97.9' CO2 73.4' 73.9' 73.8' 66.2' CO3 73.4' 73.9' 73.8' 66.2' TC01 73.4' 74.7' 73.1' TCO2 75.1' 80.2' 71.4' C04 76.2' 81.7' 70.6' Vol.,. 5 78.1' 83.7' 70.1' C06 70.0' 83.1' 69.6' 65.3 C07 104.4' 104.3' 69 Y 65.25' MT 88.2' 93.2''l5�.4' 4%Fpf ®�go�� �re49r°1:ro• ��� m ^" Lc 94 49 , d l STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF MINING & WATER MGMT WATER WELL RECORD LOCATION OF WELL ' - BOROUGH SUBDIVISION Murg li-r ITC LOT BLOCK SECTION QTRS SECTION TO RANGE MERIDUW . [IN ❑E • ii'If5 [Is 13W WELL OWNER: n G•a DEPTHS MEASURED FROWEIcasing top ❑ground surface WELL DEPTH: DATE OF COMPLETION Depth o} hole: S S=5 tt / Depth of casing: t to 12 /� BOREHOLE DATA: Depth Material Type and Color From To DEPTH TO STATIC WATER LEVEL: Ll ft belowtop of casing ❑ Around surface Date: G/ l < J A -t METHOD OF DRILLING: •Fair rotary. ❑ cable tool ,/ r t t /� `j ❑ other ,j USE OF WELL: 0domestic ❑ irrigation ❑ monitor ❑ public supply ❑ other CASING STICK-UP- �9 ft. Diam: O in. to It — Casing type:_.y.+:77 g=_1n. to it WELL INTAKE OPENING TYPE: D open end ❑ screened ❑ perforated 21 open hole Depths of openings: to ft SCREEN TYPE: Diam: in. Slot/Mesh Size: Length: ft GRAVEL PACK TYPE: Volume used: Dept to top: GROUT TYPE:-- """ Depth: ffbm ft'ta ft DEVELOPMENT METHOD: •�i . . Duration: -7 PUMPING LEVEL AND YIELD: after 3•- hrs pumping 3 gprn PUMP INTAKE DEPTH: It Horsepower: WELL DISINFECTED UPON COMPLETION? ELYES ❑ NO CONTRACTOR INFORMATIO REMARKS: PLEASE MAIL WHITE COPY OF LOG TO: DNR/DIVISION OF MINING & WATER MGMT 3601 C St, Suite 800 Anchorage, Ak 99503-5935 Ph(907)762-2538,Fax(907)562-1384 MUNICIPALITY OFANCHORAGE Development Services Department On -Site Water 8 Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Permit Number: SWO10076 Legal Description::MARGUERITE HILLS LOT to -1 4-21 -al l0'OOrr,. Date Issued: Apr 20, 2001 Expiration Date: Apr 20, 2002 Parcel ID: 020-161-26 Design Engineer: 0062 Pannone Engineering Services Site Address: 7415 BIG MOUNTAIN DRIVE Owner Name: DAVID L. MATTISON Lot Size: 395588 SQ. FT. Owner Address: PO BOX 110467 Total Bedrooms: 4 Permit Bedrooms: 4 ANCHORAGE . AK 99511-0467 This permit is for the construction of: Q Disposal Field Q Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage 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 (18AAC72 ) and Drinking Water Regulations (18AAC80 ). 3_ The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (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. Received By: Issued By: Date: 7 -D -G1 Date: 4 •- 2 0% 01 Municipality of Anchorage e Development Services Department e Building Safety Division ' a Onsite Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907)343-7904 ON-SITE SEWERMELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING 0✓20-161-26 Parcel I.D. W \ I , MtV_ U6 OA-rb 1 l Permit Number SWO/0076 Property owners) Idtly� � nDay phone 3 g15_S V5 S ailing address (1) �•d �jOX ��Ot}� -Mailim address (2) 720/ MDL!NT WRWLEY PR_ Legaldescription (Lot, Block & Sub'd.) Zip Code l �� au�tZ`� I�i115 Legal description (Section, Township & Range) L Lot Size 39�Acres q.F Number of Bedrooms J THIS APPLICATION IS FOR: Sewer Only Well Only ❑ Sewer and Well Water Storage ❑ Sewer Upgrade ❑ THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: '�'3.Z O - o u Waiver Fees: Date of Payment: q. Z. Op— Date of Payment: Receipt Number:o Receipt Number: (Rev. 12100) __- r > ;l Txr f ^ r 'tI<S f fi t4,•r / I PAGE, 1'OF ,.may bt. •'"! ' .� "� MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O..BOX 196650, 825 -L- STREET, ROOM�502 ANCHORAGE, ALASKA 99519-6650. rx ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT ;PiEiMT NUMBER:SW970020 DATE :ISSUED: 2/14/97. i1ffSIGN ENGINEER:STEVEN R. PANNONE EXPIRATION DATE: 2/14/98 OWNER NAME:MATTISON DAVID L OWER ADDRESS:P.O. BOX 11467 ANCHORAGE, AK. 9511 PARCEL ID:02016122 - faij) s:IEGAL DESCRIPTION: 'ASARGUERITE HILLS LT 1 - t]�:., v�a lA-I - Q I F�aaid ',�I,OS SIZE: 742400 (SQ. FT.) MMSBER'OF BEDROOMS: 4 THIS PERMIT: 4 :'SSSS"PERMIT IS FOR THE CONSTRUCTION OF: - DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: ;2.'� 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 ,(18AAC72) AND DRINKING WATER REGULATIONS '(18AAC80). ."'3.; THE!ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDS NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)' ..-4JC.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 SAM.7 DAY ,,.B..COVERED, SEALED AND HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. "SPECIAL PROVISIONS: :RECEIVED BY: Y" v' ` DATE: 02-/I ISSUED BY: 1'!; t �f�U tf rn- DATE: D 4 �• r Steven R Pannone, P.E. P.O. Dox 142025 Cooiu1tin#En&oa Aoch=M M&Aa, 99514 (907) 272-9218 (9071272-9219 F« 26,1997 icipality of Anchorage Dept. of Health & Human Services -Site Services Section P. O. Box 196650 horage, Alaska 99519 .Subject: Lot I Marguerite Subdivision Well and Septic Permit Gentlemen: My firm was contacted to investigate the possibility of installing of a new system at the above referenced property.Currently the lot is undeveloped. Three test holes were excavated on September 26, 1994. The report and percolation test results are on file with your department. A copy of the soils loss are attached. Ground water was monitored for seven days. No ground water was encountered or monitored. hole two encountered bedrock at eleven feet below ground level. No bedrock was encountered in test le; one or three. e lot is approximately 40 acres in size. The owner plans on subdividing Lot I into three lots. Lot I slopes e southwest at a rate of approximately 10 to 15 percent The proposed installation will be located on the +;,•'i,.northern portion of the lot, and on the eastern portion of future Lot IA. The proposed location will be greater than 100 feet away from the proposed well serving this property and 25 feet from the water service The surrounding systems are located greater than 200 feet from the proposed installation, the lots to northsouth and cast are undeveloped. The proposed installation shall not impact the future dZ./clopment will over nt of the surrounding or existing lots. See attached design. The new system wil er six feet vertical '-."..:':'i�eparation to the bedrock and over four feet vertically to the ground water. have any questions about the proposed installation, please contact me at 272-8218 ,,,Sincerely, .:Amchmcnts: 7a16OPM1-MARC tte­. I r� -5. -DES IGNI is T Z tte­. I r� -5. -DES IGNI is T 41 WASTEWATER ABSORPTION,SYSTEH,t oA OT I MARGUERITE -SUBD. tte­. I r� Detal • Area.' "TP I PROPOSED ,ol-See Sheet 2 of 3. LOT IA k Proposed solt absorption system % See Sheet 2 of 3 PROPOSED. LOT 1B 0 TP 2 PROPOSED LOT IC TP 3 SITE PLAN Steven R. Pannona%; Mr. Dave Mattlson O.0 P.D. Box 110467 c Anchorage, AK 99511 (907) 345-8715 Ir' PANNONE ENG. SVC P. 0. BOX 142025 ANCHORAGE, :ALASKA 99514 274-0308, 272-8218 Fax DATEm o 1-20-97 ' DESIGN 4ZrA1 r11-2M h- -5. -DES IGNI 1/3 41 WASTEWATER ABSORPTION,SYSTEH,t oA OT I MARGUERITE -SUBD. Detal • Area.' "TP I PROPOSED ,ol-See Sheet 2 of 3. LOT IA k Proposed solt absorption system % See Sheet 2 of 3 PROPOSED. LOT 1B 0 TP 2 PROPOSED LOT IC TP 3 SITE PLAN Steven R. Pannona%; Mr. Dave Mattlson O.0 P.D. Box 110467 c Anchorage, AK 99511 (907) 345-8715 Ir' PANNONE ENG. SVC P. 0. BOX 142025 ANCHORAGE, :ALASKA 99514 274-0308, 272-8218 Fax DATEm o 1-20-97 ' DESIGN 4ZrA1 r11-2M h- 5 ;+L ♦A i r'•^'•• , . { ' "ir�"�. ,fT'.^^ ;Si _. ,.lyy�' YfJtai. - v 4. !1, 1 � DESIGN ..:. 2/3 i WASTEWATER ABSORPTION SYSTEM r t t OT 1 MARGUER T S/ ' t 1 Y • 1. } t t. r I I A. "' This area Is opc O undeveloped .. l sW Q. It j_ , Proposed Vett I C3 f Y..I �l2% ( 44 � W Proposed I hbedroom I - r,. New 1250p i.-�� { .. ._..-+�•• o_ /'Septic Tank i 5%I I Primary Abs�rptlon Fleld 1 - IS% Dlverter va yr loe'n Secondar bsorptbn Field it Installed at tare time oWls� pr6+ary. A aver -ter valve / be Instalted between the _. t.o systems If secondary system .- �` Is hnstalled. There ¢rr no Wells 07 Sectbn Ume Gsera^it •.v •�. �_----� systems Wlthtn 200' m TRACT A of proposed system LOT 7 ,l LOT 6 1" rwvo-kv-wwcd. i Soil Rating = 125 sf/br ; ,; f , 4 Bedroom House '' h� 375 sf Rqd L K4 41 Deslgro 5' Effective 8' Total Depth W, 66dd 2' Wide, 40' Long Total Effective Absorptl;n = 400 sf PREPARED FOR, = ,'• PANNONE ENG, SVC � > en R. Pannone1 Mr. Dave Mattison P. 0. BOX 142025 f ' No. CE 8149 AnOchorage04AK 99511 274-0308,E 272-8218 Fax l4 (907) 345-8715 - DESIGN <'� l`r '.l ♦)I � f Y �!'�``P ter'% 1 -. - Ile 1.7 —��4' DESIGN:' DETAIL sl� �w WASTEWATER ABSORPTION,SYSTEM X3/3 4 LOT 1, MARGUERITE:A4 S/D 6I 4 . CL C U 0 L4 Z JC 3CU NOMM L CL 14 LLJ .3 � 0 0 3 0 00 0 00 C JPO0 00 0 C LL. 0 C C V)C 0 0 0 0 00 0 0 C 0 0 0 a C 00 0 600 0 lrckv= C 3 5 MONT13 ifENYTO 4- Y 4- a "a 06 CAVw$,M inOW43M �Yia 009 a %fill k u inowvm m3uvawuj 4C— TH R. Pannone! RED FOR, PANNONE ENG. 4VC. -ja A CE 8 14. - Dove ve Mattison P. 0. BOX 142025 No. P.O. Box 110467 (2,0 ANCHORAGE. ALASKA 99514 Anchorage, AK 99511 274-0308, 272- 8218 FAX (907) 345-8715 DESIGN DATE NOT ALM Wa-,& 1,7 c° LEGAL ,fr.. �Ty.�j . w jMi.f, r l.If\ •` <c�'+. 41 i< �- '> h� lf., i �I(!; r�i') Y i f ; `� ' Ti• rte. . \ i L F\ ` Municipality o1 Anchorage j >R 197 J ; DEPARTMENT OF HEALTH 6 HUMAN SERVICES . ...... 825 L" Street, Anchorage, Alaska 99502 -MO" , "rigS t �• l ......:.. . st SOILS LOG —PERCOLATION TEST' 0 1517 E MED FOR: G$VCi 14a -W DATE PERFORMED; ,�rf.p,pT;fl.I. L-DQE-ZMs/'4ue�"i:C Unship. Range. Secilon: r"11N O ►"x%'07 / / � L S &C/y a ddC/ sated Y Grave; CC, -8`;7i 0f'7 a/ Co&% acrf+ Flo/e SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES. AT WHAT L DEPTH? P E NO c All r?.5 w ==mmm® 194 1 20 `•f', •' Ll HOLE DIAMETER 'I '<^�•',.:;i'; PERCOLATION RATE L' (mmuuelmchl FT AND PERC 194 1 20 `•f', •' Ll HOLE DIAMETER 'I '<^�•',.:;i'; PERCOLATION RATE L' (mmuuelmchl FT AND PERC TEST RUN BETWEEN _�_FT .:'ppMMENTS 1r.:Xf •1'... Ilk, ERTIFY THAT THIS TEST W PERFORMED IN 1AIMED BY. ROANCE WfTM ALL STATE AND MUNICIPAL GUIDE E (R.•l StGI a, F. IN EFFECT ON TMS DAT DATE: I" 'I, -- municipallty of Anchorage -Z DEPARTMENT OF HEALTH & HUMAN SERVICES 825'L' Street. Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST., Ftr'()RMEO;oiR: 0-2 14�a A&64—k 52-45� DATE PERFO .AL ESR,PT,4C-r1 ga!pwa fie 1/174 -Township. Range, Seclion:7-. Ifiv 2 4 54. 7 '. 71 9 0 13 14 A� ::17 19 20 of 7 2p /P I C- 5a;ldy 601?'Z?;�•e/ O er, e 5p lb r7 60bbe- T-ra C- e <7 / I -C;2 Fr-ae-Nred Chi. tvf+. fp/e WAS GROUND WATER ENCOUN'TERED? OF YES. AT WHAT DEPTH? wom, /1,9 6 le no? —!Q�1131t Z % or dr w'0000 Sac /2_ PLAN PERCOLATION RATE +—,- if-- Immutmomh) PERC HOLE DIAMETER Ic- TEST RUN SETWEE-1 FT AND F1 COMMENTS ;2 " ';••-' PERFORMED BY. •EAIIFY THAT THIS TE T WAS PERFORMED IN i�COROANCE WITH ALLSTATE AND MUNICIPAL GUIDELIYESIN EFFECT CN THIS DATE DATE. 1 . I IL 0 RPWAwrj 2 0 m Em 01129M 1 W.7112 m PERCOLATION RATE +—,- if-- Immutmomh) PERC HOLE DIAMETER Ic- TEST RUN SETWEE-1 FT AND F1 COMMENTS ;2 " ';••-' PERFORMED BY. •EAIIFY THAT THIS TE T WAS PERFORMED IN i�COROANCE WITH ALLSTATE AND MUNICIPAL GUIDELIYESIN EFFECT CN THIS DATE DATE. 1 . I I• '�. a r ` `".' AX. ,1 t._ ''•i , ',,.'. Munidpailty of Anchorage DEPARTMENT OF HEALTH 3 HUMAN SERVICES 825'L7 Street, Anchorage• Alaska 99502-0650 SOILS LOG - PERCOLATION TEST %FORMED FOR: r �<<C"/:`% DATE SAL DESCRIPTION: L-fir�e�I YO`/`�r ownship• Range. Section: SLOPE , Dan<<GS t r`Yr 13,'br v arc s// N 3 � 4 ` , d `: 5 7.{Y, qry 6 . t rf act 5;;H 1(• �.a t WASGROUNOWATER QQ .•`�'. :`�.t0 �.rj ENCOUNTERED? Lam✓ iJ. �•�'� ,. i.% -t 1 IF YES. AT WHAT L L / L �- �l O .. •`��-F-� n- • DEPTH? r P E DeFN Y Wela Aller 61 Gilt 20 IKAM . im nM.a �ress�msr.�©s���o WNW9ix'L�!!.mm PERCOLATION RATE . tv.nut Ws hIPERCHOLCDIAMETER —jrL_ K. IMEO BY: ' CERTIFY THATT?e5 TEST WAS PERFORMED 7N DANCE WITH ALLSTATE AND MUNICIPAL GUIOELI S IN EFFECT ON MIS DATE DATE n �1 �yMY/�.Y � p�«nHt .e.. ,� } - }•, via •'���.'.\`h .7...' Qs� �a.1 -•�tr� . . � >.i s Municipality of Anchorage G� r Development Services Department Building Safety Division *AC On-Site Water and Wastewater Program4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. HAA# f /A oI0 2pG Expiration Date: 1. GENERAL INFORMATION Complete legal description 1-4 o,r Lo 4- 1­�— � Location (site address or directions) Current Propertyowner(s) bavc ►+tef{.;.., Dayphone Mailing address VP. 0. 6,f (f Y&; A., r (,,4 't 9> t ( Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 29 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 valid 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 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 seat 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 or Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm M(r(�.�� /�( /;" I ren n•� Address Jit;wo Sl.ish��1` �•�G,�y�ysIG Engineer's Printed Name a„h•.e,( 5. DSD SIGNATURE _/L Approved for -r bedrooms. Disapproved. Phone 3ws_33�� Date OF Al; IkX%99Tl •ENGIN�E-�ER' • ' h9CHAEL N. AND01=4 CE- 45 ; ..... c• Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: S= / 6 ' O l (R". 12M Municipality of Anchorage • Development Services Department Building Safety Division On-site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: M &v,* .aee. IL r Leo t,4—( Parcel ID: &2o- 1 41 —2 G A. WELL DATA Well type , IA.a (-e If A, B, or C provide PWSID # Date completed 4201:;L- Sanitary seal (YM) Total depth )YS ft. Cased to -LO—ft. FROM WELL LOG Date of test 4 a Static water level 417 ft. Well production 3.0 9•p•m- WATER SAMPLE RESULTS: I r Coliform �colonies1100 ml. Nitrate 0, ! m9A. Web Log (YIN) v Wires properly protected (Y/N) Y Casing height (above ground) _t -t In. AT INSPECTION 1,L-6 W c ( ( 1 —� mac✓ 4l►RY ft. d 4,A(A Other bacteria _ colonies/100 ml. Date of sample: !x/telc t Collected by: Mirkee( L-rrNn B. SEPTICIHOLDING TANK DATA Tank Type/Material 5 4"'r Date installedf / .� 0 Tank size ['0 O gal. Number of Compartments Z Cleanouts (Y/N)) Y' Foundation cleanout (YM) _4Y _ Depression over tank (YIN) A( High water alarm (Y/N) Date of pumping tJ -tto Pumper C. ABSORPTION FIELD DATA Date installed!46-2o1 Soil rating (g.p.dAt' or 1t'lbdrm) _LL- System type O t r p bene y Length 'Yb ft. Width 20 ft. Gravel below pipe (^ L #-r ft. Total depth LQ— ft. Eff. absorption area(#&M ft' Monitoring tube Y Depression over field 4 Date of adequacy test A( fw Results (Pass/Fail) For S bedrooms Fluid depth in absorption field before lest /ut. Water added gal. New depths in. Elapsed Time:.e, min. Final fluid depthtf'in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) l' If yes, give date D. LIFT STATION Date Installed "Pump on" level at _ in. E. SEPARATION DISTANCES Size In gallons in. High water alarm level at Cycles tested Meets alarm ti circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAiRsta6mon lot 180 14. Absorption field on lot 106 tk Public sewer main - ti.12 Sewer /septic service line 's o t f On adjacent tots 10014, On adjacent lots ro 0 14 Public sewer manhole/cleanout Holding tank / SEPARATION DISTANCES FROM SEPTIC/0-TANK ON LOT TO: Building foundation JV0 t,A Property line &14 Absorption field Water main iter N Water service line /vu 14 Surface water /uo Wells on adjacent lots If 0 0 1 i in. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: / Property line 924004a lid Building foundation � Water main PIL4 Water Service line toy 14 Surface water too If Driveway, parking/vehicle storage Curtain drain111_ Wells on adjacent lots fQo F. COMMENTS G. ENGINEER'S CERTIFICATION �p1�.•••••,,:OW gS�ij� I certify that I have determined through field fnspectlons and r �?� •9 review of Municipal records that the above systems are In k 49TH conformance with MOA HAA guidelines in effect on this date. / X. ....... Engineer's Printed Name MteG�rte•i Aj/lted �r,rn �� s` ; MieN ei . ANDCRSCN ; 94f I Date 510 I�+ rI�'•. S HAA Fee $ 100 Date of Payment C; If S Receipt Number 00 45(e ({ (Rev.12000) Waiver Fee S Date of Payment Receipt Number