HomeMy WebLinkAboutELMORE BLK 2 LT 9 '~"""~ MUNICIPALITY OF ANCHORAGE ( t
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO:
Iwe''I Ab'°'Pt'°nt rP
DISTANCE TO:
IF HOMEMADE: I Inside length
Well J Dwelling
Well
DISTANCE TO:
No, of lines ~. Length of each line
Top of tile to finish grade ! I
Type of crib Crib diameter
Well
DISTANCE TO:
Depth
Dwelling
Width
DISTANCE TO:
[] UPGRADE
NO. OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
PERMIT NO,
Material Liquid capacity in gallons
Foundation Nearest lot line PERMIT NO.
Totallength ofl Trench width
~ inches
Material beneath tile I
Depth
Crib depth
Building foundation
PERMIT NO.
Total effective absorption area
Nearest lot line
Driller D~$tence to lot line
Building foundation Sewer line Septic tank
OTHER
SOIL TEST RATING
INSTALLER
.EMARKS %//'
APPRO ED /~
724313 I Re~.. 3/78) ~__.~¢
DATE LEGAL
· ~ . DEPARTMENT OF HEALTH AND ENVIRONHEHTAL PROTECTION D
-- 825 ~L~ STREET, ANCHORAGE, AK.
PERMIT NO. ( B104-~9 )
APPLICANT JAMESE SCHEFERS l~8?H ANO 9950? 248
LOCATION BUFFALO SHOHSHI
LEGAL L9 B2 ELMORE SUB LOT SIZE 21000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TREHCH
MRXIMUM NUMBER OF BEDROOMS
SOIL RRTING (SQ FT?BR)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH: 5 LE~GTH: 64 GRA%~EL DEPTH:~ 2 ~
THE LEHGTH DIMENSION IS THE LENGTH (IN FEET> OF THE TRENCH OR DRRIHFIEL~.
THE DEPTH OF A TREWCH OR PIT IS THE ~ISTRNCE BETWEEN THE SURFACE OF THE
GROUN~ AND THE BOTTOH OF THE EXCAVATION (IN FEET>.
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCRVRTION (IN FEET>.
REi~U ! RED _c:EPT t C: TRN[( $ T ZE= ::LOOO C~iRLLOt~:
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURIHG THE
INSTALLATION IWSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDEHCES THRT THE WELL WILL SERVE.
t[qO ( 2 ) I r~PECT I 0~ ARE REQU T RED
BACKFILLING Of ANY SYSTEM WITHOUT FINAL INSPECTION RHD APPROVAL BY THIS
DEPARTMEHT WILL BE SUBJECT TO PROSECUTION.
MINIMUt! DISTANCE BETWEEH R WELL RND ANY ON-SITE SEWRGE DISPOSRL SYSTEM IS
lO0 FEET FOR A PRIVATE WELL OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DI~TRNCE FROM R PRIVATE NELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS ~5 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIH ~ DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIRGRRMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERr~ I t E×P I RES DECEr~BER _~:L.. 1981
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REOUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: I WILL INSTALL THE SYSTEM IH ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE EHLRRGEMENT IF THE
RESIDEHCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
SIGNED :G~~~-J :
~PPL I CANT JRMES~CHEFER5
V4. 0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 Lo Street, Anchorage, Alaska 90S01 2644720
SOILS LOG -- PERCOLATION TEST
PERCOLATION
TEST
LEGAL DESCRIPTION:
4-
5-
6-
7-
8
9
SLOPE SITE PLAN
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
ENCOUNTERED? , O
P
IF YES, AT WHAT ~ I F...
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BE'FWEEN
FT AND
.(minutes/i.ch)
FT
72-008 (6/79)
•
•t ��• so,e
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904 SAFETY
Certificate of On-Site Systems Approval �i '
Parcel I.D. 018-171-14 Expiration Date: `�� —a17— l4
1. GENERAL INFORMATION
Complete legal description Elmore Block 2 Lot 9
Location (site address) 4941 Shoshoni Ave.
Current Property owner(s) Teresa Zimmerman Day phone
Mailing address 4941 Shoshoni Ave. Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well El Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
rt1 .,
WaiverNariance request fc • �� • Distance:
Received Date: /Q#
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ Z(o — Waiver Fee $
Date of Payment (p Date of Payment
Receipt Number 4 S /G Receipt Number
COSA# QWaiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined
in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,and regulations in effect at
the time of installation.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe 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 soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 6/21/2018
"W\`
4�OF AL. 'kk
4.•.0.4_$
6. DSD SIGNATURE F' 7
x System #1 Approved for 1-( bedrooms t••.S{even'I.•l anno`n—e _
/ r �,• CE-8149
System #2 Approved for bedrooms �� 9s •
Disapproved 11,/eFES9100A
Conditional approval for bedrooms, with the following stipulations:
jv ON-SITE ti
WATER AND '
WAS I EWATER o
G=
,‘ PROGRAM
Original Certificate Date: C.Q.
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheeti ..
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Elmore Block 2 Lot 9 Parcel ID:018-171-14
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 8/3/1981 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 94 ft. Cased to 94' ft. Casing height(above ground) 21+ in.
FROM WELL LOG AT INSPECTION
Date of test 8/3/1981 2/13/2018
Static water level U N K ft76.4 ft.
Well production 15 g.p.m. 4 9 g.p.m.
WATER SAMPLE RESULTS:
r �
Coliform � ielcolonies/100 mL Nitrate i •� `.) mg/L
6/11/2018 PES
Arsenic Ni I/ ug/L Date of sample: Collected by: _
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/4/2013
Tank size 1250 gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) fN High water alarm (Y/N) N/A
Date of pumping �'Z2- lib Pumper br-f'�til CU1,i ` �� r
C. ABSORPTION FIELD DATA
Date installed 9/4/2013 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPD/SF System type Shallow Trench
Length 64 ft. Width 5 ft. Gravel below pipe 2.6 ft.
Total depth 5.6 ft. Eff. absorption area 500 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 2/13/2018 PASS
4 Results(Pass/Fail) For bedrooms
Fluid depth in absorption field before test DIN in. Water added 600 gal. New dh Dry in.
e t
fiidr600+
Elapsed Time: 120 min. Final fluid dept y in. Absorption rate >= g.p.d.
N
Any rejuvenation treatment (past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas_100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
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 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION � OF,�A�,l
1 certify that I have determined through field inspections and 0/,i''"pj'�:- ��; y��f
review of Municipal records that the above systems are in *; - • I /\ •*y
conformance with MOA COSA guidelines in effect on this date. /••••• •• ••' •• •‘• •• r
Engineer's Printed Name Steven Pannone , '...Si everi .*ISannorie.••1
Date
6/21/2018 �+T4s• CE—8149 • "
X141 cEssl
COSA canary sheet_2-6-15.doc
_ Frontier Surveys,LLC Project No:17-013 Date:January 20th,2017
NORTH Ordered By:Teresa Zimmerman Plat:P-635 Grid:N/A
Scale 1"=30'
I
589°46'30"W 132.57- I
•—w--o.—tr.—u.mss—tw—.r—,. ,.. — I
10'UTILITY EASEMENT \4. LT,
I
o.\ I
,t51 ;S1 0. s
Elmore Subdivision 4, "--..e. I
Lot 9,Block 2 \4` 1
23,711 sq.ft.+/-
49415hoshoni Avenue 4',,,,.
3 Story Wood Framed Nouse a�s I
w/Attached 2 Car Garage ,r(� ,
I
2ND STORY DECK �'��
m3RD STORY DECK \ vsi �\ e.
^. 4 t0 0 / 45.9 3 W
Or t
g 1� /////// ?K IL
y �_\ ,/ N CC
LOT 10
QQ 1 ak pis '45 ` "4)
V �K�KO`T 2I, Q
U.
—5.1 ...% -46.4 r‘i -58.6,4" /)s` m
p9.9 41IF -...,3 , ,� \49.4
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0 93r �Y '781, t"/ \ I
1
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11 P
j, ` / li ��� I 30.0 R.O.W.^I
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l j t N89.46'30"E 132.80 I
ORNAMENTAL STONE WALLS // Il I
/ o
\
re rP / 9
t•.2.11 Ig I
----------tet SHOSHON/AVENUE------------L------1
Legend:
a
1,,E] Electric Meter/Outside Power (-4)Telephone Pole FStreet Sign I
IZ''� Gas Meter 0 Deck Fence -- Light Pole LEA Electric Pedestal
rm
1S; Septic 'W)Water Well []f Mailbox —aw—Over Hanging Power LT, Telephone Pedestal
General Notes: `/
1.This document is created for the purpose of a single property transaction and is subject to Federal Copyright Law.
2.Excepting for gross negligence,the liability for this survey shall not exceed the cost of preparing this survey. 0 30 60
3.All measurements/setbacks are to the visual/apparent building footprint. 15
4.Dimensions to property lines are plus/minus 0.1ft. MIIIMMIIM Feel
`\``••\\\\\111 I I This survey complies with ASPLS Mortgage Location Standards.The survey represents visible improvements and
OF •• 111,
conditions at the time of the survey.This document does not constitute a boundary survey and is subject to any
..NQS i,r inaccuracies that a subsequent boundary survey may reveal.It is the responsibility of the Owner to determine
^—.�P•' r� the existence of any easements,covenants,or restrictions which do not appear on the record plat.Under no
y 1 '.'9 i� circumstances should this document be used for construction or for establishing a boundary or fence line.
*. 49TH/\ ...* As-Built Survey of:
Lot 9 Block 2, Elmore Subdivision
p FREDERIC W. NER :: I,Frederic Wagner,hereby certify that this Mortgage Inspection Survey was performed by me,or
NO.5.5.-9946
i�''c�1/ 30/2018 �S"1 under my direct supervision on January 20th,2018.
rr o�• � = Frontier Surveys,LLC FRON'T'IER
I t t�` Ess oNg- .��` 650 W.58th Ave.Suite E Anchorage,Alaska 99518 Su.V ti
907.460.1686-info@frontiersurveys.com
PROFESSIONAL SEAL www.frontiersurveys.com
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
GENERAL INFORMATION
Complete legal description
Lot 9; 8~oc~ i; E,b~zo,t.e Su. bd. Zui6ion Add/J.:Lion #l
Location (site address or directions) 494! S~6hon, i.
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
~n,~fd £ ~eE~f~. [~,~ Day phone 345-8557
~ 562-3740
~. O. Box 101966 Anchorage. A,~c6~ 99510-1966
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
e
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL.'
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
o
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the vaiidation 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
$ & $ ENGINEERING
17034 Eagle River Loop Road No,
Eagle River, Alaska ~)9577
Phone
DHHS SIGNATURE
Approvad for bedrooms.
Disapproved.
~ Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: ,/~"~'~ d~z~.~'-,~Z~ 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 r~gistered 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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELl DATA
Well type ~V~TF.
Log present (~/N)
Total depth
Sanitary seal (~N)
If A, B, or C, attach ADEC I~tter.
Y/~'-~ Date completed
C~?' .Cased to c~?
ADEC water system number
~,~- ~-~ t Driller
Casing height
Wires properly protected ~N)
FROM WELL LOG
Date Of test ~ J.'z.>- ~ [
Static water' level C,{I(
Well flow I ~
Pump level (z~ I~,
SEPARATION DISTANCES FROM WELL TO:
Septic/b~k~g tank on lot J[-~'
Absorption field on lot ~ ~-F-"w ~
Public sewer main
Sewer s(~rvice line
g.p.m.
AT INSPECTION
' "~,0 g.p.~ ~O~
; On adjacent lots
; On adjacent lots ' ) 00'~'
~..J/A Public sewer manhole/cleanout ~'-)/~
~,~t~~'1- Petroleum tank [~\c~ ,=-
WATER SAMPLE RESULTS:
Coliform C) Nitrate I, ;)-- rn~-/~ Other bacteria
Date of sample: /"'/~~o-c~;~-, Collected by: ~ ~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed ~- I ~-~ I
Cleanouts ~1) ' ~/~,~"
High water ala~'m (Y/N) . "~: ~'J/~ ·Alarm tested (Y~
Date of pumping · L./;~ ') Pumper
SEPARATION DIsTANCEs FROM SEPTIC/I::I~c'I~G TANK TO:
Well(s) on lot '1[~ ~' ' ' ':" '
' On adjacent lots ~00 ~'
Topropertyline · I~ ~4- Absorption field ' ' ' ~" '
Surface water/drainage I (~(~ ~ 'k
Tank size 1('~5 ('~,~(,. Compartments
Foundation cleanout ~/N) ~'~ Depression (Y/i~
Foundation
W~ter main/service mine
72-026 (Rev. 7/9t) Front · CONTINUED ON BACK PAGE
C. LIFT STATION -/ . . ,-,, ~"
~. ·,'"'~"--~ --~~')/A . , .' "' '" .i Manufacturer " i',"/
· ' i :' Manhc~l;/ACces;'(":/:')'Yrd "' --
gallons~;---,~
Size
in
Vent (Y/N) ' ~elat ' ' '
"Pump
off"
level
at
High water alarm level ~ Cycles tested
Meets MOA electrical codes (Y/N) ~ .~ * a ' r ''
SEPARATION?ISTANCE FROM LIFT STATION T0: , ~
Well on lot "On adjacent lots ~ Surface wate-~,-~
D. ABSORPTION FIELD DATA
: Date installed /~ - i 0 ' 8 ( Soil rating
Length ~0',3~3:., '- '?.~.' Width '~'
· Total absorption area ',-,-~ ~.~'
Depression ~r fi~l~ (Y/~ . ~
Peroxide treatment (pa,t 12 month*) (Y/~
~'~C~ ' ~:F/rJll' System type
Gravel thickness ~, ~
Total depth
Cleanouts present ~N)
Date of adequacy test
for ,~ bedrooms
If yes. give date .... '
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot '
To building foundation
On adjacent lots
Surface water
Curtain drain'
On. adjacent lots /00 C/.. P.r.operty line
(-,0 ~ To existing or abandoned system on lot
Cutbank ~o/o F_ Water main/service line
Driveway. parking/vehicle storage area
Eo 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.'
. ~ : S&SENGINEERING .
Signature 170~ Eagle River Loop Road No.
Engineers Name
HAA Fee $ l~O.~ -
Date of Payment q izq/~
Receipt Number ~,~/~4D (g'77~")
Waiver ,Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVIc:ION OF COMMERCIAL TESTING & £NGINEER[NG CO.
,t{~. ~;T,~.'"~'/ ANC'---"~OR,GE. ALASKA~{9-------'--;'; TEL~PHONE(90~--"~~
FAX: (g07) 561-53oi
m)
1.2 ~/1
~~ M(.mbe: o~ the SOS Gro,JU ($¢c~,:~, O~'nOralo de Surveillance)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~ i .~'.~ -X'~'('~'/..~,.-'~
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date \'7... ~ \~' -'~q
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot. block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ~" ·
Mailing Address '~---'~ ~
(c) Lending Institution t'~'_-'~.
Mailing Address
(d) Real Estate Company and Agent
Address ~.
Telephone: Home
Business
Telephone
(e)
Telephone ~"'J L.~ - '~C:> I
Mail the HAA to the followina address: or:. Check here~, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family,S-
Number of Bedrooms
WATER SUPPLY
Individual Well ~Z~ Community r"l Public I'-I
Note: If c(~mmunity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite,~J' Public I-I Community I'1 Holding Tank r-I
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
AS certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in etfect on
the date of this inspection.
Name of Firm 5 & ~ =:!'~!HEFglt;G Telephone
Address 17034 ~.~;le Riva' Leap Road No. 204
Eagle River, Alas"a ~"lJ
Date
Approved for ..7'~,'/' .~_~oedrooms by . . _ Date
Approved ~/~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
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.
WELL DATA
Well Classification
ENVIRoN. MENTA. .~ i"CHO2AGE
MUNl~/~[~ OF ANCHORAGE (MOA)
"~/ ~ ~LTH A~HORI~APPROVAL(HAA)
--G~ CHECKLIST - FEBRUARY
2~744
RECEIVED Legal Descr~~
J ~.51~,J t ¢~,.3,~.-~. If A, B, C, D.E.C. Approved (WN)
Well Log Presentd~N) Date Completed ~" ~ - ~>~ Yield
Total Depth ¢~4r t Cased to ,,~1 Depth of Grouting -- '
Static Water Level ~>,~ t
Casing Height Above Ground
Electrical Wiring in Conduit~)
Separation Distances from Well:
To Septic/Hoh~qg-Tank on Lot
Pump Set At ~
Sanitary Seal on Casing~N)
Depression Around Wellhead (Y~
\ \¢=.:~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~ 'Z--~ ; On Adjoining Lots
To Nearest Public Sewer Une ' - To Nearest Pub c Sewer . ,
· CleanouUManhole To Nearest Sewer Service Line on Lot
Water Sample Collected by ~'~;:l''''~C~ t ~''''~(-~; Date ~'Z-'-"z'~':~ ~
Water Sample Test Results ~-""~"~'-'t ~-'~ ~ ~'~'~'~7_ '--' '~ ~'~'-~-' ~ ~t~
Comments ~ ~ ~ ~ ~ ~ ~
B. SEPTIC/i. IOL-Dll~ TANK DATA
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Datelnstalled ~-'~c~--151 Size
Standpipes {~YN) Air-tight Caps (:~N)
Depression over Tank (Y/I~
Pumping/Maintenance Contract on File (Y/N) . .
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic,'~,c.',~:;',G Tank:
No. of Compartments
Foundation Cleanout(~[TN)
~ . Date Last Pumped ~."Z.-~
,A. ; for
/
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~'~'~ !
To DisposaIField · ~ "- '~' .- ,' ~-'" '"
To Stream, Pond, La~e, or Major Drainage
Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~:~'-~'~¢'~-~- Type of System Design '"~'"'~
Date Installed t. ~ ~ ~ c~ -- ~ I Length of Field ..~1-. I ~--~
Width of Fiel~ * ~ ~ ~' Depth of Field ~ ~
Square Feet of Absorption Area
Depression over Field (Y,~.
Results of Last Adequacy Test
Separation Distance from Absorption Field:~
To Water-Supply Well '
To Building Foundation
Lot r"3
To Water Main/Service Line
Gravel Bed Thickness '~'
"'Z.-'~GS* ~ ¢ Standpipes Present
Date of Last Adequacy Test
To Property Line ~
To Existing or Abandoned System on
; On Adjoining Lots ~
~ ~:> I..{... To Cutbank (if present)
, \ t.k
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vel'ticle Storage Area
Comments /x).'/~-.t z~,~,~ ~'~l ~~''' ~
D. ' LIFT STATION '
'Size in Gallons~
"Pump On" Level at ~
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions.
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Adequacy Test. MOA
Meets
°° CheckPermitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA a. nd HAA guidelines in effect on the date of this inspect on.
Date of Payment '
A ount:
Page 2 of 2
5633 B STREET ANCHORAGE, ALASKA ~3§16 TELEPHONE (907) 562-2343
FEDERAL TAX ID ~ 92~40440
~IS ~ ~ ~
Client POS -* VI~L Req L'
~le l~'c'd : DP 30 87
Ordered By :
~end
I~ports To:
$ & S ~l(;Itl~RIl~
I~M ~ RIV~ I~P RD., 1204
F. AG~ IH~, ~I. 99577
b~rk Order lb. :
'Client Men~nt :
Date R~port Printed: D~C 31 87 9 13:29
I~leased By :
Reports Addrm 12
Special COI, LKI~ 12-~0-87 AT 1340
Instruct:
{Zmlab Ref l: 8727 Lab $mpl ID: I Ilatrlx: Water
Allo~able
Parmeter T~ted It~-Jult/Onlts ~th~l Limits
IIIT~T~-R 0.90 mg/I 10
APPLI T FILLS OUT UPPER'HAL" :ONLY
Lending I~lfl~Uon Phone
Realty ~. & A~nt Phone
Type of Resl~nce
~lngle Family
~ Multiple Family No. of B~
~ Other
Wate~ Supply
~lndivld~l A~ACH ~LL LOG. A wa~ I~ Is r~utr~ ~o~ all weUs drl~ed since June 1975.
~ ~mm~lty For weUs ~llled prior to th~ date, give well depth (attach I~ U avallabte).
~ Public Utility
Sewer Disposal /
~ Public ~U{{y ~h~n ~m~lM Io Pub{l~ Utility: ~/~
~ Holdlno Tank
NOTE; THE iNSPECTION ~E ~UST ACCODPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
APPROVED B~DROOMS ~ ~ - / , 'CONDITIONS OF APPROyAL / /
Rating Oat~ln,~. -- Well TO ~,Orptlon Area Well Log ,ecelv~
~ Well to Tank Septic T~k Size
January 31, 19B4
William Piotrowski
1303 W. 23rd, #3
Anchorage, AK 99503
Subject: Lot 2, Block 9, ~ilmore
Approval for the individual sewer and water facilities cannot
be Granted until the following items have been completed:
~,/~/ A well log submitted to this office for our files and
review.
0~' top the well casing should be sealed so that it is
The
of
water tight.
The septic tank pumped with a receipt submitted to this
department.
"6An adequacy test needs to be performed on the existing ~/°'~
adequate according to National Standards. A listtn0 of
,~)rivate firms performing tho test is enclosed. This report
~A~needs to be submitted to this office for our review.
The depression over the sewer system will need to be filled
l~C-~o that surface water drains away from the sewer system.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-472U.
Sincerely,
Enclosure
cc: Stuart
Anchorage,
Jim Roberts
Associate Environmental Specialist
Watkins and Associates
AK 995
APPLIC"'NT FILLS OUT UPPER HAI'"',ONLY
Type of Resl~nce
~ Single Family
~ Multiple Family No.
~ Other
~ Holding Tank
NOTE: THE INSPECTION
Time Time Time Time
( ) CONDIT~NAL APPROVAL* .