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Home My WebLink AboutPOLLOCK HOMESTEAD BLK 1 LT 1APollock Block I Lot lA #017-111-25 'z ~" , Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 545-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number:. SWO00114 PID Number:. 017--111 --25 HOm':scoTI' PEPPERS WastewaterSystem: [] New · Upgrade 10224 FRONTAGE ROAD EAGLE RIVER, AK 99577 ABSORPTION FIELD I Na. of Bedrooms: Ph°ne:(907) 694--9681 *0 mDeep Trench []Shollow Trench []Bed [] Other LEGAL DESCRIPTION lA 1 POLLOCK r~ EAGLE MTN. EXC. 6/19/2000 SEPARATION DISTANCES [] Septic · Holding [] $.T.;' P. To Septic Absorption Uft Holding ~ub~c/P~ from ~'QnkR*U St~Qn T,nk S...~ U~. ANCHORAGE TANK 2000 · well - - - 75'+ - STEEL 1 _ _ _ ,0o.. - Une - - ~ lk ' Foundat;on -- -- -- 5'+ -- Curtain p~m~ ~T~[~c~tc~ k~ ~f~m*d ~c. Drain NONE KNOW~ I Remork~: 'TH; N~W NOLD~N¢ TA.K ONLY SE~S THE ~N BENCH MARK ~¢ccn;~ c~r-~L[nn~ ~¢ ~n ~ TOP OF ~ABL[ FLO0. 100.00 D~padm~nt o~ ~,alth ~nd Human 8~i~o~ R~vlewed and appmv~ by: D~///~~ate:/- ~"~ "~'~': AS BUILT DRAWING SW000114 ' 017-111-25 /--NEW 2000 GALLON -- / / / HOLDIN0 TANK - / A B DBL1 24.3 32..3 DBL2 23.6 33.2 ST1 22.9 33.9 ALARM 17.4 40.0 ST2 14..3 45.7 ALASICti WATER & WASTEWATER c.~.o./~.LM. , CONSULTANTS, INC. SC~aE: SCOTT PEPPERS (907) 694-9681 2 OF $ POLLOCK SUBDIVISION; LOT lA, BLOCK 1, AS-BUILT OF SEPTIC SYSTEM UPGRADE SWO00114 ' 017-111-25 /--PNAL t~P-AI~ -¢~,4~ NEW 2000 GALLON HOLDING IANK ~R~ FOR: PHONE NUMBS: P~E NUMBS: ~ SCO~ PEPPERS (gO7) 804-0681 ~ OF ~ ~ ~ ~.le Ir [~:":'"~ POLLOCK SUBDIVISION; LOT lA, BLOCK 1, .'.....IJ-7953.....' PROILE AS-BUILT OF SEPTIC SYSTEM UPGRADE (HOLDING TANK) ~.¢'"}E~~ MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: May 19, 2000 Expiration Date: May 19, 2001 Permit Number: SW000114 Legal Description: POLLOCK BLK 1 LT lA Design Engineer: 0041 AK Water & Wastewater Consultant Owner Name: Scott Peppers Owner Address: 10224 Frontage Road Eagle River, AK 99577-0000 Parcel ID: 017-111-25 Site Address: 005000 RABBIT CREEK RD Lot Size: 210198 SQ. FT. Total Bedrooms: 0 Permit Bedrooms: 0 This permit is for the construction of: [] DisposalField [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage construction must be in accordance with: 1. The attached approved design. 2. mi requirements specified In Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of AJaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. THE BARN FOR WHICH THIS HOLDING TANK PERMIT IS FOR SHALL HAVE ONLY THE FLOOR DRAINS IN THE BARN CONNECTED TO ITAND ONE (1) WASH BASIN. NO FURTHER RECEPTICLES SHALL BE PUT IN THE BARN. Received By: Issued By: Date: Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2B ~ Anchorage ~ Alaska 99504 Phone (907) 337-6179 ~ Fax (907) 338-3246 Consulting Engineers August 17, 1999 Municipality of Anchorage Department of Health and Human Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Sewer Upgrade for Pollock Subdivision; Lot lA, Block 1. llOLDING TANK To whom it may concern: The existing house is served by a private well and a septic system that consists ora 1500 gallon septic tank and a trench type drainfield. This septic system is located on the west side of the lot. The owner wishes to build a garage south ofthe existing barn which is located on the east side of the lot. The existing barn is served by a private well and a I000 gallon holding tank. We are proposing to install a 2000 gallon holding tank that will serve both the existing barn and the proposed garage. There will be no bathroom/toilet and only a sink and floor drains will be connected. The tank will be located approximately 46 feet south ofthe northern lot line and over 75 feet a~vay from the closest well. Little Rabbit Creek flows through the middle of the property. The proposed holdin~g tank will be over 100 feet away from the creek. A copy of the proposed design is attached.~you have any questions, please contact us at 337-6179. ALASKA WATER & WASTEWATER CONSULTANTS, INC. May3, 2000 Municipality of Anchorage Department ofHealth & Human Sen, ices On-Site Services Section P.O. Box 196650 Anchorage, AK 99519-6650 Attn: Dan Roth REFERENCE: Lot lA; Block i; Pollock Subdivision Dear Mr. Roth, In December, 1999 our submitted design package for a holding tank for an existing barn/ garage was denied by your Department. We were to dig a testhole to confu'm that the soil conditions could not support an on-site wastewater disposal system and that a holding tank was the only alternative. A testhole was dug north ofthe barn in April, 2000, (see drawing). We checked the liquid levels in the testhole on April 28, 2000 and found water within 2 feet ofthe ground surface. Request you proceed with the review ofour design package for installing a holding tank, since there is no alternative with the high groundwater levels. Ifyou require additional information, or have any questions please contact our office at 337-6179. E. M.S. JAG/gd 6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * website: akwwc.com ALASKA WATER & WAST~WATBR CONSULTANTS, INC. .=,.~.'~'~-~'~'~,e PHON£ (907) 337-6t79 * FAX (907) 338-3246 PERFORMED FOR:, SCOTt PEPPERS I I ~[mU~ OR~ICS TEST HOLE [~&~ GM CL 4 ~?~ ~f GC OL DEPTH TO I ~ROUNDWATEP . DATE I 4' 4/14/00 ~' +/- 4/2~/oo 10 - 11 DATE READING CLOCK NET TIME WATER LEVEL NET DROP TINE (HINGES) RE'lNG (INCHES) 12 13 17 19~ PERCO~TION ~TE (MIN./INCH) PERC. HOLE DIA. ~(INCHES) 20~ TEST R~ BETWEEN FT. ~D .FT. COMMENTS: UNSUff~LE FOR ON-S~ SEP~C ~M PERFORMED~Y A~ WATER A W~ATER. I, JEFFR~ A. GARNESS, CERTI~ ~T ~IS W~ PER~ED IN ACCORD~CE WEE ~ ~ATE ~D MUNICIP~ CUIDEUNES IN EF~ ON DATE: ~ DEPTH TO I ]ROUNDWATEP .DATE 4' 4/14/00 2' +/- 4/28/00 I I RABBIT cREEK ROAD ---------- ~'2000 HOLDING TANK / AT.AS~ WAlK ~ WAS~WA~K CONS~T~S, ~C. PHONe (90~ ~7-elT./r~: (907) 3~-3246 PO~OCK SUBDIVISION; LOT lA, BLOCK mm8.17.99// a~w. ~: s~ NOT~: 1. 114£ CONTRACTOR tS RESPON~IB~r FOR I~NT~N]NG ~1-1£ 75' UN~. ~ ~R S~ ~ ~E WA~ UNE P~O~Y ~ PRIOR TO ~E ~VA~ON OF ~ HO~NO T~K. ~ ~ ~E JOl~ ~IN 10' OF ~E WA~ UNE S~ ~AS~ WAlK ~ WAS~WA~R CONS~T~S, ~C. POLLOCK SUBDIVISION; LOT lA, BLOCK I ~ o~ ,o,~ L~"~.~.-L~ ~''' SCO~ PEPPERS (907) 694-6981/250-8~48 ~8_17_99// ~:K.D.W. 1 = 50' 2 OF 2 MUNICIPALITY OF ANCHORAGE / DEPARTMENT OF HEAL.TH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 I_ Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME _ PHONE {`NEW ❑UPGRADE L +..'� MAILING ADD ESS LEGAL DESCRIPTION 7 P4L.LOCK -- LOCATION_ /ant C. �. - c ._� ., l:, 't Cs r-e_:J/L Imo' "A o/ NO. OF BEDROOMS Well Absorption area Dwelling =�� PERMIT NO. Z7 U DISTANCE TO: •Zto Is LI _ y F Z wF Manufacturer C ✓��" Materiae s No. of compartments to Liq. rapacity, iii gallons IF HOMEMADE: Inside length .r-- Width �� Liquid deptli_.- Well Dwelling PERMIT NO. J z DISTANCE TO: Z Material Liquid capacity in gallons h Manufacturer J S w DISTANCE TO:LU Well yq Foundation ! O Nearest lot line / PERMIT N0. _j u. z Z w No. of lines Length of each line Total length of line Trench width ,kiinches Distance between lines = ~ pW. Top of the to finish grade �- Material beneath the l-�� Total effective absorption area � . inches p Length Width Depth PERMIT NO. W Q F Type of crib Crib diameter Crib depth Total effective absorption area W a — w ti -LO: Well Building foundation Nearest lot line DISTANCE J J Class Depth _ Driller _ _ Distance to lot line PERMIT NO. W Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER - PIPE MATERIALS SOILTEST RATING (t % Z/ 12-5 11 8c1rm __ INSTALLER t lT".`l1 O REMARKS Y( l'mi)A"lax APPROVED DATE LEGAL 72-013 (Rev. 3/78) � �EPHRTME�T DF HERLOA HHD LAW, IJIOHMEdTHL PROTECTION STREET, ANCHCIA HGE, H4 99501 264~4728 1 TH 74 !RE 2 " R un A �nUfAwy T "T, PERMIT NO ( 820441 ) HPPLICANT ROY RICHRRDSON ]527 VHSSHR �R LOCHTION LEGRL TPOLLOCK LOT SIZE 400000 SQUHR- FEET TYPE OF SOIL RBSURPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF GEDRUOMS c 5 SOIL RATING (SQ FT/BR)n- 125 THE REQUlRED SIZE OF THE SOIL HBSORPTION SYSTEM IS� �TEE to, �� Evil iE-E �' !j li� . ..... j -j- 1-1 =no A05 On V0 TQ foll '&E1.. �RYE go, ��` � THE LENGTH DIMENSIOH IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD THE DEPTH OF H TRENCH OR PIT IS TH2 THE SURFHCE OF THE G�OUND H�D THE BOTTUM OF TH."'., EXCHVHTION (IN FEET) THERE IS NO S�T WIDTH FOR TRENCHES THE GRHVEL DEPTH IS THE MINIMUM DEPTH UF GRHVUL 8ETWEEN THE OUTF8LL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEETZ FT? FEE WTI U Z 14 TEE f1v :ii V ENE M -1 - :11 Q �oil �� ::V ;�::i'-"�B.E��.�:: �- �� jiy�� PERMIT HPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTALLATION INSPECTIONS OF AM" WELLS HDJRCENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THRT THE WELL 1101- SE0E. —.1 1. �in q 0 & :21 On 1 :1 Q110415 lot FT 1�7 �V q I.: lFr!:,E�H: 110 � BHCKFILLING OF ANY SYSTEM WITHUUT FINHL INSPECTION HND HPPROVHL BY THIS DEPHRTMENT NILL BE SUBJECT TU PROSIMUTION. 1=4 H Too I V81: J- PEE Q -c M 1 Pon U 11; 121 EEO 171 FEE 0 W6 10 BEE Pon it M/ M.�� I CERTIFY THAT 1� I HM FHMILIFit? WITH THE REQUIREMENTS FOR ON~SITE SEWERS HND WELLS AS SET FORTH BY THE MUNICIPHLITY OF ANCHORAGE. 2 I WILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH THE CODES ]I UNDERST8ND THHT THE ON~SITE SEWER SYSTEM MRY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 5 BEDROOMS HPPLICHNT R HRDSCIN ISSUE� BY,. . ^/y_ ~/-.'�~~_DRTE...L(Y~��/.4�. 414. 0 � � SOILS LOG -� MUNICIPALITY OF ANCHORAGE f\1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 1:1 PERCOLATIONTEST 825 L. Street, Anchorage, Alaska 99501 264-4720 \ SOILS LOG - PERCOLATION TEST PERFORMED FOR: i'`r C Gt 2 /' i's v—, DATE PERFORMED: LEGAL DESCRIPTION: ^/�a � SLOPE SITE PLAN k) COMMENTS DEPTH (FEET) vy-5 2✓r i C' 1- Depth to Water Net Drop S?r 3 ` c� p� 4-' �'• � 2I"A jap, 5 6 7 8 9 10 11C6�> 12 13 -E 14- 15 16- 17 18- 81920 19- 20- COMMENTS 0 WAS GROUND WATERa ENCOUNTERED? L9 L —D P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE, —(minutes/inch) TEST RUN BETWEEN FT AND FT Xk X yc/. PERFORMED BY: l2E (Y• CERTIFIED 8Y: 72-008 (6/79) DATE: ALASKA �l OR011 nTAL COnTROL SbUIUS, InC. engineerinq & enuironmenlol SJludies December 20, 1982 Municipality of Anchorage Department of Health & Environmental Protection 825 L. Street Anchorage, Ak. 99501 Re: Health Authority On December 8, 1982 our company collected a water sample from the house located on Tract lA Pollock Subdivision. The property owner is Roy Richardson. The water contained no coliform bacteria. The well was located over 100 feet from the septic tank. The electrical wires are encased in conduit annd the well seal was adequate. The well casing stands are 1 foot above the ground. All cleanout pipes had caps. A copy of the report is attached, f+ o 6r. 0°0c- Dens•. '+•V3° W , I.oroy C R id, Jr. ;^t±:f �• a r ov �O E.5 1200 Wesl 33rd Auenue, Swe B 9 Anchoraqe, Alaska 99503 • (907) 276-1361 ® P )j \ O H 6-650 �� P'�� S��-,�� \ ANGI-iOFiP,GE, AL.ASI(A 99502-0650 01I (907) 264-4111 Fd' nch,.aIl acg,P, �� Ft /. ,TONY KNOWLFS. AIA YOR DEPARTMt.N'V OF HEALTH AND ENVIRONMENTAL_ PROTECTION May 17, 1984 Mr. Larry D. Montgomery Alaska Environmental Control Services 1200 W. 33rd Avenue, Suite B Anchorage, Alaska 99503 RE: Lot 1A, Block 1, Pollock Homestead Subdivision Dear Mr.. Montgomery: As discussed with you last week, this Department cannot entertain your proposal for installation of a holding tank until an investigation is made determining the suitability for an on -••site septic system. This is according to State regulations (18AAC'72.025). Soil, ground water., slope, separation distances, and any other factor affecting the feasibility of installing and maintaining an on-site septic system must first be investigated. Liquid waste product elimination from the horses kept on this property must also be addressed. It is understood that solids are to be contained on the property. Proof of zoning approval for this project should also be supplied to this Department. Currently, the well proposed to serve the paddock is our greatest concern. It is understood that this well is located down -- gradient from the stable area, a possible source of contamination requiring a setback of 75 feet according to State regulations. Shallow bedrock further enhances the prospect of shallow aquifer contamination from waste products generated and stored or disposed of on the site. A background analysis of water samples taken from the paddock well as well as a plot plan showing slopes and adjacent lot: facilities would be required to further address your request. This Department is not adverse to installing a holding tank for the minimal use proposed, providing all other factors previously mentioned are adequately addressed and are acceptable. If you have any questions, please call me at 264-4720. S i *�erel.y, Keith E. Bandt Environmental Engineering Manager KB3/ej/D16 ALASKA ChuffinUTAL COnTnOL SC UOS, InC. Cngineerinq & enuironmental Sludies April 25, 1984 MUNICIPALITY OF ANCHORAGU Department of Health and Environmental Protection DEPT, OF HEALTH & 825 L Street ENVIRONMENTAL PROTECTION Anchorage, Alaska ,.. APR .', U `1:i(5' Attn: K. Bandt, R. Robinson RECEIVED Subject: Lot 1A, Block 1, Pollock Homestead SID As per our conversation of April 13, 1984, Mr. Roy Richardson intends to build stables and paddock on his property. This structure is to be served by his second well (see sheet #1). The well is to be used only for this purpose, and its use is limited to that designated above. The residence is served by another well, which is located 110-120 feet from the proposed stables. The stables are intended for personal use only, and not for public use. Four stalls are anticipated, housing two horses. The stables do not constitute another residence; therefore, the well is not designated as a community well. The anticipated use of the well is limited, providing water for the animals, cleaning of the structure, and to operate the facilities within the structure. Mr. Richardson proposes to furnish the structure with one commode and one handsink. The anticipated usage of these facilities is also quite limited and designing an on-site septic system to serve them is impractical. The use of a 1000 gallon holding tank would suffice for the anticipated use of the facilities within the proposed structure. Futhermore, the holding tank will be provided with the required high-water alarm, and pumping agreement. The pumping of the holding tank would likely be on a quarterly or semi. -annual basis since the use of the facilities does not constitute any great amount of wastewater. In addition, the use of a holding tank would circumvent any problems with questionable disposal size of on-site septic for one commode/handbasi.n (sheet #2). The paddock itself (defining the open pen) would be in an excess of 100 feet from the creek; thereby, complying with required setbacks. The only questionable circumstance to this proposal is the distance from the second well to the paddock. This was measured and anticipated to be in an excess of 43 feet. It is important to note here that this well is to serve only the paddock and facilities with the stables. The question of possible contamination of the well and thus the aquifer can be eliminated by the depth and strata of the 1200 West 33rd Auenue, Suite B • Anchorage, Alaska 99503 9 (907) 276-1361 existing wells (see attached well logs). Since the 2nd well is not connected, a sample was taken from the well serving the residence. This was performed to establish the existing condition of the aquifer. The sample (attached) was satisfactory. In addition, Mr. Richardson intends to devote part of the area north of the structure (>100' from well) for subsurface containment of the animal wastes. This area is to be fitted with a rain -proof lid, and the waste material to be utilized for future landscaping. If the amount of material exceeds expectations, then it will be removed from the property. This would also aid in elimination of possible contamination of the well/aquifer. Mr. Richardson had sought zoning approval for this project in 1983, and considering the area in question, this is unlikely to present any problems, as he has adhered to proper setback distances from the creek, property line, etc. In conclusion, the facilities mentioned above will be of minor usage. Contamination of the wells is very unlikely with the provisions mentioned. It is impractical to consider on-site septic as an option, since the confinements of available space and predicted usage of the facilities are quite limited. Therefore, a permit for holding tank installation is requested, noting that the facilities will probably not involve daily usage. If this office can be of further assistance, please contact us at 561-5040. Sincerely, r L. D. Montgomery Sanitarian ALASKA ENVIRONMENTAL do,3 &' �L��// �5 �� Q i Potloa Flayyc �,S 7fc� CONTROL SERVICI INC. SHEET NO.OF Z 1200 West 33rd Avenue Suite s ANCHORAGE, ALASKA 99503 CALCULATED BY A DATE z Phone 276.1361 CHECKED BY �,/ DATE_ SCALE �r� JV' _ Ptio%m2N.iJ , Irc.. G,2, Mss. 0!t]I Of h -o �5u - : /DO ti 49 a^'eweli 90 ... too C(os is _ _.... ca Ptio%m2N.iJ , Irc.. G,2, Mss. 0!t]I ALASKA ENVIRONMENTAL CONTROL SERVICE 'NC. 1200 West 33rd Avenue ouite B ANCHORAGE, ALASKA 99503 Phone 276.1361 JOB C1i�I e/CSC., I10C K f�orrlFS l FG�C� CJ SHEET NO. -or OF CALCULATED BY- DATE CHECKED BY SCALE caaarta4i a iz. G'nr n 01171 REiU',: TO: Division of Geological and G, 3001 Porcupine Drive (Tele, Anchorage, Alaska 99501 C Drilling Company Name LOCATION OF WELL I M .tt ,slcal Surveys (DGGS) _: 277-6615) W A T E R W E L L R E C O R D oi.... .,,mei. r. wither la. Ib, or Ic. U.S.G.S. Local No. Drilling Permit No. A.D.L. No. STATE Of ALASKA DEPARTMENT OF NATURAL RESOURCES Ia. Borough Subdivision Lot Block It. Fraction Section No. iC )SGC., !,� I,R J I / / / lc. Distance and Direction from Road Intersections Street Address and Area of We! i Location 2. WELL WELL LOG Feet Below Surface Material Type Top Bottom 3. 4. Township Range Merid Ian N/S�E/W -- OWNER OF WELL: Address: 1 WELL DEPTH: (completed) Surface Elevation Date of Completion - ft. - - []Cable tool ❑ Rotary []Driven ❑ Dug ❑ Auger ❑Jetted ElBored ❑ Other: ,�. I 6. USE: ❑ Domestic ❑ Public Supply ❑ Industry ❑ Irrigation ❑ Recharge ❑ Commercial Nest Well ❑ Other: - -- - 1. CASING: ❑ Threaded ❑ Welded in. to ft. Depth Weight _lbs/ft. in, to ft. Depth - - - 8. FINISH OF WELL: Type: Diameter: Slot/Mesh Size: _ Length: - Se[ between ft. and ft. Fittings: - •, is .�. ... ,. ... i.; � .. ... .. -z 9, STATIC WATER LEVEL: ft. Above ❑Below land surface Type of Measurement: --- 10. PUMPING LEVEL below land surface ft. after hrs. pumping g.p.m. ft. after hrs. pumping g.p.m. 11. WELL HEAD COMPLETION: ❑ In Approved Pit ❑ Pitless Adapter inches above grade 12. GROUTING: Well Grouted: ❑ Yes ❑ No Material: ❑ Neat Cement ❑ Other: 13• PUMP: (If available) HP _ Length of Drop Pipe ft. capacity ___ 9-P• Type: ❑ Submersible ❑ Reciprocating ❑ Jet ❑ Other: 14. REMARKS: Wates Tom Terature; ----- 15. WATER WELL This well • Address: Signed: __ ... CONTRACTOR'S CERTIFICATION: was drilled under my jurisdiction and this report Is true to the best of my knowledge and belief: Registered Business Name oh CFact' License Number ''C:.1 V 'Y1 ''r..� Date: Authorized Representative ... ..... r]umeY _ it r ,,,.. RE70'1 TO: Division of Geological and Gr vsical Surveys (DGGS) 3001 Porcupine Drive (Tele, 277-6615) Anchorage, Alaska 99501 . u W A T E R W E L L R E C 0 R 0 Drilling Company Name LOCATION OF WELL Please complete either Ia, 16, or It. A Ia. Borough Subdivision Lot Block Ib. Fraction Section No. w t It. Distance and Direction from Road Intersections Street Address and Area of We'i Location 2. WELL LOG �— Feet Below Surface Material Type Top Bottom STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES U.S.G.S. Local Ilo. Drilling Permit No. A.D.L. No. Township Range Meridian N/S E/W 3. OWNER OF WELL: Address: / r r fo) 4. WELL DEPTH: (completed) Surface Elevation Date of Completion ft. 5• ❑ Cable tool ❑ Rotary ❑ Driven ❑ Dug ❑ Auger ❑ Jetted ❑ Bored ❑ Other:__ 6. USE: ❑ Domestic ❑ Public Supply ❑ Industry ❑ Irrigation ❑ Recharge ❑ Commercial ❑ Test Well ❑ Other: 7. CASING: ❑ Threaded ❑ Welded - in. to_I_ft. Depth Weight lbs/ft. in. to ft. Depth 8. FINISH OF WELL: Type; Diameter: Slot/Mesh Size: Length: - Set between ft. and ft. Fittings: 9. STATIC WATER LEVEL: ft. ❑ Above ❑ Below land surface Type of Measurement: 10. PUMPING LEVEL below land surface ft. after hrs, pumping g.p.m. ft. after hrs. pumping g.p.m. 11. WELL HEAD COMPLETION: ❑ In Approved Pit ❑ Pitless Adapter Inches above grade 12. GROUTING: Well Grouted: ❑ Yes ❑ No Material: ❑ Neat Cement ❑ Other: 13. PUMP: (if available) HP Length of Drop Pipe __ ft. capacity _ __ g•p, Type: ❑ Submersible []Reciprocating ❑ Jet ❑ Other: 14. REMARKS: �— r wime1'8ture 15. WATER WELL CONTRACTOR'S CERTIFICATION: This well was drilled under my jurisdiction and this report Is true to the best of my knowledge and bel lef: i' r'1 7 rl r,. ,I U f.,ri Registered Business Name Contrac t•License u�l mTer Address: i C _,'.: V1 Y3 T'= � ?r l`. �, .`',��: t> Signed: Date: _ Authorized Representative .. ._ - .. . . .. ,11 c., . nnlc ouiv _ n.;11 .. r?4pRv - fustnmer 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 SYSTEM PERMIT PERMIT NUMBER:SW910249 DATE ISSUED: 8/26/91 DESIGN ENGINEER:S & S ENGINEERS EXPIRATION DATE: 8/26/92 OWNER NAME:RICHARDSON ROY H OWNER ADDRESS:5000 RABBIT CREEK RD ANCHORAGE,AK 99516 PARCEL ID:01711125 LEGAL DESCRIPTION: POLLOCK BLK 1 LT lA LOT SIZE: 210198 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 0 THIS PERMIT IS FOR THE CONTRUCTION OF: 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 PROVIS N,tS: RECEIVED BY. ISSUED BY: DATE: 7 DATE:_ Parcel I.D. 017-111-25 Municipality of Anc On -Site Water and Wastewater (907)343-7904 Certificate of On -Site Systems 1. GENERAL INFORMATION Complete legal description Location (site address) �. 4 2016 Zi Expiration Date: / D —Ig L Pollock Homestead, Block 1, Lot 1A 5000 Rabbit Creek Rd. Current Property owner(s) David Brauner Mailing address Real Estate Agent Day phone 5000 Rabbit Creek Rd. Anchorage, AK 99516 2. TYPE OF DWELLING: Q Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request 1. COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5f , Date of Payment (n 1 a-1 I i (o Receipt Number 63W 34 COSA # O)CA(o I R57 r Waiver Fee $ Date of Payment Receipt Number Waiver # 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 On4ite. 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 flies and from my investigation and inspection, the on-site water supply andlor 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 lifeof 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 Alk. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE T System #1 Approved for -- bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for Date 6/24/2016 4 Steven R. E3annorie . CE -8149 �t with the following stipulations: By ww Original Certificate Date: The Municipality of Anchorage Development Services Division (DSO) 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet t If more than 1 septic system is on the lot: COSA Checklist # I of 2 Structure served by this system 1 Certificate of On -Site Systems. Approval Checklist Legal Description: Pollock Homestead, Block 1, Lot 1A gottiseetcel ID:017-111-25 A. WELL DATA Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y Date completed 1982 Sanitary seal (Y/N) Y Wires properly protected (Y)N) Y Total depth 343 ft. Cased to 22 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1982. 6/8/216 Static water level Unknown ft 41 ft Well production 5 g.p.m. 3'0 9 - p.m -WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 0.166 mg/'L Arsenic ND ug/L Date of sample: 6/$/2016 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel date installed 7/18/1982 Tank size 1,500 gal. Number of Compartments 2— Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y//,N) N High water alarm (Y/N.) N Date of pumping & !.-q t �C Pumper A4 lyvv e. 9eryi c.) S C. ABSORPTION FIELD DATA bate installed 7/18/1982 Soil rating (g.p.d./f:2 or ftz/bdrm) 125 SF/BR System type Deep Trench Length 95. ft Width 3 A. Gravel below pipe 4 ft Total depth 8 9ft. Eff: absorption area 760 ftz. Monitoring tube Y Depression over field N' Date of adegLacy tc t 68/201.6` .. Results (Pass/Fail) PASS For 5 bedrooms Fluid depth in absorption field before test 0 in. Water added 767 gal. New depth 16 in. Elapsed Time: 205 min. Final fluid depth 0 in. Absorption rate >= 750+ ' g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date r D. LIFT STATION Date installed "Pump on" level at Datum _ Size in gallons _ in. "Pump off" level at _ Cycles tested _ Manhole/Access (Y/N) in. High water alarm level at _ Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON.LOT TO: Septic tank/liftstation 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 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven Pannone Date 6/29/2016 COSA canary sheet 2.6-15.doc Absorption field 5+ Surface water 100+. Water main 10+ Driveway, parking/vehicle storage,1 0+ in. If more than I septic system is on the lot: COSA Checklist # 2 of 2 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Pollock Homestead, Block 1, Lot 1A 11CV-nParcel ID: 017-111-25 A. WELL DATA Well type Pt IVate If A, B, or C provide PWSID # Date completed Unreadable Sanitary seal (Y/N) Y Total depth 302+ ft. Cased to Unmaable ft. - FROM WELL LOG Date of test Unreadable Static water level Unreadable ft Well production Unreadable 9 - p.m -WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate ND mg/L Arsenic ND ug/L Date of sample: 6/8/2016 B. SEPTICIHOLDING TANK DATA Tank Type/Material Holding Tankf6-r ag-L Tank size rzorgal. Number of Compartments Foundation cleanout (Y/NY Depression over tank (Y/N) N Date of pumping -Pumper Well Log (YIN) Y Wires properly protected (Y/NY Casing height (above ground) 12+ in. AT INSPECTION N/A N/A ft N/A g.p.m. Collected by: PES Date installed ae-c''e '3/114/110(1 Cleanouts (YIN) Y High water alarm (YIN) Y C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft3 or ft2/bdrm) System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff absorption area fta Monitoring tube _ Depression over field Date of adequacy testy Results (Pass/Fail) For bedroom's Fluid depth in absorption field before test in. Water added gal New depth in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) If yes, give date D. LIFT STATION Date installed Size in gallons _ "Pump on" level at in. "Pump off" level at Datum Cycles tested _ Manhole/Access (YIN) in. High water alarm level at Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent iots 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 55 Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field N/A Water main 10+ Water service line 10+ Surface water 72 Wells on adjacent lots 140+ ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main Water Service line. Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots F. COMMENTS This form is for the agricultural well on the property and the serving the barn. The barn does not have a toilet. CASA G. ENGINEER'S CERTIFICATION t certify that I have determined through held inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven Pannone Date 6/29/2016 COSA canary sheet 2-e-15.doc in. 9ROGEVEW DRIVE N00'01*35*W 508,46 30 0 09 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section CEW P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # (�)L) - \ 1 \ 1. GENERAL INFORMATION HAA#. kAQ'2\)lla\Z _ Complete legal description1-0 � I A)_ B I(>-- �-- l 1'oI/oc� - -_ �� -.S/D Location (site address or directions) _ S-000 Rah 6i k Creek Rd Property owner lion a (P. Swanson Day phone '311-8077 Mailing address 5000 Ra56'4' Creep [?a AMCACL5rT A -k 99Si" Lending agency Pru den F(u ( Day phone Mailing address Agent Address - Day phone Unless otherwise requested, HAA. will be held for pickup. 2. NUMBER OF BEDROOMS: 5- 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. 1 �, 4. - TYPE OF WASTEWATER DISPOSAL: i Individual on-site Holding tank Community on-site Public sewer t t 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 021 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 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. NameofFirm F(aff�TecAnica( Servc'cel _Phone 3yS-5S Address EcAo SA. A/IcAar-0!4e 1+6< 99S1 V Engineer's signature �� %?20 �� Date June !3, 199s' v * :49TH : W; /f.frrfrrr••r R...R.. r�/lj��R//�bK�lY�'tV�Yr SIL Y►u R•..R•• ... RrrIFY # o&THEODORE F. 4AOOREbe New* CE - 3589 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 6- 2 8 ' 9 ., The Mur'lidpality of,, i"& orage Department of Health and Human Services (DHHS) issues Health Authority 'A'pproval Cartificate,�;based only upon the representations given in paragraph 5 above by an independent professional end ineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and theirlEnding 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. 72-025 (Rev. 1/91) Back MOA N21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: _Pok\oc,k }_VDvv.p S-�ecs-8 jot IA QI. 1 Parcel I. D. A. Well Data Well type P ri ✓ c< Fe If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) y Date completed Iqg Driller Vefrv�' s Total depth 3'i3 Cased to Casing height I a" t Sanitary seal (Y/N) _ Wires properly protected (Y/N) i FROM WELL LOG AT INSPECTION Date of test 7 / 9.5- MUNICIPALITY OF ANCHUFAUL Static water level -70ENVIRONMENTAL SERVICES DIVISION Well flow S g.p.m. y. I 13 1995 Pumplevell — _ > 3t2 RECEIVEmD SEPARATION DISTANCES FROM WELL TO: t� 1. V i Septic/holding tank on lot 200, ; On adjacent lots Absorption field on lot .2/01 ; On adjacent lots > o0 Public sewer main N 4. Public sewer manhole/cleanout IV 4 Sewer service line > e S' Petroleum tank 1\1012P 5 e po WATER SAMPLE RESULTS: Coliform 0 cot l 1 oo m . Q Nitrate < 0. / m / C Other bacteria _ None reI Date of sample: 6/ 7 /95- Collected by: T. F /'l oon`e B. SEPTIC/HOLDING TANK DATA Date installed '-I- I Tank size 1 s00 q Compartments a Cleanouts (Y/N) Y Foundation cleanout (Y/N) _ Y _Depression (Y/N) N High water alarm (Y/N) N . A Alarm tested (Y/N) _ At. I Date of pumping 9/ r7 19y _Pumper 60 �& R O0 F -e r SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot = T.00 ` On adjacent lots 7 too, Foundation q/' To property line 90 ` Absorption field S' Water main/service line 7,ar, ` _— Surface water/drainage 72-026(3M)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" Level at Cycles tested Surface water Date installed 1- iz� - % a Soil rating (GPD/Ft2) 161 s p SP- -System type -Tmllc k Length q 5 _Width 3 1 Gravel thickness IT'' Total depth 1?`' Total absorption area I & d Cleanout present (Y/N) r Depression over field (Y/N) _ Y Date of adequacy test 4 / 7 / M Results (pass/fail) for 5 Bedrooms Water level in absorption field before test 2 3 " After test _ 28 Peroxide treatment (past 12 months) (Y/N) IVon e lin ocun of If yes, give date V. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot z 2 /L _On adjacent lots - :;� 1 UO ' _Property line 31 To building foundation 60, To existing or abandoned system on lot _ N' 4 On adjacent lots _> 3o I Cutbank - .s o '_ Water main/service line Surface water � l 10' Driveway, parking/vehicle storage area Curtain drain None seen E. ENGINEER'S CERTIFICATION 1 certify that have checked, verified, or conformed to all MOA and HAA guidelines �ke�gcr 4iate of this inspection. Fp��*6!: p rz, v / /7.,/� _ }��nup9A pYo p9w�p4apop4 pkbt<t b'<+�. Signature — A 07,1,,:.h�!�;'';r Engineers Name s -rh eo CG rr Ttii:000ae r. s:aaua� Or CE " ),5 9 Date Dune 13, (99S HAA Fee $ 3 Date of Payment Lz 13--96 Receipt Number LC,)('t'L1 72.026 (3183)' Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES �} j 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, n� Parcel I.D. # C)l I — 1 ) 1 -,Q4 HAA # 1. GENERAL INFORMATION L &JnC2 I Complete legal description Z4ae-t IA;I'-PoZtock Subdivision; Location (site address or directions) 5000 Rabbit Cne.ek Road Property owner Roy R.ichaJcdhon Day phone Mailing address 5000 Rabbit Cneek Road, Anchon.age, Ata,5ka Lending agency Day phone e Mailing address 4, Agent Cta�.n. Ramhey JACK WHITE COMPANY Day phone 563-5500 9 a #100 Anchon.a 1 Address 3201 C St)tea qe, A2a,6fca 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 5 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: 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 021 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 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 Phone Address 17034 Eagle River Loop Road No. 204 Engineer's signature Date 63— i q_ q1 411TIe, 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 orderto 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, 72-025 (Rev. 1/91) Back MOA #21 ry Ty V y 6. DHHS SIGNATURE A : •x .v -(n// Approved for bedrooms. Disapproved. Conditional approval/for bedrooms, with the following stipulations: / C4�rri`r+lnf� �i� 1 Additional Comments / /io /0�) Z c4�1 Pell Lel4IV / uS� �lBvCd 7"Ji%� o4C/ ��oS iiiss�a/ ih 74 4-T [YitGN ling i� �o '7�15 ho/o�i�f 7�an ,11 By: �y�cr 2a� — Date 917_61A;1'1 _o 411TIe, 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 orderto 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, 72-025 (Rev. 1/91) Back MOA #21 o Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:,_ 11AQ11rr_1S -L — Parcel I.D. A. WELL DATA 9_i Well type6--1L If A, B, or C, attach ADEC letter. ADEC water system number ) —_ Log present (Y/N) Ln Date completed .—�qf1Z DrillerIL1d5 r Total depth_' Cased to 2 (6cdLro Casing height Sanitary seal (Y/N) —— Wires properly protected (Y/N) MUNI IPALITY OF ANCHORAGE FROM WELL LOG AT INSPECTIORWVIRUNMENTAL SERVICES DIVISION Date of test ( C, 2 c1 I 11.iE l 1, 1991 Static water level > RECEIVED Well flow a g.p.m. �> g.p.m. Pump level V OW /,\ -Z_r4f-�, \�6L V�r�1Gt�4 SEPARATION DISTANCES FRT WELL TO: Septic/holding tank on lot / OD f _ ; On adjacent lots 100 Absorption field on lot I OLS I _ ; On adjacent lots too 4 Public sewer main — ti�lA Public sewer manhole/cleanout %J/6 Public sewer service line h>1� Petroleum tank LoNe, KNoWry WATER SAMPLE RESULTS: Coliform��"� l5 j<r4 0�__ Nitrate c- od i Other bacteria ZC__M Date of sample:3 - �� ' CT I Collected by: nJG iN E� V !h)G B. SEPTIC/HOLDING TANK DATA Date installed a - 18 - e 2 Tank size I TOP !� P-1 Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) /1� High water alarm (Y/N) rJ I W / �t Alarm tested /(Y//N) J,l A Date of pumping - - ( /��%111/G� ) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I On adjacent lots (00 F —Foundation -1 0 f . r To property lined—C Absorption field Water main/service line ( C2 Surface water/drainage / UO rt 72-026 (Rev. 3/91)Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level Manufacturer Manhole/Access (Y/N) p on" level at "Pump off" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacen Cycles tested Surface water Date installed _[ - 1 -62 Soil rating_[ `a s tf $ P_ System type _j nJ ^ Length !�J S Width 316 Gravel thickness �11 Total depth Total absorption area to Cleanouts present (Y/N) Depression over field (Y/N) /J — Date of adequacy test F='i _17t Results (pass/fail) ��:> for G� Peroxide treatment (past 12 months) (Y/N) _LJI_IA If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: bedrooms r , Well on lot 100 �1- On adjacent lots—( 00 1_ Property line /0 t To building foundation / Q F To existing or abandoned system on lot 't) / I'1 _ On adjacent lots :!S O i Cutbank Water main/service line DO t Surface water / c�0 �F Driveway, parking/vehicle storage area �O Curtain drain __._6J1A E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in of this inspection. rr " •1� S & S ENGINEERING Signature 17024 Eagle River Loop Ito" No ^A Eagle River, Alaska 99577 "``ll' °' Engineer's Name Date 8� % �� G% 1 t� `�•�� ,• �" r; r�..; �' , HAA Fee $ �' Waiver Fee: $ Date of Payment 4 - �� v� Date of Payment Receipt Number y �5 l 8S8 Receipt Number 72-026 (Rev. 3/91) Back MOA 21 I� N2 llll r 0 i I I I ngtr\ Imm August 14, 1991 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 RECEIVED HEALTH AUTHORITY APPROVALS Munici-pati-ty o5 Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Stn.eet A^,unicipality of Anchorage P.U. Box 196650 D0r't, I-:QHuman Services SEWER &. WATER Anchorage, Alaska 99519-6650 MAIN EXTENSIONS REFERENCE: Tract IA; PoUock Subdivision; Request you issue the attached Health Centijieate {yon the on-site well SEWER &WATER and septic system serving the 5 bedroom house located on .the Le6ekenced INSPECTION Pnopenty. Alamo located on .the pnopenty is a barn which is served by a separate wW and a holding tante.. The holding tank " a septic tank which has ENGINEERINGSTUDIES been conveiLt/.ed to a holding tante. by the outlet. There is no PORTS AND REPORTS sink bathroom within the barn; only a sink and drains. The holding tank is used to collect water. {yrom the {yloon drains when the barn Moors ane washed. WELL INSPECTION L, Since the holding tank does not %eceive domestic vaztewate,%, we are &FLOW TEST unaware 06 any separation distance requirements. However, it should be noted that the holding tank is located 55 gt. Unom the we.2l which senvez only the barn, and 72 Ut. {yrom Little Rabbit Creek. SITE PLANS There has also been a non -eatable water sign pasted near the ufic,tity sink within the barn. 1{y we may be ob 6unthen service, please contact us. ROAD DESIGN Sincerely, SOILTEST ROGER J. SHAFER, P.E. RJS/gm PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. V LAAO RgTO q1Y 5633 8 STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 582.2343 PAX: (907) 581.5301 ANALYSIS REPORT BY SAMPLE for RUSHordert 37474 Date Report Printed: AUG 21 91 1 16:04 Client Sample ID:TRACT 1A POLLOCK BARN PWSID :UA Collected AUG 20 91 t 13:55 his. Received AUG 20 91 @ 15:02 hrs. Preserved with :AS REQUIRED Client Name :S R S ENGINEERING Client Acct :SNSENGP BPO t PO I NONE RECEIVED Req I Ordered By :R. SHAEER Analysis Completed :AUG 21 91 Send Reports to: Laboratory Supervisor :ST PHEN C. EDE 03 G S ENGINEERING Released By (f. 2) .........................,........................................................................................................... Chemlab Ref t: 914257 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Unite Method Limits ------------------------------------------------------------------------------------------------------------ NITRATE-N 0.15 mq/l EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: R.J.S. Remarks: .............•................................................................................................ 1 Teets Performed See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT -Less Than, GT -Greater Than ISO 8GS Member of the SGS Group (Socldt6 GAnArale de Survelflance)