HomeMy WebLinkAboutSCIMITAR #3 BLK 1 LT 4imiter
lock I
Lot 4
051 - 132
-71
~oO
M U h! I C I P A L I T Y [) F A N C H 0 R A G
Depar. tmerrL o~' Health & Human Servic:es
82.5 I_ St.r~e'L, Ar'u::horage, Filaska 99501
0 N -' S I 'T' E W E L I .... P E R M I T
F:'er. mit, Number: 880178
Dat, e Issued: 0910!/88
Enlargement.
Owner' Name: GARY JOHNSON
EAGLE; RIVI~ER, Al<
9957'7
Parcel Id: 051-','132-','71
Lot Legal: Subdivisic)r): SCIMITAR ~3 Lot: 4 Blc~ck: 1
Section: t0 "f~)wr~sh:i.p: 15N Rarlge: 1W
Lot. Size 4C>!7C) (sc!. ft.. of acr'es)
Max Bedrooms: 'T'h:i.s F'er'mit.: 0 Tectal Capacity:
563-,'2242
F:'ROVIDE DHHS WITH C;OMPL. E:'TED WEL.L LOG IAI I ]]'"I ]: I\I "FEI",I DAYS OF WEL. L.S
C[)MF::'LET I ON., TH I S F:'ERM I T I S I SSUE:D FOR A ,~]; INGLE [:'AFtI LY RES ]:DENCIE
ONLY AND E:XF'IRES I;:2!/31/88.
I CEFCI"IFY TI'4AT'~
I am familiar' ~it.h the r'equirement, s for (::n"~-.sit. e sewers and wells as set
¢orth by t. he idunicipality oF Anch~:mage:, (IdOA) and the St.a'Le o¢ Alaska.
2. I wi:il install 'Lhe sysi:.em in ac:c(2r'danc:e wiCh all M[)A (zc;)d(;~ ai"lcI
¢~r~(::l in compl:i, ance with the desigrl cr'J.t, eP:[a of' Chis
3. I t,,~:J, ll adher'e t.o ali. MOA ancl St. at.e of Ala~d<a requirement, s for' the set. bac:k
dist.¢~nces From any existing we].l, wast. ewater c:Jispl:Jsa], system of pLlb].:Lc:
sewer'age sysi:.enl on t.h i s or' any ad) ac:erft or r'((.)~al"by ].ot.
4.. .1. uncler'stand
alscl Ltncler's
¢~1'] y
S i g n (._--., d ~.
I I /~
~ t. his peprn:i.{ :i.s valid f'cm a maximum of' 0 beclrooms: I
nd____/~]hat' t. he .c:apac:it.y of' {l']e {ot. al sysl'.em :i.s :3 bedr'aoms and
n,~l p(.~tSr e an add i t iona t per'mit..
WE[_[..: I....og must be submitted i:.o Municipal:i.t.y of Anchor'age Depar"L,'nent c)f' klealt, l'"~
arid l-~um.a.r'i SenvJ. c:es wit. bin
SCALE
,. ,.' MUNICIPALITY OF ANCHORAGE
~ ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
] Liq~{~allons Inside length W~dth Liquid depth
~z~ ~ DISTANC~ TO: Well ~ ~' Dwelling PERMIT NO.
O Z < Manufacturer / ~ ~
-- ~ ~ Material Liquid capacity in gallons
~. DISTANCE TO: WeT/~ / Fo~ion /~' NeareSt ,,n~ PERM IT~
~ ~ No. of lin% Uongt~rh~n¢ T°t~gh el'rs Trenc~J~ ',inches Distanc~7~s
;~1 Top o~ t~ini~rade M,~r~l ben~ tile ,, Total effectrve absorption area
Length Width Depth PERMIT NO.
~ ~ Tgpe of crib Crib diame Crib de~th Total effectiue absorption
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class~,~- ~_~/~ ~//~Depth ~ Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS ~--
REMA~S ~ -
] ~Rev. 3/78)
Permit ~
Applicant: p~~/~ ~..~ Mailing Address:
Location: Phone Number:
Legal Description: Z ~/ S~/~ ~/Z~ Lot Size:
Type of Soil Absorption System Is:
Trench: ~ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ ... Soil Rating(sq.ft/br) ~--
The Required Size of the Soil Absorption System Is:
DEPTH
LENGTH ----/ GRAVEL DEPTH WIDTH
Department, =-h&~i%h-~d ~v'i~~- 'rotection
825 'x-.-~/' Street, Anchorage, AK. '~3~501 ~~ ~.. ~
264-4720 ~ ~3
~ * * * HANDWRITTEN PERMIT * * *" ~~' .
' WELL AND~OR-ON-SITE SEWER PERMIT
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /0~0~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 B * * *
I certify that:
!) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
2) I will install the system in accordance with codes.
3) I understand that the on-site sewer system may require enlargement if
t~ residence is remodeled to include more that 3 bedroQm~.
Applicant ~ / / - ~
SWP/024(1/81)
SOILS
LOG
MUNICIPALITY OF ANCHORAGE
[] PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
TEST
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
c, OATE PER ORMEO -- O¢ ';':-5
SLOPE SITE PLAN
I
10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER ~ ~_
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND
COMMENTS ,~,
PERFORMED BY: ~ ~' ,~ ~t,=,,~- -n e~t~t ¢,,~,.,5,) CERTIFIED
72-008 (6/79)
WATER -WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
· Drilling Permit No.
LOCATION OF WELL (Please complete either la, lb or lc.) f, A.D.L. No.
~a.lleorough Subdivision Lot alack 'b. II '/4qtr$. Section No. TownehiP N~] Range E~] Meridian
lc. DISTANC~ ANO DIRECTION FROM ROAD INTERSECTIONS $. OWNER OF WELL: ?~
2. WELL LOG Surfaco ~t.~ -- --
M ~terlol Type Top Bottom
(/~e~ne uJ~& Zage~ O~ ~ ~ ~Auger ~detted ~Bored ~Other:
~ed ~C~ 7. USE: ~Oomelllo ~ Public Supply ~ Industry
C~ MW:~ ~ 3~ 0 Irrigation 0 Recharge 0 CommeHcel
diam. in. t~ ft, Depth Stickup ft.
MONiCIPALiT¢ OF ANCHO~ ~ .
DEPT. OF HEALTH & e.F~N~S~ OF WELL:
~NVIRONMENTAL PROTECTI~ )~
Type: Diameter:
Slot/Mesh Size: Length:
FEB 6 t987 Set between ft. and ft.
P K IVFF Backfilling. .Gravel paok
I0. STATIC WATER LEVEL: ft.
~ Above or ~ Below land surface
Equipment used:
II. PUMPING LEVEL below lend surface end YIELD
~ft. after bra. pumping g.p.m.
ft. after hrs. pumping g.p.m.
12.GROUTING Well Grouted:
IS. PUMP: (if available) HP
Length of Drop Pipe ft. oapaoily 9.p.m.
16, WATER WELL CONTRACTOR'S CERTIFICATION:
15. Wefer Tempereture ~o ~ F~ ~ C
Form O~-WWR (11/81~ Copy Distribution; WHITE-State DGGS~ PINK-Driller~ CANARY-Customer
lunicipality of Anchorage
Development Services Department
Budding Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw Street
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
Parcel I.D..,, 051-132-71
GENERAL INFORMATION
Complete legal description .J~~~l~_Ct3
Location (site address or directions) 19836 Seika Chu iak AK 99567
Current Property owner(s).. Mr. Ralph Dunham
Mailing address
Expiration Date:
Day phone.688-5962
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
U.S. Inspect
Day phone~00-872-3660,499
Un/ess otherwise requested, HAA will be held by DHHS for pickup HAA picked up by:
2. NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Ciasa
Public Water System
We~l
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~]
Individual Holding tank E~
Community On-site ~
Public Sewer ~
The Municipality of Anchorage Department of Health and Human Services (DHHS) 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) on properties served by a single family on-site wastewater
disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of
Health Authority Approval are valid for 90 days from the date of ~ssue fcr properties served by a private or Class C
well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year
fcr prcoert es served by Class A or B ,,veils cra ~L,b,,~ ',vst~,,' s',/st~m T."e ,Mu~c~oahty of Anchorage is ,not
responsible for errors or omissions in the professional engineer's work. '
,'Rev :1 99,
,:\5 csrt.;f;ed by my' so3! affix.sd hereto and as :f the ,.,3hdst:sn 2~.t~ s~'cv/'~ 3o ::v; ! ','er:;;' t'-,at m)' :nvestlgation
based on procedures outlined in the Health Authority Approval Guidelines for th~s Health Authority Approval
application shows that the on-site water supply and/or wastewater disposa! 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone En.q. Svc. Phone
Address P.O. Box 102954~ Anch, AK 99510
Engineer's Printed Name Steven R. Pannonel P.E. Date
Engineers Comments' In conducting an adequacy test I attempt to provide a thorough conscicnuous
rcoortcd rcsuhs dcscri~ thc Frfo~ancc of thc svslcm ~dcr thc conditions encountered al thc time of thc
test and separation distances m~sur~ to readily identifiable I~aturcs. Thc o~rat~onal hie of all x~clls and
, . .
septic systems depend on thc l~al ~il condition, greed x~atcr levels that may fluctuate d~ng thc year.
and thc x~ atcr usa .c of ~c family bcin, sen'cd by thc ~'stcm These conditions arc outrode thc con~ol o1'
future nerfo~ancc of the system nor do thru' ~t~ ~at ficre ~c ~ hidd~ def~ts or cncroac~cnt~~..~
PES can therefore not rovidc am x~a~antv for furze pc~o~ancc nor g~e ~y cshmatc o~nox~ tong tl~c
t'slu rcpo~ i · ~or thc sole bcmcfit o~c o,,ncr list~ a~vc. Any rcli~cc u~n or usc oCthis report hx an's . . . ~' h r crson or arty is not authorized nor xvill it confer any legal right x~hats~vcr.
DHHS SIGNATURE
)(' Approved for ._~
Disapproved.
Conditional approval for
Additional Comments
bedrooms.
bedrooms, with the following stip.gl~i~RE:..
,~'"'"~//,
~: WATER AND ·
' WASTEWATER
~ PROG~M .'
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Expiration Date: 2 - ?--t~ 2.
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Reissue Date: //- ~'- ~ /
P.O,'Box i~1~~, AK '1S~114110
i
WIIIIypI, E
get Nmmier~ Omll$lilm$.~1
kl
"' MliM elITn & droult wluklmln~?
)UXKI/pMm flMd on lot 11i
Pul]lk: w mMn WA
on ~leom k~s lae~
SEPARATION J:Jl~t~ FJJOMI-~'~, ON LOT TO:
AIJMpllon flMd WA
Prope/ty Nne lB
'WMer OeMoe line" 2M.
i ( .iI
Steven R.
,i
· 2. NUMBER
e
CommonRy Class Well , .,~
Public Water System
The Municipality of Anchorage Department of H~aith and Human Services iDHHS) 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) on'properties .served by a Single'*family on-site wastewater
disposal and/or water supply system. DHHS also issues HAAs Upon request' to home owners. Certificates of
Health Authority Approval are valid for 90 days from the date of issue for prope~ies served by a private or Class C
well and may be reissued with new water sample results less thah 30 days old. 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, . ~
(Rev. 11/99)
.:.
Additional Comments
the following stipulations: ' ..?~'...i.,,
.,.
.~'~ ON-SITE .~
~; vm~AND : ~,
~ : WASTEWATER :'
~ _~.. P~O~mu ..-
~%].. ... ~..~
By: ~
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Expiration Date:
(Rev. 11/99)
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ - '~ -. C)/
Reissue Date:
A. WUI.L DATA
We*I typo~
Dm ~'mrtl~m
Totel dll:Wl 401/eM ff
.. Weft production 1.m; O.p.m ' '
WATER 8,MAFIa' RESULTS: ·
A~ INSPECTION
fl
_ O.P.m,
New depthto in.
AMmpticm rote >~ M)O+ g.p.d.
If yM, give Me
LIFT STATION
~.te insl~lled
'Pump on' level at
Datum
SEP~TION DIST~S ~ffi ~0N'L~ ~" '
in
Septic tank/lilt sMtion on
Absorption Md on ~ 11~
Public sewer iTmin NrA
Publtc.~~ WA ''.,
SEPARATION DISTANCE8 FRO~ SEPTIC/HOLDING.~ ONt,OT TO:
Building foundation 1~i ".i PiOpertyline...~
Water main WA '' r ''; *:, Water servloe line ~+
Drairmge 100, . .Welleon~lM~.lOO*
Absomtlon fled 19
8urfem.wat~.~. 1om.
SEPARATION DISTANCE EROM~.g3$ORPTION FIELD :ON kO?TO.:
Property line
Building founcl~ 2~i
Water 8ervtoe lire
Curtain dreln 1116.1. .
F.' COMMENT8
I*
Mw of Municipal reoords that the above .ysilmi,em in
confMmanoe with MOA HAA gMne4 bt MIWlIM ~ ' '
Engineer's Printed Neme
Sloven IL Pmnone.
R ,eceipt Number ~ ~ ~ ........ . . .
(l~w. 11/89)
' R.' PO'nnOne
No. CE 81,
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D.# '/"~.~\- ~ ~.-"'~ \ NAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 4: BLOCK I..- SCIMITAR.
Location (address or d rect ons)
MN S~ZF~. D~uLve.
(b)
Property owner G~.~u./Johnson
P,O,B°x.. ~ 771251
Mailing Address
Telephone: (home)
Rive,t, Ak. 99577
Business 563-2242
(c) Lending Institution
Mailing Address
Telephone
(d)
Real Estate Company and Agent JAC_K QK~rTE COMPAk~' OF EAGLE RIFE~ AT/~:
Address 10928 ~. ~v~ ~ ~. ~v~ ~ 99577
Telephone 69~5500 '~-'
(e)
Mail the HAA to the following address: (or check here ~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEEP-tNG
17034 Eagle River Loop Road No. 204
2. TYPE OF RESIDENCE
Number of bedrooms
Single-Family Q[X
3. WATER SUPPLY
Individual Well ~
Community [] Public []
Note: If community Well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site~ Pu[~lic [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
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, Iverifythat 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 regulations in effect on the date of this inspection.
Telephone ~ ~'¢~¢ ? ~'
17034 EagJe R|:ver Loop Road No. 204
Name of Firm
Address
Date
6. DHHS APPROVAL
Approved for ?,~.h¢~::. (~.~bedrooms by
Approved ,~ Disapproved
Terms of Conditional Approval
/
Conditional
Date
I~:I, II / [I] ~ 1
The MunicipalityofAnchorage Department of Health and Human Services(DHHS) issuesHealthAuthorityApproval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHSdo 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. 7/88) Back Page 2 of 2
~'~ o~ Health Authority Approval (HAA)
~Gx~.~.~¢' ~ .~,~ CHECKLIST- FEBRUARY 1984
~.o ~0~'~ ~ ~.~"5 :343-4744
t.C.'-t'~ ~%%%% ~,,~) Legal Description: ~ ~
A.
WELL
Well Classification ~t~ ¢~ ~ ~,¢'0 ~ IfA/B, C, D.E.C. Approved (Y/N) r4 ~,~
Well Log Present~;~N) ~Date Completed ~,¢/~:~"~ Cf ~/~ Yield
Total Dep~ Cased to~ ¢t"~ Depth of Grouting "-'--- q.
Static Water Level '~-'-~'~' ~ '~-'""~'1'c;~ PumpSetAt ~¢"1''1!
Casing Height Above Ground i.~.,~lj¢ Sanitary Seal on Casing~N)
Electrical Wi'ring in Conduit~) ~' Depression Around Wellhead
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot I 'c;:t;~! J¢ ; On Adjoining Lots
To Nearest Edge of Absorption Fl~ell.~n Lot \c::~=~l ~r ; On Adjoining Lots
To Nearest Public Sewer Line TO Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ ~'
Water Sample Collected by ~ ¢-~ '~c;:~t~~ ;Date ~, ~,~, -'='to
Water Sample Test Results ~~ ~ ~ -['~z~, ~
Comments'"'~,'-'SL~ ~ ~ '~\ ~ "~--1 ~'--1,~ ~,.~,,'~-~--
B. SEPTIC/HOLDING TANK DATA
Date Installed 1_(:2 ~\'"~'~ Size I. ~ No. of Compartments
Standpipes~N) "-/ Air-tight Caps ~N) ~ Foundation Cleanout CN)
Depression over Tank (Y/~j~ f~ r_% /Date Last Pumped (¢2-'¢'~
pu mping/Maintenance Contact on File (Y~.~/,,¢i,. /'/~ ;for r~' /,.z~
Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well \ ~\-~r To Building Foundation ~
To Property Line \ c~ ~'J¢ To Disposal Field
To Water Main/Service Line ~ ~ tj¢
To Stream, Pond, Lake or Major Drainage Course ~. ~
Comments "~-~2'-'/~' ~--~¢~¢2°c~c~
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
[::)ate Installed \~ ~ \
Width of Field
Square Feet of Absortion Area
Type of System Design '""~
Length of Field
Depth of Field
Gravel Bed Thickness ~ ~
Statndpipes Present(C~N) "-/
Depression over Field (Y/2]~ fA Date of Last Adequacy Test
Results of Last Adequacy Test ~-~ ~ ~- ~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well \ ~-¢-¢-¢-¢-¢-¢-¢-¢-¢~ I ~ To Property Line k c~
To Building Founda,tiop ""'~"::> ' ~ To Existing or Abandoned System on
Lot FA/,/:''. ; On Adjoining Lots ~'~O t 2¢
To Water Main/Service Line ~. ~ To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course \ ~ t ~
t
-I-o Driveway, Parking Area, or Vehicle Storage Area ~ c:>
Comments
Date~nstalled Dimensions
Size in"GaJ. Lons Manhole/Access (Y/N)
"Pump On" Level at'~'"~ "Pump Off" Level at
High Water Alarm Level at . ~""~
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Vent (Y/N)
~'"~---Rq/~ping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in .e~[~¢t, on the date of this
inspection. ~,,%. crc. /~ ',~,
Signed ' ' ' · o'~'~'-
1;'034 ~Ole R,ve~ Lo F ......... 204 ~ ~ ~.,'" / ~d~ . '~% ,~,. %
Company Ba~l~ ~i~,r,~l~ska ¢95~Y ..... * ..... ':'
Date // 2.~ ~~~r,~ :] ~
MOA NO. / C/~ ¢~ /¢ ~ ..... ' ' "'
Receipt No. Receipt No. ~ .~ .,
Date of Payment /" ~% 2 ~ Waiver Fee: $
Amount: $ //~ o Date of Payment
z,-o2~ (R,~. ~/~) B,c~ Page 2 of 2
& GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order ~ 19224 Date Report Printed: JAN 11 90 @ 10:27
Client Sample ID:L4 Bi SCIMITAR
PWSID :UA
Collected JAN 8 90 @ bxs.
Received JAN 9 90 @ 13:$0 hrs.
Preserved with :AS REQUIRED
Client Hame : S & S ENGR
Client Acer : SHSENGP
P.O.~ HOHE RECEIVED
Req %
Ordered By : R. SHAFER
Analysis Completed :JAN 10 90 Send Reports to:
Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGR
= ~Released By.:~ ~.~ 2)
Special HOLD FOR PICK-UP UPON COMPLETION.
Instruct:
Chemlab Ref $: 9151 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
NITRATE-N 0.88 mt/1 EPA 353.2 10
Sample ROUTINE SAMPLE
Remarks: SAMPLE COLLECTED BY R.P.
I Tests Performed * Sea Special Instructions Above UA=Unavailable
ND= None Detected *' See Sample Remarks Above
NA= Not Analyzed LT=Less Than, 6T-Greater Than
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASIfA, t£VC.
TELEPHONE (907) 562-2343 5633 g Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
'~EB.L~TE WATER SYSTEM
Name S & S ENGINEERING Phone No.
17034 Eagle River Loop Road No. 204
Mailing Ad~e River, Alaska 99577 .~
City State
SAMPLE DATE: ~ D~ay ~
Zip Code
SAMPLE TYPE:
~¢-- Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
31
41
51
Time Collected
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~ Satisfactory
[~ Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received /- ?-?O
Time Received /,3 ~-'~'
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
I?/:/-/ I l-r-d
I IFF1
I IFF1
I IFFI
I IF1-]
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter: Direct Count (~
Verification: LTB
Final Membrane Filter Results ("__~
Reported ~~~¢¢~:z-- ....
TNTC -- Too Numberous To Count
OB = Other Bacteria
PART ONE OF TWO
REMAINDER TO FOLLOW
Collform/100ml
BGB__
Collform/100ml
aim,
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Location (address or directions)
lb) Property owner
Mailing Address
(c) Lending Institution
Telephone: (home) Business
Telephone
Mailing Address
(d) Real Estate Company and Agent "~../'/~
Address ~ ~L¢ C::~:~ ~1~_~,¢_,~---~ -/¢2c~i~:::> i~.¢_.., ~
Telephone ~ ,..2~-~ ,¢:f¢-~ ~C>
(e) Mail the HAA to the following address: (or check herect~Jf hold for pick up.)
List contact person and day phone number below:
$ & S ENGINEERING
17034 Eagle Ri~er Loop Road No. 204
Eagle River, Alaska 99577
TYPE OF RESIDENCE
Single-Family..~'"~ Number of bedrooms
WATER SUPPLY
Individual WelJ.~/ Community [] Public []
Note: If community well system, must have written confirmation from the State DePartment of Environmental
Conservation attesting to th legality and status.
SEWAGE DISPOSAL
On-site~" Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page I of 2
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'e,tBs s! tue),s/,s lesOds!p Je~,e/,~e),se~ ~o/pue /qddns Je~Bt~ ei!s-uo eq~, ~eql s~oqs le^o~ddv /qpoqTn¥ q),leeH
s..q), ,to uo!],e6Rse^u! ,~u~ ieq],/,].p e^ I '~oleq u/~oqs e~,ep uo!~ep!lBA eq~, jo se pus oTeJeq pex!,t,te IBes/~w ~q pe!,t!iJeo eV
NOI.LVlNI~O-INI (3N~f ¥.L'CQ 'H31:IV=I$ ~!'11=1 '$/$t.L '$NOI.LO~IdSNI ONIQI^Oldd IN~II-I 9NII:It~]NIONt 'g
A. WELL DATA ~F, ~,;, ~.~. :'
Well Classification
Well Log Prese,nt~)'N..) ~/~ Date Completed
Total Dep~c~ ~ v"'~'~ased to~l.~l"lo Depth of Grouting
MU~.~,Gc~.PA~,LITY OF ANCHORAGE (MOA)
Authority Approval (HAA)
~:~'~HECKLIST - FEBRUARY 1984
343-4744
Legal Descnpbon: ~
Static Water Level ~.-~'~' ~ '~ ~1~'
Casing Height Above. Gropnd ~'~'~lJC
E ectrical Wiring in Conduit~C~N) 7
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ~
If A, B, C, D.E.C. Approved (Y/N)
Pump Set At
Sanitary Seal on Casing ~[~/N) 7
Depression Around Wellhead (Y~
; On Adjoining Lots
To Nearest Edge of Absorption Field~ op Lot
To Nearest Public seWer Line 14//~. To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~'
Water Sample Collected by /¢~r'~ ~¢:~'~{~-~ ;Date
Water Sample Test Results ~--~. ~-L~"~~
t
Com mints/"~N~o ~¢¢2/.~ ~ ~ ..-~
B. SEPTIC/HOLDING TANK DATA
Date Installed [O-'1-' ~"~ Size
Standpipes~)'N) '7' Air-tight Caps(i~TN)
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)i~ ,)
Holding Tank High-Water Alarm (Y/N)
No..of Compartments
'~' Foundation Cleanout ¢~N) ~/'
Date Last Pumped ~:~ ~---'~
/
, for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water, Supply Well
To Property Line
To Water Main/Servic~ Line
To Stream, Pond, Lake or Major Drainage Course
Comments
To Building Foundation
To Disposal Field
72-028 (Rev. 7/88) Front Page 1 of 2
Square Feet of Absortion Area
Depression over Field
Results of Last Adequacy Test
C. ABSORPTION FIELD DATA
SoiLs Rating in Absorption Strata
Date Installed ~c:~ / -- ~"'~ Length of Field
Width of Field Lc~::v ~ Depth of Field
Gravel Bed Thickness
'~---Lcc:T~' Statndpipes Present ¢~N)
t-J Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Y
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D, LIFT STATION
Date Installed
Size in Gallons
"Pump On"&,e.v..e] at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
ng Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
inspection.
Signed
Company
Date
MOA No.
S&$ ...............
17034 Eagle River Loop Road No. 204
Eagle River, A~laska 99~.77
Receipt No. ~ ~_..3/~) ,~ /~,~_~ ~:~ C)
Date of Payment '¢¢/¢~ //////~/,~
Amount: $ //.,,7" d~ ~ ¢)
72-026 (Rev. 7~88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES ENVIP, ONMENTALSERVICr-S DIVISION
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROV~JG 2 8
1987
OF ON-SITE SEWER AND WATER FACILITY
Application Date 77~ 47/~ ~
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAE)
(a) Legal De~ription (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b)
Property Owner ~,4¢¢~- .,,~"'7¢~¢~,~¢-elephone: Home
Mailing Address
Business
(c) Lending Institution 'T~l~p'hone ....
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the followin~ address: or: Check here ~, if hold for pick up.
Ust contact person and day phone number below.
,~ & .~ ENGINEERING
17034 Eagle Ri~er Loop Road
Eagle River, Alaska 99572'
TYPE OF RESIDENCE
Single-Family ~
Number of Bedrooms
WATER SUPPLY
Individual Well.~ Community [] Public []
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~, Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page I of 2
72~025 (Rev 8/861 Front
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 regulations in effect on
the date of this inspection.'
Name of Firm
Address !70~4 l~_n~le River Loop P. oad
Date Eagle River, Alaska 99577
Telephone
DHHS APPROVAL
Approved for '7~/~/'~'~'~Pbedrooms by ~ ~'~ '~~
Approved ~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal anU 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.
Page 2 of 2 72-025 (Rev 8/86) Back
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MUNI¢IPALI'P~' OF ANCHORAG~HECKLIST - FEBRUARY 1984
DEPT. OF HEALTH & 264-4720
ENVIRONMENTAL PROTECTION
AU6 2 8 t987
RECEIVED
Well Classification
Well Log Present'N) Date Completed
Total Depth ~'C~ Cased to ~ ~
Static Water Level ~ ~ !
Casing Height Above Ground "~ ~ ~
Electrical Wiring in Conduitl~N)
Separation Distances from Well:
To Septic/J:J4~Crlg Tank on Lot ! ¢;~/'~
IfA, B, C, D.E.C. Approved (Y/N)
!
~. ~;~'"~'~ Yield
Depth of Grouting
Pump Set At ~2~__._,
Sanitary Seal on Casing t~N)
Depression Around Wellhead (Y~)
; On Adjoining Lots
Field on,Lot -J' ! ~' On Adjoining Lots
To Nearest Edge of Absorption --/ ;
' ¢'~//~ To Nearest Public Sewer /
To Nearest Public Sewer Line
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Comments
B. SEPTIC/I~ TANK DATA
Date Installed .~,¢~
Standpipes ¢¢~N) Air-tight Caps
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/14e~ Tank:
To Water-Supply Well ~, ~:::~ I ~.
To Property Line
To Water Main/Service Line
No. of Compartments "~
Foundation Cleanoutd~D~N)
Date Last Pumped ~::::~[
t..-.~/~&. ;for
Temporary Holding Tank Permit (Y/N)
I
To Building Foundation '"~'~-~ '~-
To Disposal Field ~
To Stream, Pond, Lake, or Major Drainage
Course
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundati
Type of System Design
Length of Field '¢~/
Depth of Field '¢~
~ravel Bed Thickness ~
Standpipes Present ~',J)
Date of Last Adequacy Test
To Property Line 1__ ~-~ ~--~
; On Adjoining Lots
To Existing or Abandoned System on
To Water Main/Service Line \ ~ t ¢r~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutba. n~ (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
i.. Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection,
Signed S & 5 F. NGiNF_.EEiNG Date ~/~~
Company7034 Eagle Rb/er Loop Road No~ No. ~-~ -/~' ~¢-~--~
Eagle River, Alaska ~9577
Receipt No. //'~ / ~ ~ / ~
Dateo, Payment -- <~Y/~;' 7
Amount: $ '/'Z~2'~2 ~ /
Page 2 of 2
72-026 (11/84)
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
CHEMICAL.& GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5--'~'~'~' ] ]
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[~ PUBLIC WATER SYSTEM I.D.#
PRIVATE WATER SYSTEM
Name Phone No.
$ & S ENGINEERING
Mailing Ad~r~ River, Alaska 99577
City State
Day
SAMPLE TYPE: ';,
Routine
Check Sample (for routine sample
with lab ref. no. .)
[] Special Purpose
Zip Code
[] Treated Water
[] Untreated Water
SAMPLE
NO. / LOCATION
2 I
s l I
Time Collected
Collected _~
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received //
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
I CCI
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter: Direct Count
Verification: LTB BGB
Final Membr~ne/~l~ ....
Reported By".,J J ~,~--J/~ Date
~ Time:
TNTC -- Too Numberous To Count
OB = Other-Bacteria
Coilformll00ml
Coilformll00ml
a.m.
p.m.
?
'~ MUNICIPALITY OF ANCHORAGE
DMSION OF ENVIRONMENTAL HEALTH
DEP~NT OF HEALTH ANqD ENVIRONMENTAL PROTECTICIN
APPLICATION FOR HEAL%/4 AUTHORITY APPROVAL CERTIFICATE
i. -General Information Application Date
(a) Legal De.s.cript~ion (incklkde lot, block, sub~ivision~ section, township, range)
Lcc~aAion ~add~ess or directions)
(b) Applicants NarrOW;-:
(~) App!i~ant is
Su~e~ ~ ~ ~e~ ~ (e~!ain)~
(d) Lending Institution
Telephone
Address
(e)
l~al Estate Co. & Agent
Telephone
2. Type of l~esidence
Single-Family
Number of Bedrooms
Water, Supply_
Multi-Family
Other (describe)
Individual Well ~ Co ,m~uni-ty ~ Public ~
Note: If-co~nity ~11 system, must ha~ ~it~n ~nf~tion ~ ~e State
~p~nt of ~viro~ntal Con~rvation attesting to t~ legality ~d status.
Is ~e ~11 ade~ate for the n~r of ~ s~cified in this ~ (Y~)
~ge Dis~al
Onsite ~ ~blic ~ ~nity ~ ~. Holding Ta~
Is t~ ~s~water dis~sal system a~quate f~ ~he ~r of ~dr~ (Y~)
[Page 1 of 2]
2-15-84
5. Engineering Fibrin P~o_vldlng Inspections, Tests, ~ata and Information
I certify ~ ha~ checked~/verified, or conformed to all MOA HAA C~idelines in
effect on > ' date ' ' pection.
Date,, ,:~/0~-~
Te lephons
Date
( ENGINEER SEAL)
6. DHEP Approval
Approved for '~ keclrccms
Appromd ~ Disapl~romd ~
Terms of Conditicnal Approval
Conditional~-~
The Municipality of Anchorage Department of Health and Environmental Protection dces
not guarantee the continued satisfactory performance of the water supply and/ct t~
wastewater disposal system. This approval indicates that, as of the validation date
shcwn above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and ~astewater disposal system is safe°and func-
tional for the nu~r of bedrccms and type. of s~uctu~e indicated.
(DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Page 2 of 2]
2-15-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEA~LT~{ AUI~ORITY APPROVAL
CHECKLIST - FEBRUARY'1984
Well Classificat~
Well Log P~esen~_~,~.
Total Depth -~,~O~ Cased to
Static Water Level ~ ~_~_~
Casing Height Above Ground~
Electrical Wiring in Conduit _~/~)
Separation Distances f~om Well:
To Septic/~e~3r. Tank on Lot
To Nearest Edge of Absorption Field on Lot//~~-
~pth of Grouting "---'-'--
Pump Set At
Sanitary Seal on Casing~~
Depression A~ound Wellhead~
~ On' ~joini~g Lots
; On Adjoining Lots
To Nearest Public Seg~r Line . ,/%/ /~f~ To Nearest Public Sewer
C!eancut/Manhole ~//_ .~ To Nearest Sewer Service Line on Lot
Water Sample Test P~sults ~/~ iF-//~2 '~ ~ ~'~ /
C~nts
SEPTIC/~]8~K~ TANK DATA
Date Installe~/0 ~/-- ~ ~ Size /~CO,CJ /~No. of Ccmpa~tments
Standpipes (~Y~ .~7,,A,,, i~-tight Caps~ Foundation Cieanou (~
Depression ok~'vve~ Tank ~!~ .Date Last ~P~mped__ ,~
Pumping/Maintenance Cont~a~ct on File (Y~///<~; for
Holding Tank High-Water Alan/n (Y/N) ~ Temporally Holding TaD_k Permit (Y/NF -~/_~
Separation Distances f~om Septic;~l~FTank:
To Water-Supply Well /~ O 7L To Building Foundation ~.~ /
To Property Line //~)
To Water Main/Service Line
Course
Comments
To Disposal Field ~ /
To S~eam, Pond~ Lake, c~ Majo~ Drainage
[Page 1 of 2] 2~15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorpticn~?a
Depression ove~ Field (Y~)/
Results of Last Adequacy Test
Type of System Design
Length of Field ~ ~
Eepth of Field ~'/
Gravel Bed Thickness
~. ~A __ Standpipes Present
Date of Last Adequacy Test
Separation Distance from Absorption Field:
TO Wate=-Supply Well //.3'- ,/L To P~operty Line /~_3 ~-
To Building Foundation .~ To Existing or Abandoned System cn
Lot /~ ~O~ ; On Adjoining Lots ~/z3CC7 .
To~/Se~vice Line ~-~) ~- - To Cutbank(if present) .~-~ /70_
To Stream/Pond/Lake/c~ Major D~ainage Coarse /~f ~ ~/~
To Driveway, Pa~king Area, or Vehicle Storage Area ~-~gO /
Con~n~nts
D. LIFT STATION
Date Installed Dimensions
Size in Gallons ~ f~l ~ Manhole/Access (Y/N)
"Pump On" Level at
.'i Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested fo~ Pumping Cycles du~ing Adequacy Test.
Electrical Codes (Y/N)
Meets MOA
Cor~aents
** Check Permit~t~ Beclroc~ Rating Against HAA Request **
I certify th~at I ~ve .che. cked~Zverified, or conform~ to all MOA HAA Guidelines in effect
Signed f///~/~/~_~/~~/////////~/'/~/~~'/~/~ Date
[Page 2 of 2]
MOA No.
2-15-84