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RAYMOND TEDROW BLK 5 LT 3C
Raymond T drow Block 5 Lot 3¢ #050-155-52 / MUNICIPALITY OF ANCHORAGE z DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION i 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCE TO: ~m ~ Manufacturer ~ ~ MateriaJ~- ~ No, of compartments ~ hiq. capacitv in gallons, ~O IF HOmEmADE: InsideJength 0 I~ Width ~ LiquiOOepth ~ I ~¢~ DISTANCE TO: Well ~ Dwelling PERMIT NO. ~ Manufacturer Material ~iquid capaciW in ~allons ~ Well Foundation ~earest lot line P~B~IT ~O. ~ DISTANCE TO: ~ ~5 ~ ~o. oflin.s ~ ~en0thof,achl,no~ Totall,n,thofl,n.s~ Trenchmid~l~ ,nch.s O,stance between lines ~~ ~ ~ ToO of tile to finish 0rede Material beneath tile ~ O ti *otal effoctiue t area Length Depth PERMIT NO, ~ Typeofcrib ~ C~diameter Crib depth Total effective absorption area ~ tWill ~ Building foundation Nearest lot line ~ DISTANCE TO: Depth Driller Distance to lot line PERMIT NO. Buildinfl foundation Se~er line Septic tank ABsorption area(s} ~ ~ISTA~CE TO: OTHER PIPE MATERIALS SOIL TEST RATING REMARKS J' DAT~ LEGAL ..... A~VED 72-013 ( 3/78) [!ii:;,'.tZiLllqr> F:IHt> 'ii !!ii; !?,OF"f'(3H OF: FllE!;i:{i; ;[::i; i'.,IO S;i!::;T H];I>TI.! i::'Ed:;:: !'1,!l:; [iif:;'.l:::¢,/!E!.. I>I!;I:::"!'tl ;[ ::!;; '1! .Ii!ii; I'"i l:::li'.,!D '!'l.i~i; Ii?,()F'f'EIH [3F:' !"F!!:!i; !;~;;>::[]I:::I',,,'l:::l'[ I>I:]:::'!::!F:'.'I i'lli!]'q'l H ]:!,1. i:i:i;:: 'ii;t,.ll;!',,q:i!;(;:! 'i"O I::'l:;i:():!i;[!?;:l.,IT;!; ii' l~,st,~t Oyster i~94 2?74 So,is fl Fonndat,ons Performed for: Name: Legal Description: !Z~,th Lf e~e, t_U.. GEC ECHNICAL 8 DEVEL.;PMENT CO. 694 2774 or 688 2280 E~lrl Ellis SOIL LOG 68~-22p,0 Land Development '- ": '">~ '>' ' ' "~'--,~ '~¢'~ ~:7.<-Tel, NO, ;C.'~_ -. '-;v' ~ Mailing Address: '~:, :'-- :, .-._ .:-/ .4< -*-"45/5~ .Sgtj Character/sttcs_ /- Grourd Water En(:ountered: Yes No Pr'oposed Installation: Seepage Pit If yes, what depth ........ Drain Field " · :,,, -: e r e of ilea a u an rvic s ....... "~: ':*~:~ %.: ~: Division of Envir0nm~ntal Sen/ices' '-: * = '" o= ' ,,'~' ~ ', ..... ' *' -* Or~-S~te' services Section 825'L" street' Room 502 ' :.* ,:~:' ,-. :.; ~' ,.'-, L' , ,~ :: =ir ~.' RO~ BOX 196650 ~AhChorag'e,'AK :99519-6650~ .: ' - · . ,:: ,,.. ~.,.., ·: ,:: ,, .. r ':" ;*.''" : ; ~,/WW. Ci.~.nchorage.ak.us !~ *.. , . · ' ' ~ 'f :;: {907) 343-;4744 ~: '. "' ",. .: .... - ' ' "' i': "+CERTIFICATE OF HEALTH AUT'~01~i'I~ AppROVAL · FOR A SINGLE FAMILY DWELLING ' Parc~l'l.b;'~ *" "' -' ".'~: "- Expiration Date: GENERAL INFORMATION ~ocation (site add~e~ or directions) //~ ~~ ~ ! / Current ProPerty Owner(s) ~//v~ (/' ~'~,~./l~,,,,~'~.f Day phone Mailing address//~F~ /~/~--- ~",~_..Z_~/-. ~ ~//,,/c':-'~- //Z) ~ Lending agency Day phone , Mailing add[ess : · Real Estate Agent" · . ' Mailing Address Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:' 2.' NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site ~' Individual Water Storage [] Individual Holding Tank E] Community Class Well [-I Community On-site [] Public Water System J~ Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Cedificates 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 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. 72-025 (Rev. 5: STATEMENT OF INSPECTION BY ENG NEER ,: -~ ·-,.: .,, .... '. . '.,, i ,..,.' .-., . - As cerlmeo Dy my seal amxeo nereto ana as or.the val~aatlon,o, ate shown De OW, .based on procedures outhned in the Health'Aut ,h~.nty Approval Guldehnes for the Health Authonty Approval. ,~ : · ',apphcabon show that the on-site water supply and/or, ~vastewater dlsposa system s safe, funct ona and: .',,- ' · . . adequate for the number of bedrooms and type of s,tructure nd~cated herein.-I further venfy that based on the. Informabon obtained from the Mun~c~pahty of Anchorage files'and from my invesbgat on and nspect on the on- . site water supply and/or wastewater d~sposal system, is.m compliance with all applicable Municipal and State" · COdes 'oidinance~ ~nd'r~gul~tion,~ in Na~eofFirm ' ':', ' " ' ' '~ '~'~:'-" ' ~" '"~ )' ' ' ~ ' '-- '" ' Address Eagle R ver,.Alaska 99577~, ,.-. '.? ,...¥ .,~ · ? ~ ,:.~ ,%~.:~, , (.... ; .. - . . Engineer's Printed Name · "", ,,, , ~ - ''~ ~ ,*~ ~ ' · ' ''-~-* ~ ":~ ',';,* ;~"'~-t, tJl'. ~ '~.- .- · ....................... · · .:- . , , · . .. .... , ..... 6 ' DHHSSIGNAT~'~' ,' · i/" -' -.'Approvea t'or ~ beorooms · - ,. '~ ',) c,· ' '. (t)~,'; (',?---':- -"..;-..-;" - -.; p?~sapproveo. - ....... ........ , ., td{{(([/hf<, - ' Ad~li't'ionai ~3omments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: Original Certificate Date: ,/'-~- / (o ~ 0 / · Reissue Date: 75-025 (Rev. 01.'00)° .. ": .~ .'-, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~ ~ ~~~~~~~J Parcel I.D.: i~'~ -/'~" - ~'~" A. WELL DATA ' "~/~"~ Well type ~~ If A, B, or C, a~ch ADEC leEer. ADEC ~ter system numar L~ p~em (Y/N) Date ~mptet~ ~ To~l deffh C~ to ~ ~ ~i~ (~ve gmu~) San~ se~ (Y~) ~i~ ~ p~ (Y~) FROM ~ LOG / ~ I~P~TION Date of te~ / ~ ~ S~fic water I~el / ~ ~ Well p~u~on / . , g~m. g.p.m. Date of sample: Collected by: SEPTIC/HOLDING TANK DATA Foundafioncleanout~.)' -- ~'~'3' Deprassion(Y~ /~,/'0 HighwateraJarm(Y/N) /V'/~O~- Date of Pumping ~ Pumper _.~ 1,3 C. ABSORFTiON RELD DATA r"~ ~'~ Date instafied ~ Soil rating (g.p.d./fF ol System type Length ~' Width ,~1 Gravel thickness below pipe ~ ' Total depth Effectlveabe°rl~onar"I'Jr-.,Z:~ MonitoriegTubepresentt~? ~'~.~_~.~__Depressionoverfleld(Y~'.~)) /~O Date of adequacy test_~_~/~') Resu s (Pass/Fail). For ~bedrooms Fluid depth in absoq~tion[/'field before test (in.); .3 ' ~ Immediately afte .~ggal. water added (in.): Fluid depth "~ / (ins) Minutes later: ~- Absorption rate - ~g.p.d. Peroxide treatmem (past 12 months) (Y/N) /~A/~4/d/If yes, give date 026 (Rev. 3/96)* I). UFT STATION Date installed ~d/~(' /'""~ize in gallons Manhole/Access (Y/N) ',,O~p on" level at* High water alarm level at' ~ 'Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line 'Pump off" level at* ,./On adjacent lots Pu adjacent lots On blic sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~" "t4' Property line ~ ~ Absorption field Water main/service line /~:~/'/' Surface water/drainage ,/~ ~/' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Proper~y line /~ ~- Surface water Curtain drain //C? '/.~' Building foundation Water main/service line /~) /4-- Driveway. parking/vehicle storage area / Wells on adjacent lots ENGINEER'S CERTIFICATION S,gnature HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE//~/' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) Application Date _~Sep]b_e~be~ 23~- ] 986 Legal Description (include lot, block, subdivision, section, township, range) Lot ~-C Block 5 Raymond Tedrow T14N, R1W, Sec.12 Location (address or directions) _ EaAl~e River (b) Applicant Name C:J~td~y_ GorhmAp_ Telephone: Home 694-563© Business Applicant Address P.O. BOX 771631 ~e Rlver, Alaska 99577 (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Alaska Mutual Telephone Address P.O. Box 771068 Ea~iE_ River, Alaska 99577 (e) Real Estate Company and Agent Address 694-95_71 Telephone ~A (f) Mail the HAA to the following address: __p~ cl~pJW engineer _ 2. TYPE OF RESIDENCE Single-Family~ M t~-Fan~ily [] Other Number of 3. WATER SUPPLY Individual Well [] Community [] Pub Note: If community well system, must have written confirmation from the State Department of attesting to the legality and status. Environmental Conservation 4. SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDIhu INSPECTIONS, TESTS, FILE SEARCH, DA,A AND INFORMATION ~- As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection, *exempt from salld filter requirement, Name of Firm Telephone Address EAGLE RIVER ENGINEERI[~!6 SERVICES ~¢¢/,,.. ~ EAGLE RIVER, AK 99577 Date 694-5195 /cf-- Approved for ~J bedrooms Approved ~ ....... Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MO~l HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Well Classification t°L~' ~ /' '4- '/l'(JJ /¢J'cf' If A, B, C, D.E.C. Approved (Y/N) /~ Well Log Present (Y/N) Date Completed Yield Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date Comments SEPTIC/HOLDING TANK DATA Date installed /9 ? ¢ Size No. of Compartments Standpipes (Y/N) ~" Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /v/ct Separation Distances from Septic/Holding Tank: To Water-Supply Well ~.~,o / To Property Line ~ ~ To Water Main/Service Line ¢-/~ / Course c-/do, ~,~t~jj~A,,),,~Y OF ANCHORA~I~ OEP'f, OF HEALTH & i~lVJ~,,3N M~J'4TAL p~OTECrI©N RECEIVED /V Foundation Cleanout (Y/N) Date Last Pumped ~-~- /~ ; for *~"/'~' Temporary Holding Tank Permit (Y/N) To Building Foundation -¢' / To Disposal Field ~; / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ,/~ Width of Field ~ / Square Feet of Absorption Area Depression over Field (Y/N) /"~ Results of Last Adequacy Test ~'-¢, Separation Distance from Absorption Field: To Water-Supply Well ~'~,3_~,~ To Building Foundation /->~ / Lot /¢27/~/,~.~ / Type of System Design / // Length of Field Depth of Field // Gravel Bed Thiokness Standpipes Present (Y/N) Date of Last Adequacy Test /U To Water Main/Service Line /¢ ' To Cutbank (if present) To Stream/Pond/Lake/or Major Drainag. e~2ourse //o~," To Driveway, Parking Area, or Vehicle Storage Area ~',"~ ' To Properly Line ¢'/~) ~ To Existing or Abandoned System on ; On Adjoining Lots /- --~'; / Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~'~=~'~~- Date Company ~/~~,,¢L¢'-¢%~'~ MOA No. Receipt No. ~ ¢ (~./ ¢J¢)0 ~ Date of Payment /0~/¢ --0¢>.~' Amount: $ ~j~ ~~ Page 2 of 2 72~026 (11/84) Eagle River Engineering Services P. 0. Box 773294 Eagle River, AK 99577 694-5195 Engineer's Seal "'~ ....... '- ' .... ~Ui'~l~i PALITY ~, :~:~. ~ ~ I ~. ~, I ,.; _Al O~' INI.)IVIDLiAL. w/ITl:fl Phili~ and Audrey Iverson (Builder) 694-9555 c/o A~ c/o Area Realtors - Eagle River, Alaska ~one at present James F. and Cynthia L. German WORK 694~9571 P. O. Box 1631, Eagle River, AK 99577 P. O. Box 1~20~ Anchorage, Alaska 99510 Mau~~ 5~ayt0n ~. Ar~.~;:~ ........................................... Parkgate Offlce P. O. Box 249, Eagle River, ~ :/.1 L3C B5, Raymond Tedrow Subdivision I~I]N Fireball Street, Eagle River~ AK I(~. 'f'Y[d\ O[: ~iEb!DIy~]CE [qUk4i~g:t'~ O~: F_J Om~ F-] F(mr [? Otne Ftn~shed F~ Two ~l Five (~ q hroe [2] Six "ATT/\CII WELL LOG. A well log IS requi '(r fro' alt wells since Juno 1975. For w~dis drilled prior to that date. flivo [-_~ VU[~LIC t] 1 ,,_ I'I'Y ch'u;th n~n,sn moil if [-~ INDIV DUAl, F)N-SI-I'E~' -"II indlvkhu:~/on-s;~u, q,¢,: installalim~ date ............... J~] PdBL. IC IJF I..I I'Y i~!O i-{: ill',.{ ,~<..I :0 I(' !! l-liE MUST A,,';CC)¥1F'AN";' I}ACll i-il:tiLil:.g'[ 1., .., ,], ,_ PI./OCit,'-:SiI'~G (;!',N I~E! It\iITIA'FL:D. * Please send me some more of these application forms if possible. Thank you. 2. W,'\TtT R,AJrr' '-'P I_~,' INDIVIDUAl_ COMMUNITY PLJDLIC UTILITY Com~ecdon Verified ......... 3, 5EWAGiE b,~ 0o,,.~,. 8YSTEIvI [~ J INI) IVl 1') (JA I.,,'ON -SITE LIPUbI_h. '" ' ' ,J i II..l~ h I, I ",'? E Of- 17 [:filOl.~l',lCl:. NLt ',,[1Dt OF ISEDI::O .'~MS r'-'l ...... ['~i ()NJ: hfJ TItR, EE I~'3 FIVE F_] O'I'IiEI{ ,_, ,)IN(_~ _[: F,/\!L]iI Y [1'3 MUI..T!PLi~ I':/-'ivl! L'r [ ii PI~[][V!I [ NUf'dflE[:i DATE DFU I~'E D' [cia ~_EaT~5- ......................... PEHMI~ NLJMfJ ER [2.%eniic 1 a~,-. ~i' ~ ' [ii-)l-loldin.q Tank ~'~"~, (..~.~.,.,u'-~,-,.~. . Size:. L~- _ If Tank is homemade ~:~[[~(j 'n-',~ o~ wu~ .............. ~;~TZ~:i:(J~,~i~ ................................... ....................... 'f OT/XL AI/SORPTION AREA MATdRIAL -~,~'~APPP, OVED rOl~. __~ ........ BEDROOMS CONDITIONAl. APPROVAl_ (letter mLISt accoml)anV r;,n tificatr0 DI~;APPROVED ......................... [ ~,,q-~-~" -~ ..........................................
