The URL can be used to link to this page

Home My WebLink AboutSPRING BROOK VISTA #1 BLK 3 LT 3pr,ng ook Vista lock 3 Lot 050-09 -04 Municipality of Anchorage Page 1 of 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: $W910100 PID Number: 05009104 N;'mo: RobOt KaL~6r Wastewater System: ~ New ~ Upgrade A~dress: ~71~9 C~ Cz., Eag~ River 99577 ABSORPTION FIELD Phone: ~4-~ I NO. of Bedrooms: ~ ~ Deep Trench ~ Shallow Trench ~Bed ~ Mound ~ Other I ,,, '" Tolal Depth from original grade: LEGAL DESCRIPTION so,,~,~:~ 5'-6' "' Block: Subdivision: '~ ~ Ooplh to pipe botlom from original grade: G~ave~ depth beneath pipe Lo~: ~ 3 Spring B~ooE Vi4ta 4.5'-5.5' Ft. 0..5 ~t~ '~owns~ip: 14NIiw,Isecti°n; I F illaddedsboveoriginalgrade: [Ft. I Gr~vellength: '" Number of lines: Distance between lines: WELL:~ New U Upgrade 'G~a~d~ ~h ~Ft. ~ 4, .~Ft. Cl~sslf~cation (Private, A,B.C): Total Depth: Cased To: rolal absorption area: Pipe material: A Ft. ~t 645so F~ AST'MD~034~VC Yield: GPM ]~ ~ump 8et ~t: Fl Ii O~ing Height Above, GmUndFt T~NK ' Tan~ ~ ' ' ' Mated~L Numbe~ o~ Oomp~dmenls~ we[[ 200, 200+ - - 200+ Ste~ '-' Surfa~'e ~ LIFT STATION Water ~ 00+ ~ ~0+ - - .... '-- ~ .... . ~ ~water alar,n al. 'Pump on" level Foundation 7 ~ ~2 ~ - - ' Curtain _ - - ' Electrical Inspeclions peHormod by: Remarks: * SAND FILTER INSTALSED. BENCH MARt(_ " ~. '~:~%:%>%~% ~ocation and Descr p ,on ' Inspections~dBr'medby' S g_S ENGINEERING Dates:lst &/~4 Reviewed and approved by: ~~~ Da,e: ~ 72-013 (1/01) MOA 25 Permit No. ~1~ ~lOIbO Page 2~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 e Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: PID No.: ~5'DQ¢~ / ~¢/--/' .. 72-013 A (2/91)MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR~ SLQPE 1 2 4 5 6 7 8 9 lO 11 13 14 15 16 IVED 17 1 0 ' 992 uT Anohoraoe 1 .c Human 2O Township, Range, Section: SITE PLAh WAS GROUND WATER ENCOUNTERED? S IF YES, AT WFIAT 0L DEPTFI? P E Depth to Water Aiter.~ ~onitoring? -- Date:_ G~oss Net Deptl~ to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ / tm~nutes/mch) PERC HOLE DIAMETER (-~ ,~ TEST RUN BETWEEN '¢~'~FTAND ~-'~' FT ~ ~ _// ~¢, ~ cEm~rv THA~ ~,S ~E~T W ACCORDANCE WI~H ALL S~ATE AND MUNICIPAL GUIDEL ~S I~ - : ' "' 72-008 (Rev. 4/85) 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 1 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910100 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:KAISER ROBERT J & OWNER ADDRESS:17739 CHILKAT CT. PEACE DR EAGLE RIVER, AK 99577 DATE ISSUED: 5/15/91 EXPIRATION DATE: 5/15/92 PARCEL ID:05009104 LEGAL DESCRIPTION: SPRING BROOK VISTA #1 BK 3 LT3 SEC. 1, T14N, R1W, SM. LOT SIZE: 20927 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: PERCOLATION TEST MUST BE SUBMITTED TO THIS OFFICE PRIOR TO CONSTRUCTION OF ABSORPTION BED. SOILS TEST FOR THE ALTERNATE SITE MUST BE SUBMITTED WITH PERC TEST ON ORIGINAL SITE. ISSUED BY: ~%,/'~/f I /~,~'_/c___ DATE: DATE: May 8, 1991 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 3; Bloc~ 3; Spring Brook Vista; PERMIT REQUEST NARRATIVE ROBERT SHAFER, P.E. ROGER SHAFER CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST In March of 1986 we p~rformed soils testing on the property for purposes of determining site suability for on-site wastewat~r disposal. At this t~me we propose the insta~ation of a 1000 gallon septic tan~ and a l~achfield bed with a 2 ft. sand filter due to the GW soil conditions. Unfortunately our proposed alternate leachfield site do~s not fall within the 30 ft. test hole radius as required by today's ordinance. We propose performing the test hole for the alternate site during system construction. The property is served by the Municipal Water System. There are no wells within 200 ft. of the proposed septic system. There is a "cutbank" located to the southeast portion of the property. It is a natural change in topography but it drops off steeply at approximately 80% - 100% slope. We have shown the proposed atternate leachfield site as 50 ft. from the top of the ban~. The t~o adjacent properties are vacant. Due to the public water supply there are no need for wells in this area, therefore, we foresee no negative impact~ on neighborin~ properties by the development of the referenced ~erty. PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS !RT A. SHAFER, P.E. /gm ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE PERFORMEO FOR: Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL OESCR,.T,ON:~' :~ /¢3..~.~/.4./¢..~bA'../f~J'¢TownshiP, Range, section: r /--£~o.r' 2' /_. //,J',~ WAS GROUND WATER ENcOuNTe ED ,4,/O SITE P'EAN ,.~ -- - s L IF YES, AT WHAT ~ O DEPTH? p i?F~u/i' Del}Ih lo Water *ll[r: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17 18 19- 20- Reading Date Gross Net Depth to Net Time Time Water Drop ( '3 D - COMMEN S ":. PERFORMED BY: S~' ]{'6X I~/' ~ ~ CER]IFYTHAT THIS TEST WAS PERFORMED IN // 72-008 [Rev. 4/85~ PE ~I~' Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN 825 "L" Street Anchorage, Alaska SOILS LOG -- PERCOLATION 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O % ,. WAS GROpN'~:,~A~ER IF YES, AT WHAT DEPTH? Reading /Dete Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN __ ~ (minutes/tach) PERC HOLE DIAMETER~ FT AND FT COMMENTS PERFORMED BY: , , . :., r' / ./-' ·'''~ CERTIFY THAT THI/S TEST ~AS PERFORMED IN ACCORDANCE WI'TH ALL STATE AND MUNICIPAL GUIDELIN~N'/~'FFECS ON THIS DATE. DATE: (~,/,//"'/¢~/,//¢:~/ ¢ /2-008 (Rev. 4/85) N unicipa tYof Anchorage P.O. .,X 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES. MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES April 24, 1987 Bob Johnson PO Box 770456 Eagle River, Alaska 99577 Subject: Lot 3 BLock 3 Springbrook Vista Subdivision On-site Sewer Permit #860091 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of April 18, 1987. Your permit expired on the date of issue basis by authority of Municipal Ordinance existing at that time. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. The new permit will come under the calendar expiration date as per the new Wastewater Ordinance (effective May 20, i986). If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report (three part form) and must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4744. Sincerely, R.W. Robinson Program Manager On-site Services RWR/ljw enc: copy of permit HLINIFSiPAI_ITY 0'- ANC HURAGE DEPARTNENI' OF HEfiLTH AND E .ONMENTAL PROTECTION G25 L STREEi, ANCHORAGE, AK ?V501 264-4720 ON--SITE SEWER PERMIT PERHIT NO: 860091 DATE ISGllED: 04/18/86 APPLICANT: BBB JOHNSON ADDRESS: P.O. BOX 770456 EAGLE RIVER~ AK 99577 CONTACT PHONE: 694-2543 LEGAL DESCR1P: SUBDIVISION: SPRING BROOK VISTA LOT: ~ SEUTIGN: 1 TOWNSHIP: 14N RANGE: 2W LOT SIZE: 20?27 (GO,FL OR ACRES) MAX BEDRGONS: ~ Listed below ape tAD oRtions available ID yDO in designing your septic system. Choose the option that best fits your site. TRENCH BED W.DRAIN DEPTH TO PIPE DGTTGI~ (FT.) 4,0 4.0 4.0 GRAVEL DEPTH (FT.} 6,0 0,5 2.5 TOTAL DEPI'It (FT.) IO,O 4.5 6.5 GRAVEL WIDTH (FT;) 2.5 t4,0 5.0 GRAVEL LENGTH (Fl',) 26,0 20,0 ~3.0 GRAVEL VOLUblE ICU.YDS.) 15.7 14.6 18.4 TANK SI2~E IGALS) 1~000,0 ** 1~000.0 *e l,O00.O ** SOIL RATING IGD,FT,/BR) 102 85 85 ~- TANK UUGT ItAVE AT LEAST THO COHPARTHI"NTG I certify that: t, I an familiar with the requirements IBP on-site sewers and uells as set ~oPth by the ~4unicipality o~ AncboPage (MOA) and the State ol Alaska. 2~ I will install the system in accordance with all NOA codes add PeCulations, and iD compliance with the design criteria BI Viis permit. 5. I will adhere Ko all MOA and State BI Alaska DequiPements iBP the set back distances from any existing well~ wastewate~ disposal system or p~blic sm~Dage ~yste;~ on this DP any adjacent o~ nearby lot. 4. I understand that this permit is valid top a ~axi~om BI 7 bedrooms and any enlaDgement will require an additional ReD,it. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY NOA BUILDING CODES, THEN (I) AN ELECTRIllAL PERI~ilY AND INSPECTION MUST BE OBTAINED; ID) AS-GUILTS I,HLL NOT BE APPROVED W1TUOUT AN ELESI'R!CAL INSPEGTION REPORT; AND (~) THE ELECTRICAl. WORK MUST BE BONE BY A LICENSED ELECTRICIAN, . 5RB 196x Eagle ~iver, ~~~"~"*~ I hereby certify that I have surveyed t~e ~ollowing Anchorage Hecording Precinct, Alaska, and that the pro- posed improvements, as planned thereon by the builder, will be within the property lines and will not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the pr~mises ~n question and that there are no roadways, trane, mission lines or other visible ease- ments on said property except as indicated hereon. Dated at Eagle River, Alaska ROBERT C, JOHNSON 5~/,~'?:- SCALE: Registered Land Surveyor No. 880-LS 1" = 50. Box 456, Eagle River, Alaska Phone 694-2543 Er~gle ~ive), ~Ias~ SUBJECT: C,_ ,vJPUTATION SHEEr DATE: SHEET BY CKD OF Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERV: 825 "L' Street, Anchorage, Alaska 99502~06i SOILS LOG -- PERCOLATION TE: LEGAL DESCRmT,ON:_Z~ ~/~'~'~-'~"'//'"¢:O .~ ("/J7"/I Township, Range, SectiOn:sLOPE /~/JS,TE 4LN Z ~./' 6 7 8 9 --.10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER ENCOUNTERED? IF YES, ATWHAT DEPTH? Oeplh Io Water AFter Monitoring? ~ Date: Reading/ /'Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN {minutes/inch) PERC HOLE DIAMETER FT AND __ FT COMMENTS AOOORD^NOEW,T ALLSTATE^.D UNiO,P^L ,DELiNC EOTO T.,SOATE. D^TE: 72-008 (Rev. 4/85) PERFORMED FOR: -.~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPT,ON:L'. ~ /'~.?~-~/2/,4./5-,~¢/r,.U¢¢Township, Range, Section: /.c/ 1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT --- ~) DEPTH? . p E Depth Io Water Afte~,,~ /.,~,~.,_ Moniloring? ~ Date~,~/'; WAS PERFORMED IN COMMENTS ACCORDANCE WITH AL'L STATE AND MUNICIPAL GUIDELIN~'~ ~N'E'CFECT ON THIS DATE DATE' 72-008 (Rev. 4/85) PERCOLATION RATE __ (m~nutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ___ FT AND ~ FT Reading Date Gross Net Depth to Net Time Time Water Drop NtunicipahtY03 Anchorage P.O. B~ . 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YO,q DEPARTMENT OF HEALTH & HUMAN SERVICES June 23, 1986 Bob Johnson P.O. Box 770456 Eagle River, Alaska 99577 Subject: Lot 3 Block 3 Spring Brook Vista Subdivision On-site Sewer Permit #860091 - Issued April 18, 1986 On May 20, 1986, The Anchorage Assembly approved a new ordinance regulating on-site wastewater disposal systems (septic systems). Ail septic systems constructed after the effective date of this ordinance are subject to the provisions of this ordinance. Our records show that you currently hold a permit for the installation of a septic system. We strongly urge that you contact this office prior to constructing your system. Auy changes in the code lhat could impact the construction requirements of your septic system will be identified and brought to your attention. Please contact the · Environmental Services Division at 264-4720 Thank you for your cooperation. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/SSM/ljw 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.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-091-04 HAA # /_./-~ L~ / ~) ~---~ Expiration Date: ./~ - ..~ o - O ~., 1, GENERAL INFORMATION Complete legal description ' Springbrook Vista #1, Lot 3, Block 3 Location (site address or directions) 12321 E Prince of Peace Drive, Eagle River, AK 99577 Current Property owner(s) Susan Garrett Day phone 696.6341 Mailing address (same as above) Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Un/ess otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ,, 3 e TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Well Public Water System TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] I The Municipality of Anchorage Development Services Department (DSD) Issues Cedificates 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 Se 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 fudher 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. Name of Firm KND En.qineerin.q Address 20441 Ptarmiqan Blvd. EaRle River, AK. 99577 Engineer's Printed Name Kenneth M. Duffus Approved for '~ Disapproved. Conditional approval for Phon~' 696.6111 Date 10126101 DSD SIGNATURE ~',~%,..,...,... ~.~, ~. bedrooms. ,,. .... ¢. ~ bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory. , X Maintenance Agreements · Supplemental Engineer's Report Other Original Certificate Date: (Rev. 12'00) Municipality of nchorage 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: ~Sprhl.q Brook vista Block 3. Lot 3 Parcel ID: .050-091-04 A. WELL DATA Well type pUBLIC Date completed ~ Total depth ,~ Date of test Static water level Well production If A, B, or C provide PWSID # ~ Well Log (Y/N) Sanitary seal (Y/N) Wires properly protected Cased to fi. Casing h~ound) FROM WELL~ECTION. fl[. ~ g.p.m g.p.m. WATER SAMPLE RESULTS: Coliform colonies/lO0 mi. Nitrate~ mg./I. Other bacteria~ coloniesll0Oml Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Anchoraale Tank ! Steel Date installed 6/25/91 Tank size 1000 gal. Number of Compartments 2__ Cleanouts Y__Foundation cleanout Y__Depression over tank N__High water alarm NA Date of pumping .91t9101 . .... Pumper JR'a C. ABSORPTION FIELD DATA Date installed 6/25/91 . Soil rating (g.p.d./~ or ~/bdrm) <1 mln/Irl System type Bed Length 43 ft. Width 15 fl. Gravel below pipe 0,5 ff. Total depth ,5,5 ft. Eft. absorption area 645 fl2 Monitoring tube Y Depression over field N Date of adequacy test 10118101 Results (Pass/Fall) P. ass For 3__ bedrooms Fluid depth in absorption field before test ~ in. Water added 450+ gal.' New depth6 in. Elapsed Time: 1440 min. Final fluid depth ~ in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Yes- Terralift If yes, give date 9118101 Ee LIFT STATION Date installed NA Size in gallons Manhole/Access (Y/N) in. 'Pump off' level at. in.High water alarm level at Jim *Pump on' level at Datum ~ m _ Cycles tested .... Meets alarm & clements? SEPARATION DISTANCES ~ SEPARATION DISTANCES FROM WELL ON LOT TO: ~ Septic tank/lift station on lot ~ ~,,,~J~-djacent lots ~ sewer/septic service line ~ . Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line t0'+ Building foundation t0'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage Curtain drain 50'+ Wells on adjacent lots 200'+ 25'+ F. COMMENTS 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 HAA guidelines in effect on this date. Engineer's Printed Name Kenneth M. Duffus Date t01261~1 HAA Fee $300 Date of Payment Receipt Number (P, ev. 12/o0) Waiver Fee $ Date of Payment Receipt Number MUNICIPALI'?~' OF ANCHORAGE ~I~, DEPARTMENT OF HEALTH ;% HUNIAN SERVICES (~¢,~'~ ,,~,~ Division of Environmental Services ~ On-Site Services Section P.O. Box196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.O. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 3~ Block 3; Sp~n,qbroo~ Vista #I Location (site add'ress or directions) 12321 Prince of Peace D~Zve Property owner Mailing address Bob Kaiser Day phone 694-9663 2611 C[~lkat Court Eagle River, Alaska 99577 [_ending agency Mailing address Day phone Address 1660¢ C¢.~,¢¢~fx'.oSr/ D,~x'u¢., Eag.?¢ Rx'v¢.r; A~,~._ 99577 Unless otherwise requested, HAA will be held for pict(up. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: Day phone_" 694-420¢ If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: ×X Individual on-site 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. 72-025(Rev. 1/91) Front MOA #21 ,:Ns ce dried by rny seal a~'Fixed h~:}: e~o afb;: :S of the validation date ShOWn below, I verify that my 'nvestigation of thi(~ Health Authority Appro,'ai apDlic~,i; :,n shows that the on-site water supp~'/ 3nd/or wastewater disposal system is sa~e, functional arid p. deo.~.~e for the number of be¢~roorns and typo of structure; indk:ated i"~erain, I fur[P, er m~,qf7 ihat beset on ::i' ~ information ob[dined from !r~e Municipality of Anchorage files and from rn'/investigation and ins/)ection, the om:~te wa'for ~¢.mply and/or waste,Nato,, dispo?:d system ~s in cornpliance with all Municipal and Slate codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Engineer's signature -?H~IS SIGNAT!JF( :~ _?/~.~. Approved for Disapproved. Conditional approval for S & 5 ENGINEERING 17034 Eaqle River i.~agie idver, Alaska _Phone bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given ih 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. 72-025 (Rev. 1/91) Back MOA~21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: _~rr"/¢~ "¢~'~ A. WELL DATA Well type HL)CJ ~/~¢/~"{.-4f A, ~:3, or C, attach ADEC letter. Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. AT INSPECTII3'J~JNIctPALiTY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION' · &B6 .i V E D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ,~,¢::;, I,.~ ; On adjacent lots Absorption field on lot '~'¢¢'¢~f-'~ ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed , ~¢'" '~".~ ~ I Tank size Cleanout~N} '~ High water alarm (Y/N) Date of pumping Compartments Foundation cleanoutd~:~N) "7' Depression (Y~;~) Alarm tested (Y/N) /V/~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To propertyline Surface water/drainage On adjacent lots "~;;~:21"~ Foundation ? Absorption field Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date in%ed~_ Size in gallons .... -- Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed (~¢--- '~,¢~'¢~ Length ~_jC-'2:p Width Total absorption area Depression over field (Y¢~ Peroxide treatment (past 12 months) (Y~E:~ /%/ On adjacent lots Surface water Soil rating ~ / /(ll-[,.~.~ystem type Gravel thickness ~-'~r ~ Total depth Cleanouts presentCN) Date of adequacy test for bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~. (::::;~c::~/-nb Property line To existing or abandoned system on lot Cutbank ~ / .4- - Water main/service line Driveway, parking/vehicle storage area S & S ENGINEERING Signature 17034 Eagle River Loop Road No. Eagle ~iver, Alaska 99577 Engineer's Name Date ~'"- '~ ~:~ / E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Waiver Fee: $ HAA Fee $ / Date of Payment Receipt Number 72-028 (Rev. 3/91) Sack MOA Date of Payment Receipt Number