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HomeMy WebLinkAboutWHALEY #3 BLK 1 LT 1Whal y Block Lot I #051-492-50 ~ MUNICIPALITY OF ANCHORAGE '- L/ 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 PHONE ~J~IEW NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well I Absorption area ILiq. capacity in gallons I ,: u~:~nn~, ~ Inside length Manufacturer /A ~ %* Material be~a~ til~ Top of tile to f~nish grade ~ / ] ~ Length Width Depth Type of crib Crib diameter Crib d Well Building f ation Class Depth D~ Driller OISTANCETO: Building foundation~w~li~/ /~ Material Nearest lot line ~.~ ~ Trench wi th No, of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO, Distance between lines Total; f f~'i~_.~ S ~i~O n~a r~ea PERMIT NO. Total effective absorption area Nearest lot line Distance to lot llne PERMIT NO. Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING ~/~ INSTALLER ~eo 7T REMARKS ~~APR OV ' ~r' i::'F_'- F'. H I T f",! O. !~ FF ......r f', , LJ] E:i::iT I ON L.EGI:~L L.OT .:, _. ,~ E T'YF'E OF :::' :'r_ FiE:SOF:PTtON :~.;'-/~.';TEM_,-,T':: _-'~-';'¢ TIJF'T-r:'.i, .. _ .. ~ .-F" HFI::':'.I,r"IIJM .............. N P::EF:' -iF:' BEE:,R£)OMS =; ~.;. SO :[ £~ RRT i t'.,IG "E 'J, FT/E:F:: :: .... ;:L±4- TNE F:E]!..IF:!ED :,I,~.E. OF THE SOIL F~E'.E'ZRF'T!ON S'¢STE!"! T:,. THE LENGTH [:,IMENS):ON IS THE LENGTH ,::.I.'N FEET) Of: THE TREi'.,!CN Oi~'. DF:FIZNFIEI_D. TFIE [:,EPTI'4 OF R TRENCH OR PIT iS TNE DZ'Z, TRNCE BETNEEN TNE SLiRFFICE OF TNE GROLIN[) RND THE BOTTOM OF' THE EXE:FIVRTZ£::!N (!N FEET). TNE GFR~',,,'EL DEPTN IL:; THE M:!.'NIHUM DEiF'TH OF GFRFIVEL. EK.{"I'NEEN THE Ou"rFRLL PIPE FIND THE' BOTT'OH OF: THE E::-::E:Fi',,,'RTIOi'.~ ,::i1'..! FEET). Er~.,lI~ FIPPLICFfi',IT NFiS T'HE ..~%,SF'rqf',iS'[E~t_'!T'.? TO I'.,tFERf,1 Z i'.,l'E TF__.Frl- Z: I''1 Z I'.,ISF'ECT I Oi'..!S IF FIN'T' I,IELLS FI[:,..)'RCEI',IT T'O NLtMBER OF RES!DEIx!CES THFIT THE I,£EL.L £,.IiM_. SER','E. , ! ! :, [:,EF'RR1-MENT [:,LiF:'. I NG THE I = ~:'~. "'" '!"HE HI_, P~']F'ER!"T' ,,,.!L- B FI C t< F I L. £.. I N G £] F FI !'.,! ? S ¥' S T E N !. ,~ I T H O LIT F ! N R L Z I'-.!'~.; F' E C T :r 0 h,! FtI% [', FI F' F' .F.:: O V F:! L. E','~" 'f' F! I S C, EF'RF:TMEI"~T I,.1 ~LL. E,E. _,UE, J ,_t..T T -~ F'P- ': E' ": rf,' ~ Oi'.,!. MINiMLIM DIS'TRNCE E:ET!.4EEN FI NELL RND I::IIq'T' ON-SITE SEI.,.IFiGE [:,ISPC~SF~L S?S'FEH :LETO FEET FOIl'. R F'RI',,,'RTE 14ELL OF: !5E~ TO ;?.¢~E~ FEET F'F~OM F! PUBLIC NELL DEF'ENDING UPON THE T'¢PE. OF P£JE:L!C NE:EL MINIHUH DISTRNCE FROM R F'RIVI::ITE !.4ELL TO R PRI',/FtTE SEI.,.IER LINE IS 25 F!ZET RN[:, TO R E:OMHLINIT'~.' L:;.,EI4ER LINE IS 75 FEET. !-,.!EL.L LOG5 FIRE.: I';i:EC!UIF'.ED RN[:, MUST E~E F:ET£JF.:i',!ED TO OF ']'HE !-,.!ELL COMF'L. ET:£ON. OTHE,~?. F;EQUIF'.EMENTS I"lff¢ FIPF'L'?'. .'.21PECIFiCRTlO~,IS FINE:, C:ON'.:;TF?.IJCTiON R',,,'F~IL~BLIi~: TO Ii'.4SUP. E F't:ROF'EP. INSTRLLP, T!ON. ! CERT!F'?' THRT .1_: I RM FFIMILIFIR !41TIq THE REQ£JiREMENTS FOR ON-SITE SE!.,.!ERS FIND NELL'.:; FIS SET FOF?.TH E:'¢ TI.-IE I','IL!i'.,!IE:IPRLIT'¢ OF RI',!C:F!OF~'.F]GE. 2: I 1.4ILL iNSTFILL. THE ::.';'¢STEM If-,! RCCORDFINCE i.,.!!TH THE C:ODES. ]:: ! UNB, EF:'.STF~I'.,iD 'T'HRT THE ON--SITE S;EI.,.iEF: S'T'STEM I'IR? P. EQUIF-.".E ENLRRGEMEHT IF TNE RE'_:;IDEf'.,iCE iS REMODELED TO INCLUDE I"tOFtE THI:IN ,ll-r ._ 11...h I'1 .... F~ ' -"~ ~- I SS£JE[:' E'.'¢ - }FI"f'E .... (,~/ ~.~.j ~ 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: 1 10 12 13 14 15 16- 17- 18- 19- 20- SLOPE SITE PLAN ENCOUNTERED? ~ pO E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN COMMENTS by DOC CO. dba SULLIVAN WATER WELLS P, O. BOX 272, CHUGSAK, ALASKA 99567 · TELEPHON 5 688-2759 OWNER OF LAND J;' A'~J ADDRESS .~" ~'' ~' LEGAL DESCRIPTION ~. 7 ~ /~e& 7< DATE - Sta,ea 7,/ 'fl ,/Y'~ Ended PERMIT NUMBER' DEPTH OF WELL / -~"~ / STATIC LEVEL OF WATER FT. GA~. PER HR KIND OF CASING // d KIND OF FORMATION: From ('.~ Ft. to ~'? Ft. From ' -, Ft. to 0 Ft. From ~ Ft. to"Z~ 5'"' Ft. From__.Ft. to Ft. Fmm~Ft. to /O ~'Ft. From__.Ft. to.__Ft, cC~tq r~ ,'~.q / ~' ,~?'~d ~ From Ft. to Ft. ~ ,,'~ a ~ ~0 ,,<F-e [~ From /6h Ft. to /,'~O Ft. ,_3.~J~-o~d] (_~ ,~,,,.; ~ From Ft. to Ft. ,d' /~ o ~-' < ~C ,~ -[ From /.~)O Ft. to /~/~'~'Ft.i ,,~'~,,~,9 ' From/%'~ Ft. to /~d~Ft. ,5'7/~ ~t~. /c From Ft. to Ft. ~O ~( ~7~. From __Ft. to Ft. From Ft. to Ft From __ Ft. to Ft. From Ft. to__ Ft. From Ft. to Ft From__Ft. to Ft. From Ft. to__.Ft From Ft. to Ft. I~UNICIPALITYOF ANCHORAGE From Ft. to Ft. DF~T C-! ..... · - ENVI~.,u r..~. .O F , From Ft. to Fr From Ft. to Ft._O~l o ~ Jg~ From__.Ft to FD ~/'~l'; V[~,/,.~..F D From Ft. to Ft. From Ft. to Ft. From Ft. t0 Ft. From Ft. to Ft From Ft. to_ Ft From Ft. to Ft From Ft. to___Ft From Ft. to Ft. From Ft. to__.Ft. From Ft. to__.Ft MISCL. INFORMATION: DRILLER'S NAME Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 w,,wv.cLanchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. (~/- ~CI~ - ~0 Expiration Date: '~- ! "~- O ;='='='='='='='='=~- 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Current Property owner(s),d Lt<~, h c,. ,.~ ~-o.. ~...,1~5 v~ ~,.~ Day phone ('EC~ Mailing address ~--~'O~L'} Q~vM. ~¢,) (1./tL4~/o~.'/o,, /~' Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for p/ckup. 2. NUMBER OF BEDROOMS: "~ 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] DE] Individual Holding tank Community On-site [] 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 fam~y on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further vedfy that based on the information obtained from the Municipality of Anchorage flies 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. Eagle River Engineering Services P.O. Box ~73294, Eagle River,~ 99577-3294 Name of Firm Address Engineer's Printed Name 5. DSD SIGNATURE .~--/~ Approved for 3 Disapproved. Conditional approval for Phone bedrooms, bedrooms, with the following stipulations: Additional Comments WATER AND WA:51 ['- WAI i:::R PROGRAM ..... By: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: {Rev. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bregaw St. P.O. Box 196650 Ancherage, AK 99519-6650 www.ci.anchomge.ak.us (~07) ~3-7~04 HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: ~,/haJe? ~'3.~ Zof I; ~/~ck I A. WELL DATA We~ type ~r; wte Date completed Totaldepth i1~'2.' fl. If A, B, or C provide PWSID # /d ~ Sanita~/seal (Y/N) Ycs Cesed to ~ ~' 7' ft. FROM WELL LOG Date of test -~- Static water level //~' fro Well production g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/t00 mi. Date of sample: //- ,,t_ ? ~ o ! Nitrate Collected by: Parcel ID: 0 b'l-- ~ 1'2- 5'0 well Log (Y/N) ~'q f Wires properly protected (Y/N) Ye .5 Casing height (above ground) '~ / -% in. AT INSPECTION /0- /~- ft. g, ',' g.p.m. mg./L Other bactade 0 colonies/100 mi. SEPTIC/HOLDING TANK DATA Tank Type/Material $ f(<. I Tanksize I(~00 gal. i¥' ~.,~L~,mberofCompartme~ts-2,.-- Foundation deanout (Y/N) ~. Depression over tank (Y/N)/,/0 Date of pumping Data installed Cioanouts (Y/N) ~'e5 High water alarm (Y/N) /VIA I A- 3 - o / Pumper Co ABSORPTION FIELD DATA Date installed ~[,ZO I ~ Soil rating (g.p.d./ft Length ~ 0 / fl. Width ~-I ft. Total depth ~' / ft: Eft. absorption area/--/~'~, ft2 Monitoring tube Y Date of adequacy test I~ / ~'( o I Results (Pass/Fail) Fluid depth in absorption field before test .I.I Y~. in. Water added ~' £~ gal. Elapsed Time: / -~.~ min. Final fluid depth ~ ~ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (y/N & type) 4/0 System type Gravel below pipe ~ ft. Depression over field Fo~ ~ bedrooms New depth 2. ¢ in. '+ ~ g.p.d. If yes, give date D. I~FT STATION DatXstalled "PumpX level at in. Datum k E. SEPARATION DISTANCES Size in gallons 'Pump off' level at in. Cyctes tested Manhole/Access (Y/N) High water alarm level at Meets alarm & cimuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ._J ~)~, ' "~"~' Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/deanout Holding tank .4/'/,.t' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main ~ Wells on adjacent lots Property line ~ ~ o Water service line Absorption field 5' / Surface water + ~/ SEPARATION DISTANCE FROM A~SORPTION FIELD ON LOT TO: Property line Water Service line 'J'/~ Curtain drain Building foundation Surface water t~/ Wells on adjacent lots Water main A//A Driveway, parldng/vehicte storage 4. I~' / F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspec~ons and review of Municipal records that the above systems am in conformance with MOA HAA guidelines ~1 effect on this date. HAA Fee $ ~ (~ Waiver Fee S Data of Payment / ,2/~'/~' Date of Payment (Rev. 12/00) oEr.-0$-Ol QB:4T~i Ffl~t~,,-CT&E EIGIIl~t,[flTkI. STW 907~6~5301 T-SZ3 P.O2/O$ F-T4Z CT&K Re f.,v C~ent Name Pre. ct Name~ Owle~x~d By 1018143001 F~g~e River Ear, inhering Lot ! Btk I WHaI~ l~1 Lot 1 Blk I Wh~k~y #3 Dr/nking Walg~ CTk~t Printed I~tte, rf{me 122115/2001 8:56 Calk. treed D~tefrlme I 1/28/2001 15:42 Received D~'r./Time 11/9_0/2001 PQL Init Nl:rele-N 2.43 0.500 mg/L EPA 300.U (<10') I l/2')/01 SCL c61/]O0~nL SMIS ~1222B (<1) Ilt29~1 ICAP 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. # 0 ~" I - 1. GENERAL INFORMATION ::' Complete'legaldescription ~ot [, ~[ock [, wha[e~¢s/D Location (site address or directions) 24030 Park Circle Property owner Mailing address David Fox Day phone 696-4856 Lending agency Premier/Margie Hall "M~ilingaddress 11901 Business Blvd. ,Bldg. Agent Address Day phone 696-0701 B, Eagle River~AK 99577 Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 3 NOTE: XXX Individual well Community welt Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site XXX Ho!ding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 724325 (Rev, 1191) Front MOA #21 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 Address Engineer's signature S & S ENGINEERING Eagle River, Alaska 995~ Phone Date /~/-~/~ Se DHHS SIGNATURE IJ Approved for Disapproved. Conditional approval for bedrooms. Additional Comments bedrooms, with th-e following stipulations: 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 ragistered 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% work. c ora e t<L-CEIvbb'... Municipality of An h g 825" ' Health Authority Approval Checklist Legal Description: ~../ ]' l~ ]j ~U//"/"~/-C-~7' JO//D ¢3 Parcel [.D.: A. ~LL DATA Well ~e ~ / g~ If A~ B, or C, attach ADEC letter. ~EC water system uumber Log prescu~'N) Y~ Date completed Total depth / ~-2 / Cased to / ~-2/ Sanitary seal ~q)Vd;"-5 ©5"/-~4ql-Yo Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O Date o£ sample: B. SEPTIC/HOLDING TANK DATA FROM WELL LOG /~- g.p.m. ¢'~',, 2- g.p.m. Nitrate ~., 6 q Other bacteria Collected by: ~<'t~<' ~"/F'~'/ ,/ Dateinstalled_~/f:)~- Tanksize /gS~O~ Number of Compartments '~ Cleanouts~N) / / Foundation cleanout (Y~ } ~ $' ~ Depression (Y~ ~0 High water alarm (Y~) ~/ /~ / Date of Pumping /~/Z~/~ Pumper ~ ~ / C. ABSOR~ION ~LD DATA Dateh~stalled ~ Soilrating (g.p.d./fi20~ //~ System~e Le[~h ~ Width ~ Gravel thickness below pipe ~/ To~I depth ~ ~t, Effective abso~tion area ~¢~ ~ Mo~toring Tube present~)'~ Depression over field (Y~ ~ Date ofadequacy test ~{~[~ Results~ail)~D5 For ~ be~ooms Fluid depth in absowtion field before test (in.); / ~ ~' Immediately aaer~gal, water added (in.): ~ D ~ Fhfid depth /////' (ins.) Minutes later: ~ Abso~tion rate ~ ~ = g.p.d. Peroxide trea~nent (past 12 months) (Y~O~& ~V If yes, give date AT INSPECTION Casing height (above ground) I Wires properly protected~N) D. LIIFI' STATION Date installed Manhole/Access (Y/N) HighcyclesWater testedalarm level al* 7/ / E. SEPARATION DISTANCES Size in gallons "Pomp ouTM level tit* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /Offff/"/- ; On adjacent lots __ /~gg[;) /~- Absorption field on lot /~5~ (¢ ; On adjacent lots /~?O Poblic sewer main /%//,,4 Public sewer manhole/cleanoat Sewer/septic sclwicc lioe .,~. ~- 'P Lift statioa /[ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Buildiag fouodation /L9 t.p Property line ~ (/- Absorptioo field Water main/service line /t~.~ 5 Safface water/drainage //¢~7~)/¢- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building fonndation /(Q/~ Water main/service lioe /tQ /P- Surface water //~0/C- Curtain drain /V/~,4/(~ tgffA,/F/42/~) Driveway, parkiag/vehicle storage area /g7 Wells on adjacent lots //O~) (/- Property line F. ENGINEER'S CERTIFICATION I cert~v that i hm,e determined thrufield m~ectlons and revtew ofMumctpal rec~d~l~Yhe a~al,a,{~?~b~.~ are in conJbrmance with MOA HAA guidelines m ef~ct on this date. ;;:{ c>/ .... e" ~CL' . .......... ................................................................................................................ [ ~s~a~ HAA Fcc $ ~..~,~ ~. 0,~_~ Waiver Fee $ Date of Payment [ /~' ~'~ (~ 9 Date of Payment ReceiptNamber ~/~:~C/7 ( ~OJ ) Receipt Number Rev. 8/95 OSS: haa.wk.doc BOV-Og-gg IS:]6 FROM-CI'E ENVIRONMENTAL ~t~m~CT&EEnv; ton men raise rv;ce$lnc. T-744 P.O~/O3 F-60~ CT&E Client Name Projo.~ Name/# Client Sample ID Ordered By PWSID Sample Rem*rlc~: 996125001 S & $ Engineering L1, BI, Whaley LI, Bi, Whaley S/D Drinking Wa~er 0 Client PO~ Printed Date/Time l 1/09/99 11:40 Collected Date/Time Ii102199 11:15 P. eeelved Date/Time i I103199 09:15 Teelmlcal Director: Stephen C. Ede Totat Cotiform 2.6~ 0.500 mS/L EPA 300.0 0 cot/lOOmL SH18 9222B Limits Date DaTe Init 11/03/~ 11/03/~ SCL 11/03/~ rap 30.1)' N 89'59'27" E 176.46' Lot 1 WOOD DECK RECERrIFIED 1HIS 18th DAY OC7OBER, 1999 NEW 15.5' X 16' DECK ADDED, LARGE SI-fED REPLACED WITH SMALL SHED. NOTE: lhls is o lecerUficcdion asbuilt - No corne~s were set this suvey OF- m-~ ~ ~ ~1~ JACK V. GARRISON ~ )ES. ~DAIE 4/04/93 hereby certify that an accurate survey of the iml)~ovements on the following desmibed p LOT '1, BLOCK 1 WHALEY SUBD., 3RD ADD. was mode on April 1, 1995, and thrlt improvements situated thereon ore within Ihe on the p~operty lying edjncent thereto crud on the premises in quesUon, except os shr~wn ond '.hot there ore no visihle or plotted trion U~ose shown in U~e recorded Dior. JACK W. GARRISON, PLS Phone 892-6160 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.# ('~\-LIcI~-,~~'3 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner -~J'd)/;/-^~ ~ ~/-/~',J,~ ~-/)o&~,~ Day phone ~-o~o¢'¢Z-~ Mailingad~r~ss EOF-- ~/~ :.,"~-~'Z~ ,,~b"~/ :// Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 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 Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (Rev. 1/91) Front MOA ~21 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 Davi,'l Re Daytml P-E. Phone (' 20210 Donalar St. Address Chugiak~ Alaska 9956~ Engineer's signature ~/~'~ ~'/~' ~"~ Date r~,,/~-~ DHHS SIGNATURE Approved .for Disapproved. ~bedrooms. Conditional approval for bedrooms, with the following stipulations: 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 a. independent professional engineer registered in the State of Alaska. The DH HS 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.  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: (.oH-,cH~,?,?,?,?,?,?,~¢ ~,~ ,'~ ~-'°~ Parcel I.D. A, WELL DATA Well type ~/Lzd,~¥,r~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed '7/'7 / ~'Z_. Driller Cased to 1 ~'Z- Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test '~/7/'¢'z~ Static water level ,) / Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /' Absorption field on lot //~'~ Public sewer main Sewer service line g.p.m. AT INSPECTION ; On adjacent lots /ac) '-¢'~' ; On adjacent lots /z~¢*¢~' Public sewer manhole/cleanout /t'/,/ctc- Petroleum tank /~o/Jt~ )i~,---LO WATER SAMPLE RESULTS: Coliform ~.-) Date of sample: Nitrate Other bacteria Collected by: ~ ~ ~¢'¢'~m'¢¢''] B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) Y High water alarm (Y/N) Date of pumping Tank size / ~¢~2) Compartments Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) Pumper ';~¢'5 ~//u'wT/~~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I C) '~. On adjacent lots ~ 0~' 1~ To property line Surface water/drainage Foundation "~ Absorption field ~2 Water main/service line 72-026 (Rev, 7/9~) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~,//~-¢,./,.~ ~-- Length z//~::~ //- Width Total abSOrption area Depressidn' over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for t-// If yes, give date System type Total depth Y bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ,/ To building foundation On adjacent lots Surface water / c~o -~- Curtain drain On adjacent lots /OO/-- Property line To existing or abandoned system on lot Cutbank I ~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date Davi,'t R, I)aytoll P.Ig. 20210 Donalar St. Chugiak~Alaska 99567 HAA Fee $ /7~'d7~ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 D. R. DAYTON, P.E., R.L.S. ~xX~~ Chugiak, Alaska 99567 20210 Donalar (907) ~ ~,~ 696-2417 April 1, 1993 WELL FLOW TEST Legal Description: Lot 1, Blkl, Whaley Subd., Addn ~3 Date of Test: March 31, 1993 Depth of Well: 152' Static Water Level: 123.5' Driller: Sullivan Water Wells Requirements: 3 bedroom - 450 gallons per day Test: The well was pumped with the existing pump through an outside hose bib. The well was pumped with the valves fully opened.for 75 minutes. The well produced 479 gallons in 75 minutes at a rate of 6.4 gallons per minute with a total drawdown of 0.5'. The drawdown was fully recovered within 2 minutes after pumping was halted. Results: The well is currently producing adequately for a 3 bedroom home. D. R. DAYTON, P.E., R.L.S. ~x~~!~ Chugiak, Alaska 99567 20210 Donalar 696-2417 April 1, 1993 ADEQUACY TEST Legal Description: Lotl, Blk 1, Whaley Subd. Addn #3 Date of Test: March 31, 1993 Septic Tank: 1,000 gallon, 2 compartment, steel tank (DHHS Records) Absorbtion System: 3' wide x 40' long x 3' effective depth trench (DHHS Records) Soils Rating: 114 sq.ft per bedroom (DHHS Records) Requirements: 3 bedroom - 450 gallons per day Test: Water was injected int~ the absorbtion trench while monitoring time, volume, and rise in the system liquid level. 479 gallons were injected into the system in 75 minutes with a 0.67 ft. rise in the liquid level. The total rise had seeped away in 90 minutes. Results: The septic system absorbtion trench is currently functioning adequately for a 3 bedroom home. .... CHEMICAL & GEOLOGICAL LABORATORY  A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Chemlab Ref.t =93.1281-1 REPORT of ANALYSIS Client Sample ID :L1 Bi WHALEY SUB 3RD ADD Matrix : WATER Client Name :DAVID DAYTON, P.E. Collected :03/29/93 @ hrs. Ordered By :DAVID R. DATTON , Received :03/30/93 @ 10:30 hrs. Project Name : WORR Order :64420 ProJect~ : Report Completed :04/01/93 PWSID :UA Technical Director ~C. Released By :~~ Sample Remarks: ROUYIRE SAMPLE COLLECTED BY: D.R.D. QC Allowable Extract Analysis Parameter Results Qual. Units Method Limits Date Date Init NITRATE-N 1.47 ~g/l EPA 353.2/300.0 10 03/31/93 LLH * See Spemial Instructions Above UA - Unavailable " See Sample Remarks Above NA ~ Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT - Less Than D - Secondary dilution. GT - Greater Than MUNICIPALITY OF ANCHORAGE DMSION OF F~NVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND EN~JIRONMENTAL PROTECTION 1. C~ne~a! Information Application Date / / la) Legal, E~.scrip~tipn ('~/c~u~e lc>t~ block,, sub_division, se*tion, to, reship,-range) Location (adci~ess c.~ direct~on~) ~ ¢ , (c) Applicant is (check orm) lending Institution ~; Cwn. er/b~i%~; Buyer ~--~ ; Other ~ (explain); (d) Lending I nstitutio~ ~h/'~:t'~ ~"~'~ ~'~ ~ (e) Ileal Estate Co. & Agent Address Telephone 2. ~,_ of l~sidence Single-Family~ Number of Redrooms 3. Wate~ Su_~pl~_;; Individual r~ 1 lX[~ Multi-F~nity ~ Other (describe) Note: If ccrm~anity %~11 system, must have written confirmation f~om the State Depa~tmsnt of Enviromrmntal Conservation attesting ~o the legality and status. Is the well adequate fo~ the nun~ber of kedrccras specified in this HAA f~{)/N) .Sewage_~Di~posal Onsite~ Public~-] Cormr~nity~ Holding Is the vastewater disDosal system adequate for hhe [Page 1 of 2] 2-15--84 Engineering Firm Providing Inspections, Tests, Data and Information I o~tify tha~ve ct~cked, verified, or conforn~d to all MOA [t~A C~ideliFms in Nar~ Fi~m' Telephone Address Signed ky Date (ENGINEER SEAL) 6. DHEP Approval Approved for__~7~ kedrcorns Approve d~<~ Disapp~om d ~ Temrs of Conditional Approval L/ ' ~-~ ~'~ Conditional ~ The Municipality of Anchorage Department of Health'and EnviroD~renta]. Protecticn do not guarantee t_b~ continued satisfactcry perfo~m~nc~ of the wate~ supply and/or tb wastewate~ disposal system. This approval indicates that, as of the validation ~ sh~n above, based on the data and information furnished b~f sn ep~ineer registered the State of klaska, the water supply and wastewater disDcsal system ~s safe and f tional fo~ the p~unbe~ of bedrooms and type of s~uctu~-e indicated. ( [~qEP SEAL) ' 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH A[YI~ORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification ~ Well Log P~esent~ ~N) Total Depth /J~-2 rs ~ Static Water Level //8 ~ Casing Height Above Ground MUNICIPALITY OF ANCHORAGB DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED' If A, B, cr C, D.E.C. Approved(Y/Nl Date Coapleted Cased to [~/~//~//y~D~ g]~Y/w~ ~ Set At Electrical Wiring in Conduit. ~N) Separation Distances from Well: Depth of ~outing Sanitary Seal on Casing'~./N) Depression Around Wellhead (Y~ To Septic/~zc%~ Ta~k c~ Lot /O~ /~ ; onCA~]JOining Lots / ~ ~"., To ~a~est ~ge of ~so~ption Field oD~t ; ~ Adjoining ~ts /-~ ./~ Clean~t~a~ole ~ ~est ~ ~vi~ Li~ on ~t Wate~ S~le Colle~ed By ~ ~6~' Wate~ S~le Test ~sults B. SEPTIC/~ TANK DATA Date Installed 7,~'-~2~? Size /,~(~6/~ N~o of Cczapa~tments Z. Standpipes ~) Ai~-tight Caps ~) , Foundation Cleanout (Y~ ~p~ession o~ Ta~ (Y~ · ~te [~st ~d ~ P~ing~intenan~ ~n~a~ ~ File (Y~)/~;. fo~ Holding Ta~ High-Wate~ Ala~ (Y~) ~/~ ~a~,y Holdi~ Tank ~t ~) Separation Distances from Septic/~ Tank: To Wate-~-Supply 9~11 /~ /~-~ TO Property Line To Water Main/Se~e L1 Course TO Building Foundation To Disposal Field _____~/~- To Stream, Pond, Lake, c~ Major Drainage Comments [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~. /)(/ ~ Type of System Design .~K,~/,Vf-/~;~/~ Date Installed 7~t9 '-5 '2- Length of Field ~D ~ Width of Field Square Feet of Absorption A~ea Depression ove~ Field (Y~J) Results of Last Adequacy Te'st Depth of Field ~ / G~avel Bed Thickness ¢ ..~ Standpipes P~esent ~N)~ of Last Adequacy Test /~'~'~/ Separation Distance f~om Absorption Field: · /,~ . TO Water-Supply Well //~ ~ TO P~ope~ty L~ne To Building FouD/~tion ~3 /'~ . TO' Existing Or Abandoned System To Wate~ Main/Service L~ne ~/(/~ To Cutbank(i.f p~esent) To St~eam/Pond/Lake/o~ Majo~ D~alnage Course To D~iveway, Pa~king A~ea, o~ Vehicle Sto~age A~ea /(,~L> "~ Conn~nts D~ LIFT STATION Date Installed Size in Gallons "Pump O~" Level at High Wate~ Alarm Level at Tested fo~ Electrical Codes(Y/N) Dimensions Ma~ole/Access ( Y_~_~ )_ / '~m~ Off" Level at. /~ / ~ Vent (Y/N) PumpLtC~les du~ing Adequacy Test. Meets MOA Counts ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines. i~.~ffect on t~ date of this inspection. Signed Company K~l/dS/s Dateu~/~ ~ / [Page 2 of 2] 2-15-84 APPLI( iNT FILLS OUT UPPER HA[,,._: ONLY Property Owner L~/3 ~(..~/~) ~. ~' ~1~ ~ Phone Buyer Address Lending Institution ~ / ~/~/' , ~ l-'.. Address · , , ~'~ / ' /? Realty Co. & Agent Zip Code Zip Code Phone Phone Type 9f Residence C]~ Single Family [~ Multiple Family No. of Bedrooms ~] Other Water Supply ~ Community ~ Public Utility ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available). Sewer Disposal /-/ []]"individual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Insp~tor Insp~tor Insp~t ~ra~ Insp~t°~. SEP 9 1982 ( ~PROVED BEOROOMS *CONDITIONS OF APPROVAL Soils Rating Oate ~wer Installed We~ To Absorption Area Well Log Received