HomeMy WebLinkAboutBROADWATER HEIGHTS BLK 1 LT 2Broadwater
Heights
Block
Lot 2
#050-081-20
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program to
4700 Elmore Road Z
P.O. Box 196650 "
Mark Begich Anchorage, AK 99507 s n E T Y
Mayor www.muni.org/onsite
(907)343-7904
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue:
Parcel Identification Number: 0 50-- DS 1- ?.d
Legal Description Property Owner Name & Ad
�7ss:
y►� 1 Ll 15 L J- LJI Z
2- /SYG '12..4inkwnrG►2 CI
L Z ri �
Pump Installation Date: 6 /2 G // �y
Pump Intake Depth Below Top of Well Casing: �/Z feet
Pump Manufacturer's Name: rRp a -ctcF_ 7-
I Pump Model: 5 5 2 5 -
Pump Size 5 hp
Pitless Adapter Burial Depth' / 2 feet
Pitless Adapter Manufacturer's Name: ✓1'j�A 12.7 �rJ 5 0 �f
Pitless Adapter Installer: /N 14
Well Disinfected Upon Completion?�es ❑ No
Method of Disinfection:G(..,_ 7e_1&t.-
Comments:
Pump Installer Name: A -L-10 *P5
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: <~i o0~"o PID Number: O..qO<:~
Name: '~Y~ ~r,~'~¢ Wastewater System: ~New ~ Upgrade
Address:
P~g~ ~,16f ~4~ 99¢~ ABSORPTION FIELD
Phone: ~'7~i~ ~,o.o,~drooms: ~DeepTrench ~ShaltowTrench ~Bed ~Mound ~Other
LEGAL DESCRIPTION Sol, Rating: Total Depth from original grade:
~ ~ GPD/Sq. Ft.
Block: S~divisi~n: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Section: Fill added above original grade: Gravel length:
Townshi~;~¢ Range: ~.,,~ ~ ~ ~ ~ i Ft. ~' Ft.
WELL: ¢ New ~ Upg rede Gravel width~ , Numbe/of lines: ]Distance between lines:
Ft. ~ Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: Date installed:
Pump Set at: Casing Height Above Ground:
Yield: i,O GPM ~i¢ Ft. iS" Ft. TANK
SEPARATION DISTANCES ~ Septic ~ Holding ~ S.T.E.P.
TO Sephc Absorpbon Lift Holding ~ublic/Private Manu~r~r: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~~Y ~0
Well toe I0¢ '~¢~ Material:~ ~ Number ~ompartments:
SurfaCewater ~OO +~¢ +~o LIFT STATION
Lot ~¢, ~%, ~ ~¢ Size m ga"o~: I Manuf~ctu~e~:~
Line
, / "Pump on" level at: ~'levelat: High water alarmat:
Foundation J 0
Curtain / / ~el Electrical Inspections performed by:
Drain / ,
Remarks: ~,~,,~ ~ ~'~,,~ ~h ~,~.~,r-,~ BENCH MARK
~n~ ~ ~ Location and Description:
> L Assumed Elevation:
Inspections performed by: C¢¢.,~.~, ~,,~ Dates: 1st ~=-7-s-*]. I
Department of He'nd Hum~ervices approFal /,.
72-013 (Rev 9/91) MOA 25
Permit No.
Page ~- of ~-
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: J-~-r7-- '~loc~.] 'E,,c~.~.~,~.~ue.~, /.~,~
PID No.: C~O ~1~
~Jc.. LL
o
,j
72-013 A (2/91) MOA 25
1220l
12200
12126
120~8
11721
117 $ I
86
/ /
//
//
12239
12~40
12~,16
12244
12~27
12305
12350
12117
f~'- 12118
12005
12212
lille
WEST SKYLINE DR,
343
T~ 8-/
18315
IITI5
11721
11707
11654
11641
11631
4
11609
E.R. LooP
11627
11807
TO E R. LOOP
116~5
85 -.~(~ 87
¥
NW 253
Eagle River/Chugiak Area Reference Map--lC
(~) COPYRIGHT 1989 JMR 93
Rick Mystrom,
Mayor
Municipa ty of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
January 17,1995
Jerry L. and Rita D. Hendriks
12146 Rainwater Circle
Eagle River, AK 99577-7911
Dear Mr. and Mrs. Hendriks:
During the fall of 1994, the On-Site Services Section of the Department of Health and
Human Services conducted a review of on-site septic systems involved in the legal
proceedings concerning Chuck Landers. Your property, Lot 2, Block 1, Broadwater
Heights Subdivision was involved in this review process.
Following site visits and submittal of additional required information by the engineer
on this project, Mr. Henry Wilson, P.E., your system was determined to be in
compliance with applicable municipal codes.
One of the additional submittals required for your system was a Certificate of Health
Authority Approval for a Single Family Dwelling. I have included the original of
this certificate and an additional copy for your files. The original blue copy of the
certificate should be delivered to the lending institution which processes the mortgage
on this property, for the existing original in their possession includes an invalid
signature.
All remaining paperwork (permit designs and/or as-built inspection reports) concerning
your on-site septic system has been updated and is on file at the Department of Health
and Human Services. Should you desire, you may obtain a copy of this paperwork for
your files.
If you have any further questions regarding this matter, please contact me at 343-4744.
.~~ e~serely' ,
P.E.
Program Manager
On-Site Water Quality
cc: Robert O. Baker, Ph.D., Acting Manager, Environmental Services Division
HENRY WILSON
9601 BUDDY WERNER DR.:
ANCHORAGE, AK 99516
(907) 346-2000
En
neers
CHARLES A. LANDERS
HC83 BOX 192-A, MYRTLE DR.
EAGLE RIVER, AK 99577
(907) 694-9098
July /, 1994
Muncipality of Anchorage
DHHS, On-Site Services
Po Box 196650
Anchorage, AK, 99519
re: Lot 2 Block 1 Broadwater Heights Sub
Septic inspection report; Health authority approval
checklist and certificate
Gentlemen:
Please substitute the attached original signed reports for the
reports originally submitted and processed, and remove the file
copies and send to me at the above address.
Henry H. Wilson, P.E.
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: (::)l OO':/'O PID Number: C~O
Name:
~-¢,,-~-u[ P,e,ncJ~-f~<.~ Wastewater System: ~ New [] Upgrade
Address:
Fo~o.., 9~,4. ~ A,-,ck~ 99<~o~ ABSORPTION FIELD
Phone: J No. of B~:jrooms:
6~.~. '7'4 t~' J~DeepTrench [] Shallow Trench [] Bed [] Mound [] Other
LEGAL DESCRIPTI O N soil Rating: Total Depth from .original grade:
O, ~ GPD/Sq. Fi. 14'
Lot: ~ Block:I '~r'02,¢~, G,~ '"~v-Subdivisi°n: ~ !Depth to p pe bottom4tfr°m original grade: Fi. Gravel depth beneath/o/ pipe ¢'~' Ft.
Township: 141~II Range: ~,lu~II Sectioru~, I//~I' ~'~¢'~ [ Fill added above~original ~,~grade: Ft. Gravel length:
Ft.
~ Number of lines: Distance between lines:
WELL: ~ New ~Upgrade eravel~F~h: ~ ~f Ft. ~ ~ Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: ~Ok~ - ~O~
Driller: Date Drilled: Static Water Level: Installer: Date installed:
J Pump Set at: Casing Height Above Ground:
Yield: ~. 0 GPM ~'S Ft. 18" ,~. TANK
SEPARATION DISTANCES a Septic ~ Holding U S.T.E.P.
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~~ ~
Well I O~~ t O~ ¢ ~, Material: Number of Compartments:
SurfaCewater+~' +~' ~o' LIFT STATION
Lot Size in gallons: Manufacturer: ~
at: I "Pu 'level at: High water alarm at:
Foundation "Pump on" level ~ I
GurtainDrain~ ~~ Boctdcal Inspoctions podormeO
Location and Description:
w~iJ ~o,~, TI~k >f.~SP~ IAssumed[levation:
I
ENGINEER'S SEAL
-- 0
Department of Healt~nd Human Se~es approval ~:~ .. ...;~
Reviewed and approved by: , Date: ~
72-913 (1/91) MOA 25
Permit No. ~ I 0o~0 Page '~ of ~.-
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL, SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
PID No.: (~0 08 t7..43
72-013 A (2/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910070
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC.
OWNER NAME:HENDRIKS JERRY L &
OWNER ADDRESS: P.O. BOX 91164
ANCHORAGE, AK
DATE ISSUED: 4/25/91
EXPIRATION DATE: 4/25/92
PARCEL ID:05008120
LEGAL DESCRIPTION: BROADWATER HEIGHTS BLK
2
1 LT
LOT SIZE: 30744 (SQ. FT.)
NUMBER OF BEDROOMS: 6 THIS PERMIT:
6
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
NEW WELL MUST BE ABANDONED IN ACCORDANCE WITH DNR REGULATION
S PRIOR TO PLACING WASTEWATER SYSTEM IN USE. ENGINEER MUST
NOTIFY DHHS AT LEx~A~ST~HOUnRS PRIOR TO EACH INSPECTION.
RECEIVED BY'~~~ DATE:
ISSUED BY: 3OH~ ,~'k'9/T'~ DATE:
PROPOSED SEPTIC LOCATION
t 61. /. N qr
ABSORPTION AREA CALCULATIONS: 6 Bedroom X 150gpd/bedroom = 900 sf
Soils rating: 0.8 gpd/sf
900 sf / 0.8 gpd/sf = 1125 sf required surface area
l125sf/(10'/'x 2) = 57' trench, with 10' gravel.
~e~cl4 ~o'l"to~ ~' ~ O~llu,q~,Cx%~,9 ~o'c.~ff.A~L'-I'M-~c~¢~$$
IMPACT ON ADJACENT LOTS: This resubmittal for permit # SW910070 is due to the
inablity to develop sufficient water from the new well and therefore being
required to utilize the existing well which was shown as abandoned on the
original submittal. The original well was been tested for a period of two
weeks and produced 0.45 gpm. It was hydro-fractured and tested to produce at
1.1 gpm. The result of these changes is to relocate the proposed septic
system as shown above.
SITE PLAN DETAILS--PROPOSED ABSORPTION SYSTEM
LOT 2 BLOCK 1 BROADWATER HEIGHTS SUB
PREPARED FOR: JERRY HENDRIKS
PO Box
~CHO~GE, AK, 99509
CONSTRUCTING ENGINEERS 3&6-2000
9601 BUDDY WEBER DR 69&-9098
~CHO~GE, AK, 99516
DRAWN BY CAL
DRAWING # 91-S2-05-2(b)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE
Township, Range, Section:
11
12
13
14
15
16
17
18
19
20
COMMENTS {-~(.~ ~, IO'?' (.,~ ,~.,,.
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
s
L
IF YES, AT WHAT O
DEPTH? IO~ p
E
Depth to Waler Alter
Monitoring? IO~ Dale: ~''
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE ~ lm*nutes/mch) PERC HOLE DIAMETER
TEST RUN BETWEEN__4'' FTAND ~'-~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: ~'/ E/(:~ [
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION=
DATE
Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
SLOPE SITE PLAN
/
Cc ~
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water Afte~r
Monitoring? 'NoN~ Date:
s!
Gross Net Depth to Net
Reading Date Time Time Water Drop
~' I k,,- ~ T"~, ,.,' 894~" 'z.'/t
¢= I ~,1~'~,~,! t~-~,~. ~ ~/+ ~ Z~
PERCOLATION RATE '"'/ (m~nutes/inch) PERC HOLE DIAMETER
TEST RU~ ~ETWEE,__4- FT A,D $-~ FT
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4~85)
DATE:
CERTIFY THAT THIS TEST WAS PERFORMED IN
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910070
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC.
OWNER NAME:HENDRIKS JERRY L &
OWNER ADDRESS: P.O Box 91164
DATE ISSUED: 4/25/91
EXPIRATION DATE: 4/25/92
PARCEL ID:05008120
LEGAL DESCRIPTION: BROADWATER HEIGHTS BLK
2
LOT SIZE: 30744 (SQ. FT.)
NUMBER OF BEDROOMS: 6 THIS PERMIT: 6
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1.
2.
1 LT
THE ATTACHED APPROVED DESIGN.
ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0).
THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ADDITIONAL TEST HOLE WILL BE INSTALLED AT TIME OF CONSTRUCTI
ON. DEPTH OF BEDROCK MUST BE CONFIRMED BY TESTHOLE. WELL MU
MUST BE ABANDONED ACCORDING TO DNR REGULATIONS PRIOR TO
PLACING SYSTEM INT USE.
RECEIVED BY:
?
DATE'
DATE:
~>c
-1
RECEIVED
APR 2 2 199!
Municipality of Anchorage
Dept. Health & Human Servic~
t
RECEIVED
APR ~. ~ 19~1
O M.m.~icip. ality of Anchorage
ep~. Health & Human Services
/ /'
Municipality of Anchorage .~',, ~ ~'"'~ ~ ~'~
SOILS LOG -- PERCO~TION TEST
LEGAL DESCmPTION: ~ ~l ~~~nship, ~ange, Section:
~A ~ SLOPE SlT~ ~LAN - '
1
2
3
?
8
WAS GROUND WATER kJ
1
0
ENCOUNTERED?
11
L
IF YES, AT WHAT O
12 DEPTH? p
E
Depth to Water Aftjr _
13 ¢C~= Monitorino? 1;:;;~'lg' ,~ bt,: c~. ~ _
Reading Date Gross Net Depth to Net
Time Time Water Drop
14
15
16
17
18
19
2O
PERCOLATION RATE __ Immutes~inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ___~T/ND
FT
COMMENTS ,./ ,/ S & S ENGINEERING
17034 ~.agie kiver L~ ~d No 2~ //' ~-
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUID~ECT~~ ON THIS DATE.
1~-~8 (Rev
4/85}
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
k.) sC It' -t-,,~c.c.
DATE PERFORMED:
~,~Township, Range, Section: ~'~
SLOPE SITE PLAN
; GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Oepth te Water After NON~ ~.- I-~ |
Monitoring? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
~' 7,,.~,¥' ' " ~qls" '" 5'~/,~"
G ~6~- ~o,.~ i I '/,t.' q ~/~,,
'~ 4-.,-- " * '7 ~'/$" *
/
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: ,, L X.., ~,~¢ I "~*"~.,m'~.,~k~'~.."~4..~'~'~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
Township, Range, Section: %E.
RECEIVED
APR ~ 2 lgg!
Itty of Anchorage
& Human Services
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? "--"
P
E
Depth to Water Alter
Monitoring? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
-... 4.12~ I¢] -. -- z,, ....
~ ~ ~ k~ ~ 1~/~'' G'Is"
PERCOLATION RATE -7 m~nutes/mch/ PERC HOLE DIAMETER
TEST RUN BETWEEN '~ FT AND ~"/7._. FT
Well Owner
M-W DRILLING, INC.
DRILLING LOG
Ken Best Use of Well Dom
Location (address of:
L2, Blk ls
Township, Range, Section, if known; or distance main road
Broedwater Hts, Raa~e Piver
Size of casing 6 Depth of Hole
Static water level 320 ft. (~T~')
Screen ( ); Perforated (
750 feet Cased to 30, _ feet
(below) land surface. Finish of well (check one) open end (
None
(minute) for 3 hours with ] 00%
Describe screen or perforation
Well pumping test at 1 gallons per of drawdown from static level.
x );
ft,
Date of completion !4 Auq 76
Depth in feet from
ground surface
0 TO 2
2 .TO 2R
,~0
· '3(,~ TO.~7
WELL LOG
Give details ot formations penetrated, size of material, color and hardness
· Casing ~'£ickup
SilTy Gravel: sar, d.v/cobbly
Bedroc'k~ lt. gray, silSstone arioillile, sooradic
water se~ps in fractures,
TO
TO.
200' - 20 GPH, S.L. 30'
7;13' ' 30 GPH~ $.'L. 287'
TO.
TO
.TO
__,TO
TO.
.TO
I~VWA Certified Co~tracto~
STATE
Well Owner
Ken Best
M-W DRILLING, INC.
DRILLING LOG
'~337
Use of Well Dom
Location (address of: Township, Range, Section, if known; or distance main road
L2, Blk l, Broa~water Hts, Rao~e Piver
Size of casing 6 Depth of Hole
Static water level 320 ft. (h~{~]~)
Screen ( ); Perforated (
Describe screen or perforation
Well pumping test at. 1 gal~01~s-Per of drawdown from static level.
750 feet Cased to 30.3 feet
(be]ow) land surface. Finish of well (check one)
).
None
(minute) for 3 hours with
open end ( X );
Date of completion ! 4 Auo 76
e/.
Depth in feet from
g~ound surface
0 . TO. 2
2
TO
TO ~ 7
TO,
WELL LOG
Give details of formations penetrated, size of material, color and hardness
· Casing ~Tickup
SilZy Gravel: sandy./co~,~bly
BedroCk, lt. gray, silk.tone ariQilli~e, sporadic
water se~Ds in fractures.
TO
TC
. ..TC
TC
TO
TO
TO
TO
· _TO
TO.
TO.
200' - 20 GFH, S.L. 30'
~05 7'13'-- 30 GPH, $.'L.
287'
NWWA Certified Co~t~act~r
Ccrii[i,~,tc ,~-~J=' 8!4 & g/3
cd ~LC. LoC-
2- STATE
Municipality of Anchorage
Development Services Department
Building Safety Division
O
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www,cLanchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 050-081-20
1. GENERAL INFORMATION
HA~ ~ 452- O O~5-
Expiration Date:
Complete legal description BROADWATER HEIGHTS S/0; LOT 2, BLOCK 1
Location (site address or directions) 12146 RAINWATER CIRCLE, EACLE RIVER, AK
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
99577
JERRY & R~A HENDRICKS Dayphone 694-7415
12146 RAINWATER CIRCLE, EAGLE RNER, AK 99577
Day phone
KATHY OLMs1EAD w/ REMAX OF E.R. Day phone 694-4200
16600 CENTERRELD DRIVE, EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 6
3. TYPE OFWATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL: '
Individual On-site
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 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (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 Munic!pality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
Note:Alaska Water and Wastewater Consultant$, Inc. shall be paid $ / ~-'0'~ at, or pdor I
to closing for the engineering services provided.
I
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedA/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
forthe 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 ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone
Address 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name JEI-~-hlEY A. GARNESS, P.E. Date
337-6179
Engineer's Comments:
In conducting this evaluation. AWWC, Inc. aitempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evalualor of the system. Satisfacto~/ test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. A VVl/VC, Inc. can therefore not provide
· any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report ia for
the sole benefit of the owner listed above. Any reliance upon or use of this repo~ by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
J Approved for /.',C' bedrooms.
Disapproved.
Conditional approval for __
'-F' A i U.. c e._ ,L ;'/' / e', /
Ge,- A / I
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisopy
bedrooms, with the filowing stipulations:
Manitenance Agreements
Supplemental Engineers Reo~
.....
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building ~afety Division
On-SEe Water & Wsstewater Program
4700 Soul~ Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchomge.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Des~ipflon: BROADWATER HEIGHTS SUBDMSION; LOT 2, BLOCK 1 Parcel ID:
050-081-20
A. WELL DATA
Welltype f'mVA~ IfA, B, orCpmvidePWSID~ N/A Well Log (Y/N) ~[S
Date completed 8/14/76 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Totaldepth 750 ft. Casedt~ 30,3 ft. Caeinghelght(aboveground) 12+ in.
FROM WELL LOG AT INSPECTION
8/14/76 12/12/01
520 ft. 34' fl.
0.70+ g.p.m.
g.p.m.
Nitrate 1.16 mg./L. Other bacteria 0 colonies/100 mi.
12~13./01
Date of sample: 1/3/02 Collected by: AWWC, INC.
STEEL
2
Depression over tank (Y/N) NO
Pumper
Date of test
Static water level
Well production 1
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Atsanio: 0.002 mg./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Matedal
Tank size 2000' gal. Number of Compartments
Foundation cteanout (Y/N) YES
Date of pumping 1/5/2002
C. ABSORP:FION FIELD DATA
Date installed s/2'/,/91 Soil rating {~or It=/bdrm) 0.8
Length 58 ft. Width 3 ft.
Date installed 6/27/1991
Cleanoute (Y/N) YES
High water alarm (Y/N) N/A
JR's PUMPING
Totaldepth 14 R. Eff. abso~flo~ama 1160 ft2 Monttodngtuba YES
Date of adequacy test 12/12/01 Results (Pass/Fall). PASS
Fluid depth in absorption field before test O in. Water added 1013 gal,
Elapsed Time: 45 min. Final fluid depth 29.5 in. Absoq3tton rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN
System type TRENCH
Gravel below pipe 10 ft.
Depression over laid NO
For 6 bedrooms
New depth 34.5in.
900+ g.p.d.
If yes, give date -
O. LIFT STATION
Date installed
'Pump on' level at in.
Datum -
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons
"Pump off' levgl et
Cycles tasta~
Sel3flc tank/lift station on lot 100'+
Absorption field on lot 100°+
Public sewer main N/A
Sewer/septic sewice line 25'+
In.
Manhole/Acce<~ (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
Absorption field 5'+
Surl'ace water 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water sowice line 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+' Building foundation I0'+
Sudace water 100'+
Water service line 10'+
Curtain drain NONE KNOWN
COMMENTS
Wells on adjacent lots 100'+
G. ENGINEER'S CERTIFICATION
I certify that I here determined through field inspections and
mt4ew of Municipal n~'cls that the strove systems ere/n
conformance with MOA HAA guidelines in effect on this date.
Engineer's Pdnted N~me
Date
JEFFREY A. GARNESS
Water main N/A
Driveway, partdngfvehicte storage
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12m0)
Waiver Fee $
Date of Payment
Receipt Number
in.
25'+
ALASKA WATER & WASTEWATER
CONSULTANTS, INC.
August 6, 2002
Municipality of Anchorage
Development Service Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650
Anchorage, Alaska 995 ! 9-6650
Reference; Request for a tlealth Authority Approval release of conditional for Broadwater
Heights S/D; Lot 2, Block I.
To Whom It May Concern:
We are requesting a release of the conditional HAA issued originally on January 25, 2002. All
work has been completed as discussed at that time.
If you have any questions or concerns please contact us at 337-6179. Thank you for your time.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
Municipality of Anchorage
Development Services Department
Building Safety Division
On*Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.a nchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 050-081-20
1. GENERAL INFORMATION
Expiration Date:.
Complete legal description f. SROADWATER HEIGHTS S./D; LOT 2, BLOCK 1.
Location (site address or directions) 12146 RAINWATER CIRCLE, EAGLE RIVER~ AK
Current Property owner(s)
~'":'. '~.~Mailing, address
Lending agency
Mailing address
Real Estate Agent
Mailing address
99577
JERRY & RffA HENDRICKS Dayphone 694-7415
12146 RAINWATER CIRCLE, EAGLE RNER, AK 99577
Day phone
KATHY OLMSTEAD w/ REMAX OF E.R. Day phone · 694-4200
16600 C£NTERF1ELD DRIVE, EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 6
3. TYPE OF WATER SUPPLY:
Individual Well ~
Individual Water Storage
Community Class Well ~.~
Public Water System
TYPE OF WASTEYVATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Cedificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (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 engineers
work.
Note:Alaska Water and Wastewater Consultants, Inc. shall be paid $ /.~ 7 0 at, or pdor
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 redly 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.
NameofFirm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE. AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in ecco~ance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
. ,. distances measured to readily identifiable features. The operationallife of all walls and
"' s'.e.~, systems depend on the local soils condition, groundwater levels that may
] t~ct~Jate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactoq/ test
results do not guarantee future peffonwanca of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report I$ for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal tfght whatsoever.
5. DSD SIGNATURE
Approved for -, - ' bedrooms.
Disapproved.
~ Conditional approval for (.O bedrooms, with the fllowing stipulations:
as stated fa En~tnee~ letter dated Jam,dry l~.~00~. ~'
HM Checklist ~ Manitenan~ Agreements
Septic System Advisow Supplemental Engineers Reod
Well Flow Adviso~ ~ Other
Original Certificate Date:
(Rev. 12~01)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wsstewater Program
4700 South Bragaw St.
P.O, Box 196650 Ancttomge, AK 99519-6650
www.cLanchorage.ek.us
(gO7) 343-7go4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: BROADWA~'I~,R HEIGHTS SUBDMSIONi LOT 2t BLOCK I Parcel ID:
A. WELL DATA
Well type PmVAT~
Date completed
Total depth 750 ft.
Date of test
Static water level
Well production
050-081-20
YES
IfA, B, orC provide PWSID~
8/14/76 Sanitary seal (Y/N) YES
Cased to 30.3 ft.
FROM WELL LOG
1 g.p.m.
Well Log (Y/N)
Wires pmparly protected (Y/N)
Casing height (above ground)
AT INSPECTION
12/12/m
34' ft.
0.70+ g.p.m.
YES
12+
in.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Arsenic: 0.002 mg./L.
e. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL
Tank size 2000 gal. Number of Compartments
Foundation cleanout (Y/N) YES
Date of pumping 1/3/2002
C. ABSORPTION FIELD DATA
Date installed , e/~'/gl
Length 58 lt.
Nitrate 1.16 mg./L.
Date of sample: 1/3,/02
2
Depression over tank (Y/N) NO
Pumper
Soil rating ~ fl~edrm) 0..~.8
Width 3 ft.
Other bacteria 0 colonies/100 mi.
Collected by: AWWCt INC.
Date installed 6/27/3~gq 11
Cleanoute(Y/N) YES
Hlgh wateralarm(Y/N) N/A
JR°s PUMPING
Totaldepth 14 fl. Eff. absorption ama 1160 fl= Monltoringtuhe YES
Date of adequacy test 12/12/01 Results (Pass/Faa). PASS
Fluid depth in absorption field before test O in. Water added 101,3 gal.
Elapsed Ttme: 45 min. Final fluid depth 29.5 in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN
System type TRENCH
Gravel below pipe 10
Depression over field~
NO
For 6 bedrooms
New depth 34.5 in.
g00+ g.p.d.
If yes, give date -
D. UFT STATION
Date installed Size In gallons ~
'Pump on" level at in. ' P u mp_ _O .o .o .o .o .o .o .o .o ~ ~ High ~ter alarm level at
~ Cycles tested. Meets alarm & circuit requirements?
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tenldlift station on lot 100'+
Absorption field on lot 100'+
Public sewer main
Sewer/septic sowtce line 25'+
On adjacent lots 100%
On adjacent lots 100%
Public sewer manhola/deenout
Holding tank N//A
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ . Properb/line
Water main N/A Water service line 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
Absorption field 5%
Surface water, 100'+
Water main N/A
Driveway, parking/vehicle storage 25%
G. ENGINEER'S CERTIFICATION
I cerfify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Nam/e JEI-~-~EY A. GARNESS
Date
Receipt Number
(Rev. 12~e)
Waiver Fee $
Date of Payment
Receipt Number
ALASIG WATER & WASTEWATER
CONSULTANTS, INC.
January 15, 2002
Municipality of Anchorage
Development Service Department
Building Safety Division
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Request for a Conditional Health Authority Approval for
Broadwater Heights Subdivision; Lot 2, Block 1,
Thc existing 3 bedroom house is served by a private well and septic system. On December 12,
2001, a well flow test and septic adequacy test were performed on the referenced property. All
standpipes for the septic system were found except for the double cleanouts. The homeowner is
the original owner and does not recall that these pipes have ever existed. Due to the accessibility
to the backyard in winter conditions to repair or install these pipes, we request that a Conditional
Health Authority Approval be granted. The repair or installation will be done in the spring of
2002 and money will be escrowed for the cost of this work.
If you ha~v7 any~{.~stions, please contact us at 337-6179. Thank you for your assistance.
[
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
Municipality o.f Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewatcr Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Health Authority Approval # 020025
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block 1, Lot 2 of Broadwater Heights
subdivision, the well's productivity was determined to be 0.7 gallons per
minute. The minimum well productivity required by this Department (AMC
15.55) for a 6-bedroom residence is 0.6 gallons per minute. Although the
subject well currently exceeds this minimum requirement, all parties
concerned are advised that the production capacity of the well may fluctuate.
Restriction of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
ALASKA WATER & WASTEWATER
CONSULTANTS, INC.
WELL FLOW TEST DATA
LEGAl. DESCRIPTION: ~.ot,4:~,n~,~ ~etowrt ..~ ~ Lox ~ .~ Ig,.-oc../c. |
NUMBER OF BEDROOM: (..
GALLONS PER DAY NEEDED:
WELL: *SEE ILA.A. SITE VISIT CHECKLIST*
1. Cas!ng Height (A~Lg. ve Grou.n.d): ] 8
2. Sanitary SeaI:(Y.F~_..~/NO (ff "NO", describe !.n Comments)
3. Wires in Conduit:c-.YF-~ / NO (if '.NO",~esc.ri,',be In Comments),
4. Water Samples Needed: (~ / N~if' YES , date taken: ~ )
5. D~ression around Well: YES /q:,IO;(if "NO", describe in Comments)
6. Does Well need Four Hour Flow Test (Y~lK):~V"fi'~ NO
METER NUMBER OF FLOWRATE STATIC
TIME READING GALLONS (G.P.M.} WATER LEVEL DRAWDOWN
t~oo ~ ~ ~7 I~ o.~ ~t~~ -~/-M~~
tI~o ~7z~ ~z/,~m o.6v ~'
~o ~ ~ -- ~s~' ~'/~,~'
WELL PRODUCTION: ~ GPM ( GALLONS IN MINUTES)
Comments: ~;.
Signature: Date:
6901 [kbarr Road, Suite 2-B * Anchorage, Alaska 99504 * Ph: (907) 337-6179 ' Fax: (907) 338-3246 · awws~alaska.net
I HEREBY CERTIFY .THAT I HAVE SURVEYED THE /.-~.5.~ 'T. ~%.~
FO~LOW~,~ D£SC,~BED .RO~RTY.' ,?.~' ol:.xl ~
~ND~CA~. IT ~S THE RES~S~B]LI~ OF THE ff~/
~m ~ .~zE~.[ tHZ ~STZNCZ O~ ANY mm, .~"'"~/ .... ...~
E~ENTS, COVENANTS, OR RESTRICTIONS ~.~ t.~~~~
WHI~ ~ NOT ~AR ~ THE RE~ ~BDI- ~ ~ ~ ...~..~,~ ~.,,~ .. ~ ~
VISION P~T. UND~ NO CIRCUMSTANCES S~ F~ t~.... LS-591B ..' ~
~ D~* .m~ B~ US~ FO, CO,S~U~O. ~/-~ *~'~ ........ ..~
~ FENCE LIN~ OR mR E~LISHING ~ND- DRA~, '~%~~'
ARY LINES. ~ ~.
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
~.~"~ ~..m~¥,'k.( Day phone
· Day phone
Day phone
J
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
NOTE:
Public sewer -', '
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
w
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 C__.¢~uc..~_,~
Address ~::~0~ ~,..,~ gU~v'~_.,~
Engine,s signature
Phone
Date /'/'- $-~'~
DHHS SIGNATURE
Approved for
bedrooms.
Disapproved.
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 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. ·
/2-02~(Rev. 1/91) Back MOA~Z1
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present (Y/N)
¥
7%9'
Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number W A
Date completed ~9-76 Driller /~-~J ~;~ I,,'~'~
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test (~- 14~'7 (o
Static water level 5 7.0'
Well flow o.5'
Cased to ZS' Casing height z.'~"/~,,~,~,~'~&
'¥ Wires properly protected (Y/N) Y
AT INSPECTION
Pump level1
.g.p.m. g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line +~O'
WATER SAMPLE RESULTS:
; On adjacent lots
;On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Coliform
Date of sample:
Nitrate
O. I ~/ Other bacteria
Collected by: ~__~b v¢~ ~-~
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size Z.coo Compartments
Foundation cleanout (Y/N) ¥ Depression (Y/N) .r,,J
Alarm tested (Y/N) --
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot Io .~'
To property line ~ ~
Surface water/drainage
On adjacent lots -+loo' Foundation
Absorption field 7 ' Water main/service line -~ ~o'
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Manufacturer ~
Manhole/Access (Y/~~
~mp off" Level at
Vent (Y/N) "Pump on" level at ~,,
High water alarm level '~ ~...~~Cycles tested
Meets MOA electrical codes (Y/N) ~
SEPAR~FT STATION TO:
W~..ll-~lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed ~-{-.91 Soil rating (GPD/FF)
Length 5' 8' Width 3' Gravel thickness
Total absorption area 11 Go ~ Cleanout present (Y/N)
Date of adequacy test r4'~ Results (pass/fail)
Water level in absorption field before test ~
Peroxide treatment (past 12 months) (Y/N)
O, g D pa://5 ~' System type ~'¢ewc ~-~
I b' Total depth I ~'
Depression over field (Y/N)
for
After test
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots ~' ~:~'
Surface water
Curtain drain -~ So'
On adjacent lots -FI oo' Property line
To existing or abandoned system on lot
Cutbank ~- 5 o' Water main/service line
Driveway, parking/vehicle storage area '+ ~--~'
E. ENGINEER'S CERTIFICATION
I certify that l have checked, verified, or conformed to all MOA and HAA gu/dehnes ,n effe~~~i~s, insPection.
Signature
~ ~ '.',:~ :~:::~: .:::~:~.::::::~. ::::::::::::::::::::::: j~:::.:,:+" e
Engineer's Name ~ ~,z/ ~ __~ , ~ /~ ~ ~
Date 4 ~ ~.~... ~ ~,.~,.-...,,.~,~
HAAFee$ ~17O°~
Date of Payment cj_ ~ -~-~
Receipt Number 7.5o ~ / '~...~-~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Parcel I.D. #
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
05o0~t7_.o HAA# ~ ('~ ~ ~"~ ~-'\,-"~--'~
GENERAL INFORMATION
Complete legal description
.~.}Location~(site'address or directions)
!.~. ;,. Property owner
' Mailing address.
Lending age'r~Cy
. Mailing address
Agent
Address
Day phone
Day phone
Day phone
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.
72-025 (Rev. 1/91) Front MOA #21
Sa
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 frorrr 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 C-~,~-J¢¢~, ~--~ ~:'~.~l~ ~j~
Address ~l ~u ~ ~~r ,
Engineefs signature
Phone
Date
DHHS SIGNATURE
._~ Approved for .~/:~. ~.~_?
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineeds work.
72-O25 (Rev. 1/91) Back MOA
Legal Description:
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D.
A. WELL DATA
Well type ~P~'
Log present (Y/N) x/
Total depth -7 z~'
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to 7- ~'
FROM WELL LOG
Date of test
Static water level -) 7--O
Well flow O,
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/hei~lie~-tattk on lot
Absorption field on lot [0.%
Public sewer main -h~'
Public sewer service line '~'
Casing height
Wires properly protected (Y/N)
AT INSPECTION
'z..9~
I,O
g.p.m.
ADEC water system number
I ~'"/~, Driller
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
I
-Jr-~ oO '
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ,~ Nitrate
Date of sample: ti_ 1 ~' ~91
Collected by:
Other bacteria
B. SEPTIC/ ............ ,.~ DATA
Date insta~l,,e~i , ~- ~r ~ ~ ~
Cleanou~s (Y/N) , ~/ ~-,
Tank size
Foundation cleanout (Y/N)
High water alarm (Y/N) .
Date of pumping
Compartments
Depression (Y/N) ~
Alarm tested (Y/N)
SEPARATION DISTANCES 'FROM SEPTIC/HOLDI NG TANK TO:
Well(s) on lot ' tO~' On adjacent lots '"kt °° ~
To property line +~JD~ Absorption field ~ ~
Foundation
Water main/service line
Surface water/drainage
"t'"t O0 '
72-028 (Rev, 3/91)Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at F~:
High water alarm level .
Meets MOA electrical coif __.
SEPA~A-71'O~ DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole~
~ "Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed <~- I -~ t
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Soil rating O' ~ I"~' '~'~-J/~' System type
Gravel thickness I O' Total depth
Cleanouts present (Y/N) X/.~
Date of adequacy test
for
bedrooms
Peroxide treatment (past 12 months) (Y/N)
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot IO~ ~ On adjacent lots -+~ Oo' Property line
To building foundation ~(o' To existing or abandoned system on lot
On adjacent lots 4- 30'
Surface water +
Curtain drain
Cutbank +~-O' 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
Signature
Engineer's Name
Date
HAA Fee $ //
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Well ! Pump Se~ice
WATERWELL - TEST PUMP REPORT
~OWNER_ Jerry Hendr£cks ADDRESS 12146 Rainwater Circle
Eagle River, Alaska
ENGINEER Chuck Landers/Constructing Engineers
WELL LOCATION Lot ~ Block ~ Broadwater Heights, Eagle River, Alaska.
TOTAL DEPTH 750 DEPTH OF CASING 30' SCREEN FROM N/A TO N/A
CASING SIZE 6" SCREEN DIA N/A SCREEN SLOT N/A
REMARKS Due to deptht water level monitored electronically.
PUMP INTAKE DEPTH 715 PUMP SIZE 1½ AIRLINE DEPTH Electronic
STATIC WATER LEVEL 129 AVG DISCHARGE 3.7 GMP 710 MAX DRAW DOWN
PUMP 0N:.9:20 TIME 5-30 DATE PUMP OFF: 2:30 TIME 5-31 DATE~'
PIEZO FLOW
DATE TIME TUBE RATE WATER LEVEL COMMENTS
METER
'5-30-91 9:20 PM 10.0 30' 0130250
10:20 8.0 0130800
10:43 6.7 0130890
11:00 5.7 0131000
11:10 4.7
11:20 4.5 0131090
12:00 AM 4.7 0131280
12:20 4.5 0131370
12:45 4.0 0131470
1:00 4.0 0131530
1:20 3.0 0131590
1:45 3.0 0131660
2:00 3.0 0131705
2:30 AM 3.0 670' 0131800
-WELL S~RESS !EST PRI)R TO ACTUAL PUMP TEST-
NO~ES:
- ~umping at 19 PSI unrestricted. /
- Pumped 5 hours 1550 gaLlons, would not ~,ump dry).
W~I ! Pump ~rvice
WATERWELL - TEST PUMP
OWNER_ jler__r~_~Hendricks ADDRESS__l.~_~46 Rainwater Circle
Eagle River, Alaska
.._~.~I~ .... bit Chuck Lan~.~_Uc~:~ng Engineers
WELL LOCATION Lot ! Block 2 Broadwater Heiqhts~ Ea~!e River~ Alaska~,.
TOTAL DEPTH 750 DEPTH 0F CASING 30' SCREEN FRO~N/A T~ ~/A
CASING SIZE 6" SCREEN DIA N/A SCREEN SLOT' N/A
REMARKS Due to depth,_~ater level monitored electronicallz~
PUMP iNTAKE DEPTH 715
~.~ WATER LEaL 129
PUM? 0N: 2:30 TI~ 5-31 DATE
PUMP SIZE 1½ AIRLINE DEPTHElec~mo~ic
AVG DISCHARGE 3.7 GMP 710 MAX DRAW
PUMP OFF: 6:30 TIME 5-31 DATE~'''~
PIEZO FLOW
TIME TUBE RATE WATER LEVEL COMMENTS
PRES o
2:30 PM
2:40
2:59
3:00
3:10
3:20
3:30
3:40
3:50
4:00
4:10
4:20
4:30'
4:40
4:50
5:00
5:10
5:20
5:30
5:40
5:50
6:00
6:10
6:20
6~30 PM
4.0#
4.0#
3.5#
3.5~
3.54
3.0#
3.0#
3.0#
3.0#
2.5#
2.5#
2.0#
1.9#
i~7#
i.~#
1.5#
1.4#
1.2#
1.1#
1.0#
1.0#
.7#
.7#
.7#
.7f,-
7.0
7.0
6.7
6.5
5~8
5.6
5.4
5.2
5.0
5.0
4.6
4.3
4.0
4.0
3.7
3.3
3.3
3.0
3.0
3.0
3.0
2.5
2~5
2.0
2.~
END
129
169
188
246
295
329
368
456
547
591
648
660
670
690
700
700
710
TEST
METER
0131800
0131870
0131940
0132010
0132075
0132130
0132200
0132250
0],32300
0132350
0132400
0132438
0132480
0132520
0132560
0132593
0132630
0132660
0132690
0132720
0132750
01.32775
0132800
0132820
0132840
- SEE
~EPEF~AT~
RECO%~RY LOG -
ANCHORAGE WELL & PUMPS SERVICE
6901 Tanaina Drive
ANCHORAGE, ALASKA 99502
(907) 243-0740
JoB Lot 1 Blk~2~roadwater Heights
S,EET NO. 3 OF 3
CALCULATED BY J. Hendricks DATE05--3]--91
CHECKED BY J. Ridqway DATE 05--31--91
SCALE Well Recovery Check
PRODUCT 204-! ~ Inc., ~rotoo, Mu~. 01~171,
ANCHORAGE WELL & PUMPS SERVICE
6901 Tanaina Drive
ANCHORAGE, ALASKA 99502
(907) 243-0740
JOS Jerry Hendricks
SHEET NO. Lot 1 Blk 2 Broad6~ater Heights
CALCULATEDBYJ. Ridqway DATE 05-31-91
CHECKED BY DATE
SCALE WELL PRODUCTION CALCULATIONS
........ ~ . ~
........ :: ~ ........ ~ ......~ ........ ;!~ : ....................... : ...................... : ..........
........... : :~ ~> :
.......::~ : ~.; ~
_~/~01~ ~ ~ 0 ,~ ~ : .......... :~ ..........
" . ' [ ~ ...... ~~.~,~'~C~:-~i~-~' '~ ~ ~ (~:' ~ ~ : ~ .....
.................... ;; ..... ~ S.~.~ ~.'~i:.. ~)~ ....... ;~ :~ .... ~l ~ ~o~r~O~) O0,'~f~ ~3 ~,,~ ~'~(~*~ ~ ' : : ;
PI{OiXlCT Z04-1 ~ Inc., G~, Ma~. 01471,