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HomeMy WebLinkAboutPARK HILLS #1 BLK 1 LT 1Park Hills Block Lot #017-142-04 WATER WELL RECORD "~ STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geol~gicol a SeophysicoISurveys Drilling Permit No. : either to or lo.) A,D.L, No. I~.IBOrOugh Suhdivleioo .~ 90t Block b '/4qtre Sect on No Township . Rcnge :":'E ' -:· ' " sE3 wE ' ' - IC*~DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WELL: ~.~._ Street Addresl and Area of Well Location ' 2. WELL LOG . . . Feet Below 4, WELL DEPTH: (final) 5. DATE OF COMPLETION Material Type Top ~ Bottom , ~iluv:Lu~: h-.o~':n color and soft~ 0 aO e. ~c~b,. ,oo~ ~,~,~,y 'lluvitu;i: Er.:'r color end medium 20 ~6 ~Auger ~d*l~ed ~8ored OOther:. ' :~I,~O.~B~e ~ 7. USE;~Oomeltic ~ Public Supply ~ Industry , ' ,'.llu' 'viu~'~ .... br':.v.m color and mediur~ 56 ' 55 ~ ,.r,~,.o. ~ ~I&~.~¢C,¢. ,,, ~ Test Well ~ Other; , ~l!uviuu; M-,;;~'n ~'" soft. '66 77 . ct~3,4 . 9. FINISH OF WELL: 015¢~ bolo/perforated 3..!h'.v~un~. b:..'ca-m color, ~ediu~ 81 93 s., ~,,..~.' 93 heftiness. Backfilling ,.. 6rovel pack ' t2& ........ ~ ~ Above or ~8elow ~and surface :(-.:iz',:'c':: b~-,'-,::rey and hard, 96 107 - -~ '~' Equipment used:~;':~d '-"' ---- "''"'~' ,'.mci hard. 107 177 II. PUMPING LEVEL below Iond .urf.co .nd YIELD '- ' ' LC.T.O. -e:,~o?...:: '~¢_~ c.t. ; r~,en crud" '~ ~77 200 12.GROUTING Well Grouted: ~Yos ~ No IS, PUMP: (if available) HP Leagth ef Drop Pipe fl. cepecily g.p.m. ' D Sub~. D Jet O Centrific~l O O,her 14. REMARKS: ~ 16. WATER WELL CONTRACTOR'S CERTIFICATION: o ~ C  T~i~ well ~os d~illed under my lurlsdicllon end this repot1 is true lo the besl of my knowledge end ' ~'" A'u~h~ed Representative ~ ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTI~(~TION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE [] NEW LO°AT,O. 0* do/¢I¢ v,' w Manufacturer 0-r C~°r Liq. capacity in gallons I [ ~-~z'O I IF HOMEMADE: Man ufacturer DISTANCE TO: ~OP Length of each line /0~' No. of lines/ Top of tile to finish grade Length Width Absorption area // / Inside length Dwelling Foundation Total length of lines Material beneath tile Depth Dwelling Material,,~/.~,~ Width NO. OF BEDROOMS4 PERM IT NO'(~3~1 ~ ~_.2 ¢ No. of compartments 2 Liquid depth PERMIT NO. Material Liquid capacity in gallons Nearest lot line ] ~ w Trench width~) inches -~' inches Distance between lines.~ Total effective absor~)~n>r~4 PERMIT NO. Type of crib Crib diameter Well Crib depth Building foundation Total effective absorption area Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER P'PE MATER'^LSp V(~ ~]_- SOIL TEST RATING INSTALLER REMARKS -/ APPROVED~L~ 72-013 (Rev. 3/78) DATE LEGAL ~- i¢-~ L~f I ~/~ I PERMIT NO. DEF'RRTMENT ;_~, HERLTH RND EN',,,'IRZNi"!ENTRL' ?OTEC:TION ~ 825 '"L" STREET., RNCHORRGE., RK. ~950Z 264-4720 8]:040D ) F'. 0. E,. ,::. 4 - 2:--:82 LOT SIZE 999999 SG!URRE FEET I'iR>:;IMUM NUMBEF: FIF E:EDROOMS = 4 SOIL RFI]' I NE~ THE REG!UIRE[:, SIZE OF THE SOIL RBSORPTION S'T'STEM IS: [:, E F' T H = tS L is f¢~~ CD -F H = -1 (:'l [5 ~3 IGc-: F~ %-' E L [:, E P T H: THE LENGTH DII'"IENSION IS THE LENGTH (iN FEET) OF THE TRENCH OR DRRINFiELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNC:E BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEE]';,. l-HE T'KqEt-~C:F-~ i.~ i [:,TH X S ~;. ~E~Z~ F-EEl'. THE GR.R',,,'EL DEPTH IS THE 15INIHUbl DEF'TH OF GRRVEL BETNEEN THE OUTFFILL PIPE RND THE DOTTOH OF THE E'XCRVRTIOIq ,(IN FEET:). PERMIT RF'PLICFINT HRS THE RESPONSIBILIT'¢ TO INFORM THIS [:,EPRR. THENT DURING THE iNSTRLLRTION INSPECTIONS OF ~N'¢ WELLS FI[:,JRCENT TO THIS PROPERT'¢ RND THE NUHBER OF RESIDENCES THRT THE WELL WILL SERVE. BRCKF!LL. ING OF RN'¢ %'T'STEM WITHOUT FINRL INSPECTION RND RPPROVRL B'T' THiS DEPRRTMENT WILL BE SUE:JECT TO PROSECUTION. i'tiNIHUH DISTANCE BETWEEN R 14ELL FIND RNV ON-SITE SEWRGE DISPOSRL SYSTEM IS ±00 FEET FOR Ft PR I ',,,:RTE WELL OR ±50 TO 200 FEET FROH R PUBLIC bIELL DEPENDING UPON THE TVF'E OF PLIDLIC WELL HtNIHUM DISTRNCE FROM R F'RIVFtTE WELL TO R PRt",,'RTE SEWEF.: LINE IS 25 FEET RND TO R COMMUNIT'¢ SEWER LINE IS 75 FEET. WELL LOGS RF.:E RE~]UIRED RND MUST BE RETURNED TO THE [:,EPRRTMENT ktITHIN 2:0 [:,R'~'S OF THE WELL COMPLETION. OTHER REOUIREHENTS PIR'¢ RPPLV. SF'ECtFICRTtONS RND CONSTRUCTION DtRGRRMS RRE WCRILRBLE TO INSURE PROPER INSTRLLRTION. RE'Z; [:, E C: E E-I E: E F-: i C:ERTIF"F THRT · i: i BM FRMi/..iRR NtTH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH B'T' THE MUNICIPRLIT'¢ OF RNCHORRGE. 2: I WiLL INSTRLL THE S'T'STEN IN RCCORDRNCE WITH THE CODES. ]:: i UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR¥ REL::!UIRE ENLRRGEMENT IF THE RESIDENCE iS REHODELED TO INCLU[)E MORE THRN 4 BEDROOMS. S i GNE[:,: .... h F L I _.MN F E:RRE:,L¥ JORE:,RN V4. 0 THE; F;:E(i:!U:I:F:~D SIZE "-fi::' IF'!!:: :!i.?};~ .................... THE L.iEh!GTH D i i'!Ei',i::~; '~ ON i S THE L. EN(::'iTH ,:: I N F:EET ) OF THE TFi:ENCH OF-'.' C,i:-:.'~F:~ i NFl EL.D. THE DEPTH gF !::! "fRENCH ,';:)R F'ZT i'S THE E:,ZSTFff',!E:!:~: BE"F!4EEN THE %I...iRF:RCE OF' THE GF:Ed...!i".~E) R!'-,!!) THE E~O'i'TOH OF THE E::.::Ii::i::iVi:::!"i" i (:)i",! ( i t"~ FEET), THE ';:3F:RVEL. DEF'TH Z'.~; THE hi!NZHUH DE.:PTF! OF' GRF!VEL. BETHEEN THE OUTFFE...L. F'ZF:'E RND 'THE E',EiT'T'()FJ Eft::' THE: E::.':{:::Fi',,,'~:~'I":[Oi'~ ,::1~I"~ FEET). i CEF:T Z F'"? 'T'HFtT :!.: i RH F:F~i"!:i:L.I!':iF;: i.,,!!'TH TFIE F'.E(;!UIREHENTS FOR Oi",i'-'.:,:.;!TE SEF!EF;:S F!ND HELLS F!S F.;iE'f F:'OF:TH Ei"¢ ]1HE .i','IL!i'.,! )1C ! F'F~L. i T? OF' ~Z: T ~.,.i i L.L. i NSI"I:::Ii....L. THE :5'.?STEH t l'q F!C:CEifEDF!NE:E 141 TH THE E:ODE:~;. 3:: ~ Ui",!DEF::;~;Tf:!ND THRT THE ON""'S:[TE: :~SE~,.EEF~: S"?:STEH HFi'7 F:E:~;:¢J!F:E. ENL. F:~RGEh'IEhF!" iF' THE F:ESiDENC!Z :IS F~:EHODEMED "['O ii":iCLUi:)E HOF:E THRH ,4 E',EDROOHS. 7 8 '12 13 "~-J' MUNICIPALITY OF ANCHORAGE'~ ~\ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 SLOPE [] PERCOLATION TEST ~ ~0~ DATE PERFORMED: SITE PLAN J Verdi ~l'~r- 17 18 WASGROUND WATER ENCOUNTERED? IF YES, AT WHAT ~ .,~ \ IG,H I DEPTH? v Gross Net Depth to Net Reading Date Time Time Water ~ Drop 19¸ PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN , FT AND '-~'.-~-.~ FT COMMENTS Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Waste~ater Program 4700 South Bragaw St. P.O Box 196650 Anchoroge~AK 99519'~650 wwv.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-142 -04 1. GENERAL INFORMATION Expiration Date: "'~- ~- 0 { Completelegaldescription PARK HtLLS SUBDIVISION ~1; LOT 1, BLOCK 1, Location (site address or directions) 14500 GOLDENVIEW DR[VE· ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency MICHELLE HARTLINE Day phone 14500 GOLDENVIEW DRIVE * ANCHORAGE, AK 99516 Day Phone. 263-4116 Mailing address Real Estate Agent Mailing address BONNIE HOCHSTEIN w/ REMAX Day phone 2600 COROOVA STREET ' ANCHORAGE, AK 99505 276-2761 Unless otherwise requested, HAA will be held by DSD for pickup. 2. HUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well I Individual Water Storage [] Community Class Well [] Public Water System [] I~¢PE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Se~.ices D. epartment (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representattons 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 pdvate or Class C well end 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.) Ce~ticates 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. Note: Alaska Water and Wastewater Consultants, Inc, shall be paid $ t, 195.00 at, or prior to closing for the engineering services provfded. . 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat affixed hereto and as of th~ vali~lation date shown below, I veri~ that my investigation, based on procedures outlined in the Health Authodty ApprOVal Guidelines for this application, shows that the on-site water supply and/or wasteWater disposal system is(are) safe,' fu~ctional and adequate for the number cf bedrooms and type cf structure indicated herein. I further verily that based on the information obtained from the Municipally of Anchorage files and from my investigation and inspection, the on-e/to water supply and/or wastewater disposal system is(are) in compliance vvfth all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Nameof Firm ALASKA WATER & WASTEWATER CONSULTANTS. INC. Phone Address 6901 DEBAER ROAD, SUITE 2B ° ANCHORACE. AK 99504 Engineer's Printed Name JEFFREY A. CARNESS. P.E. Date 337-6179 Engineer's Comments: In conducting this evaluation, AWWC, Inc. attempted to provfde a thorough, conscientious engieeedng analysis of the system in accordance v~th ADEC and MOA DSD Guidelines & Regula~iees. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the Iocal soils condition, groundwater levels that may, fluctuate dudng the year, and the water usage of the fami~/ being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactoq/ test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, In~ can therefore not prot~de any warranty or future estimate of how long the system ~11 continue to meet the operational requirements of the ADEC er MOA DSD. The content of this report is for the solo benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor v~ll it confer any legat ~fght whatsoever. 5. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for .~;.G .' · '~ . bedrooms, with ~e fllowing stipulati~: '7¢,.. ..... Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Soufft Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ct.anchorage.ak.us (eoT) 343-7eo4 Legal Description: A. WELL DATA Well type. PRrCATE Data completed Total depth 223 HEALTH AUTHORITY APPROVAL CHECKLIST PARK HILLS S/D 1~1; LOT 1, 8LOCK 1, ParcellD:. 017-142-04 If A, B, or C provide PWSID~ N/A Sanitary seal (Y/N) YES Cased to 97 ft. FROM WELL LOG 8/9183 33 ft. 8/9/83 ft. Weft Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) ~" in. AT INSPECTION 3/7/01 46 ft. 2 g.p.m. 0.61 g.p,m. Date of tast Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Data of sample: 3/7/01 B. SEPTIC/HOLDING TANK DATA Nitrate 0.5 ag.IL Other bactarla 0 colonies/100 mi. Collected by: AWWC, INC. STEEL Number of Compartments 2 Depression over tank (Y/N) NO Tank Type/Mataflal Tank size 1250 gal. Foundation deanout (Y/N) YES Data of pumping 5/7/01 C. ABSORPTION FIELD DATA Date installed 6/14/e3 Length 105 ft. Data installed 6/14/83 Cleanouts (Y/N) YES High watar alarm (Y/N) N/A Pumper OLD MCDONALDS [*BELOW PROPOSED FINAL GRAD[J Soil rating (g.p.d./ft~or~'~ 225 System [ype TRENCH Width 5 ft. Gravel below pipe Total depth .6.s ft. Eft. absorption area 905 fi= Monitoflng tube YES Data of adequacy tast 3/7/01 Results (Pass/Fall) PASS Fluid depth in absorption field before tast 0 in. Wataradded 451 gal. Elapsed TIme: 10 min. Final fluid depth 4 Any rejuvenation treatment (pest 12 mo.) (Y/N & type) 3 ft. Depression over field NO For 3 bedrooms Now depth 16 in. 450+ g.p.d. If yes, give date - In. Absorption rata >= NONE KNOWN D. UFT STATION Date installed Size in gsllom "Pump on" le~l at in. ~ ~ ~ cy~ee tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1 o0'+ Abeorptlon field on lot100'+ Public sewer main N/A Sewer/sep~c service line ~, ~ '~' High water alarm level at in. Meets alarm & circuit requirements?. On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cieanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ . Properly line 5'+ Water main N/A Water service line 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field 5'+ Surface water 1 oo'+ Property line 10' + Water service line 10' + Curtain drain NONE KNOWN F. COMMENTS Building foundation. 10'+ Surface water 100'+ Wells on adjacent lots 100% Water main N//A Driveway, perking/vehicle storage __ 20'+ G. ENGINEER'S CERTIFICATION I cerSfy that I have deten~lned through field inspections end review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's PdTed I~ame Date JEFFREY A. GARNE$S HAA Fee $ 3 ~'"~) Data of Payment Receipt Number {Rev. 12mo) Waiver Fee $ Data of Payment Receipt Number MUNICIPALITY OF ANCHORAGE M E M 0 R A N D U.M WATER WELL ADVISORY During a recent Health Authority Approval on-site inspection. and test of the potable water supply well on Lot Block I of p~_.wk ,~.,'//¢ .~. / Subdivision, the well's productivity was ~etermined to be O_~ gallgns per minute. The minimum well productivity required bY this Department '(~C 15.55) for a ~ bedroom residence is ~,~ gallons . per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory muzt be attached to all copies bf the subject Health Authority Approval. 'MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION Complete legal description HAA# ~c~ Lot 1; Block 1: Park Hills Subdivision Unit Location (site address or directions) 14500 Golden View, Anchorage, Alaska Property owner Mailing address Lending agency Mailing address Michele Hartline P.O. Box 91724/ Anchoraqe, Alaska Day phone 263-4116 99509 Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: 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 o STATEMENT OF INSPECTIO~I BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm $ & $ ENGfNEERING Phone 17034 Eagle River Loop Road No. Address Eagle Rivet': Alasl~a 9g~77 Engineer's signature Date Ncri'E: The conditions of the Health Authority Approval issued 2/10/92 DHHS SIGNATURE ~ Approved for -~ bedrooms. Disapproved. Conditional approval for have been met ~.¢. 0~o~,7%,,%~%~~~''' '"'~- bedrooms, with the following stipulations: Additional Comments Date f- /'¢-~72 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 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 OFHEALTH & HUMAN SERVICES : Division of Environmental Services . On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# 1. GENERAL INFORMATION Complete legal description Lot 1; Block 1; Park Hills Subdivision Location (site address or directions) 14500 C~-!den Vie~,~: Anchorage: ProPerty owner Mailing address Michele Hartline P.O. Box 91724, Anchorage, Alaska Day phone 263-4116 wk 345-4438 hm 99509 Lending agency Mailing'a~dCess Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 "~ : TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: individual on-site Holding tank Community on-site NOTE: xx~ 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 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal arid State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 17034 Eagle River Loop Roa~ _No. Address E_-g!_- R!v~_.-, A!=:k~, Engineer's signature RECOMMEND APPROVAL ON THE CONDITION THAT AD~ITIONAL FiLL IS PLACED OVER SYSTEM FOR A TOTAL COVER OF 3.5 ft. TO PREVENT FREEZING. ESTIMATE APPROXIMATELY 40 yds. REQUIRED. Phone 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for D~ E g ,~' bedrooms, with the f'GT~wing stipulations: 3'uz y, Additional Comments Date 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 and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not resl~6nsible for errors or Omissions i'n the professional engineer's work, : ' ' · 72-025 (Rev. 1/gl) Back MOA ~1 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~O-C I,~ ~/..I¢-. ! / ~PrgK- ~r[cc.~ Parcel I.D. A. WELL DATA Well type ~RUJ Log present Total depth Sanitary seal Y~N) If A, B, or C, attach ADEC letter. Date completed Cased to °1'~'' Casing height Wires properly protected ~.~N) ADEC water system number Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION o0, g.p.m. I'O SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank /00 Sewer service line WATER SAMPLE RESULTS: Coliform (~ Date of sample: II I~ Nitrate Collected by: Other bacteria /~ord ~ B. SEPTIC/HOLDING TANK DATA Date installed (~/~ '~ Cleanouts (~N) High water alarm (Y/(~ Tank size /~%O G-/f~ Compartments -~, Foundation cleanout (~/N) ]/'~,¢C Depression (Y/~ )'%'~ Alarm tested (Y/N) ~ Date of pumping II ~-%\°t~-- Pumper SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO: Well(s) on lot JOO To property line I Surface water/drainage On adjacent lots [00' Foundation Absorption field II ' Water main/service line 10o * 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed -- ~fL)//~ Manufacturer VentSize in(y/N)gallons _""~"--~_,,'"'"'~ ..., Manhole/A~N) --~1 at "'Pump off" level at High water alarm level~'"'"'"'""~J Cycles tested __ Meets MOA electrical codes (Y/N) J ~ D, ~/i'li~ ';~10 N F/~iE~ DA TA On adjacent lots S u r f ace"8'"w~..~ Date installed _ ~/~'~ Length /O~' Width Total absorption area Depression over field (Y/I~. Results (g/fail) Soil rating c~,~ 5'~=/&~.._ System type Gravel thickness Total depth ¢ Cleanouts present ~N) Date of adequacy test ~ for Peroxide treatment (past 12 months) (Y/~)) ~"'"~O bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot [00 ~ On adjacent lots ICC "ff Property line To building foundation On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION To existing or abandoned system on lot Cutbank ~0~v~ Water main/service line Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in ef~.e~,,iCr~;~h~..*~lat¢, of this inspection ~_~.- ~,~ ..~? ,. ,,,~ . Signature 17{'i34, S~,j!,~ Dlv~ I.~n? ~0~ ~0, ~ Eagle ','~iver, Alaska 995~7 Engineer's Name _ Date ~ ~ ~ HAA Fees / - Waiver Fee:$ Date of Payment / ~ '~-"7~ ~-- Date of Payment Receipt Number ,..d_.~'22~ ~(~) -~2 Receipt Number 72-026 (Rev. 3/91) Back MOA 21 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 App,,cation ate GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name~' . ~/OL~t....~Tt~ BT' Telephone: Home '~'~ -~TH ~ Business Applicant Address I t~O~ ~ O & t'~ _1~::/X/ I~ I/~'~ (c) Applicant is (check one): Lending Institution []; Owner/builder ~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address ~, ~ '7 ~ ~ O ¢~,)"~ ~,~ N Telephone ~' '~ ~ ~' ~¢ -~ ''~ '~ (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family~ Multi-Family [] Other Number of Bedrooms _. .-~ 3. WATER SUPPLY ~. Individual Well~l~ Community~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL i ?E] Onsite]~, Public[] Commu it 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 ~ 72-025 (11/84) 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 ~"~/~'~'~'~%/ -~__-'~./~,~,~'/~ ~'J~- Telephone Address .j~,~) '~ ~ /~ Date Engineer's Seal 6. DHEP APPROVAl.. Approved for ~:~- ~/)bedrooms by Approved //~/ Disapproved Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP)issues Health Aut~°rity 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 om ss OhS n the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST ' FEBRUARY 1984 WELL DATA Well Classification Well Log Present (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (Y/N) Y" Depression Around Wellhead (Y/N) iN/ ~¢O O '~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments /~ ¢ ¢' ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date SEPTIC/HOLDING TANK DATA Date Installed ~/~'~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding/Tanl~: To Water-Supply Well )~¢20 To Property Line / ~ To Water Main/Service Line Course /~O N~. size /"~"-~ No. of Compartments Air-tight Caps (Y/N) ')¢" Foundation Cleanout (Y/N) 'Y' ~ Date Last Pumped {~/'/A ;for Temporary Holding Tank Permit (Y/N) To Building Foundation '"¢~1/ To Disposal Field // To Stream, Pond, Lake, or Major Drainage Comments 72-026(1 ~/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ~ N o"'r Separation Distance from Absorption Field: To Water-Supply Well 10 © "~' To Building Foundation To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field /O Depth of Field '7' ' Gravel Bed Thickness ~ Standpipes Present (Y/N) . ~"/" -- Dste of Last Adequacy Test '~ ~', To Property Line ~ ~: To Existing or Abandoned System on ; On Adjoining Lots ,/d¢t¢.) ~ /'Y'o/V Z.~. To Cutbank (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 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 ~/5~'-~f-¢-~¢--,~' Company ~2~"~ ~~ MOA No. { Date of Payment Amount: $ ~ ~'~ ~ ~?~ ........... ~/,,~ Engineer's Seal Page 2 of 2 72-026 (1 ~/84) ./203 W. 15th AVE "C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 CONSULTING ENGINEER SEPTIC SYSTEM ADEQUACY TEST LEGAL: LOCATION: OWNER: RESIDENCE: WATER SYSTEM: SEPTIC SYSTEM: DATE OF PUMPING: DATE OF TEST: TEST PROCEDURE: TEST RESULT: LOT 1, BLOCK 1, PARK HILLS 14500 GOLDEN VIEW DRIVE T. VOLLSTEDT SINGLE FAMILY, FOUR BEDROOMS ON SITE WELL FROM MUNICIPAL RECORDS: TANK: GREER STEEL, 1250 GALLONS, TWO COMPARTMENTS ABSORPTION SYSTEM: WIDE TRENCH ABSORPTION AREA: 905 SQ.FT. SOIL RATING: 225 INSTALLATION DATE:JUNE 1983 JULY 3, 1985 NOT TESTED, SYSTEM IN OPERATION FOR LESS THAN TWO YEARS. The operational life of all septic systems depends on the local soil conditions, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this septic system. We can therefore not give any estimate of how long the system will continue to meet the operational requirements of the Municipality and State. ,,203 W. 15th AVE 'C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 CONSULTING ENGINEER RESIDENTIAL WELL INSPECTION LEGAL: LOT 1, BLOCK 1, PARKS HILL LOCATION: 14500 GOLDEN VIEW OWNER: T. VOLLSTEDT TYPE OF WELL: RESIDENTIAL WELL LOG AVAILABLE: YES INSTALLATION REQUIREMENTS MET: YES WELL YIELD FROM WELL LOG: NOT GIVEN WELL YIELD FROM TEST: 1.1 GPM. PUMP YIELD: 5 GPM DATE OF INSPECTION: JULY 2, 1985 TEST PROCEDURE: WELL WAS PUMPED FOR 40 MINUTES WITH DRAWDOWN AND WATERFLOW MONITORED. WELL RECOVERY WAS MONITORED FOR 20 MINUTES. TEST FOR COLIFORMS: NEGATIVE TEST RESULT: THIS WELL MEETS THE REQUIREMENTS OF THE MUNICIPAL CODE. The Municipal requirement for well flow is 150 gallons of water per bedroom per 24 hours.This well surpasses this requirement. The assessment of the condition of this well applies only to the conditions as of this date. The flow rate of the well may change due to subsurface conditions that may not be observed from the surface, and changes in land use and other factors that may impact the conditions of the aquifer feeding the well. APPLI( ,NT FILLS OUT UPPER HA[.,. .,ONLY Property Gwner //~ ~,. ?. ~_.~ // p G Phone Mailing Addre~ ~ ': ~9 "~ ' Address Zip Cede Address Zip Code Address Zip Code Type of Residence ~S~le Family ~ Multiple Family No. of Bedroo~,., ~ Other Water SuBply ~'~ A~ACH WELL LOG. A well log is required for all wells drilled since .June 1975. ~ Community~/ For wells drilled prior to that date, give well depth (attach log if available). ~ Public ?ility Sewer DispoSal " ~ Public Utility When Connected to Public ~ti~ity: ~ Holding Tank - ' NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING OAN BE INITIATED. Time Time~ Ti~ Time Date Date Date Oat~ _~ {~ % '-~ Inspector Insp~tor Insp~tor Insp~tor Field Notes: f~ ~ ~ MUNICIPALI~ OF ANCHORAGE. DEPT. OF H~Z, LTH ~;~', ENVIRONM2N/AL P~OTECrlON RECEIVED ~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ( ) DISAPPROVED CONDITIONA~ APPROVAL* Hatina Date ~wer Installed Well To Absorption Area Well Log Reoeived 8oils ~~ Well to TanR 8eptio T~k Size / ~ ~ ' ' 72-023 (3182)