HomeMy WebLinkAboutELMORE #2 BLK 7 LT 1Elmore #2
Block 7
Lot 1
#018-172-28
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
AME
PHONE
C� — I5
NEW
❑ UPGRADE
AILINGVADDRESV
�f 0
--GAL DESCRIPTION
L1, ✓'Jy`�7��X��/Io�Ce
JCATIONv " '
NO. OF BEDROOMS
DISTANCE TO:
Well (
�QQ -+—
Absorption area
Dwellir}g� /
/
PERMIT NO.
Uy
iQ
w
y FLiq.capa
Manufacturer ,f,/- _ _
city in gallons Inside length
IccLL IF HOMEMADE:
Maters
Width
cpartments
No. om
Liquid depth
6UY
DISTANCE TO:
Well
Dwelling
PERMIT NO.
_? F
Manufacturer
Material
Liquid capacity in gallons
J
Lux =
j LL Z
DISTANCE TO:
No. of lines l
Well Q Q /
Lengt f e9ch line
Foundation
Total IQng h 9f lines
f
Nearest llot/line
Trench width
inches
PER T Off.
Distance between lines
1- Z ¢inches
1.,.
C
w
Top of rile to finish grade /
Length Width
Material beneath rile
Depth
/ /
l9.
Total effective $bsorption area
oZ-
MIT NO.
U
n F
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
wa
w
y `
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PE@041 ToNQ. O
l CMCJ
J
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS C
1
SOIL TEST RATING/�s ,-i
INSTALLER
REMARKS
5
APPROVED DATE LEGAL
?-3t-78
72-013 (Rev. 3178)
' M.W DRILLING, INC. ........ .
DRILLING LOG
Well Owner Jerry' BrLske
· ' - _Use of Well
Location (address of: Township, Range, Bectfon, If known; er distance main road ..Lot 1 Block 7 Elmore Subdivision
DO~1,
Size of casing 6** l')et~th of Hole
Static Water level 60 ~t.
Screen ( ); Perforated (
Describe screen or perforation
.163 feet Cased to ].60.9 feet
(below) land t:'.rface, Finish of well (check one) open end (
).
Well pumping test et 8 gallons per
of drawdown from static level.
Date of completiop 6 / 2 8 / 7_8' "'
Depth In feet from
ground surface
2 TO - 3
3 TO, 1,8,
18. TO 19
19 TO 24
2/, To
., 44 TO
, ~0 TO 133_
(minute) for ]-,. hours with 100~
' 'q ':'' WELL tOO
Give details of formations penetrated, size of material, color end hardness
__ Cas Xn.S',:s cickuP
Organics .,.
Silty cobbles.. ~rav. elly
. Cravat' a~d clay
Gr ltv hard nl i:
a~e .' tl
Gravelly hard ~n~
~ ~rav
~0
xx );
Ct*ru~rlcflte 'tA)'(' ,ql.t *q,- IY'/'l '
- M U N I C I P R L I T V OF= R N C H O R R O E 0
- DEPARTMENT(7 HEALTH AND ENVIRONMENTAL," OTECTION
V 825 'L.' STREET, ANCHORAGE, AK. 9�;,.mVl
• 264-4720
WELL RNO ON—'S ITE SEWER F='ERM I
PERMIT NO. C 780360 > --T�-r\ 0--•/i t "Y"
APPLICANT JERRY BRISKE 2140 E DIMOND 9-1524
-3%- 4
LOCATION RIVERTON AVE
LEGAL L1 B7 ELMORE LOT SIZE 39936 SQUARE FEET
6, -rvio
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH C� ,AI 3 7h 7
MAXIMUM NUMBER OF BEDROOMS N f; SOIL RATING <SQ FT/BR)= 115
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
38
E>EF7TH= 10 LENGTH= SreOt GRAVEL_ DEPTH= iS
THE LENGTH DIMENSION IS THE LENGTH CIN 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 CIN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET). /.:?. 's� 0
REClU I REE? SEPT I C TRtJK S I Z7- I-= A+ c GRL_L_0r4F>
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- T W O C 2] I N S P E C T I O N S RF2 E R a Q U I R E E> ---
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELLi OR
150 TO 200 FEET FROM A PUBLIC,WELL DEPENDING UPON! THE TYPE OF PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERM I T EXP I RES F7ECEMBER 31.r 1970
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREME14TS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT T E ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE I5 REMOP TQ INCLUDE MORE THAN -3 BEDROOMS.
SIGNED
BRISKE
ISSUED BY __ £� 14/
V3. 2
( j P' SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION
Pouch 6.650, Anchorage, Alaska 99602 276-2221 TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: B -B pr S Construction DATE PERFORMED: 5/19/78
LEGAL DESCRIPTION: Lot i r Blk. 7 Elmore Subd. Add. #2
rcr_r.s SLOPE SITE PLAN
muv ■ENN
OVER BURDEN
OL ....
2 9,
3
4
5 oa ;
,o
6-
8 Q�b�l
9. b0
•11
12
13
14
15
16
17
18
SANDY GRAVEL
W/IARGE COBBLES
USCS. CLASS. GP
M
19
20
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS Lot has good natural drainage and is coverd with large
spruce and birch trees. ,Qe ao -' ,,57^r,
'ERFORMED BY: S.R. CUNDY CERTIFIED BY ATE{ /22/78
I
008(7/76)
WASGROUND WATER
ENCOUNTERED?
IF YES. AT WHAT
DEPTH?
We
S
L
O
P
E
ED
Date
Gross
Time
wo
Depth to
Water
MEN
11
d
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
11
d
0
i
SOIL L°�RSS
lCRAUE� 'o�C
3 G q, � D7tf
�NStSi►)NT
i v
L `'I NSf na,Jc, Fr
WItTEP—
r.
rT
s
es.vr
q(
14�
Q I
I
1
�-
p .Attd5 s,wKd�d s ut b -lxQs
d5 cP chs�c c l� ��,t a L 4 ` fa ro tie h o e�sca e .
Municipality of Anchorage
• Development Services Department "`G '
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING 1
Parcel I.D. 018-172-28 COSA It 0�C
Expiration Date: 9-
1.
-1. GENERAL INFORMATION
Complete legal description Elmore #2 Block 7 Lot 1
Location (site address) 14401 Elmore Rd., Anchorage, AK 99516
Current Property owner(s) Dave Goggins
Day phone 244-0203
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent FSOB
Day phone
Mailing Address
Unless otherwise requested, COSA will
be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Q
Individual On-site
0
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the 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 Spurkland Enginneering
Address 203 W. 15th Ave., Ste 202, Anchorage, AK 99501
Engineer's Printed Name Lars Spurkland
Phone 279-3916
Date May 31, 2012
All
of
H.
5. DSD SIGNATURE JJ SPURKLAND;E�
Approved for 1" bedrooms. 0' AE)�Su 0Disapproved. 1 PR
Conditional approval for bedrooms, with the following stipul t ons"��~4
Attachments
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: -� e✓
i
(Rev.11105)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: EM2 - ft 2 SLK _1 J 1 Parcel ID: 41$ -112- 2S
A. WELL DATA
Well type P1E5. If A, B, or C provide PWSID # — Well Log (YM) 7
Date completed 6125 76 Sanitary seal (YIN) Y
Total depth I b3 ft. Cased to t61 ft.
FROM WELL LOG
Date of test 28 $
Static water level ft.
Well production 00 9•P•m•
WATER SAMPLE RESULTS:
Coliform —/VF -G- colonies/100 mL Nitrate U.W mg/L
Arsenic: A/D ug/L date of sample: 4 _241112.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material G Q S (E
Tank size IZ50 gal. Number of Compartments 2
Wires properly protected (Y/N) Y
Casing height (above ground) -5 Z in.
AT INSPECTION
s zW 1z.
9 b ft.
10.3 g.p.m.
Collected by: LAP -5 S-uyki KrA
Date installed
Cleanouts(YIN) i!
Foundation cleanout (Y/N) y Depression over tank (YM) IV High water alarm (Y/N) N/A
Date of pumping _511d, Pumper Ai gormb pu1«S
C. ABSORPTION FIELD DATA
Date installed 731 .$ Soil rating (g.p.ddft2 o /bdr ) 115 System type DEE? TIZENC.N
Length 41 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 11' ft. Eff. absorption area q92 ft2 Monitoring tube y Depression over field
Date of adequacy test5 24 ! Z Results (Pass/Fail) A For A bedrooms
Fluid depth in absorption field before test 51,5 in. Water added gal. New depth ?2 in.
Elapsed Time: I(0 min. Final fluid depth 0 in. OWN
rate >= g•p•d•
Any rejuvenation treatment (past 12 moa (Y/N & type) NONE Kf W N If yes, give date
D. LIFT STATION
Date installed — Size in gallons Manhole/Access (YIN)
"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
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 10014- On adjacent lots 1001+
Absorption field on lot 1001+ On adjacent lots 10&+
Public sewer main M4 A Public sewer manhole/cleanout /J�A
Sewer /septic service line Z Q 5 + Holding tank NLA
Animal containment areas SO *CMO, Manurelanimal excrete storage areas
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Q t
Building foundation Property line 10 + Absorption field +
6
Water main V /A Water service tine EU Surfacewater 1001+
'
Wells on adjacent lots 100t+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
r E
Property line 10 + Building foundation 2O } Water main
43 1 f -
Water Service line 40'+ Surfacewater 1001+1,6
Driveway, parking/vehiGe storage
Curtain drain A/[A 5O Wells on adjacent lots 1� Q
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal recordsthatthe above systems are in
conformance with MOA COSA guidelines in effect onthis date.
Engineer's Printed Name LMS SPgkklowy1
Date 5L31Ii2–
COSA Fee $__ `1 UID
Date of Payment (01 S 117. C
Receipt Number (Dal 3A 6l
(Rev.4110)
Waiver Fee $
Date of Payment
Receipt Number
OF
ow
%y49H
110
cL/anr/
c-vGE
x
Ared Wolatka
est NO. 3255-S
.12-
Srd
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON - THE RECORDED
PLAT ARE NOT SHOWN HEAEON. F8 q?_7 r':1
2ps
i Yz STY-
DE4K I
ver) t
cK-6-/3-93 (P 6-9-12
AS -BUILT NO CORNERS SET THIS DATE
I hereby certify that I have performed a Mortgagee's in-
spection of the following described property:
.�..I�, � `EGC�I-•iL� f'�i-=%'C�I'it[�t-.3 'iC�
J
Anchorage Recording Pr Alaskay and that the improve-
ments situated thereon are within the property lines and do
not overlap or encroach on the property lying adjacent there-
to, that no improvements on property lying adjacent thereto
encroach on the premises in question and that there are no
roadways, transmission lines or other visible easements on
said property except as indicated hereon,
Dated at Anchorage, Alaska
this 24lrh day of JULY 19
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
MUNICIPALANCHORAGE
• '� DEPARTMENT OF HEALTH
&HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ( — t12 4A
HAA# 1100111na_10
1. GENERAL INFORMATION
Complete legal description L I• F3 7 E� #�
Location (site address or directions)
Mailingaddress
L !� .... •
o aaencv Day phone
Mailing address
Agent 5/7or'90 0-je1212 Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. 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 -MIA". 1/911 Front MOA F21
S. 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 S2__L r0� R "�Pho �' X57
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
By:
Additional Comments
Date-_-0-Li21_
;7 1517 E
bedrooms, with the following stipulations:
111717
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.
re=(P«.uvi) Back MOAm
Municipality of Anchorage
!�HEADepartment of Health & Human Services
LTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LlB% rCfmnr'P ? Parcel I.D.
A. WELL DATA
Well type Qr'1 V �"FC If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) x Date completed /0 ^Z6� — % a Driller I C
Total depth ! i� / Cased to , 6 0 ` % ( Casing height R
Sanitary seat (Y/N) Wires properly protected (Y/N)
V
FROM WELL LOG
Date of test
Static water level r
Well flow 9•P•m•
Pump level U Joe Wa
AT INSPECTION
✓�- Z O - 2WNICIPALITY OF ANCHORAGE
tNYIKUIWALINII SERVICES DIVISION
;.i+ 01.1993
�'• g.p.m.
�1II(/loty/I RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 100 / o
14) ; On adjacent lots 0/ C -
Absorption field on lot b0(9/()
/%
C. LIFT STATION
Date installed
Size in gallons I
Vent (Y/N) "Pump o ' vel at _
High water alarm level
Meets MOA electrical codes-( N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
— Manufacturer
lanhole/Acces ' N)
"Pump off' level at
Cycles tested
7
Surface water _
rL !� r
Date installed, 3 I —2 7 J
1 Soil rating System type
Length �� Width Gravel thickness Total depth
Total absorption area �T2 - Cleanouts present(Y/N)
Depression over field. (Y/N) Al Date of adequacy test
Results (pass/fail) ',� �� for bedrooms
Peroxide treatment (past 12 months) (Y/N) �' If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot r00' (4) On adjacent lots 100 / Property line 10 '(,4
To building foundation To existing or abandoned system on lot
r �
On adjacent lots �� LAI
Cutbank JVOh `e Water main/service line
r �
Surface water Ln0 Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Enginee Nameva �� 6,5i
Date Z - (o /1//&
Cy
HAA Fee $ 76
Date of Payment ^ 2 `9'3/
Receipt Number
72-M IRw. 3/911 BWX MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
Oa�4d�p�0�e55'�►���
NORTHERN
TESTING LABORATORIES,
INC.
3330 INDUSTRIAL AVENUE
FAIRBANKS, ALASKA 99701
907456-3116
2505 FAIRBANKS ST.
ANCHORAGE, ALASKA 99503
907.277-8378
ociates
Report Date: 05/26/93
6410 Switzerland Drive
Anchorage AR 99516
Attn: James Sizemore
Our Lab 1:
Location/Projects
Your Sample ID:
Sample Matrix:
Comments:
Lab
Number Method
A123545
L1 B7 E1 More
Water
Parameter
A123545 EPA 353.3 Nitrate -N
�.c
Reported By: Susan C. Tif tal
Microbiology Supervisor
Date Arrived:
05/20/93
Date Sampled:
05/20/93
Time Sampled:
1120
Collected By:
JS
* Definitions *
B - Below Regulatory Min.
H - Above Regulatory Max.
E - Estimated Value
M - Matrix Interference
D - Lost to Dilution
MDL - Method Detection Limit
Unite Result * MDL
mg/l
0.3 0.1
Date Date
Prepared Analyzed
05/25/93
MUNICIPALITY ANCHORAGE
O DEPARTMENT HEALTH 8 HUMAN SERVICES
of
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # e2/ !7% 2e
1. GENERAL INFORMATION
HAA # ."(L 7-7 f
Complete legal description Lot 1; Uock 7; Etmoae Subd.Lv.ie.Lon 02;
Location (site address or directions) 14401 Etmon2 Road
Property owner Robyit 6 XucAeM Henson Day phone
Mailing address 1259 ten itdegn6o Loa Atmos, N.M. 87544
Lending agency
Mailing address
Agent
Sharon Gtenn HERITAGE.REAL.ESTATE
Day phone
Day phone 562-1222
Address 3230 C St4eet Ancho4age, A-aska 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 ✓
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
Holding tank
Community on-site
Public sewer
NOTE: It community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025)R".V91) Fwt MOA'21
S. 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 furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
S & 5 ENGINEZRING
Address
Eagle River, Alaska 99577
Engineer's signature
6. DHHS SIGNATURE
Approved for `r bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Phone �9�%Zy79
Date
bedrooms, with the following stipulations:
By: J O Rt4 ,S M (T4- Date % 8 LI -131
•
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 engineers work.
7225 (R... i,v+) 6. MOA n1
.� Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: oQt :t, Parcel Parcel I.D.
A. WELL DATA
Well type Su W b9m&_ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) 11Date completed la Driller AA 4-10 L rt LL
Total depth 121, Cased to (� �• `1 Casing height 12 -
Sanitary
Z
Sanitary seat (Y/N) —
Date of test
Static water level
Well flow
Wires property protected (Y/N)
FROM WELL LOG
Pump level V K
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
?
C f
F
(O l
n
r
a
M
-`
``snN
g.p.m.<
F
rn
to
L
D
o
Septic/holding tank on lot nD /f ; On adjacent lots too f"
i
Absorption field on lot ( no f ; On adjacent lots /00 t
Public sewer main /J/LA Public sewer manhole/cleanout A)
Public sewer service line IJ lA Petroleum tank n)O�JG' 1C rJ oW h!
WATER SAMPLE RESULTS:
Coliform 'SA:46c.tnr11 Nitrate.f d1 At " Z )Other bacteria Z e b
Date of sample: (n " - Collected by:�r+' int ee(P
B. SEPTIC/HOLDING TANK DATA
Date Installed 31' B Tank size I Z 50 G o4 Compartments Z
Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) IS1
High water alarm (Y/N) N,bA Alarm tested (Y/N)- i ! w
Date of pumping (p — Z to - �(( cA ` fdoMc Senv� ces
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot It DO f On adjacent lots 100 t Foundation S 1
� t i
To property line 1 O Absorption field i Water main/service line 7 f
Surface water/drainage / Oc> t
7242e(ew.W)Fwt MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION ,
Date Installed
Size in gallons
Vent (Y/N) - ' um
High water alarm level
Meets MOA electrical codes (Y/N
'SEPARATION DISTANCE FROM
Well on lot
on" level at —
Manufacturer
Manhole/Access(Y/N)
"Pump off" level at.
_ Cycles tested
STATION TO:
\ 1 1
'
rt adjacent lots _
Surface water
t.
D. ABSORPTION FIELD
DDrDATA
Date installed_ T — I ` — Soil rating System type � � mss_ r -k
Length _m_ Width 3 Gravel thickness la Total depth_(_[?
Total absorption area Cleanouts present (Y/N) �+
Depression over field (Y/N) Date of adequacy test to ' Z 7- s
Results (pass/fail) Pel S S for 4L ir e - bedrooms
Peroxide treatment (past 12 months) (Y/N) If yes, give date u A
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ( On 7+ Onadjacentlots ( 001t Propertyline to r+
To building foundation ( n t To existing or abandoned system on lot - y%
On adjacent lots 3 O t Cutbank 1
��Watermain/service line I O 'f'
Surface water IOD r't Driveway, parking/vehicle storage area
Curtain drain V . - of
E. ENGINEER'S CERTIFICATION
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
O.l'Y..a��.
Signature S 8 S ENGINEERING
17034 Eagla River Loop Road No. 204
Engineer's Name U-1- River.Alaska 99577
Date
0
HAA Fee $lT/) Waiver Fee: $
Date of PaymentQ Date of Payment
Receipt Number # Receipt Number
72-M (Rev. 191) eetk MOA 21
c..
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS REPORT 11 SANeLE for WOREorderi 35463
Date Report Printed: JUN 24 91 / 10:31
Client Sample ID:LI R7 ELNORE S/D 12
PkSID :UA
Collectad JUN 21 91 ! 13:30 his.
Received JCN 21 91 4 14:00 hre.
Precerved with :IS REQUIRED
Analysis Completed :JUN 21 91
Laboratory Super isor : TEPF.E/N C. EDE
Released 1y <!f
Chemlah Ref is 912913 Lab Smpl ID: 1
Parameter Tested
NIIRATE-N
Sample ROUTINE SX) -TLE COLLECTED 11: R.D.J.
Remarks:
Client Name :S i S ENGINEERING
Client lett :SNSENGP
1PO i PO t NONE. RECEIVED
Req 1
Ordered By :R SNAIER
Send Reports to:
1)S 6 S ENGINEERING
2)
.................................................................................
Matrix: NATER
Allowable
Result Unite Nathod Limits
------------------------------------------------------------
0.26 mg/l EPA 353.2 30
..............................................................................................................
1 Tests Performed See Special Instructions Above UA -Unavailable
ND- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than.. CT -Greater Than
or
-� — 1MEF1 101131-70
115 WAD
y MUNICIPALITY OF ANCHORAGE
Ml1NICIPALITY OF ANCHORAGE
DEPT. Ci 1 "..71 &
' \ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIp�
8215 L Straat • Anchorage, Aloka 99501
t'tvIRONN.i-NTAL I :.::::Ci1CNJ
•
ENVIRONMENTAL ENGINEERING DIVISION
JUN
Telephone 264.4720
FF
((�� LOU
OU
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER`IaALMt_iD
DIRECTIONS: Complete all parts on page 1. Incomplete requesb will not be processed. Plaanetloes ten 00) dew lueprooming.
1. PROPERTY OWNER
❑ MULTIPLE FAMILY
Ob E
MAIL DRF,SS
*ATTACH
s-rL-
WELL LOG. A well log is required for all wells drilled
PROPERTY RESIDENT III different from above) VQ
/8a7 77. /5— A,
p�
/o
PHONE
2. BUTPHONE
S. SEWAGE DISPOSAL SYSTEM
LIN ADDRESS 4$0 -lc
P? W, /
Zro
c.
s
E
I7fNO ITUT N
r
by this Department.
PHONE
a�9-o6
MAILING � yRES$e � �j //��� � ff
f" 12 ' h/GX.G. Oe -'ns
p G'
/ /s�3
4. R71ORtAGENT
PHONE
a78 -ase f
ING DORESS
5. LEGAL DESCRIPTION Q
STREET LOCATION
ep.L_I�
S. TYPE OF RESIDEN E
NUMBER OF BEDROOMS
❑ One 0 Four ❑ Other
I SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
*ATTACH
INDIVIDUAL'
WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled pri r o th t rlr ive well
❑ PUBLIC UTILITY
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE..
"If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
❑ PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
/I
�ee)
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME -
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLICUTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
1
IN TALLER
❑Septic Tank or ❑Holding Tank
Size: /Z- -0 If Tank is homemade
give dimensions:
SOILS RATING
f
TYPE OF TANK
MANUFACTURER Q t
•~l�dl'.�(. --J
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic Holding Tank
Absorption Ara
Lina
rat a iM
AMorption Arm to Merest Lot Lim
5. COMMENTS
APPROVED FOR _� BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY Tid
LEGAL DESCRIPTION
72-010 (Rev. 3no)
