HomeMy WebLinkAboutELMORE #1 BLK 5 LT 11 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
EnvtronmentaJ Health Dlvl~on
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
"~__~ DISTANCES
A/T~ M ~ SEPTIC ABSORP110N
"~'~ F~OM~ WELL
~ TANK FIELO
TANKS ~t~ ~ ~ ~ N
TYPE OF SYSYEM
D TRENCH ~eED D W. DRA;N D OTHER
m,O,~ ~,~ , ~ FT
~ SOFT
~ '~/
- - G'/ '/ /
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REMARKS:
72-013 (3/8.5)
hi U N I C I P A L I T Y 0 F A N C H 0 R A G E
Department e[ Health & Human Services
825 L Street~ Anchorage, Alaska 99501 345-4720
Permit Number: 900211 Upgrade ~L.L.~C~L~\~.
Date Issued: 07/20/90 Engineer Designed
Owner Name:
[Iwn~r Address:
FANNIE MAE
155 LOS POBEES AVENUE,
ANCHORAGE, AK 99515
SUITE 500
Day Phone:
561-0828
Parcel Id: 018-172-25
Lot Legal: Subdivision: ELMORE ~1~; Lot:
Section: 54 Township: 12N Range: 5W
Lot Size 41293 (sq. ft. or acres)
Max B~drooms: This Permit: 3 Total Capacity:
Block: 5
SEPTIC TANK: Minimum total septic tank capacity: 1,0A0 gallons. Each septic
tank must have at least 2 cempartments. Depth to top of septic tank(s) < 4.0
teet requirers insulation over tank(s).
INFGRM I>.H.H.S. PRIOR TO INSPECTIONS BY ENGINEER.
CONSTRUC] PER ENGINEERS ATTACHED DESIGN.
~HIS PERMIT EXPIRES 12/31/90 AND VALID PeR A SINGLE FAMILY HOME.
I CERTIFY IHAT:
l. I am familiar with
5.
Signed:
(Owner)
Issued By:
the requirements ~or on-site sewers and wells as set
~orth by the Municipality o~ Anchorage (MOA) and the State of Alaska.
I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria o£ this permit.
I will adhere to all MOA and State o~ Alaska requirements ~or the set back
distances ~rom any existing well, wastewater disposal system or public
sewerage system on this er any adjacent or nearby lot.
I understand that this permit is valid ~or a maximum o~ 5 bedrooms.
also understand that the capacity o~ the total sys~e~ is 5 bedrooms and
any enlargement will require an additional per'it?'
.............. ....
FA~IE MAE .
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PE.POR~,ED FOR:
[~4 ~v~--GI~., .~ L-II ),~'Township, Range, Section:'T'l~.~. ~- ~l/~J
LEGAL
DESCRIPTION:
SLOPE ¢~ITE PLAN
2
.!
3
I
N
//
///
ENCOUNTERED? ,
DEPT.,'FYES'ATW"AT ~.~-t .o
E
Monitoring? Balm
5
6
7
8
g
10
11
12
13
14
15
16
17
18
19
20
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE __ (m~nutes~mch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PER~OR"EeBY: ~ ~;~ I ~¢ ~ CERTIFY THAT THIS T[ST WAS P[R~O.UE~ IN
?J Iolqo '
A~O~OANO[ WI~H ~LL 8~A~E ~N~ MUNICIPAL 8UIgELINE8 IN EFFECT ON THIS ~AJ[. ~AJE: ' '
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D ANCHORAGE
MUI jPALIYY 'OF.
EPT: bF 4ALTf: &
ENVI ��fMFfn1TAL' PR0.FECTION 1
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~ 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 ~ PHONE I ~, NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Il Well Z [ Absorption area O~lting/O / PERMIT~/~NO.
~ Manufacturer *~ Materlal ~
liq. capacity in gallons inside lengt~ Width Liquid depth
~O Well Dwelling PERMIT NO.
DISTANCE
TO:
O Z ~ Manufacturer Material Liquid capacity in gallons
= Well Foundat,o~ ~ Ueorest lot hne Z PERMIT NO.~
No. of lines Length of ~ch line Total Distance ~t~en lines
Trench width
~ DISTANCE TO:
Cla~ ~ Depth Driller D~stance to lot line PERMIT NO.
Building foundation Se~r lin~)~ ~ Septic tank . Absorption area(s)
DISTANCE
TO:
PIPE MATERIALS OTHER
SOIL TEST
INSTALLER
ri ..,
REMARKS
APPHOVED DATE LEGAL
_MUNItIPALITY OF ANcHoRAGE... ~ ~ ~'/~
- Departmental Health and EnviroD-menta--?ro~ection (
. - -' 825 ~ Street, ~chorage AK' 9501, ~ ~ .
' . ' · 264-4720 ~ ~1.~_~ tl~
_ . ,_ ~_ ~ * * * HANDWRITTEN PERMIT * * * ~ qi~'%~
Legal Description: ~// ~J ~ Lot Size: --
T~e of Soil ~so~tion System Is:
Trench: Dra~field: ~ Seepage Bed: ~ Holding Tank:
~ N~er of Bedrooms: %~ Soil Rating(sq.ft/br)
The Re~ired Size of the Soil ~sorption System Is: '
DEPTH ~ .LENGTH ~ . GRAVEL DEPTH ~ 5 WIDTH
The length d~ension 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,
~e gravel depth is the m~ depth of gravel between the` outfall pipe and
the bottom of the excavation(in feet).
' * REQUIRED SEPTIC(HO~ING) TANK SIZE = /~ GALLONS * *
~e~t a~iica~t has the ~es~o~sibiiity to i~o~ this ~epa~tme~t ~=iag the
~sta[latio~ i~sDections oE a~y wells a~ace~t to th~s ~oDe~ty a~ the
oE =esi~eaces that the weii will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * *
B~ckEiil~g o~ a~y system without E~al iasgectio~ .aa~ app~ovsl by this
wil[ be sab~ect to ~osec~tio~.
~=~ distaace betwee~ a weii a~ a~y o~-site '~ewa~e disposal system is lO0 Eee
Eo~ a ~ivate well o~ 150 to 200 Eeet ~om a ~blic well de~e~di~g uDo~ the ty~e
oE ~biic well. Hia~ diet,ce ~om a ~ivate weil to a p=ivate sewe~ iiae
is 25 Eeet an~ to a co~ity sewe~ li~e is 75 ~eet. Well ~ogs a~e =e~i~ed
aa~ m~st be ~etu~ to this department withi~ 30 ~ays oE the well
Otbe~ ~eq~i~eme~ts may apply. Speci~icatioas a~d co~st~uctio~ diag~s
available to i~s~e g~o~e~
· * * PERMIT EXPIRES DECE~ER 3i, 1 9 ~2 * * *
~ certify that:
([)
(2)
(3)
signeR:
~plicant /
I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
I will install the system in accordance with codes.
I understand that' the on-site sewer system may require enlargement if
the residence is remodeled to include more ~3 b~e~ms.
,,
SWP/024 (1/81)
Issued by:
Date:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION
825 I.~ Street, Anchorage, Alaska 99501 264~t720
SOILS LOG --PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
FERFORMED FO.=
LEGAL DESCR~FT,ON=
O- 0'5'
i 0,5-- 7.o
~ 3 ~.7/,~u,~.-!-
~OD ~1
5
6-
7-
8-
9-
SLOPE
OATE FERFORMED= qu~.y 7~ ,~' a
10-
11-
12
13
14
15
16
17
18
lg - HO. 1732-E
Juno 22, 1g~8
20-
COMME.TS ':'"blZ,"F t~
PERFORMED BY:
WAS GROUND WATER I~~ Si_
ENCOUNTERED? p~
E
IF YES, AT WHAT
DEPTH? 7,0
Gross Net Depth to Net
Reading Date Time Time Water Drop
t.i."~i E R CO LATIO N RATE
, ~.~.~.~,~¢.~,~I'EST RUN BETWEEN
(minutes/inch)
, FT AND FT
lt,.,'$ u 4. A~ 7'~'49 uJ
72-008 (6/79)
• 23456 ••
7 E
• '-�
Municipality of Anchor, 1 '- ego
P tY
On-Site Water and Wastewater Prog - J,q� a •,j
(907) 343-7904 J N
S A F E T Y
l(2oe
Certificate of On-Site Systems A..1 eoval
49 �-7 E2
Parcel I.D. 018-172-25 Expiration Date: "—/ —
1. GENERAL INFORMATION:
Complete legal description ELMORE#1; BLOCK 5, LOT 11
Location (site address) 4301 Riverton Ave. *Anchorage 99516
Current Property owner(s) Shelli Cutting Day phone 227-7734
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: 5
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 reque for: ! Distance:
r
Received by: Date: 21/118
COSA to be released to th=en• •e-r,unless o erwise requested by the engineer.
COSA Fee $ 5A4, Waiver Fee $
Date of Payment PI/fig Date of Payment
Receipt Number 00 9 Receipt Number
COSA# 66 CIF/COLI Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal,affxed 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: 1 /lo I
a 00000ip�4
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o
in accordance with the guidelines and regulations established by the Municipality of Anchorage and 0��•O�.. `- c j
industry practices. The reported results describe the condition of the system/s on the date/s of the ' P. Q,1
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or . ,..,4.._ U
encroachments may exist that were not identified during the evaluation. The operational life of all wells :• 4 rr TO .•7'VO
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, �.."" ..• ' '• Q
groundwater levels (that may fluctuate during the year), quality of construction (materials and Q
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary,and ; . . 0
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the 0 e'f,: A. . . -ss:• e'
system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of (/ CI-773 `Q:
the well or septic system. GEG makes no representation whether an alternative well or septic system Q. •• •<PO
can be installed on the property in the event either of the current systems fail to perform adequately in �4fe, ..I. 3.0J& coo
the future. The content of this report is for the sole benefit of the person/party that retained GEG to ��Pdprofess�enooz
perform the evaluation. Reliance upon the information provided in this report by any other person or �DOOO000�
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
—
x System #1 Approved for S bedrooms
System #2 Approved for bedrooms �Y'� tlgi,�,'-
Disapproved = V�QP�\ v�''S'
--J •
N.-SITE
Conditional approval for bedrooms, with the followitt st4tga AND m
;r�� WASTEWATER z
PROGRAM
O,o Z .
��'SER\J C
B� t"'"•1\ -' �.4.A.asi Original Certificate Date:2—( — (2
The Municipality of Anchorage Development Servi -s 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 Checklist26' 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: ELMORE#1; BLOCK 5,LOT 11 Parcel ID: 018-172-25
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N)
YES
Date completed 7/14/1982 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 137 ft. Cased to UNK ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 7/14/1982 1/10/2018
Static water level 80 ft. 75.1 ft.
Well production 50 g.p.m. 4.6+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate 1.29 mg./L. Collected by: GEG,Ltd.
Arsenic: <5.0 ug./L. Date of sample: 1/10/2018
*NO INTERIOR ALARM JUST
B. SEPTIC/HOLDING TANK DATA ADVANTEX WITH SINGLE AX-20 POD REMOTE MONITORING
Tank Type/Material STEP/STEEL Date installed 7/6-8/2004
Tank size 2000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank(Y/N) NO High water alarm (Y/N) *YES
Date of pumping Pumper SEE ATTACHED FIELD MAINTENANCE REPORT
C. ABSORPTION FIELD DATA **BELOW EXISTING GRADE *CAT II APPLICATION RATE
Date installed 7/6-8/2004 Soil rating .p.d./t2or ft2/bdrm) *4.0 System type BED
Length 2@16 FEET(32 TOTAL)ft. Width 2@12 FEET(24 TOTAL) ft. Gravel below pipe 0.53 ft.
192 x 2 2 ***YES depth **3.16+ ft. Eff. absorption area =384 ft Monitoring tube Depression over field NO
Date of adequacy test **1/11/2018 Results (Pass/Fail) PASS For 5 bedrooms
Fluid depth in absorption field before test 0 in. Water added **791 gal. New depth 2 in.
Elapsed Time: 120 min. Final fluid depth 0 in. Absorption rate >= 750+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date -
• WEST DRAINFIELD WAS SURCHARGED UPON ARRIVAL
• TESTED EAST BED ONLY
• **BASED UPON THE VALVE CONFIGURATION OF THE LIFT STATION, NO EFFLUENT WAS BEING DISCHARGED TO
THE EAST DRAINFIELD. PER CONVERSATIONS WITH TIM ECKLUND AT MOA ONSITE ON 1/11/2018 A PRESOAK
WAS REQUIRED ON THE EAST DRAINFIELD.A PRESOAK WAS PERFORMED ON 1/10/2018(INPUT 1558 GALLONS-
APPROVED BY TIM ECKLUND ON 1/10/2018)
• MT3, MT5 AND MT7 ON 2004 INSPECTION REPORT COULD NOT BE LOCATED
• ADVANTEX SYSTEM WITH A SINGLE AX-20 POD AND 2000 GALLON S.T.E.P.TANK WAS APPROVED IN MAY OF 2004
*PER 2004 MOA ELECTRICAL INSPECTION REPORT
**SEE ATTACHED MAINTENANCE AGREEMENT
D. LIFT STATION ***SECOND COMPARTMENT OF 2000 GALLON STEP TANK
Date installed 7/6-8/2004 Size in gallons ***667 Manhole/Access (Y/N) YES
"Pump on" level at TIMER in. "Pump off' level at TIMER in. High water alarm level at ** in.
Datum BOTTOM OF STEP TANK Cycles tested ** Meets alarm &circuit requirements? *YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots *100'+(WITH CAEAT)
Absorption field on lot 100'+ On adjacent lots *100'+(WITH CAEAT)
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
*ONLY THING FOUND ON ELMORE#1; BLOCK 5,LOT 2 WAS A SINGLE CLEAN-OUT
**NO SURFACE WATER WAS NOTED WITHIN 100'OF SEPTIC.GROUND FROZEN WITH SNOW AT TIME OF INSPECTION.
THERE ISA CREEK THAT RUNS WEST ALONG THE NORTH SIDE OF THE LOT
G. ENGINEER'S CERTIFICATION `P,.•• """" ,. j.
I certify that I have determined through field inspections and 4� oili�
review of Municipal records that the above systems are in • • •
conformance with MOA COSA guidelines in effect on this • ■
/ .. 0
date. ♦cn':J: f,: i A. Game- i•�:
Engineer's Printed Nam? JEFFREY A.GARNESS ••���� �,I •+.g��� �
Date I I ZO /h8 **Fpp ••.I. ..4 P�, ..
/ •ttROFESS`T'..4
LICENSE I1i�"`%'
*AECC884
(Rev. 10/12/12)
•
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''!l�Q�y 15d9ta ,1 HEREBY CERTIFY THAT I NAVE PERFORMED A SURVEY
Vp�<,_. ,,,,,...1...,
G�� OF THE FOLLOMINS DESCRIBED PROPERTY 1
`tA�-•`W P.
LOT 11, BLOCK 5, ELNORE SUB. NO. 1
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
/TICVISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
TME PROPERTY LIMES AND NO VISIBLE ENCROACHMENTS
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15T95.. FB 1N -57,117-S 345-2215
Parcel I.D. #
01817225
GENERAL INFORMATION
Complete legal description
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
Elmore SUb"'L~% 11, Block 5
Location (site address or directions)
Property owner
Mailing address
Lending agency.
Mailing address
Agent
Address
Tim StaD~ey
Day phone
Day phone
Day phone
562-1500
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well X -,.,""
; . ' -::.~; ..~: ~ .. 17 ,' ..
community well .-~ ..... "'
................. '* --J'~; .... t..< t'l. ~ ...'
Public water * . ;~ ·
NOTE: If communi~ well s~tem, provide written confirmation from Statd ADEC ~ttest- : '
lng to the legality and status of system.· '. '~ ~, ., ,..~.
'..'/ti ;5.~,
4.' TYPE OF WASTEWATER DISPOSAL:
· Individual on-site X ............
'" ' ' Holding tank ' ,
Communityon-site . .;,-. :..~ - . _ -
Public,ewer " ': "'""~:; "?;:""::':"" """ ~'" "' " ' ":'~ ' -
NOTE: If community wastewater'sj/stem~"~r~vld~'written confirmation from St-a~e A~DEC
attesting to the legality and stat~s o~ system.
STATEMENT OF INSPECTION BY ENGINEER .. "~. '
' :" · ' ~ '~ . · ,~, . 14
As certified by my seal affixed hereto and as of the vahdabon 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 furtherverify that basedon the Informabon' obtmned' from" '.
the Municipality of Anchorage files and from my inves.ti.,qation and inspection, the on-site water.
supply and/or wastewater_disposal system is in compliance with all Municipal and State codes, ·
ordinances, and regu at ons in effect on the date of this inspection.
Name of Firm Mounf.~ f n ~n_crt n~ert n_~
Address 3868 Shannon Ci~:c].e, Ancho]:acje
Engineer's signature .....
Phone 562-1500
99508 '
Date
6. DHHS SIGNATURE ...................
"'.Disapproved.- ......... . ................................ ::"~::. .' :
Conditional
t~rooms, with the following stipulations: ' '
· !" Additional Comments ·
.~ ,.'1 "1 ;.~ .,
The Municipality of Anchorag~ Departmer~t"~ H~lth 'a~d Human Service~'iD~lhSj"is~d~S {~i{~"~orit;/:' "~
Approval Certificates based only upon the representations given in paragraph 5 above by an Independent .
professional engineer registered in the State of Alaska. The D HHS does this as a courtesy to purchasers of ho roes
and their lending Institutions In order to satisfy certain federal and state requlrernenta~ Employees Of DHHS do not ,:
,: co~d.uct I. nspec:tions or. analyze data before a certificate is issued. The Municipality of An~:h~age ,Is not '-' '
responsible for errors or omissions In the pmfeesl0nal eno neer's work: .' ' .~. '.,'. :','.' .~ ' .,..-: ~ ·
.' ... :, :;.:~'::., ! ::.:;; - :..
MunicipalitY of Anchorage ,~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription: Elmore0 Lot, 13, R3c.¢q, 5 PamelI.D. ¢'1817225
A. Well Data
Well type Private
Log present (Y/N) Yes
Total depth 137 '
Sanitary seal (Y/N)
.lf A, B, or C, attach ADEC letter. ADEC water system number.
Date completed 7/14/82 Driller Daily Drillinq
Casedto C,T ~, Casing height GT 2'
Yes Wires properly protected (Y/N) Yes
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
7/14/82 8/23/94
~O' 75.5'
50 g.p.m. 6.5 g.p.m.
117' 76'
; On adjacent lots GT 150'
; On adjacent lots GT 150'
Publicsewermanhole/cleanout None
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 100 '
Absorption field on lot 125 '
Public sewer main None
Sewer service line Nnn~,
Petroleum tank None
WATER SAMPLE RESULTS:
Coliform 0
Date of sample:
R/~/q4
.Nitrate
· 66 Other bacteria
Collected by: ~-~n~- '~-.nr~:
B. SEPTIC/HOLDING TANK DATA
Date installed 8/82
Cleanouts (y/N) y
High water alarm (Y/N) Y
Date of pumping 6/1/94
Tank size 1,000 Compartments 2
Foundation cleanout (Y/N) y Depression (Y/N)
Alarm tested (Y/N) N
Pumper Anch Cesspool
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 100 '
To property line GT 10'
~Surface water/drainage
724326 (3/93)' Fm~t
On adjacent lots GT 150 '
Absorption field GT 10 '
1_00,
.Foundation 5 '
.Water main/service line None
CONTINUED ON BACKPAGE
C. LIFT STATION
Date installed 8 / ] / 90
Size in gallons 250
Vent (Y/N) y
High water alarm level
Meets MOA electrical codes (Y/N)
'Pump on' level at
10"
Manufacturer ~n,-h,~?, Tank
Manhole/Access (Y/N) y
'Pump off' Level at ! 6"
,Cycles tested 3
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot 117 '
On adjacent lots RT 15t3'
Surface water ' CT 1_ 00 '
D. ABSORPTION FIELD DATA
Date installed
Length 51 ' Width
Total absorption area 6 ] ~ .~ F
Date of adequacy test 8 / 23/94
Water lei, el in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) ].25 SF/.~DR .S, ystemlype
12 Gravel thickness /~l,~
' Total depth 4 '
Cleanout present (Y/N) ¥ Depression over field (Y/N) N
Results (pass/fail) Pa s s for 3 Bedroorn~
3'2" //,~':,z~.,r./~f ~,r.~,. I' After test 3' 2,,// #~/~-~/~-'7 o~-~'4."~
k. r .' '
No ,If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 1 ~ 5 '
To building foundation
On adjacent lots GT 55 '
Surface water GT 100'
Curtain drain None
On adjacent lots nm 1~0' Property line 55'
GT 40 ' .To existing or abandoned system on lot 1,5 '
Cutbank None Water main/service line Nnn r,
Driveway, parking/vehicle storage area 1 5 '
E. ENGINEER'S CERTIFICATION
I certify that I have checked, vedfied, or conformed to all MOA and HAA guidelines in effect._oD._~.~at?..~.is inspection.
Engineer's Name _ ,, .?.%.
· '~. '% CE - 77'~n .'~-~ '~'
. ,.-
Date . _ ,.;, ~,,:,..... ,...~ ~,-
.AA Fee $
' r Waiver Fee $
Date of Payment C~ _~:::~ _~C/' ~ % Date of Payment
Receipt Number ~ ~ ~ ¢ ~ 7.~ Receipt Number
72-028 (3/g3)* Back
Parcel I.D. #
MUNIClP~,LITY OF ANCHORAGE ~
Department of Health & Human SerYIces
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH ~UTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
ELMORE SUB., LOT 11, BLOCK 5 '~
Location (address or directions)
4301 RIVERTON, ANCHORAGE
(b) Property owner
Mailing Address
Telephone: (home) Business
(c) Lendin~ Institution Telephone
Mailing Address
(d) Real Estate Company and Agent FANNIE M~, NANCY GILBERT
Address 3601_ C ST, , ANCHORAGE
Telephone 561-0828
Mail the HAA to the following address: (or check here I~, if hold for pick up.)
List contact person and day phone number below:
CONTACT MTN. ENGINEERING @ 696-1700 FOR PICK-UP
(e)
2. TYPE OF RESIDENCE
Single*Family [~ Number of bedrooms
3. WATER SUPPLY
Individual Well r-Iz Community cI Public []
Note: If community.well.system must have writ. te~ confirmation from the State.Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [~[X Public [] ' Community [] Holding Tank
Note: If comh~bnity we I system, must have written confirmation from the State Department of Environmental
Conservati0h 'attesting to the legailty and status.
?2~s (.~,.?~) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, 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 end 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 Mountain Engineering Telephone 696-1700
Address 10251 Crestview East Eagle River, AK 99577
Date
AUGUST 9, 1990
6. DHHS APPROVAL
Approved for .~ bedrooms by
Approved ~./~ Disapproved
Terms of Conditional Approval
· Conditional
Engineer's Seal
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) .~"~ · Health AuIh__QrlIy Approval (HAA) ,
ELMORE SUBDIVISION
AUG ]. 0 ].990" Legal Description:
A. WELLDATA ,', RECEIVED
RESIDENTIAL
Well Classification
Well Log Present (Y/N) -YES Date Completed
LOT il, BLOCK 5
7/14/82'
Total Depth 13?'*Cased to?40'
Depth of Grouting
IfA, B,C,D.E.C. Approved(Y/N)
Yield >iOGPM
UNKNOWN
N/A
77'
Static Water Level
>2'
Casing Height Above Ground
YES
Electrical Wiring In Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
100'**
To Sept[c/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N/A
To Nearest Sewer Service Line on Lot
Pump Set At UNKNOWN
Sanitary Seal on Casing (Y/N) yES
NO
Depression Around Wellhead (Y/N)
· ' ;On'Adjoining Lots >100'**
>100'** ; On Adjoining Lots >100'**
To Nearest Public Sewer Cleanout/Manhole N/A
>25'
Water Sample Collected by Mountain Engineering ; Date. JUNE 7, 1990
:PASSED - COLIFORM & NITRATES
Water Sample Test Results
Comments *PER WELL 'LOG 7/14/82 **MEASURED FROM STANDPIPES
B. SEPTIC/HOLDING,,/~r~ANK DATA .....
Date Installed 87,-,2* Size 1000. ' ~ ' No. of Compartments
Standpipes (Y/N) YES Air-tight Caps (Y/N)
Depression overTank (Y/N) NO
Pumping/Maintenance Contact on File (Y/N) N/A
Holding Tank High-Wate.r. Alarm (Y/N) N/A
2*
YES Foundation Cleanout (Y/N)
Date Las! PumPed 6/7/90
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DIsTANCEs FROM SEPTIC/HOLDING TANK:
To Water-Supply Well 1_00 ' ** '
To Property Line 5'**
To Water Main/Service Line >10'**
To Stream. Pond. Lake or Major Drainage Course
To Building Foundation >5'**
To Disposal Field >5 ' **
i00'***
Comments *PER AS-BUILT'8/31/82 **MEASURED FROM STANDPIPES
***RABBIT CREEK RUNS BEHIND PROPERTY
YES
Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 8/~./~0
Width of Field 3. 2'
~25 SF/BR
Square Feet of Absortion Area 63. 2 SF
Depression over Field (Y/N) NO
Results of Last Adequacy Test *
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well > 110 '
To Building Foundation ;>40 ' '
Lot APPROX.:'I~' . ' ·
To Water Main/Service Line >40'- ' - -
Tyl~e of System Design
Length of Field 51 '
Depth ,of Field 3 '
Gravel Bed Thickness 1 '
Date of Last Adequacy Test
To Stream, Pond, Lake, or Major Drainage Cour{e >1OO' .....
To Driveway, Parking Area, or Vehicle Storage Area 15 '
Comments *N'~W CO~RTP[ICTTO~ - ~ TNRPFCTTON RF.P~RT
MOUND/SAND FILT
YES
TO Pr(~perty Line
To Existing or Abandoned System on
; On Adjoining Lots > 30' ....
To Cutback (if present) NONE
D. LIFT STATION
' Date Installed R/1 ./.qR
Size in Gallons
"Pump On" Level at
High Water Alarm Level
Tested for
Meets MOA Electrical Codes (Y/N) y~, -
Comments · NEW CONSTRUCT_TON - S_wE _TNSp_wCT~ON P~PO~T
Dimensions R' nT AMETER
Manhole/Access (Y/N) Y * ~
"Pump Off" Level*at 'I[oq''~ ~t'O~
Vent (Y/N) Y
Pumping Cycles during Adequacy Test.
"Check Permitted Bedroom Rating Against HAA Request" n..*' -
I certify that I have checked. Cerified, or conformed to all MOA and HAA
inspection. . , :- -,
Signed H,~rR P~ar~on
Company Ho,in f.a ~n En~'ineer~n~
Date AUGUST 9~ 1990
MOA No. CE89-007
Receipt No. ~,~,~../~) '~L, /
Date of Payment ~' --l0" ~O
Amount: $ / '7'~9 ,~
72-026 (Rev. 7~) Back
~'~,.e~fect on the date of this
~, .... ~~"~'---~ Engineer s Seal
Receip[~ .....
Waiver Fee: $
Date of Payment
Page 2 of 2
IilINICIPALITY OF ANCIt0RA~E
DIVISION OF ENVIROI~NTAL HEALTIt
DEPARTHENT OF HEALTH AND EI~IVIRONI~NTAL PROTECTION
APPLICATION FOR. HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Infor~ation
Application Date /-tm
range)
(a)
Legal Description (include lot, block, su.bdivisiou,, sectiou; township,
(b)
Location (address or directions) '
Applicants Name J~4~5 SC//~'/~ Telephone - Home ~ Business 3
Applicants Maress ~ ~/ /~7-~ ~W~
(c) Applicant is (check one) Lending Institution
Buyer[---~; Other~._l(explatn);
(d) Le~ding,Institution
Ad~_~ss
O~ner/bullder~;
Telephone
(e)
Real Estate Co..~& Agent
Address
Telephoue
(f) HaLt the HAA to the following address:
e
Type of Residence
Single-Famlly.~ M~lti-FamLtYF--~ Other (describe)
Number of Bedrooms .... · ~
Water SupPly? ~
Note: IX' community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Note: If 'community well system, must have written confirmation from the State
Department of Enviromnental Consetwation attesting to the legality and status.
[Page 1 of 2]
Ensineerin~ Firm Providin~ Inspectio~st Testst File Searcht Data and Iufot~nation
As cer~ified by my seal affixed hereto and'as of the validation date shown below, I
verify that my investigation of this Health AuChori~y Approval shows that the on-site
rater supply and/or vastewater disposal system is safe, functional and adequate for
the number of bedrooms and ~Tpe of structure indicated herein.. I further verify tha~,
based on the information obtained from the 14unicipality nf Anchorage files and from my
investigation and inspection, the on-site wnter supply and/or waste~ater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Address
DHEP Approval
Approved 'for+A~-~)bedrooms
Approved / Disapproved
Coaditional
Terms of Conditions/ Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE I~PAI~IIdENT OF I/EALTH AND E~IROI~f~-NTAL. I~0TECTION
(DHEP) ISSUES IIEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN ~: STATE OF ALASIiA. THE I~IEP DOES THIS AS A COUI~TESY TO TPURCIIASEKS OF HOMES AND
THEII~ LENDING INSTITUTIONS IN ORDEI~ TO SATISFY CERTAIN FEDERAL AND 'STATE REQUIRE-
HENTS. EMPLOYEES OF DItEP DO NOT CONDUCT INSPECTIONS OK ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOI~ ERROI{S
0I{ OMISSIONS IN Tifl~ I~0FESSIONAL £NGINEEI{~S WORK.
(DEEP SEAL)
RR4/eJIDI8
[Page 2 of 2]
7-19-84
Wsll ¢lassi~icati(m
~ ,MUNICIPALITY OF
[~JN'~C'J~AJ,,~'"I~f ~ ~ (~ DEPT. OF HEALTH &
~I~ENT~
- 2
/)w/~-r~-- If A, B, cz, C, D.E.C. Approved(Y/N)
We]/ ~ l~esent (Y/N) _~/
Total De.ch 737 ' Cased
Static Water ~e~l Bo'
Casin~ sei~ht Abo~s Gz~und J'
Electrical WlxinG in Cc~duit (Y/N) ,
Separation Distances f~cm Well~
To Septic/Holdir~3 Tank on Lot
To Near~st ~ of
To Nearest Public Sewer ~ine
Water SamDle Collected By
Water S~.le Test Bssults
Pum~ Set At
7-/F- FL Yield
Depth of Groutir~ '~'~
Sanita=y Seal un Casing (Y/N) ~'
U~ssion a~md Wellhead (Y/N) ~/
; On ~djoinir~ Lots -~/oo
; On Adjoining Lots ~
To Nearest Public Sewer
To Nearest Sewer Servios Line on Lot
,,q- z7-',4z c
B. S~i-zC/~0LDING TkNK ~tTA
To Building Foundation /~
To Disposal Field /~ '
To Stxeam, Por~, Lake, c= Major
Receipt J
Date Paid:
Amount:
[Pag~ 1 of 2]
2-15-84
Ce
ABSOI~PTI~
Pate Instal~d
Width C~ Field
Square Feet of A~sc=pticn ;tea
Dep=essicn over Field (Y/N) ~J
Results of Last ~]eguacy ~st
Type of System Design
Length of Field ~'~- '
~pth of Field ~ ~'
G~avel Bed Thickness /
Stand~il~eS l~esent
Date of Last ~guac~ ~st
Size in Gallons ~
"Pum~ On" Level at
High Water Alarm Level at
Tested f~=
C,.~,=nts /
Manhole~ss (Y~-"'~
Vent
** (~eck Pe=mitted ~ Paring A~ainst F.%A ~gusst **
[Page 2 of 2]
Date Z-Z/-F ~
.ha No. JT'F~-~t3
2-15-84
