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HomeMy WebLinkAboutFOREST RIDGE BLK 2 LT 9Forest Ridge Lot 9 Block 2 #017-112-90 '~ Municipality of Anchorage Page / of / DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,O, Box 196650 · Anchorage, Alaska 99519-.6650 · Telephone: 343-47.44 On-Site Wasfewater Disposal System and/or Well Inspection Report Permit Number:, ~ (J,..3 ~ 50'~'-~ PID Number: Name:~O~~ '~'~ ~~ ~, Wastewater System: ~ New ~ Upgrade *~'"'~1~ ~~ ~ ABSORPTION FIELD LEGAL DESCRIPTION so,.....;: ~.~Gpo~q Ft Total~pthfromoHglnal~d~:, WELL: ~ew ~ Upgrade ~'Ft. NuT'lines:I ~ Ft ~ G..I ' a~ . TANK Ft. I I~ ~Ft. SEPARATION DISTANCES = Septic ~ Holding ~.T.E.P. w.,~ ~' Ifl~' I~~ ~ ~ "'""":~ su..~. ~ LIFT STATION w~ter J~ I~ I~ Remarks: ~ ~ ~~ BENCH MARK Inspections pe~ormed by: 1st ~/~ Depa~ment of Health'~ Hu~a~e~ices approval ~/ Reviewed and approved Date. ~' Permit No. ~ Page 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION of 2 P.O. Box 196650 · Anchorage. Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: FOREST RIDGE SUBD., BLOCK 2, LOT 9 PID No.: 01711290 cot C02 MTI MT2 ..T.& ; I ~ · 105.4' WATER FOUND 4 DDRM HSE c02132 I.q5 I tlTtlel I?e I MT2181 I92 I MT3 83 I 104 I wr4 64' 88 PRESSURIZED DISTRIBUTION SYSTEM: ......... PUMP =-20 OSI 05HH - 5 STAGE (~30 OPM) 5 LATERALS ,-, 44' LONG 6 GPM/LAT 10 HOLES/LAT (58" O.C.) 50 HOLES TOTAL ,,, 0.59 GPM/HOLE $/16". DIA._HOLES_FACED DOWNWARD 1 1/4" DIA. LATERALS 5" DIA. SOLID MANIFOLD 72-013 A (?./9 t ) MOA ~ ¢OLOH¥ ~UZL~£R$ LOCATION OF WELL STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD BOROUGH SUBDIVISION ~CTION GTRS .LOCATION/SKETCH: C " :" (,,,;~ cL-.-.,, ~o.,~..L. ~ , 0~I' '"" .~" WELL OWNER: C olo,',r ]/o,,,.o DEPTHS MEASURED FROM:l-lcasing top I-Iground surface BOREHOLE DATA: Material Type and Color Depth From To WELL DEP1/H: Depth of hole: Depth of casing:, DATE OF COMPLETION ft ft ~t 7 DEPTH TO STATIC WATER LEVEL: '7 ~ tt below [~ top of casing Date: I-I ground surface METHOD OF DRILLING: [~'.air rotary I'-I cable tool I-I other USE OF WELL: [~domestic [] irrigation [] monitor [] public supply r-I other CASING STICK-UP: ~ ft. Diam: ~, in. to/~_.5.~ Casing type: .~-~ ~, in. to / ~ ~--ft WELL INTAKE OPENING TYPE: [~'open end [] screened [] perforated [] open hole Depths of openings: to ft REC APR 1 4199 Munici Dept. SCREEN TYPE: ~ Diam: in. SloUMesh Size: Length: ft GRAVEL PACK TYPE:~. Volume used: De,th to top: GROUT TYPE: ~,.~ Volume: Depth: from ft to ft DEVELOPMENT METHOD: ~ Duration: /.--~----~-'~ - PUMPING LEVEL AND YIELD: ]...~ ~ ft after / hfs pumping C~ gpm PUMP INTAKE DEPTH: It Horsepower: __ WELL DISINFECTED UPON COMPLETION? [~YES I-I NO CONTRACTOR INFORMATION: r~egister~l Business. Name . /'- ,// Signature of Authorized flespres~n~ative Date REMARKS: PLEASE MAIL WHITE COPY OF LOG TO: DNR/DIVlSION OF WATER PO BOX 772116 EAGLE RIVER AK 99577-2116 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 #L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930500 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:NORCOL INVESTMENTS OWNER ADDRESS:5120 MANYTELL AVE ANCHORAGE, AK 99510 DATE ISSUED:12/15/93 EXPIRATION DATE:12/15/94 PARCEL ID:01711290 LEGAL DESCRIPTION: FOREST RIDGE BLK 2 LT 9 1 LOT SIZE: 64965 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AAC72) 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 OR 343-4681 AFTER BUSINESS HOURS 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: RECEIVED BY: I~, ROBERT SHAFER, P.E. ROGER SHAFER, P.E, December 1, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 S~rE P1.ANS ROADDESIGN SO~TEST PERCOLATION ,/ Municipality of Anchorage DEPARTMENT OF HEAL TH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Forest Ridge Subdivision, Block 2, Lot 9 Request you Issue a permit to drill a well and Install a septic system to serve the proposed four bedroom house on the referenced property. Two test holes were excavated and percolation tests performed on the referenced property. The approximate locations of the test holes are located on the attached site plan. During excavation groundwater was encountered at 8 feet in test hole #1 and 9 feet in test hole #2. After seven day groundwater monitoring the monitoring tubes within the holes were checked and water was found at 4.5 feet and 5 feet respectively. This property has enough area for a septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. RAS/LSU/Isu 17034 NORTH EAGLE RIVER LOOP * SUITE 204 * EAGLE RIVER, ALASKA 99577 LEGAL I DRAWN FOREST RIDGE L. S. ULSHER I CKD. I SUBDIVISION., BLOCK 2, LOT 9 R.A.s., --'°AT"2/1/9`3 ISHT. I OF 2 DESIGN CRITERIA: 4 6DRM = 600 GPD SOILS = 0.4 GPD/SQ. FT. 600/0.4 = 1500 SQ. FT. REQ'D BED: 2' DEEP ,3' LAKE OTIS GRAVEL STRUCTURES, HAS[blENT\, OR ENCROACHMENTS SHOWN ON THIS SITE PLAN ARE AS SHOWN ON AN AS-BUILT SURVEY DRAWN BY: GASTALDI LAND SUREYING IT IS THE RESPONSIBILTIY OF' THE CONTRACTOR TO VERIFY EASEMENTS, REQUIRED SEPARATION DISTANCES, AND PROPERTY LINES PRIOR TO CONSTRUCTION. 6" GRAVEL OVER AND UNDER DIST. PIPE 30' X 50' MANYTELL 100' WEI2~ PJd)IUS PROP. \ T St E ESMT. LOT 9 DR~.~ 4 BDRMI \ \ \ PROP. 1500 GAL S.T.E.P! \ \ \. \ \ \ \ \ ? PRESSURIZED DISTRIBUTION SYSTEM: BED PRESSURIZED DISTRIBU~ON PUMP = 20 OSI OSHH 5 STAGE (~50 GPM) 5 LATERALS ~ 44' LONG EA. 6 GPM/LAT 10 HOLES/LAT (58' O.C.) 50 HOLES TOTAL ~ 0.59 GPM/HOLE 5/16' DIA. HOLES FACED DOWNWARD I I/4' DIA. LATERALS 3~ DIA. SOLID MANIFOLD A~ PORTIONS OF SYSTE~{ WITH LESS THAN 3.5' OF COVER REQUIRE INSULATION. CONTRACTOR IS REQUIRED TO OBTAIN UTIUTY LOCATES PRIOR TO ANY EXCAVATION WORK, DRAWNL. S. ULSHER BLOCK 2. LOT 9 IcKD' R.A.S. IDATE 12/1/93 I sm"2 OF 2 FROM SYSTE,q DIA. SOL~D -- s' (~P) 0 ~ (rn~)] 0 ' I 1/4' DIA. LATERAL 50' 30' CAPPED (T3FP) DETAIL r 6- TOPSOIL & 5'~ED INSULATION Il / H / I a ~ O~R DI~. PIPES PROFILE ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPEClFICATIONS REFERENCE: FOREST RIDGE SUBDIVISION, BLOCK 2, LOT 9 GENERAL: 1. The scope of this project includes the installation of a 1500 gallon septic tank effluent pumping (S. T.E.P.) system and a pressurized absorption bed to serve the four bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4' cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Page two Forest Ridge Subdivision, Block 2, Lot 9 December 1, 1993 Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. PRESSURIZED MOUND SYSTEM INSTALLATION: 1. Any peat or organic matter must be removed from the elevated mound site. The bottom of the basal bed area as well as the top of the sand filter is to be within two inches of level. The distribution piping is to be of PVC (ASTM D3034 or equal). Ail joints are to be solvent cemented. The side slopes of the top layer of the mound system must not be steeper than 33% (3:1). The top of the mound shall be covered with a minimum of 6 inches of topsoil and vegetated sufficiently to prevent erosion. The distribution pipes are to be embedded in sewer rock. Care should be taken to backfill in such a way as to prevent damage to the piping system. Silt barrier material must be instal/ed between the final gra vel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Page Three Forest Ridge Subdivision, Block 2, Lot 9 December 1, 1993 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. MINIMUM MA TERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). A permeable nontoxic silt barrier ('l'ypar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5'-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. Page Four Forest Ridge Subdivision, Block 2, Lot 9 December 1, 1993 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other bacldill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours pdor to the start of construction. If necessary, a pre-construction meeting will take place on-site. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ! 7- 8- 9- 10- ., ¢ //. .- , .... , Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? 11- 12 13 ~,0,~, 14 15 16 17 18 19- .$ IF YES, AT WHAT ~r ~) DEPTH~ p Depth to Water A~ler I Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~'(~ {m,nuteumch) PERC HOLE DIAMETER PERFORMEDEB~I~:le Ejve% ~at~a ~'$27 ........ .~.~-~--~ CERTIFY THAT THIS TEST WAS pERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE$~J~q EF~ ECT ON THIS DATE. DATE: · ' . ~' ~ Municipality of Anchorage {~} DEPARTMENT OF HEALTH & HUMAN SERVICES ~ 825 'L" Street, Anchorage. Alaska 99~2~650 SOILS LOG ~ PERCOLATION TEST .OPE SITE PLAN 1 2- 3 5 6 7 R 9- 10- 11 13 14 15 16 17 18 19- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT I DEPTH> 4-~'~, 8 ' Monitoring? Oote: ~.O,B, Gross Net Depth to Reading Da!e Time Time Water Drop ~ ~o" ~" ~" PERCOLATION RATE (~- (m,nutes/inch) PERC HOLE DIAMETER .. TEST RUN BETWEEN 3'C'~ FT AND ('~"'~ FT pERFORMED BY: ! 7034 Eagle Rlv~ L~p R~d ~, ~1 ~~ CERTIFY THAT THIS TEST WAS PERFORMED IN E~ River, Ala~a ~95~ ~ / ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IR EF~ ON THIS DA~E. DATE: Parcel LD. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES D~slon of Environmental Services On-Sita Services Section P.O. Box 196650 Anchorage, AJaska 99519-6650 (~07) 343.4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING 017-11~-90 GENERAL INFORMATION Complete legal description FOREST RIDCF SUI~DMSION: LOT 9. BLOCK 2 Location (site address or directions) ,51~0 MANYTF{ L AVENUE ANCHORAGE AK. 99516 Property owner PAUL AND ANN GARDNER Day phone ('¢j07~ 000-0000 Mailing address 51~0 MANYTELL AVENUE ANCHORAGE AK. g9516 Lending agency Day phone Mailing address Agent CAROL BuTrI_ER w/ REMAX Day phone (9073 ~57-0116 Address 2600 CORDOVA STREET. ANCHORAGE AK. 99503 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- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Holding Tank Community on-site Public sewer NOTE: ff community wastewater system, provtde wdtten confirmation from State ADEC lng to the legality and status of system. 72-025 (Rev. 1~91) Front MOA #21 Computer Vemlon Note: Alaska. Water. and Wastewater Consultants, Inc. shall be paid $1100.00 at, or prior to, closing mr the engineering services provfded. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 stzucture Indicated herein. I further verify that based on the Information obtained from the Municipality of Anchorage files and from my Investigation and Inspec~on, the on-site water supply and/or wastewatar disposal system is In compliance with all Municipal a~J State cedes, ordinances, and regulations In effect on the date of this Inspection. co s , 1~iff~lilt Address 6901 DEBARRROAD, SU)TE'2B~NCI-tORAGE,^LASKA 99504 , I=ngineer's $ignat, re ~ ~ ~ Date ,q'/~/co In conducing this evaluation, AWWC, In~/ a~te~pted to prbv~de a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DRHS Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the Eme of the test, and separab'on distances measured to readily IdentiEable features. The operational life of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate dudng the year, and the water usage of the fami~ being sen/ed by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AW1/VC, Inc. can therefore not provfde any werran~y for future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DHHS. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. 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 (DHH8) 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 ceur[esy to purchasers of homes and their lending institutions in order to satisfy cedain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a ce~ficate Is Issued. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Sack MOA #21 Computer Version Lng~l Dascrlp~on: A, WELL. DATA Well Type ?~NATE Log present (Y/N) Tolzd depth 125' 8~n~y eem (Y/N) Date of test Steli~ water level Well production Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Env~ronmentel 8ervlce~ DIvLtlon 825 't.' 6tmet, Rm 602 Anchorage, A~sk~ g9501 (907) 343-4744 Health Authority Approval Checldlst FOREST RIDGE S/Dj LOT g~ BLOCK 2 I~rcel I.D.: flA. 6, or C, attach ADEC letter. ADEC water eystem number YES Date completed Cased to 125' FROM WELL LOG 417/94 017-112-g0 79' 4/7/94 Casing height (above ground) Wlm~ properly prote~ (Y/N) AT INSPECTION 4/28/2000 9 g.p.m, p,p g.p.m. WATER 6AMPLE RESULT8: Collfmm P Nllmte Dine d umple: 4/28/2000 B. 8EPTIC/NOLDING TANK DATA Oats In~mlled 5/5/94 Tan~ gm 1500 Foundation ¢tesnout (Y/N) YES Dapresslon (Y/N) N~) Date of Pumping 4/28/2000 C. ABSORPTION REID DATA Date Installed 5/5/94 Length so' Width 0.5 mq/L Other bected= Collected by:. A.W.W.C.~ INC. Number of Comperlmente ~ Cteanoute (Y/N) YES High water alarm (Y/N) ~ Pumper NORTHLAND PUMPERS 8oll mung (g.p.dJ~t2 or fi?Fed;m) 0,4 System type BED .30' Gravel thickness below pipe 0.5' Total depth 35.5"/41.5" EffectNeabeoq~tionama 1500 Sq FT MonltodngTubepresem(Y/N) YES Dapresslonoverfleld(Y/N) No Date of adequacy test 4/28/2000 Re~Jlte (l~ss/F~dl) PASS For ~ Bedrooms Ruld depth In abemption field before test (In.); Fluid depth 0/2.75' (ine) Minutes I~ter:. Pem0dde tm~lment (.r~st 12 months) 0/5" Immedlatelyafter 809 260 Absorption rate · NONE KNOWN ff ye~, give d~te gal. w~er added (In.): 0/3.25 D. UFT STATION Manhole/A__~_ (Y/N) YES High water alarm level et*. 51.5' Cycles tested 3 SIze In gallons 1500 .'Pump on' level at" 48" "Pump off"' level at* .*Datum Bol'roId OF TANK 45" E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Sepfic/holdlng tank on lot Abeorptlon field on lot. Public sewer main Sewer/septlo senflce line 100'+ On adjacent lots 100'+ 100'+ On adjacent lots 100'+ N//A Public sewer manhole/cteanout N/A 25'+ Lilt etefion 100'+ ~ * 6.3' TO SEASONAL SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: RUNOFF N DITCH Foundation 5'+ Property line 5'+ Absorption field Water maln/sendce line 10'+ Surface waterldmlnege * 100'+ Wells on adjacent lots SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ 5'+ 100'+ .Water maln/sewlce line 10'+ $urfacewater ~t 100'+ Drtveway, parldng/vehlolesloragearea ,10'+ Curtain drain_ _ NONE KNOWN __ .Wells on adjacent lots 100'4- F. ENGINEER'S CERTIFICAll~N~/~ _,~OF"~/"~. of Municipal r~cord~ t~th~Jbov~ systems ere/n conformance ~-~:" ~ ,.,o.~ ,~ ~,,f~./~L~ ,,,e ,,.~,. ~'~.'.::..~ ~.. ~: .. F'::.*~ D,~ of P,~nt .~pt.u,.be, ~'~/; C~ ~ Waker Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box196650 Anchorage,'Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # /':'.3 t'-I - ~t -C~o HAA# ~-~ 1. GENERAL INFORMATION Complete legal description Lot 9i 8t. oc~z fi' Fo.,t~ P. Zd,qe $.bdZu~Zo~t Location (site address or directions) Property owner Mailing address COLONY BUZLDEI~S/ ~ T~/~.o~ Day phone 5540 Lorenz C,~:.c~e A~tcho~tctg¢, AK 99516 ~44-6~$5 Lending agency Mailing address Agent Address Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 4 NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site XY, X Holding tank Community on-site Public sewer 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 o{ this inspection. Name of Firm ~ -': =,';c:,'.'=."~.;;;c. ~ /] Phone ~-~/~'~ 17034 Eagle River Lool~ pT~ad N0/204 ' Engineer's signature Date 6. DHHS SIGNATURE °" '/~ Approved for ~bedrooms. Disapproved. Conditional approval for bedrooms, with the folloWing stipulations: Additional Comments By:. 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 registe red in the State of Alaska. The D H HS 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type Log present (Y/N) Total depth Sanitary seal ~;:/N) ~7-'t U~'7~-- If A, B, or C, attach ADEC letter. ADEC water system number YE c~ Date completed ~-[/~ [9 ~ Driller ~/~ ~' Cased to I~ 5 ' Casi~ height ~ ~res pm~Hy prote~ (Y~) FROM WELL LOG Date of test L/-~ ..-~ Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line $~:~0 '/ g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots .Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: Collected by: Other bacteria B. SEPTI~TANK DATA Datelnstalled g/5/~ ' Tanksize /;~) ~-/3r/... ~',7'~' Compartments ~ Cieanouts (~N) .Foundation cleanout (~N) Depression (Y/~ High water alarm Y~N) Dateotp mp ng Alarm tested (Y/N) ........ * · - SEPARATION DISTANCES FROM SEPTIC/HeL=D~G TANK TO: Well(s) on lot I ~,~ To property line ~0 Sudace water/drainage. On adjacent lots .~ ~ ' / Foundation c~) Absorption field ,.~ I.i Water main/service line lO0 '4- CONTINUED ON BACK PAGE C. UFT STATION Date installed Size in gallons High water alarm level Meets MOA electrical codes (~/N) 'Pump on' level at ~r~ n 'Pump off" Level at ~.2. ''~ L/'~ '/ Cycles tested A.~ -/'tJE'/"~ ~,!~,5;''~-'~- SEPARATION DISTANCE FROM LIFT STATION TO: Well on bt I~''f' On adjacent lots /c~ '/- Surface water. /'~ ~- D. ABSORPTION FIELD DATA Date installed Length ' "~"',· ,W'dh Total at~oq~tion area Water level in absorption field before lest Peroxide treatment (past 12 months) (YF~ Soil rating (GPD/Ft~) · .~ /" Gravel thickness Clear, out present (Y/N) ReSUlts (pass/fan) H System type ~, ,~ ' Total depth Depression over field (Y/~ /v//~ for ~ Bedrooms After test A-J',,/~-~ ' yes, give date AJ'~/']- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: To building foundation ~ { On adjacent lots //.2c) ' Surface water Curtain drain ~//q" On adjacent lots /06 'F Property line .-~"~' To existing or abandoned system on let Cutbank~ ,.~d ~,/-- .Water main/service line. ~'~ Driveway, pa~ng/vehicle storage area ~0 ~' E. ENGINEER'S CERTIFICATION I cet~'[y ~hat I have checked, vedfied, or conformed, to~a~ MOA and HAA guidelines in effect on .- of ~.< c/.._,_: z/.. ,.,, · ,,;;....? ..-.i/,~ ' ..,~, o, ~ ,....'/.,,~; / ,~ : *. HAA Fee $ ,~ C~C~ OO Waiver Fee $ Date of Payment ,~1-~ -~~'1 Date of Payment Rece~ Nuttier D. S~o~ (u,%~ Recei~ Number.