HomeMy WebLinkAboutSUE TAWN ESTATE #2 BLK 1 LT 12,Sue Tawn
sta
Block I
Lot 12
#051-501-3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
IF HOmE.DE: Inside I~ngt~
DISTANCE TO:
Manufacturer
Well
Material
We,, P°""dati°n:L Z N.are t,ot li .
DISTANCE TO: 1~ ~) '~
NO. of lines Length of ach liF~ Total len~ Trench w~
~ ' inches
Top of tile to finish grade~ J Material beneath tile
Depth
Length Width
Type of crib Crib diameter
DISTANCE TO'.
PHONE ~C~'N EW
NO. OF BEDROOMS
No. of compartments
Liquid depth
PERMIT NO,
Liquid capacity in gallons
PERMIT NO.
Distance between
PERMIT NO.
Class )epth
DISTANCE TO:
Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line
Sewer line Septic tank
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
APR 0 ED ?~
ATE
a
- Y
y
a
�
J
N
Q
00
w
w
Y
to
00
_
ltd.
acn
Y
O
_ `
Y
r'
J
►�
Lo
y
Lo
w
w
w
m
w
w
w
a
Y
acn
Y
�
_ `
J
a
a
Y
�a
w LL
LU
I
iy
W
x
m
W
Q
U
6LL
LL
w�2
y
O
a
►�
w
w
w
w
w
w
w
w
w
w
n
w LL
iy
w�2
t7o
r°l
O
O
O
O
O
O
O.
O
O "'
O
O O
s-•+
1
fy"
_v
'�'•.':
ce,
w
W
w
3
O
Q
Q
O
¢
3
A
o
w
w
w
w
w
w
w
w
w
w04
w
w
cy::, .
00:
O
"O
3
p
O
O
O
O
O
O
O
O
O
O O
H
H
w
Q
w
cG
w
w
cC
w
c4
z
0
C4
W 0G
Q
vHi
A
C7 `.L'
►�
n
iy
t7o
r°l
1;
i'i
%.T
fes'
a.
s-•+
1
fy"
_v
'�'•.':
ce,
w
W
w
3
O
Q
Q
O
¢
3
A
o
►�
i'i
%.T
fes'
a.
s-•+
µ
,;r
_v
'�'•.':
w
w
w
w
w
w
w
w
w
w04
w
w
cy::, .
00:
O
"O
w
w
w
w
w
w
w
w
w
w
w
w
z
�
vim;
,1•
_.
�;
�:
w
O
O
o
O
O
O
O
O
O
O
O
O
p
a:
W
W
CC
CL
0�
W
W
W
cL
Ca
w
w
w
w
w
w
w
LT.,
w
w
w
w
_z
x
►�
00000000000
Permit #
Location:
Legal Description: ~ /~S/~/~* /
Type of Soil Absorption System Is:
Trench: ~ Drainfield:
Maximum Number of Bedrooms:
Department
825 ~ Street, Anchorage, AK. _3501
264-4720
HANDWRITTEN
PERMIT
WELL AND/OR ON-SITE SEWER PERMIT
MUNICIPALITY OF ANCHORAGE
"' Health and Environmenta] ~rotection
Mailing Address:
Phone Number:
Lot Size:
Seepage Bedl
Holding Tank:
Soil Rating(sq.ft/br)
DEPTH
The Required Size
LENGTH
of the Soil Absorption System Is:
~ /
/
· GRAVEL DEPTH ~p 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 8 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
Signe~: ,-"~-~,~ ,'~,-~- ~' ~t J~-t,~-~'~ Issued by:
Applicant ._
SW?/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~ SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:.
LEGAL DESCRIPTION:
2
3
6-
7-
8-
9-
SLOPE
SITE PLAN
10-
11
13~
14-
15-
16-
17-
18-
19-
20-
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
· Time Time Water Drop
',/ '.. ,
•
!IN:7) Municipality of Anchorage - 9
On-Site Water and Wastewater Program 'ID I i .
z.
(907) 343-7904 E T Y
0011 3 2017
Certificate of On-Site Systems Appro
ti
Parcel I.D. 051-501-32 Expiration Dat `f r ncc' JGc�'1 4,20 �?01
�y
1. GENERAL INFORMATION:
Complete legal description SUE TAWN ESTATES#2; BLOCK 1, LOT 12
Location (site address) 18943 Melissa Lane*Chugiak 99567
Current Property owner(s) Burke &Janet Waldron Day phone
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: . --�f Date: 0/ f
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ '2-4en Waiver Fee $
Date of Payment 1,011 -7/11 Date of Payment
Receipt Number "g Receipt Number
COSA# AJC 111(4) Waiver#
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;
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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: %C)//3 //3'
oo�oOp
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o OF ,a Nin accordance with the guidelines and regulations established by the Municipality of Anchorage and ��( ..•.•••.• . 13A1)
industry practices. The reported results describe the condition of the system/s on the date/s of the .-. • / • V1
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or � . 4 H \ .�U�j
encroachments may exist that were not identified during the evaluation. The operational life of all wells / ,•; ; — V
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, �--`- a
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary,and ..� .. ... . O
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Qpp A. . n-
system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of Vn • cE— 95
the well or septic system. GEG makes no representation whether an alternative well or septic system VQ 9 �
can be installed on the property in the event either of the current systems fail to perform adequately in Op••�,. •••).D. !.3 /c c.
the future. The content of this report is for the sole benefit of the person/party that retained GEG to 4%�profess;°o°o�
perform the evaluation. Reliance upon the information provided in this report by any other person or �OO000�6
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
fSystem #1 Approved for 3 bedrooms
System #2 Approved for bedrooms �y
Disapproved 44.1,� ,0 4,�r /Conditional approval for bedrooms, with the following stips: y�.A`'�
ON-SITE ca-
WATER
WATER AND C"
WASTEWATER oz
PROGRAM
417'SFR��..
By: - Ccout.F3UOriginal Certificate Date: 10'20 11
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of_
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: SUE TAWN ESTATES#2 8LoaK 1 1.0T12.Parcel ID: 051-501-32
A. WELL DATA *WELL LOG IN MOA RECORDS IS ILLEGIBLE. INFORMATION BASED ON 2001 COSA
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) YES
Date completed *4/4/83 Sanitary seal (YIN) YES Wires properly protected (Y/N) YES
Total depth *230 ft. Cased to *230 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 4/4/83 9/26/17
Static water level 50 ft. 157.4 ft.
Well production 10 g.p.m. 3+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate 2.14 mg./L. Collected by: GEG, Ltd.
Arsenic: <5.0 ug./L. Date of sample: 9/5/17
B. SEPTIC/HOLDING TANK DATA 34 YEAR OLE/STEEL SEPTIC TANK IS APPROACHING THE
END OF ITS USEFUL LIFE
Tank Type/Material SEPTIC/STEEL Date installed 7/28/83
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout(YIN) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A
Date of pumping_ 6/22/17 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE AT MT
Date installed 7/28/83 Soil rating (g.p.d./ft2or 2/bdr ) 125 System type DEEP TRENCH
Length 32 ft. Width UNK ft. Gravel below pipe 6 ft.
Total depth *8.5 ft. Eff. absorption area 384 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 9/27/17 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 825 gal. New depth 2 in.
Elapsed Time: 102 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date -
-2017 GALLON PRE-SOAK WAS PERFORMED ON 9/26/17
D. LIFT STATION
Date installed Size in gallons Manhole/Access(YIN)
"Pump on"level at in. "Pump off' level at .• wa er alarm level at in.
• . - Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
ill
c OF
G. ENGINEER'S CERTIFICATION .�P44 � . • " f+14
C-)a ` ..I— *♦
I certify that t have determined through field inspections and I .49'i• iN ••
•
review of Municipal records that the above systems are in 0
conformance with MOA COSA guidelines in effect on this 1 ;
date. • s^ J f -y A. ss; wa
Engineer's Printed Name JEFFREY A. GARNESS '11 '. . C�jt� ::45...I.,
Date io/l I/4 •4 ' FESSt�4..•
LICENSE •Ivittt.v
*AECC884
(Rev. 10/12/12)
3°7/1
/ I Wella J.'
N
1e;,,;;nM to
76.1 - -
I I _ • .
/// t j ' - A s halt . 2 Stor11A -o
o r ,A P •Frame c)
f_ � a a
p I __._ • - HouseCO
or Drainage Easement 1/
Gravel driveway \ 30•0*CO •8.£3 - o
o
I I / C(D i
w j\ / / I ' \\ Lot 12 v
.., 2 . cva)
OG\ // / I32.4
Garage W Lot 5A cn
• \ / / I . o } >SePtic
vents M
A b
a\ // / 32.4131.9 - 0
�La, .:'\ / / Z ��� ‘ A 1
'�i� , C07r \// / �` amp P��• • ' •Ai_ .s
O.
%'�, G4, �j o Sre ice`'?'• 49tH �\
-� roo
-57I� 1?> \� / A %Fred Walatka :>? ow
0, '�
j 0„
•. 3255 - S ••s�,,,�
< \ Lot 6 '09 AMP
1 1 pRF� ENA�•�P
S510 _�
u)
oO 7\, o AS-BUILT NO CORNERS SET THIS DATE
•o N89 59 27 W 230.18
o \ I hereby certify that I have performed a Mortgagee's inspection
of the following described property: LOT 12, BLOCK 1,
\ Lot 13 SUE TAWN ESTATE, ADDITION No.2
\ 13°
Anchorage Recording District,Alaska,and that the
\ improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto,that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways,transmission lines or other
\ visible easements on said property except as indicated
SCALE: 1 50' hereon.
Dated at Anchorage,Alaska
EASEMENTS OF RECORD,OTHER THANthis 10th day of October ,2017.
W \
THOSE SHOWN ON THE RECORDED FRED WALATKA&ASSOCIATES,L.L.C.
PLAT ARE NOT SHOWN HEREON FB 17-11, pg 24 Engineers and Surveyors
UNLESS OTHERWISE NOTED. BE 907-248-1666
Mu.icipality of Anchorage
Development ServiceS DeJ artment
Building Safe~y Division
On-Sile Water and Waslewater Program
zlT00 South Bragaw St.
P.O. Box 196650 Anchorage, AK 995 t 9-6650
www.cLanchorage.ak.us
(907) 343-7904
Parcel I.D.o.Ct -5'¢ I- 3 3..
1.
CERTIFICATE Of HEALTH AUTHORITYA, Rp..R,O.V. AL
FOR A SINGLE FAMILY DWELLING ?
Expiration Date:
GENERAL INFORMATION
Complele legal description ~' Lot 12;
Location (site address or directions)
Block 1; Sue Tawn Estates #2'
18943 Melissa Lane
Current Properly owner(s) James Bennet t Day phone 696-6138
Mailing address 18943 )Ielissa Lane Chu.~iak AK 99567
Lending agency
Day phone
Mailing address
Real Estale Agent
Mailing Address
Unless olherwise requested, HAA will be hem by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
Debbie Lewis / Remax ER Dayphone 694-4200
16600 Centerfield Dr ste 201 EaRle River, AK 9957
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Comm~nity Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
Individual Holding tank []
Community On-site
[] Public Sewer []
The Munlcipalily of Anchorage Development Services Department (DSD) Issues Certificales of Health Authority
Approval (HAA) based only upon Ihe representations given In paragraph 5 by an Independent professional civil
engineer registered tn the State ot Alaska. Certificates of Heallh Aulhority Approval are required for the Iransfer of
lille (excepl between spouses) for properties served by a single tamily on-site waslewater disposal and/or water
s~pply system. DSD also issues HAAs upon requesl to homeowners. Certificates of Health Authority Approval are
valid for 90 days from tile 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. (Certificales may be reissued for a period of up to one year wilh
valid water samples.) Cerfifid~,tes are valid for one year for properties served by Class A or B wells or a public
waler system. The Municipality of Anchorage Is not responsible [or errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY E~Gi~EER
As certified by my seal affixed hereto and as of Ihe valIdalion da~e shown below. I verity that my Investlgalioh,
based on procedures outlined In Ihe Health Authorily Approval Guldellnes for Ihis application, shows Ihat Ihe
on-sile water supply and/or wastewaler disposal syslent is(are) safe, functional and adequate for the number of
bedrooms and type of structure Indicated herein. I furlher Verify Iha[ based on Ihe Informalion obtained from Ihe
Municipality of Anchorage files and from my Investigation and Inspection. Ihe on-stle waler supply and/or
wastewaler disposal syslem Is(are) In compliance i~,ith all applicable Municipal and Stale codes, ordinances,
and regulations tn effect at the time of Insla,allon.
Name of Firm
Address
Engineer's Prinled Name /~O~r~.eT'- C. C-'~,~...,.~
Phone ~?-,~ '7~
Date I~./;~¢/o f
5. DSD SIGNATURE
V"" Approved [or ~ bedrooms.
Disapproved.
Conditional approval for
~" ~_.h'GINEEi:[~c['~, ;',,:,..,~.'.},~
~-. --~ ~.;~...~ .... ¢~.,~..,..,~
~ g..% C.-8301 /~..
{t,' , .......',,,' ~
bedrooms, wi~h the following stipulations:
Addilional Comments
Attachments: ........
HAA Checklist
Septic SysJem Advisory
Well Flow Advisory
X
Mainlenance Agreements
SUpplemental Engineer's Report
Other
Original Certificate Date:.,
Municipality of Anchorage
Development Services Department
Building Safety Dlviskxt
On-Slta Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 A,.x:horage, AK 99519-6650
(997) 343-7994
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Date completed ~./~ ~
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
Sanitary seal (Y/N) ~/
ft.
FROM WEJ. L LOG
I C~ g.p.m.
Well Log (Y/N)
Wires pmbady protected (Y/N)
Casing height (above ground) I ~'~Lin'
AT INSPECTION
' ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Data of sample:
S. SEPTIC/HO. LDING TANK DATA .
Tank size t Z-~ gal. Nu~mber of Compartments
Foundation cleanout (Y/N) / Depression over tank (Y/N)
Date of'pumping Pumper
Nitrate I. ~,b mg./l. Other bacteria O colonies/100 mi.
Date installed .__:~~__
/
Cleanouts (Y/N)
High water alarm (Y/N) "~ ~ ]~
#
ABSORPTION.-.7/~J~/~ FIELD DATA (g.p.d./f~
Date ins~l~ ~ SoS rating
Lan~ ~ ~ ' ~. ~d~
To~I depth q. ~ ff. Eft. a~orpti~ ar~
Date of adequa~ ~t ~
Resul~
(P~Faa)
Fluid dep~ in abso~,onI 'field be~re test ~ ~. Wa~ adde< ~-~ gal
Elapsed Time: ~ min. Final ,uid deplh ~ in. ~s~pti~ tale >=
~y rejuvenati~ ~a~ant (~st 12 mo.) ~ & ~) ~/P~ [~ if yes. give date
System type ~
Gravel below pipe ~ ft.
Depression over field I'-,,t O
For "'~ bedrooms
New depth40 in.
~ g.p.d.
Size in gallons
D. LIFT STATION
'Pump on" level at/In.
Datum ~'Cycles tested
SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift~ on lot I
Absorption field an lot
Public sewer main
,
S,~/er/septic service line ~. ~ ..t.- Holding tank ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation _.~
Property line ~.4- Absorption field
Water main ~',,.! / ,~ Water service line I O / -~- Surface water
Wells on adjacent lots ~/
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
,
Property line ! '~ ~ Building foundation I O ~'¢'- Water main
Water Service line ~1~ I ~- Surface water ~ O ~ { Jr- Driveway, parking/vehicle storage
Curtain drain ~~Wells on adjacent lots ! 0 C~' ~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systerr~ are ~n
conformance w~th MOA HAA guidelines in effecf on this date.
Engineer's Printed Name /~;
Date
HAA Fee $ ~
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Data of Payment
Receipt Number
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
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
5'-0 J ~ ~'~2 'v HAA#'
Location (site address or directions)
· Property owner. '"'¢,o¼
.Mailing address , '"'
.Lending agency
':: Mailing address ':
Agent ~ ~ P~'
AddreSs
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~'~' ~'
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) F¢ont MOA 021
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm s · s ~_~_~6 Phone
17034 Eagle River Loop Road No. 204
Address E=~I~ Rh'~~ ,/
Engineer's signature ~ . K'~-~r~----
/[¥/'~//- ~ . Date
DHHS SIGNATURE
Y Approved for 3
Disapproved.
__ Oonditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Ar~chorage 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 s 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.
724~25 (Rev. 1/91) B~ck MOA
Legal Description:
Municipality of Anchorage MAR ~ ' ;//~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ~'~
825 L Street, Room 502° Anchorage, Alaska 99501 ° (9~0~
Health Authority Approval Checklist
,~u,~' I,~o'd ~'¥ '¢-,~ Parcel I.D.: C~J;'/ ~- ,5'-° I --3 ,')_
A. WELL DATA
Well type ?,¢.1 \l,qTl,-
Log present ('~N) L( ~; 5
Total depth ~ '?~D /
Sanitary seal ((~/N)
Date of test
Static water level
If A, B, or C. attach ADEC letter. ADEC water system number
Date completed
Cased to ,Z.., ,) ) Casing height (above ground)
Wires properly protected e~N)
FROM WELL LOG AT INSPECTION
'1
Well production
WATER SAMPLE RESULTS:
g.p.m. ~,"~¢ g.p.m.
Coliform O Nitrate
Date of sample:
B, SEPTIC/HOLDING TANK DATA
Date installed -~/,¢~/~ Tank size
Foundation ¢le~anout ~}N)
Collected by:
Other bacteria ~
~.~,. S & $ ENGINEERING
Eagle River, Alaska 99577
1.2'~.()(~) Number of Compartments ~. Cleanoutsl~ )
Depression (Y/~ f~ () . High water alarm (Y~'~
DateofPur0ping' 1¢i Pumper
C. ABSORPTION FIELD DATA '
Date installed .~¢ 1~/~/~'2~ Soil rating (g.p.d./fF ~¢/~/b~m {2.(i' Systemtype
Length ~,~ Width . ~ ~, ,,,',',, ~ravel thickness b~low pipe 7Z, Tota depth
Effective absorption area '~d"(~ Monitoring Tube present ~) (f~:?~ Depression over field
Date of adequacy test ~O {~¢ Results ~. ail) ~¢/~3 '¢ For
Fluid depth in absorption field before test (in.); .2 n Immediately afler~? ~, gal. water added (in.):
Fluid depth )[~ n (ins) Minutes later: /~ F,~,k- Absorption rate = /~ ~ g.p.d.
Peroxide treatment (past 12 months) (Y(¢ k)oNC ~¢~/~¢~.r~l If yes. give date
bedrooms
72-026 (Rev. 3/96)*
D. ' LIFT. STATION
Date installed -~- Size in gallons
Manhole/Access (Y/N) -~-~-_ ~ "Pump on" level at*
High water alarm level at* *D'~tum-_
Cycles tested
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
-I,
-/-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~ / -~' Property line ~,i~ Absorption field .~¢ / ~'
Water main/service line ~i-~ Surface water/drainage {~)0 / ~ Wells on adjacent lots /('?~ / ')
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~0 t ~.~ Building foundation /~ ~ 7~ Water main/service line
Surface water h~,~(3 ~ -h Driveway, parking/vehicle storage area
Cu~ain drain ~)~ ~ ~. to~,~J Wells on adjacent lots /d)~) / /''
ENGINEER'S CERTIFICATION
I ce~ify that l have determined thru field inspections and review of Municipal reco~fle abo
in conformance with MOA H~uide~nes in effect on this date.
HAA Fee $ ~0.00
Date of Payment.
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~...~q O~_ (~ '~ ~.
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Propedy'Owner,~/ ¢}~ Telephone:Home I~:'""~'"'~'Z'Business
Mailing Address ~, '~ ~ ~1~, ~. ~~
(c) Lending Institutio~ ~,: [)~ ~ Telephone
Mailing Address . . "~~ ~
Address ~ ~~ ~' ~~~ ~,
Telephone [~ ~ '
(e) Mail the HAA to the followin~ address: or: Check here~ if hold for pick up.
List contact person and day phone number below. --
S & S ENGINEEP. ING
17034 F..9;~ ~,;,~.~ L,.~i; R,;a.-.' NO. 2.0~.
Ea.qle River~ Alaska 9~577
TYPE OF RESIDENCE
Single-Family~
Number of Bedrooms
WATER SUPPLY
Individual Well/~ 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
Onsite~~.- Public [] Community [] Holding Tank []
Note: If community wall system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 IRev 8/861 Front
'~JoM s,Jaeu!Su@
leUO!SSejoJd aqi u] SUO!SS!LUO JO SJOJJa Jo1 alq!suodsaJ lOU S! aSBJoqouv to/q!iBd!o!unl~ eH.L 'panss! s] @~,eo!jj~JaO e
elep aZAleUe Jo suojlo@dsu] ~3npuoo Iou op SHHQ jo SaaAoldLU=~ 's$uouJaJ!nbaJ aleis pub leJapaj ulepao AlSi~Bs ol Jap JO
u! suogni!lsu! bujpual J]aql puc SaLUOq JO sJaseqoJnd o~,/~sapnoo e s~ s!q~ saop SH HQ aqJ. 'e~sel¥ jo a~,S aq~ u!
Jaau!bua leUO!SSajoJd iuapuadapu! ue Aq a^oqe ~ qde~§eJed u! ua^!b suo!~Eiu@saJdaJ aqi uodn ~lUO paseq
le^oJddv/~I!JOqin¥ qlleaH sanss! (SHHQ) saoJ^J@S UeLUnH pue q~ls@H JO luaLu]Jsdac] abeJoqouv Jo ,~l!l~d!oIun~l aqJ.
NOI.LnVC)
le^oJdd¥ [euo!~.!puoO jo suJJe/
leUO!)jpuoo pe^oJddes!Q ~(- pe^oJddv
'9
? /
euoqdela.L
'ON pl~o~] ~*~ .le*l~ ell~"~ ~'$0/I, SseJppv
.............. uJ~!~l lo eUJ~N
'uo!jo@dsu! s!ql ,~o elep
uo lOej~e u! sUO!leln~)J pue 'sa3uEu!pJo 'sapoo 91819 pu~ Igd!a!unl~ lie qlF~ eaUe!ldLUo3 u!
Jo/puB ,~lddns Jele/~ a~!s-uo eql 'UO!laedsu! pu8 uo!18b!lsa^u! ,{Lu LUOJ~ pu8 Sel!J ebeJoqou¥' JO ,~!lEd!o!unlAI eql LUOJJ ·
peu!~lqo UO!~BLUJOjU! eqi UO paseq leq3 ,~J!Je^ JeqlJnj I 'u!eJeq pe3Ba!pu! eJnlanJ~s
el~nbepe pue ieuo!lounj '@jgs s! LU GI$,~S lesods!p Je~e/~else~ Jo/puB ,~lddns Jele~ e~!s-uo eq~ ~eq~ s~oqs 18^oJdd¥ ,q!Joqln¥
qlieeH s!ql ~o UO!le§!~se^u! ,~LU leql ,~J!Je^ I '~oleq u~oqs elep uo!lep!le^ eq~ ~o se pue oleJeq pex!j~e I~aS,~LU ,~q pa!i!~Jea SV
NOIJ. VlN~dO4NI GNV Y.LV(] 'H31:1'¢:15 3'11:1 'S.LS:I.L 'SNOI.LO:~clSNI
.,.~¢.,~O~,kGr~u~IICIPALITY OF ANCHORAGE (MOA)
· \.~ O'~ ~..~_ O~'~\~(E~LTH AUTHORITY APPROVAL (HAA)
~C~,~ ~ 5~~ CHECKLIST- FEBRUARY 1984
~''~ ~ 264-4744
WELL DATA
Legal Description:
Well Classification ~..~'C~v.,]'V~ ~ If A, B, C, DEC. Approved (Y/N)
Well Log Present ~-~/N) '~ Date Completed "~ z:~ ~ (E:'"~2 Yield
Total Depth '~"~::~" Cased to "~-"~ ~' ~ Depth of Grouting
Static Water Level \ ~'~- ' Pu m p Set At L.~ ~--,
Casing Height Above Ground
Electrical Wiring in Conduit (~N)
Separation Distances from Well:
To Septic/He!di~ Tank on Lot
Sanitary Seal on Casing ~(~N)
Depression Around Wellhead (Y/~)~
; On Adjoining Lots
To Nearest Edge of Absorption Field on L~ot \ \~ ; On Adjoining Lots \
To Nearest Public Sewer Line '-~/,~'~ To Nearest Public Sewer
Cleanout/Manhole r'~/~', To Nearest Sewer Service Line on Lot
Water Sample Collected by '~ ~ '~..~'-~ ~, Ir'~;t~;;:v'z-4~¢~ ;Date ~ ~ ~'"~
Water Sample Test Results ~,.'¢'"'~T-'\ ~,~'i:'~-.~:~;-"~c;~-'-~-/ ~;~,~'~, ~ ,'
/
Comments [~"~.....L~ ,~L.-4~L,~ ~ ~::~-'-~'~---F'~ ~.--.t~
B. SEPTIC/~TANK DATA
Date Installed 1~''~(~'~ Size
Standpipes ~?/N) '~' Air-tight Caps 4[~¢)N)
Depression over Tank (Y,(:~.~
Pumping/Maintenance Contract on File (Y/N)~..~
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Hol~iag Tank:
\ ~"~ No. of Compartments '~
Foundation Cleanout([
Date Last Pumped '~Y~ I,d¢
; for
Temporary Holding Tank Permit (Y~N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Comments '~2~
To Building Foundation \ ~
To Disposal Field ~ /
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date installed ""1 ~'~-~2 ~ ~;~"~
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/~
Results of Last Adequacy Test
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present ~N)
Date of Last Adequacy Test
Type of System Design
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Y
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~
To Cutbank (if present)
Comments
'"~:::~J~st nile d
Size in ~
"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)
g Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
IsiC~:t iefdy ;~; Icl. i;; ~; ;,id r i f i e d, or co nf;:t?d t?//~ A..~TFA~g uidelines in effect on the date of this inspection.
Comparl~034 Eastle Ill,er Lop Road No,~"A No. C~./~-~
Eagle River~ Alas a 9 57:7
Receipt No.
Date of Payment CTC,~-~'
Amount: $ ,/ ~--~ (?'P~'~
Page 2 of 2
72 028 fRev 8/861 Back
~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
~',.~'o~;,~,E;"~ FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order # 6134
Date Report Printed: APR 18 SS @ 11:44
Client Sample ID:L12, B1
PWSID :UA
Collected APR 13 88 @ 10:30 h~s.
Received APR 14 88 @ 16:45 hts.
Preserved with :4 deg. C
Client Name : S & S ENGINEERING
Client Acer : SNSENGP
P.O.~$ NONE REC'D
Req #
Ordered By :
Analysis Completed :APR 15 88 Send Reports to:
Laboratory Superviaor,:STEPDEN C. EDE 1)S ~ S ENGINEERING
Released By :~~- ~ 2)
Special
Instruct:
Chemlab Ref ~: 9699 Lab Smpl ID: 1 Natrix: Water
Allowable
Parameter Tested Result/Units Method Limits
NITRATE-N 1.4 mR/1 EPA 353.2 lO
Sample ROUTINE SAMPLE
Remarks: SA},~LE COLLECTED BY R.A.
1 Tests Performed See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA- Not Analyzed nT-Lese Than, GT=Greater Than
ACHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
"~-PRIVATE WATER SYSTEM
Name Phone No.
S & S ENGINEERING
....... u,~ 2h'~i' Lool~Road ;-,i~. 204
Mailing Add~l~ye River, Alaska 99577.
City
SAMPLE DATE:
, State
Mo. Day Year
Zip Code
SAMPLE TYPE:
~ Routine
Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
.) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
31
4 I
S I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
A.~naly~ shows this Water SAMPLE to be:
~/,Satisfactory
[] IUnsatisfactory
[] Sample too long in ti'ansit; 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*
J
I FTq
I FTq
Analyst
READ INSTRUCTIONS
Membrane Filter: Direct Count /-~ Collformll00ml
BEFORE
COLLECTING SAMPLE
Verification: LTB.
'.Final Membrane Fllt~_~
,Reported By ~_~(¢
TNTC = Too Numberous To Count
OB = Other Bacteria
.BGB
Date
Time:
Coilformll00ml
.h
APPLI¢ qT FILLS OUT UPPER HAl. ONLY
Address
~ ~ >,/:/
Realty Co. & Agent Phone
Address ~) ~½~_ ~. Zip Code
Type of Residence
[] Other
Water Supply
~lndlvldual ATTACH 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 Utility
Sewer Disposal
P~bll¢ Utility When Connected to Public UBllty:
FI Noldin§ Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Inspector Inspector Inspector Inspector
Field Notes: ~ ~ ~l
( ~ ) APPROVE~ BEDROOMS 'CONDITIONS OF APPROVAL
~ ~ ~,s~.pRow~
~ ~ co.~,~,o.~...ow~'
Soils~ Date ~wer Inslalled Well To Absorplion Are~ J J ~ ' Well Log Received
~ ~ Well to Tank /~ Septic T~k Size