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Home My WebLink AboutRAVEN WOODS BLK 2 LT 4P-avenwoods Block 2 Lot 4 #015-23-216 Municipality of Anchorage Page / of Z DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW 9/O /// PID Number: Name: EOAf&z E. 1,Lq/r Wastewater System: � 11 Upgrade Address: tnOf�O , ABSORPTION FIELD Phone: No. of Bed r ms: ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: /SO GPD/Sq. Ft. ,Sv 7,5-1 Lot: Block: Z Subdivision: lfA VER/ Depth to pipe bottom from original grade: Gravel depth beneath pipe Ce/o0e9 3.6 Ft. 7 Ft. Township: Range: Section: Fill added above original grade: Gravel length: 1-1,5 Ft. 59 Ft. WELL: VNew ❑ Upgrade Gravel depth: - Number of lines: Distance between lines: ,',rFt. / Ft. Classification Private, A,B,C): Total Depth: CasedTo: Total absorption area: Pipe material: G Z22 Ft. 14T; 1 ZI 1 Ft. So. Ft. .b -303 el Driller: k f I Y II-I.III D illed: Static Water Level: Installer: f/,4,PTF,r/ Date installed: Yi G . 9 1 - Ft. 5-319- Yield: I Pufnp Set at: Iv Casing Height Above Ground: II TANK GPM Ft. Ft. SEPARATION DISTANCES ®'Septic 11 Holding ❑S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines 6 Zc/ /Z 5 O well /z8 / /2G / /y/iLES Material: STEEL Number of Compartments: i Surface Water /DO't /On /t 'IV /RYiLE'> LIFT STATION Lot Line �/� %3� /lir/ES Size in gallons: Manu rer: Foundation / / "Pump on" level at: "Pu "leve High water alarm at: CurtainPump Nll� Make el Electrical Inspections performed by: Drain All A101 N1A Remarks: BENCH MARK Location and Description: Assumed Elevation: •bLL �X%* EAL ,a4V, a 9 e� A T,.3 . a.a Inspections performed by: it/ayL IA'F,ap,DEM Dates:lst s 3o -9L 0�o®a 2nd 5-3/- 9/ sMichoel E. An&rson T see, �ss,.E Department of Heal and Hu n S rvices approval n� a �> , p� �°�r°�a•®. , Reviewed and approved by: Dater 72-013 (1/91) MOA 25 Permit No. SW 9/v /// Page -Z of z Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: f3L Z 5 PID No.: 015z-3216 E7sE m6n 7— P R r -A iz o Ec' ; OF r/ou56 72-013 A (2/91) MOA 25 a flea as+�af`Jf�aea t�aµ®o.�e s`+—+e "Iviicncel g.70 [. Anderson e W, iP o® 4 C`• 6 F1 STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF GEOLOGICAL AND GEOPHYSICAL SURVEYS WATER WELL RECORD i BOROUGH SUBDIVISION -BLLO�CK SECTION QTRS TOWNSHIP RANGE MERIDIAN )L�O?' DIRECTIONS: - -. . WELL OWNER: WELL DEPTH: ' .. Depth of hole 2/IS ,ft Depth of casing::,/`3ft DATE OF COMPLETION: MEASURING POZNT :_ top of casing - ;._ ground surface other: BOREHOLE DATA: Depth STATIC WATER LEVEL: fZ7. ft. �- Date �' Z Material type. andcolorFrom To METHOD OF DRILLING: CRair-rotAy - ❑cable tool [-]other: - ---r 014� p4 USE OF WELL: 0 domestic ❑irrigation ❑ monitor ❑ public supply ❑ other: CASING: Stick-up 1 ft.- Diam:-_(2-_in WELL INTAKE: open end ❑ screened perforated ❑ open hole Depths of openings: to ft -- 142- efuw%j❑ -. - �..j -X -� oil SCREEN TYPEDiam: in Slot/Mesh Size: Length: ft .. dd Q Set Between and GRAVEL PACK'TYI -. Volume used:_ - `Depth to top: GROUT TYP�--_-_ -Volume: Depth: from p� (�. ECEJ Az r- r ` DEVELOPMENT METHOD:_ �La, - SEP Duration: / ! REMARKS: Municj"'I Of Anchor DeAt• Health &Human SerViiCes PUMPING LEVEL AND YIELD: ft after_hrs pumping_,L:?,.gpm - - PUMP INTAKE DEPTH: ft Horsepower: Date Pump Installed - CONTRACTOR INFORMATION: WATER CHEMISTRY SAMPLE TAKEN? [:]yes a no n ` - �nn!__ �. �•_*'_ _ Well disinfected u on completion? ayes ❑no Regi tered Busines Ngne Signature of Author' ed Representative Date PLEASE MAIL WHITE COPY OF LOG WITHIN, 45 DAYS TO: DGGS PO BOX 77-2116 EAGLE RIVER, AK. 99577 WE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910111 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:HALE GEORGE E OWNER ADDRESS:11601 BIRCH ROAD ANCHORAGE, ALASKA 99516-2326 PARCEL ID:01523216 LEGAL DESCRIPTION: RAVEN WOODS BLK 2 LT LOT SIZE: 65776 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 0 PAGE 1 OF 1 DATE ISSUED: 5/20/91 EXPIRATION DATE: 5/20/92 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / 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. 9ECIAL PROVISIONS: 1. INSTALL MONITORING�I RENCH. 2. PROVIDE VERIFICATION OF CONSI OF TRENCH. RECEIVED BY: SOIL AT NORTH END DATE: 5-- Z /l9 ISSUED BY: - oaa _ zt- DATE: S- - `7i VACA,JT LoT $OO.TO 4/TM, �g� SG it y07G �� CAmpQEt e aEe,� /o' 4171, /",y Es�s'f P6RC 2 ' • RESERVE At2EA Fo7c �/� , 5EU S 5?EHy �� O / A/ 57A LL 5$ L F Or 5' W /D� C.O•'s WELL Q,2 A/NF/E1mELl 0 LD ° � q- 25o6Ac. TANK 4 BAR LOCArJOM Fkouse S% Pe ' • r TMr mom ilo r� To8E G•o. VACANT w AX LoT NO Om srr6 S�§TENS AKE LocArEb w lT14 -1 20°of TN#E' PQ°/�°S� SCALE /"-30' s�srr=ms tip Q � -1 a --I E. P.nderson L y BL z RA\/EIJ WOODS SUQo, e a . �.. a PYspe08��ea8Aq�al�asoa�a�i ��se� s EN 1S (10/78) ON SITE SYSTEM IMPACT L4 BL 2 Raven Wood Subd. Installation of an on site well and wastewater system for this lot should have little if any impact on the surrounding properties due to: 1. The soil type and absence of water in the test hole monitoring tubes during breakup, the soil provides a good condition for natural percolation. 2. Installation of a trench system now will allow absorption at the 3-7 foot depth reserving the surface area for a future bed system near grade if required. 3. Due to the topography of the lot and surrounding area there should be no impact of drainage caused by constructing an on site system(s) on this lot. 4. There are no existing systems close by on adjacent lots. If you have any questions please contact me at 561-5829. Yours Truly, L. Wayne McFadden �i ��iL"PAla a5 EP90f`O\J" Municipality of Anchorage O&W DEPARTMENT OF HEALTH 8 HUMAN SERVICES 825 "L" Street, Anchorage. Alaska 99502-0650 SOILS LOG — PERCOLATION TEST sv a q amammmmoamm :..:...;......., MichaelE. Anderson PERFORMED FOR: SPI VAJE L AIo `79 DATE PERFORh F S'ff; Lam-' i#>"r LEGAL DESCRIPTION: G 7 BL ZNy ✓Etl IA,1OODSTOwnship, Range, Section: 5 Z 3 ) Z lJ R ? w DEPTH I SLOPE �j SITE PLAN (FEET) 7 -EST 14OLE 1 I I I I 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS 130 N WAS GROUND WATER ENCOUNTERED? /t/ 0 In IF YES. AT WHAT DEPTH? Dow to war uw wwmn ? 0 /1 A Our • I L QD� PERCOLATION RATE (mmtu uwnj PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY: W, Ml FA 3h E Al 1414 ao @CERTIFY THAT THIS/TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE- 72-WO ATS72-008 (Rev. 4&51 . o s Municipality of Anchorage �� ®' e, 7 DEPARTMENT OF HEALTH & HUMANSEAVICES e 825 "L" Street Anchorage. Alaska99502-0650 �...a s�° °�® '®i86.°Q..'o. �°• ° SOILS LOG — PERCOLATION TEST �.�® a.•a•a°•• °°®a� ME.'schael E. Anderson PERFORMED FOR: S P %til til E L. N� ii1 S DATE PER LEGAL DESCRIPTION: kA UE'al U)0065 Township, Range, Section: S Z.3 T- 1 Z t`1 (z 3 W DEPTH SLOPE SITE PLAN (FEET)ITITi TEST HOLE .L � � � � � 1 2 3 4 5 6 7 a 9 10 11 12 13 14 15 16 17 1a 19 20 SM IL_ - y SA nt D WAS GROUND WATER ENCOUNTERED? IIID IF YES. AT WHAT DEPTH? 1190 n war mw Ma.mnlro? o ATERpy� -ls-9! 80H S PERCOLATION RATE (Mmtmtfwnl PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT COMMENTS PERFORMED BY: �A I Ay M E M t FA 1) O 1— N iIA wo Ajeu?tl't CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE�� 724M IRa. u851 Or�9m ` AI - Municipality of Anchorageer DEPARTMENT OF HEALTH 8 HUMAN.SEAVICES e)i Lf' e3 `3 825'L' Street Anchorage. Alaska 99502-0650 TIM SOILS LOG — PERCOLATION TEST ' PERFORMED FOR: S4',)1A1 r1 -L i-15wlep�S DATE LEGAL DESCRIPTION: L4 32 je,4VEA.1 in.l OOl) Township. Range. Section: PFlZC H6LE I SLaPE UJ s u1 SANDS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1s 19 �.'stT- a:s8 3,Uz 3;olP 3'.10 WAS GROUND WATER ENCOUNTERED? F.i IJ IF YES. AT WHAT DEPTH? _ 01011 War Ahar Mmdcnngl Galt 4381-E Rading Dan Gro Na Time Time Dwth to Want NK Drop z 3 3 15 5 tl JS ZZ /' 20 !� PERCOLATION RATE `r (mmutavmrnl PERC HOLE DIAMETER '' ff TEST RUN BETWEEN 2115 FT AND FT COMMENTS T1 -F- P,e E'.a O Fie �j,� _ PERFORMED BY: V), M I I"A p p EAa I �tCLH:bT.. Ls ' '^ d L' a C�EATFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE 72 -WS IR"- u851 e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 8251: Street. Anchorage, Alaska 99502 -MO �4• SOILS LOG — PERCOLATION TEST PERFORMED FOR: Sc/ Ai F LL NO /Yl E S DATE l E. Anderson 4381 • E LEGAL DESCRIPTION: L 4 /3 Z RAVEe.I IL/cop Township, Range, Section_ 5' Z3 % /Z Aa R OOEPTHHSLOPE SITE PLAN 11990" 1 PCRG POLE.*lZ r—r--I--- =. 1 S 1n.1 27 SAHDS 3- 4---- 4 -- 5 6 7 8 9 10 11 12 13 14 IS 3:3 0 3:33 16 3: 3e, 3;39 17 I8 19 WAS GROUND WATER ENCOUNTERED? ACO IF YES. AT WHAT DEPTH? Dem to war I11r Mallmring7 Wte: 20 IIpp u S) PERCOLATION RATE .L (mmutasnnrn) PERC HOLE DIAMETER TEST RUN BETWEEN 3 FT AND L/ FT COMMENTS NOLs= }P2FSOrtKED — PERFORMED BY: w M FAD p�I`-1 I r! JC6+.1.1+CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE�� 72-008 IRar. Va51 o■mss � 20 IIpp u S) PERCOLATION RATE .L (mmutasnnrn) PERC HOLE DIAMETER TEST RUN BETWEEN 3 FT AND L/ FT COMMENTS NOLs= }P2FSOrtKED — PERFORMED BY: w M FAD p�I`-1 I r! JC6+.1.1+CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE�� 72-008 IRar. Va51 " Municipality of Anchorage - Development Services Department': Building Safety Division On Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-23-216 HAA# Hiq 0/01169 1. GENERAL INFORMATION Expiration Date: %" 3o - o Complete legal description RAVENWOODS SUBDIVISION: LOT 4, BLOCK 2 61 ❑ Individual Holding tank Location (site address or directions) 6131 BUNNYSHOE CIRCLE, ANCHORAGE AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address GREG & DENISE GOFF Day phone 564-1667 6131 BUNNYSHOE CIRCLE, ANCHORAGE AK 99516 Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class__Well Public Water System 4 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (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. TYPE OF WASTEWATER DISPOSAL: El Individual On-site 61 ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (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 Health AuthorityApproval Guidelines for this application, shows that the on-site water supplyand/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the MunicipafityofAnchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system ls(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, AWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with AOEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of aft wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for ✓ bedrooms. Disapproved. Conditional approval for Phone 337-6179 Date `i tc) I Pro f es sio�_dl V 0 V j ;r �N�SlTE WATER> ND V 4STEVV ER bedrooms, with the fllowing stipulations: PROGRAM Attachments: HAA Checklist / Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other By: (l�� / lam, �d Original Certificate Date: 14 - 3 b - o l (Rev. 12100) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: RAVENWOODS SUBDIVISION; LOT 4, BLOCK 2 Parcel ID: 015-23-216 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 6/21/91 Sanitary seal (YIN) YES Total depth 213 ft. Cased to 213 ft. FROM WELL LOG Date of test 6/21/91 Static water level 127 ft. Well production 12 9 -P.M. WATER SAMPLE RESULTS Coliform __0_ colonies/100 ml. Nitrate 0.5 mg./L. Date of sample: _1Z Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Tank size 1250 gal. Number of Compartments 2 Foundation cleanout (Y/N) YES Depression over tank (YIN) NO Well Log Wires properly protected (YIN) Casing height (above ground). AT INSPECTION 3/21/2001 187 .34 YES YFS 24 in. Other bacteria 16 colonies/100 ml. AWWC. I Date installed 5/30/91 Cleanouts (Y/N) YES High water alarm (YIN) N/A Date of pumping 3/9/2001 Pumper McDONALDS C. ABSORPTION FIELD DATA `TOTAL DEPTH OF M.T. BELOW GROUND LEVEL Date installed 5/30/91 Soil rating (g.p.d./fCo ft /bd ) 150 System type TRENCH Length 58 ft. Width 4.5 ft. Gravel below pipe 4 ft. Total depth -9.4 ft. Eff. absorption area **600 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 3/21/2001 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test E in. Water added 653 gal. New depth 5 in. Elapsed Time: min. Final fluid depth = in. Absorption rate >= 600+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - **PER INSPECTION REPORT. 580 CALCULATED USING A 0.45 RF. D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons - High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 1 uu + On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption Feld 5'+ Water main N/A Water service line 10,+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Buildingfoundation 10'+ Water main N/A Water service line 10'+ Surface water 1007+ Driveway, parking/vehicle storage 50'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. V, . Engineer's Printed me JEFFREY A. GARNESS Date3'6 HAA Fee $ W0 Date of Payment Ll - 2Co -O 1 Receipt Number 35q I (Rev. 12100) Waiver Fee $ Date of Payment Receipt Number p MUNICIPALITY OF ANCHORAGE yam, DEPARTMENT OF HEALTH & HUMAN SERVICES 0 1 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. # 015-23216 HAA #��%�� 1. GENERAL INFORMATION Complete legal description V -�T" 1/ R,> Vev JAJOOOS Location (site address or directions) 4-13/ BViv ly srfot /A`rF Property owner GL,6_.v SoNKE2 Day phone &s15-- 7679 Mailing address Lending agency Mailing address. Agent 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 Day phone Day phone 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. 72-025 (Rev. 1/91) Front MOA 021 5. STATEMENT OF INSPECTION BY ENGINEErn 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 typeof 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 AV 0C72Sc:-: LN G,A% CC7Z,no & Phone Address !�LGu Z GC ?C'� /'f d%OiLAG� A4— Engineer's signature Engineer's iYr.`u2 �� Date 6. DIHHS SIGNATURE Approved fore,—"( 7) bedrooms. Disapproved. Conditional approval for Additional Comments bedrooms, with the following stipulations: By: /jam_`. — Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in 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 MOAR21 �. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Z y &2 XP4yevu(000 Parcel I.D. A. WELL DATA 312 Well type Plel vR TEE If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) i Date completed 6�; 9/ Driller 14Lp/n/c Total depth 2 /3 Cased to a /3 ' Casing height a V r Sanitary seal (Y/N) V Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test ��2 9//2�4 9�AUNICIPAUTY OF ANCHORAGE t ,NI SERVICES DIVISION Static water level 127 / 12 9 r ^ 5 1992 Well flow 12 g.p.m. S g.p.m. Pump level NDT CCI y L, D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 126 ; On adjacent lots >160' Absorption field on lot /2 / r ; On adjacent lots > foo r Public sewer main Public sewer manhole/cleanout Public sewer service line /LFs Petroleum tank tiibNe .16r6p fin! AizE,4 WATER SAMPLE RESULTS: Coliform S Nitrate N D Other bacteria Date of sample: /21/+/192- Collected by: B. SEPTIC/HOLDING TANK DATA Date installed S�3o�9/ Tank size /Z 50 Compartments z Cleanouts (Y/N) x Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N�A Alarm tested (Y/N) Date of pumping /z/�/i/i�92 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Wel I(s)onIot /20 On adjacent lots > loo r Foundation 9/ To property line V/ Absorption field /7 Water main/service line > So' Surface water/drainage Al6NF- NEAR LoT 72-M(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 IVl14 "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Date installed :;LL31 / Soil rating /56 Surface water System type 5' LJ I pE Length - Width 5 * Gravel thickness 5L 5* Total depth 7,5 Total absorption area /,00 Cleanouts present (Y/N) Depression over field (Y/N) N Date of adequacy test /Z 12 e Results (pass/fail) R. SS for �/ Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: bedrooms Well on lot 126 On adjacent lots > /00 Property line j 3 * To building foundation 271 To existing or abandoned system on lot Alonlfl am Lo r Onadjacentlots moo* CutbankNONEintAREA Water main/service line "? 56 Surface water > ebb * Driveway, parking/vehicle storage area > SO Curtain drain > /00 E. 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. Signature 41, t.e4 Engineer's Name 141 LMA LL D � C� • a �z/z�%yam M�_� . Date Yrt tc.,ael E..Anderson &J �3 HAA Fee $ 1,7 G Waiver Fee: $ Date of Payment 'a'- �L Receipt Number -2 3 72-026 JA". 3/91) Beek MOA 21 Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES M Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 -- 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLE FAMILY DWELLING - Parcel LD: #- -D/5Z Z. 16 HAA # �f�� 1101 lillb 1, GENERAL INFORMATION. Complete legal description LoT N' SLOC14 Z I/En/ lti/000s Location (site address or directions) _ C /3/ l�Utii,yy-SNaE CIlZ�LE Property owner Day phone Mailing address //60/ 31 ee v 2d Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: _' 3. TYPE OF WATER SUPPLY: - Individual well - ---_ -----Community-well Day phone 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 - t� 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. V91) Front MOA #21 Luvon M�e9 (l8/l '�tl15LPZL -MJOMsjoeuiBue leuolsse;ad e41 ui suoissiwo Jo sJOJJa Jo; elglsuodsaa ;ou si a6eao4ouy;o /411edloiunyq 94,1 •panssi si a;eoggiao a eJo;eq a;ep azAleue Jo suoiloodsui ;onpuoo ;ou op SHH O to see,Aold w3 °sluawaJlnbei altos pue ieJapa; uieIjao /4siles o; Japio ui suollnll;sui bulpuaj Jia4; pue , sawoq to sJese43Jnd of Asajmo3 ase sly; saop SHHa a41'L'4sei`d;o a;e;S a4; ul paJa;sl6eJ Jaeul5ue leuolsseloid ;uepuedepul ue Aq anoge g 4deJ6eJed ui uenl6 suple;uasaJdej 941 uodn Aluo_ poseq se4eollllJe0 jenoiddy A;uo4;ny 41180H sonss! (SHH(3) soowaS uewnH pue 41IeOH;0 luewjJedao ebeJogouy jo Allledlolunjnl ay°l, alfa :As , -O: sluawwoOleuol;ippb .suoljelndilS' 6uiMollol 94; pm `swooJpeq Jo; pAOJdde Iiu- 6-1 pUOJ •panoaddeslo' - -swooJpeq Jo; penoJddy' X a �t6p�s53jOL,dp 3un.LVN°JIS SHHQ- °9 3-iser J JO amleubissJaaui6u3 -7;C/ W, NV S tL 0/,-Z Od ssejppv ouo4d �r MOsw r wJij;oaweN •uopedsui s141 ;o alep a4j uo joe,49 ui suoljelnBej pue `seoueulpJo - 'sop0o ejejS pue Iedi0iunVq Ile 4jIM 90ueildwo0 ui si welsAs lesodslp Jejumalsum Jo/pue Alddns Alum alis-uo 941 `uolloedsul pue Uolje6ilsanul Aw woJ; pue sail; 95Ljogouy;o AllledlolunVy eqj woJ; poulelgo uoljeurJo;ul 941 uo p9seq;e4; A4IJena94lJn; I •ulaJe4 p9jeolpui eJnjonJls jo edA1 pue swoojoeq;o Jagwnu a4l Jol 9jenb9pe pue Ieuopun; `e;es sI u ea sAs lesodslp JelvmelseM Jo/pue Alddns JejeM ells-uo 943 le4l smo4s uoijeolldde IEAOJddy A4IJo4lny 41IeaH s141 ;o uolje6lls9Aul Aw;e4j A;u9A I 'Molaq uMo4s 91ep UoljeplleA 941;o se pue oj9J94 p9xl;;e leas Aw Aq pa!;!1Jao sy H33NIDN3 AS NOLLOUSNl d0 LN3W3.LV.LS I Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L '/ BI- Z /ZAVE'A/ IAI ODDS Parcel I.D. 01903216 A. WELL DATA Well type FR/VATS If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed 6 -2- 1 " Total depth 1 13 Cased to Sanitary seal(Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG Driller AiLQ) n t�, Z /3 Casing height a y Wires properly protected (Y/N) Y cw� /e2 g.p.m. a /6 ' SEPARATION DISTANCES FROM WELL TO: AT INSPECTION ;� _> Septic/holding tank on lot 12 O' ; On adjacent lots Absorption field on lot /Z�' ; On adjacent lots /00 r t Public sewer main M I LE5 Public sewer manhole/cleanout M t L E5 Public sewer service line M I LES Petroleum tank LOAJE A107 -FE) /N AREA WATER SAMPLE RESULTS: Coliform - Nitrate / /Z/, Other bacteria Date of sample: 9 20 - 9/ Collected by: Lit/. IW FA4 'Al B. SEPTIC/HOLDING TANK DATA Date installed 5- 30 - 4 1 Tank size 12 5 0 Compartments Z Cleanouts (Y/N) V Foundation cleanout (Y/N)_ Depression (Y/N) N High water alarm (Y/N) A6ZIMV Alarm tested (Y/N) Date of pumping AI&IAI COl15TrROCTI0IJ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot /ZO On adjacent lots 166 /f Foundation To property line y/ Absorption field /9 / Water main/service line 50 , t Surface water/drainage A16AIE .t16 2 GenT 72-026 (Re, 3/91)F,on[ MOA 21 CONTINUED ON BACK PAGE eJLQ a < w N g&T. W V L.Q F � 2 w Septic/holding tank on lot 12 O' ; On adjacent lots Absorption field on lot /Z�' ; On adjacent lots /00 r t Public sewer main M I LE5 Public sewer manhole/cleanout M t L E5 Public sewer service line M I LES Petroleum tank LOAJE A107 -FE) /N AREA WATER SAMPLE RESULTS: Coliform - Nitrate / /Z/, Other bacteria Date of sample: 9 20 - 9/ Collected by: Lit/. IW FA4 'Al B. SEPTIC/HOLDING TANK DATA Date installed 5- 30 - 4 1 Tank size 12 5 0 Compartments Z Cleanouts (Y/N) V Foundation cleanout (Y/N)_ Depression (Y/N) N High water alarm (Y/N) A6ZIMV Alarm tested (Y/N) Date of pumping AI&IAI COl15TrROCTI0IJ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot /ZO On adjacent lots 166 /f Foundation To property line y/ Absorption field /9 / Water main/service line 50 , t Surface water/drainage A16AIE .t16 2 GenT 72-026 (Re, 3/91)F,on[ MOA 21 CONTINUED ON BACK PAGE C. LIFT STATIONI //� Date installed Manufacturer Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Surface water Date installed 5- 3) —`t f Soil rating /50 System type S, f/✓/Z�)�- Length 5R, Width Gravel thickness V -5, Total depth Total absorption area 6v00 Cleanouts present (Y/N) 7.5' Depression over field (Y/N) 11.1 Date of adequacy test NEW COdISTftUC incl Results(pass/fail) PA -S5 for Peroxide treatment (past 12 months) (Y/N) N If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I14 On adjacent lots le6 ' - Property line To building foundation 27 f bedrooms To existing or abandoned system on lot NODE ON C oT On adjacent lots NobF du Zi2Mutbank h101.1E IM AIZEA Water main/service line SD 1 f Surface water Curtain drain A10ME: D M Ln7' E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area 1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on date of this inspection. %�q t f Signature Engineer's Name 14)C444CL Date ?ATA71 ";Michael E. Anc4:rson ' �7,jl c b_ 4381 HAA Fee $ 124 W Date of Payment /-,;?`d Receipt Number �L5/0 (� 72-026 (Rev. 3191) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number P,? 0