HomeMy WebLinkAboutNORTH WOODS UNIT 3 BLK 13 LT 4Northwoods
#3
Block 13
Lot 4
#051-732-25
72-013 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE '
DEPARTMENT OF HEALTH & ENVIRONMENTAL
PROTECTION
ENVIRONMENTAL ENGINEERING
0.*j
DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR
WELL INSPECTION REPORT
NAME
PHONE
NEW
'S—rt —
PGRADE
MAILING ADDRESS
VL -^� ,a ch t K
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
%-A'bi •PDp•,?-
DISTANCE TO:
Well
Absorption area
Dwelling
PERMIT NO.
vy
CoMIHcSe%:T+
��1
f
\iA DbS2�rT e.R.
az
Manufacturer
Material
No. of compartments
w F-.
rn
_ ._
ST F
'Z
Liq. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
sono
6OZ
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= z
Manufacturer
Material
Liquid capacity in gallons
_j=
DISTANCE TO:
Well
Foundation
Nearest lot line s
PERMIT NO.
LL+
wY la
S$
ilRaowct�Ycr<rY c.R-
LL Z
Z
No, of lines
Length of each line
Total length off lines
Trench width
Distance between lines
Lu¢
f-
Top of tile to finish grade
Material beneath tile
Total effective absorption area
%'
(0 inches
Q �
W
Length
Width
Depth
PERMIT NO.
a
Q F
wa
uj
Type of crib
Crib diameter
Crib depth
Total effective absorption area
rn
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
w
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
'PVQ—
801 L TEST RATING
INSTALLER
K C S e'x4z . k1C q3- i G4�_
REMARKS
0�9
99 8,
j
Y"
1
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71
o.i
fir
c C- o r
APPROVED DATE LEGAL
s�
L ° i
72-013 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
Department('^7 Health and Environmenta.?rotection
825 L Street, Anchorage, AK. v9501
264-4720
Permit # # # # HANDWRITTEN PERMIT # #
WEL AND/OR ON-SITE SEWER PERMIT
Applicant: Mailing Address:___
Location: (Phone
, Number: r :
Legal Description: LTTT
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 0 LENGTH _ GRAVEL DEPTH QL WIDTH _
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 _ _ 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 3 3
I certify that:
(1) 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
the residence is remodeled to include more that 3 b d ooms.
Signed:Issued by: -
Applica t�
Date:
SWP/024(1/81)
SOILS LOG
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
• TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
C
F
E
7
8
9
10
11
12
13
14
15
16
.17
18
19
20
COMMENTS
2
DATE PERFORMED: TO l I bi I 3
tiBlN,k 13
SITE PLAN
WAS GROUND WATER Ia II/, L
ENCOUNTERED? ��('il
O
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
a:
+�17 C)
2-: 25'
n? L3
72: 35`
_ _
• 6D
Z
°?-9
4-HZC)
: �ws
—y
21
2.55
42,L)
2'. 6T
.51)
��
3:Dt>- 1�
60
r
tllzv 01 D? )(��-gra '5b
PE40LATION RATE 3: I'S 6.2" (minutd�FlhCh)
1
TEST RUN BETWEEN FT AND FT
PERFORMED BY: t yAyz"',`re-Lana CERTIFIED
M V 'x'62.
72-008 (6/79)
DA
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D.n.II-7-72-Z5 COSH# ffA Opt 0106
Expiration Date: . S" /—/0
1. GENERAL INFORMATION
Complete legal description Lot 4; Block 13; Northwoods Subdivision #3
Location (site address) 23021 Live Alder Chugiak, AK 99567
Current Property owner(s) Je" Sanders Day phone 227-5012
Mailing address PO Boa 230090 Andwrage, AK 99523
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
Q
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Q
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (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 seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined In the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm S & s Engineering
Phone 684-2979
Address 15861 S. Birchwood Loop Rd Chugiak, AK 99567
Engineer's Printed Name Robert A. Sharer Date
t
&I7101.-4-:>(.,. _ _.4...
.... ....
5. DSD SIGNATURE � "�"" "" "' » d •;
Approved for 3 bedrooms. rd'y^•• •• ` �!l r�
ate
Disapproved. r ttD•'r:pf;"'�;;�",
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: w ' Original Certificate Date:_
(Rw IIM)
Municipality of Anchorage
Development Services Department
Building Safety Division On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
��w� &
Legal Description: L0_� Ll I� v 1 (3 MeA l) Parcel ID:QS2�S
1' %3"-
A. WELL DATA
Well typeL-
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform
uglL
If A, B, or C provide PWSID # _
Sanitary seal (YIN) _
Cased to ft.
FROM WELL LOG
mL Nitrate mg/L
date of sample:
Well Log (YIN)
Wires property protect /N)
Casing heig ove ground) in.
A PECTION
ft.
g.p.m.
Other bacteria ' colonies/100 mL
Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material � s �CQ Date installed L Z
Tank size I t10 gal. Number of Compartments Z Cleanouts ON) t p S
Foundation cleanout &N) NDepression over tank (Y/& AJ D0� High water alarm (YI& Jig
Date of pumping C� Pumper Mi'
5 L9kn?IRX ejib
C. ABSORPTION FIELD DATA I \
Date installed Zl d Soil rating p.d./ or ft2/bdrm) �_ System type S 4r l UQ
Length s._.
1ft. Width ft. Gravel belowpipe'—Tft.
Total depth ft. Eff. absorption areaft2 Monitoring tube _�P_ Depression over field AJO
Date of adequacy test � b OR Results ass Fail) MASS For 3 bedrooms
Fluid depth In absorption field before test 3(_ in. Water added gal. New depth, in.
Elapsed Time: oto min. Final fluid depth 2 in. Absorption rate >= s f g.p.d•
Any rejuvenation treatment (past 12 mo.) (Y& type) N C If yes, give date
D. LIFT STATION
Date installed Size in gallons o elAccess (YIN)
'Pump on" level at _ in. evel at _ in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cle o
Sewer /septic ce line Holding tank
a containment areas Ma ure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
r �
Buildingfoundation S 'f
Property line Absorption field
r
Water main 0 '(' Water service line /Of Surface water 1001+
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
r
Property line to ( Building foundation 16 r{ Water main 1014
I
Water Service line 10 f Surface water 100 ri Driveway, parking/vehicle storage /0 r4
Curtain drain KtA-c LAt n Wells on adjacent lots /V / /+-
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / have determined 4i
review of Municipal records that
conformance with MOA COSA auia
Engineer's Printed
Date
COSA Fee Y910.
OC,
Date of Payment
Receipt Number S S S e
(Rev. 11105)
h field inspections and
above sysfams ara,..rn
Waiver Fee $
Date of Payment
Receipt Number
r
APR -30-2009 01:21 AM
I
r
' 1,)Z --- 2Z -I.4 2-
A
A,11T, c`S C� 2.9oat
C.
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1
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AS -BUILT
1 hereby ceTtity that I have surered the following described
propert Loy 4:' ;?/,pep f?,
NLA- r...0 s sVL ; uri,
s ►r,uR rw sM
Anchorage Recording Precinct, Alaska, and that t6 Improve-
ments situated thereon are within the property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on property lying adjacent thereto encroach
on the promises In question and that there are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at Eagle River. Alaska
ROSERTC. JOH\SO\ `sic.,
SCALF. Registered Land Sun•eyor ti,..3so-LS
1" ..L' &n 71.0156, Eagle River, ALoaa 99577
one (907) 69:-25:3
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program u
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ek.us..
(907)343-7904
CERTIFICATE OF HEALTH AUTHOR.LT,Y;APPROVAL
FOR A SINGLE FAMILYDWELLKW"S. - - - -
Parcel LD:• 051-732-25 HAA# tjA O l O O f-6
Expiration Date: 2 - 2 7 - o :2-
1. 'GENERAL INFORMATION
Complete legal description. Lot 4, Block"<13. Northwoods Subdivision #1
Location (site address ordirections)•23021 Live Alder Avenue
Current Propertyowner(s) Barbara Jeffus Day phone 688-8989
Mailing address '
Lending agency Day phone
Mailing address
Real Estate Agent Remax/AudreyMason Dayphone �gj,-hgnn
Mailing Address 16600 Centerfield Dr., Ste 201, Eagle River, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup. —1,4/2 4,
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
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 welts or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validationdateshnbelo,Ierify that myInvgion,
based on procedures outlined In the Health Authorty Approvalapplication, shows that
the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the cn-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.
5 3 S ENGINEERING Phone �' �! Y —� 9 71
Name of Firm 17034 Eatils
Address Eagle River, Alaska 99577
Engineer's Printed Name
,Robert C. Cowan Date
a��6�°1
5. DSD SIGNATURE
Approved for '—
Disapproved.
rRVVRH147
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date: 2 —�
(Rev. IZO)
Municipality of Anchorage
• �" Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bregaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.enchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L �: �.Cxx o;nlnam000s�3 sto Parcel ID: OS1-73Z-ZS
A. WELL DATA
Well type 3L(/�[ Ci
Date completed
Total depth R.
Date of test _
Static water level
Well production
WATER SAMPLE RM
If A, B, or C provide PWSID # _
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
y ooionies/lo0 mi. Nitrate _
of sample: Collected by:
"►i1�11 . --1aff,
Wires property protected
Casing heigh a ground) in.
mg.A. Other bacteria
B. SEPTICIHOLDING TANK DATA
Tank Type/Material
Tank size 1000 gal. Number of Compartments Z
Foundation cieanouOY N)�L Depression over tank (Y4M N O
Date of pumping
C. ABSORPTION FIELD DATA
R
colonies/100 ml.
Date installed 4 4 9
CleanoutsON)_ 7�
High water alarm (Y/N) /t
Pumper 12 rS
Date installed /. Soil rafingl�r ft2/bdrm) 0B
Length '5B R. Width 5- R.
System type
Gravel below pipe 4 R.
Total depth (0 R. ER. absorption area '2& ft' Monitoring tube )�t Depression over field nfy
ate of adequacCyy est 2-114 ResutPas ail) S4For 3 bedrooms
Fluid depth in absorption field before test Z3 in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. // Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) I6ONf zmyt / If yes, give date
LL,,-�4 -g�N lyes 6)j -D
D. LIFT STATION
Date installed In gallons
'Pump on" level at "Pump otr level at _ in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON
Septic tank/Ilft station on lot
Absorption field on lot
Public sewer
Sewer /se0c' service line
Manhole/Aocess (Y/N)
High water alarm level at
Meets alar b circuit requirements?
fz&IC,
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
r
Building foundation 5 Property line 5 Absorption field F
r
Water main /0 1 F Water service line %Q 14- Surface water
Wells on adjacent lots N A
In.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /O r 4- Building foundation /0 1 Water main /O f
Water Service line�1r0� f� Surface water /O D �� Driveway, parking/vehicle storage /0 I �
Curtain drain dam! l�[O�iraL Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections ander i3
review of Municipal records that the above systems are in
conformance with MOA HAA gutfelines in affect on this date. `
IZ
Engineer's Printed Name 7� :� C�-ESOI : r'J�
Date } �/L /of �Ztti`,'%:
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12100)
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE 3 Z 2
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 5
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 4, BLOCK 13` NORTH WOODS III T15N. R1W. Section 4
(addressLocation
ApplicantCORNOR 011 10ZE ALDER AVE AND GREEN GARDEN DR, PETERS QRFEK AK
(b) Applicant Name AUDREY MASON Telephone: Home NA Business 694-4200
•• • BOX 772849, EAGLE RIVER .• ••
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer 0�- Other ❑ (explain); REALTOR
(d) Lending Institution AT,ASKA MTPPITAT RANK Telephone 376-3050 ATTN* T.TRRY
Address P-0- BOX 574229 , WASTT T A AK 99587
(e) Real Estate Company and Agent _MARSMN PRAT ESTATF , ATM • AT TCR
Address 1265 PARKS 111Y, WASIr r A AK 9967
Telephone 276—=4
(f) Mail the HAA to the following address:
HOLD MR. PTCKfrP RV AAGIF_ RDIE'R-ENCrINEZRINr
2. TYPE OF RESIDENCE
Single -Family ®K Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY -
Individual Well ❑ Community U Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite)M Public ❑ 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.
Page 1 of 2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm EAGI E BIVER A'1 INEERTNC SERVICES Telephone 6911-5195
Address P-0- BOX 773294, EAGLE RIVER AK 99577
Date �Z,4AZ�7
f 6
deur omovo®aeo mo mcu on umm mueoo=°
� o Louis A. Bwera a° .
is°oo CE -6736 �isR
sokkllPp� OFESS\�%`4
6. DHEP APPROVAL
Approved for•/7� bedrooms by Date
Approved --19, — Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
0F WccoopGE`oN 64-4720
CHECKLIST FEBRUARY 1981`4--
Legal Description: L6+ Zo
T ISN t21 Lo,4
A. WEA DATA,,,
Well Classifi cep ' G If A, B, C, D.E.C. Approved (Y/N)y S r^:n/ /afi�•-
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ; 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 ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 196_3 Size Ao o 5k t No. of Compartments _Z1
Standpipes (Y/N) _/ Air -tight Caps (Y/N) i Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /✓ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) 01�<
Separation Distances from Septic/Holding Tank:
To Water -Supply Well ;1, 0aTo Building Foundation %D
To Property '; �
p y Line To Disposal Field 4:5�
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course 11�a
Comments
Page 1 of 2
72-026(11/84)
i
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata Type Type of System Design /e*w
Date Installed IiY7
Length of Field 3�
Width of Field
may,
Depth of Field �
Gravel Bed Thickness 6 ��
�`�O
y
Square Feet of Absorption Area
Standpipes Present (Y/N)
Depression over Field (Y/N)
Date of Last Adequacy Test
Results of Last Adequacy Test S4 75's A,k yt
�6sd,-6> %�^+ °may 3 �� mus e
Separation Distance from Absorption Field:
To Water -Supply Well t�o�
i
To Property Line
To Building Foundation 3
To Existing or Abandoned System on
Lot
On Adjoining Lots
To Water Main/Service Line
To Cutbank (if present) N�
To Stream/Pond/Lake/or Major Drainage Course
N�5
To Driveway, Parking Area, or Vehicle Storage Area
a�
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) —
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** 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 -,. - Date r0���7
Company ��� S MOA No. S% o26S`
Receipt No.
/D6 � v a Z 6 sp,� f®qF A�4t® p
Date of Payment ��Y=°• ®°�
E 49F ®
Amount: $ 0 ®°49TH
'0® •p.2®o•®e®•®o®ee•••®.•sma•.•e m L
Page 2 of 2
r, rn Louis A. Butera
�h n°o, CE -6736
72-026 (11/84)®®0 ROFESS10�q„'
w
STEVE COWPER, GOVERNOR
a 0 a sSKa
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 "C" STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
DATE:
PWSID #: —MMI ------------
To Whom It May Concern:
563-6775
According to the records on file in this office, the _CHUHAK
UI1L111ESZNQ6IHWQQDS—______ Water System is in compliance with the
State of Alaska Drinking Water Regulations.
Sincerely,
Y
Mich P. Lewis
En onmental Engineer
1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
GERIIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date /Z t -la( -A
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, s ction, ownship, range)
TIS 3/ac L o7 q (I s N) i2 I N! r Sac 3
Location,(address or directions)
(b) Applicant Name _Sin /I r"6 Telephone: Home 376"KqQ Business _
Applicant Address10� U ht1 1' �2 r5 Cf K AK
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 2•, Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent —
Address
Telephone
Mail the HAA to the following address
2. TYPE OF RESIDENCE
Single -Family d Multi -Family ❑ Other
Number of Bedrooms
Telephone
3. WATER SUPPLY
Individual Well ❑ Community 93' Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ®/ Public El 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.
Page 1 of 2 72-028 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this in pection. I
Name of Firm..T
� Win Q S4GQW�J T lephone
�6
Address — � d j
Date
E:rpu .ra ° i s�
to
y ,iaomas En meer's Seal
RR ; r e J. Corwin v Q,�
V s•• o. CE -5283 'fed
Q� SCO �•o•, 5,'�(, as
Q E�0 AOFESSIC��'''.v
B. DHEP APPRO?+�¢�� n Q
Approved for bedrooms by ate
Approved Disapprove Conditional
Terms of Conditional Approval
CAUTION
The MUncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
eng;neer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 (t 1184)
/ MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA). ENVIRONMENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) MAR Z 0 1W
CHECKLIST - FEBRUARY 1984
264-4720 I V E D
Legal Description: i1� toaa ,
81oe.k t 3 L.o+ 4
A. WELL DATA TpumSK4P ITA , h2ahg2 j '5k r- 3
Well Classification rn U l If A, B, C; D.E.C. Approved (Y/N) V QS
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit(Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ; 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 ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size 1000qA1 No. of Compartments Z
Standpipes (Y/N) _ Air -tight Caps (Y/N) .— Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /40 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /A ; for
Holding Tank High -Water Alarm (Y/N) l Temporary Holding Tank Permit (Y/N)_
Separation Distances from Septic/Holding Tank:
To Water -Supply Well +30pt To Building Foundation Z J
To Property Line _ 578,— To Disposal Field
II 8
To Water Main/Service Line lOof To Stream, Pond, Lake, or Major Drainage
Course +400'
Comments
�tOr4 D.I.P� vvasnrri�:on l ntrn
Page 1 of 2
72-026(11i84)
D. LIFT STATION N/A
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off' Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certifythat I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company
prWiy� QSSOCc4 MOA No.SS�ZIi
� A
Receipt No.
Date of Payment' aC'� ea
e . Engineer's Seal
Amount: $ ��i ri
e J. Corwin ,
C 083
It
Page 2 of 2
PROFESSSat ®
72-026 (11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /3
Type of System Design
3
Date Installed 2.S' 83
Length of Field 5 /
Z,o
Depth of Field
Width of Field
Gravel Bed Thickness
'It �•tif! Standpipes Present (Y/N) J 5
Square Feet of Absorption Area
o r l
Depression over Field (Y/N) Ko
Z Mar
Date of Last Adequacy Test �L�--
Results of Last Adequacy Test
Off'
Separation Distance from Absorption Field:
S8 r
+
To Water -Supply Well 3�1
To Property Line
z0'
To Existing or Abandoned System on
To Building Foundation
Lot Pk
; On Adjoining Lots
rj
To Cutbank (if present)
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
t
To Driveway, Parking Area, or Vehicle Storage Area
Comments + - o(^ D N EF tr\.5P4Ji0rN
Cyr rn
D. LIFT STATION N/A
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off' Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certifythat I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company
prWiy� QSSOCc4 MOA No.SS�ZIi
� A
Receipt No.
Date of Payment' aC'� ea
e . Engineer's Seal
Amount: $ ��i ri
e J. Corwin ,
C 083
It
Page 2 of 2
PROFESSSat ®
72-026 (11/84)
♦ p
s
di g 6 BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: rso»
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
DATE: <✓fil eio,
PWS I.D.# 02 / 3 DO /
To Whom it May Concern:
274-2533
According to records on file in this office then
Water System is in compliance with the State Drinking
Water Regulations
.Sincerely, G2���
Time
APPLIC 74T FILLS
OUT UPPER 'HAII`�,ONLY
-PrProperty Owner
-'�" t�?�>yJ G -S )+1, 11. K' K 4 .. / �"p� .l t..s '% ' 1A C - Phone
Y
ailing Address
, �� , 0 (
f , t;Vp Code q� ,. 6 ^ h 91 8 '6603
Buyer
Date
Date
Address
Date
Zip Code
Lending Institution
Phone
Address
Zip Code
Inspector
Realty Co. & Agent
Inspector
Phone
Address
Zip Code
Legal Description
11- D...�
r V U)t ?9. Q� # -�.—
Y !y
Street Location
MUNICIPALITY Of ANCHORAGE
Type of Residence
DEPT. OF HEP:LTli t:
11L3 ngle Family
ENVIROti JLiNTAL PROTECTION
❑ Multiple Family
No. of Bedrooms
F'i,C
❑ Other
RECEIVED
Water Supply
*CONDITIONS OF APPROVAL
( ) DISAPPROVED
- -
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
ommun&y
❑ Public Utility
For wells drilled prior to that date, give well depth (attach log if available).
Sewer DDiiosal
DATE
EL,115dividual
Year Individual Installed:
❑ Public Utility
❑ Holding Tank
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Ck R�
Date
Date
Date
Date
1 �L
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY Of ANCHORAGE
DEPT. OF HEP:LTli t:
ENVIROti JLiNTAL PROTECTION
`
F'i,C
RECEIVED
( 5rAPPROVED BEDROOMS
*CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
1 1 2O.-,�'
DATE
Soils Rating=DateSew7er.Ins1aI,1ed
Well Tc Absorption Area
Well Log Received
3
Well to Tank
Septic Tank Size C-) O
023
Time
APPLICNINT
FILLS OUT UPPER HAI1'�IONLY
Property Owner
to
Phone
Mailing Address
� C.�% . �t z� �
' _ �� Zi Code
,A lr C � 77
Buyer
Inspector
,
Address
Inspector
Zip Code
Lending Institution
`i..
Phone
Address
(Wunicipatity of Anch011193
Zip Code
"Dept. of Health &
Realty Co, & Agent
4TIGni•
( -3) APPROVED BEDROOMS
Phone
Address
.Zip Code
Legal Description
r t C 4 -:
�" ��,xt ,__-s-•rt-i--
-Street Location
Soils Rating
Date Sewer Installed
Type of Residence
Well Log Received
2 -'Single . Family
❑ Multiple Family
No:. of Bedrooms ' =2
❑ Other
Water Supply
❑ Individual
❑"Community
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Public Utility
For wells drilled prior to that date, give well depth (attach log if available).
Sewer Disposal
L;-Mdividual
Year Individual Installed:
❑ Public Utility
❑ Holding Tank
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
`i..
AUG a 1983
(Wunicipatity of Anch011193
"Dept. of Health &
4TIGni•
( -3) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
>
Septic Tank Size
vn.ma ,vnm
Well to Tank
