Loading...
HomeMy WebLinkAboutPARK HILLS #1 BLK 2 LT 4Park Hills #1 Block 2 Lot 4 #017-142-17 Municipality of Anchorage page I of .3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 A Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: _Sw 9 Z. 0 3 6 _. PID Number:©I171412f f7 Name. Wastewater System: New ❑ Upgrade C b90 4Eftn—A LE CCA RK Add`C55 b KL AI3SORPTION FIELD Phone No. of Bedrooms: 60eep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION1.2. Soil Rating: Total Depth tram original grade: _ —_ • Z GPD/Sq. Ft. Lot: Block: Subdivision: Ll `3) Depth to pipe bottom from original grade: _ Gravel depth beneath pipe 2. AY1164) L[jlit' 1 31- fm FL `/r-6 Ft. Township: Range Range: Section Fill added above original grade: Gravel length: --i [y R. 0 Ft. WILL: 11 New ❑Upgrade Gravel width: _Z 1 Ft Number of lines. Distance belween linos: t — Ft Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. SD `V S F So. F-1. G 2t? en> '8O A N Driller. Date Drilled: Sialic Water Level: Installer: Date installed. Ft. M (9,a ✓';NbOlIkSO N OGT 2 1dj Yield : Pump Sel al-. Casing freight Above Ground: TANK GPM FI. Ft. SEPARATION DISTANCES veptic E] Holding ❑ST.E.P. To Septic Absorpllon Lilt Holtling Public/Private Manuladure'r{ Capacity in gallons: From Tans. Fiala Slat... Tank Sower Lines �y��,,y /2s -M Well /b,5, I$o Material: Number of Compartments: Watere <er� /oo+ LIFT STATION Lot, Size in gallons Manufaclurec Line 2.vl 2[I Al Foundalion Z.2 v /NJO r "Pump on" level at "Pump oll" level at High water alarm at: Curtain l A N/� l Pump Make & Model Electrical Inspections performed by: Drain Remarks: BENCH MARK Nis, Location and Description: A C Cwe —ca lc 1=1EtD 1,a,la �'rG[E u c u,-CLAS&ri=[ G;A2^c a S Assumed Elevation: ENGI!,,(§FS,Ae Nq��.A.'�y�r �v�.a�VA On __ i \'-jA`r J0. d N�v"tit S.R V" /.70,./r�7. `' �. Inspections performed by: �� �-- Dates: lsttoz3 eew'eana.au m!aauxraa.xecr an;Eaoo•o, 2nd o3ess,w.«. ..«a.. •,ma«.n.00: gp.nesFl Ai Seven R. Pannomi, a " Mp� BOA�sfd. tczua ` r��`a.I Department of Heal and Human Services approval p pp J �r d0 ep, 4'• Reviewed and approved by: Date: /_o `9V . . or•.Or.. �G®p4nRF�ES51Q —'2- 72-013 (Rev 9/91) MOA 25 CVVs nt[w t7� wLll_ A Y11 NEW 41cvsL , cl c; OUB 2 0P -L3 C.O. N8�1Jt 6 zec c.d, Gv tnw St% 5aC3cK-st•�,�'� 6Nr-� Q 7j z � m � //$ {)( \ / ./ 2® a . .. t . { /QA 7 \ CAm � / . fy®-of) \)± \ ! f J 61 § 2 & � \ / ` } �\ % e .Z.. z z y� i, � k / 'Al l i . . . ! 6 C � � \ Q 7j z � m \ ) ■ ( //$ {)( \ / \ ) ■ ( STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD LOCATION OF WELL BOROUGH SUBDIVISIONLOT pa-11Ile ter /!J / Z/ BLOCK 2 SECTION QTRS SECTION TOWNSHIP ❑S RANGE ❑W MERIDIAN LOCATION/SKETCH: WELL OWNER: DEPTHS MEASURED FROM:❑casing top ❑ground surface —-- ELL DPT& H. DATE OF COMPLETION BOREHOLE DATA: Depth Depth of hole: ft Depth of casing: //) (_eft S / / • J / rj Material Type and Color From To -- I- DEPTH JO STATIC WATER LEVEL: ,11 ft below K—top of casing ❑ ground surface Date: j .•._.Y_ "f' METHOD OF DRILLING: ,❑pair rotary ❑ cable tool ❑ other %•-•-- ( % e USE OF WELL: )FJ domestic ❑ irrigation ❑ monitor Elpublic supply ❑other_ Q CASING STICK-UP:- ft. Diam: ca in, to ft _ Casing type: in. to ft WELL INTAKE OPENING TYPE: 0 open end ❑ screened ❑ perforated ❑ open hole 0'),10 • Depths of openings: �_ to ft /11 U ( ) `2_. f 0 6 SCREEN TYPE:_ < Diam: in. Slot/Mesh Size: -- Length: ft / GRAVEL PACK TYPe\\ t, -7-- Vcluma• Used: h tc top: -- R E C E IVE D GROUT TYPE:^_ Volume: Depth: from ` ft to ft JAN 2 6 19 DEVELOPMENT METHOD: Duration: — Municipality of An( Dept. Health & Huma p 10ragu— Service -- PUMPING LEVEL AND YIELD: l U ft after �firs pumping / r gpm PUMP INTAKE DEPTH: ft Horsepower: _ WELL DISINFECTED UPON COMPLETION) ❑ YES ❑ NO CONTRACTOR INFORMATION: Regisseq d Business Name Signature Of Authorized Respre,Tentative Date 0 REMARKS: PLEASE MAIL WHITE COPY OF LOG TO: DNR/DIVISION OF WATER PO BOX 772116 EAGLE RIVER AK 99577-2116 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:SW920366 DESIGN ENGINEER:POLARCONSULT OWNER NAME:CLARK JEROME & CAROLE OWNER ADDRESS:14651 PARK HILLS DR ANCHORAGE, AK 99507 PARCEL ID:01714217 LEGAL DESCRIPTION: PARK HILLS #1 BLK LOT SIZE: 48820 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 2 LT 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED:10/23/92 EXPIRATION DATE:10/23/93 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 P. RECEIVED ISSUED BY DATE: �d RECEIVFD polarconsult alaska, inc. OCT 2 3 1992 ENGINEERS • SURVEYORS • ENERGY CONSULTANTS Municipal : Dept. Health & Hurnv ds September 1, 1992 DHHS, Environmental Services, On-site Services P.O. Box 196650 Anchorage, Alaska 99519 Attn: Mr. Robbie Robinson Re: Design and Construction Approval for On-site Septic System at Lot 4, Block 2, Park Hills S/D. Dear Mr. Robinson, Attached is the above referenced revised design for review and permitting. This has been prepared in accordance with our previous conversations and your visit to the site. The proposed septic system does not affect the current use of the adjacent properties and will have minimum future impact. If you have any questions, please give me a call. Sincerely, %� 00// ocv Mike Dahl, CE Attachments: On-site Sewer/Well Permit Application Site Plan, Sheet 1 of 4 System Design Calculations, Section, Sheet 2 of 4 Percolation Test, Sheet 3 of 4 Percolation Test, Sheet 4 of 4 1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503 PHONE (907) 258-2420 • TELEFAX (907) 258-2419 1—::>k IY[ geq E.lru,L- 0 ®PaoPoSEp 1�1E1_I_ 0 o`' o aQ � Q� z C h � u 0 w E RECEIVED OCT 2 31992 Municipality of Anchorage Dept. Health & Human Services fl �wyn>J� 5eP-n�- 0 O A )AOU t5o� o e? sty I I ne,V r9 `r 1 \r0 .. 1 ` 00 007 aabomn000 O o00 ooQ o o WILE V. AUSMAN ° C� CE - 1343 ' ©p +°�ule�skflEr� �� ,( JOB polarconsult alaska, Inc. SHEET NO. OF 1503 West 33rd Avenue • Suite 310 CALCULATED By V Y DATE ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258-2419 CHECKED BY DATE ennl r Pict �r;� I LttrT _moi �tor� RE1 LIVED CIsi yj cock*::> "6� OCT 2 31992 Municipality of Anchorage Dept. Health &Human Services 12-4 f31 I_ 1 (P �I (P Ilk 2 rrr - of A4 ®p - �o�� OwUL)norlOn O ooa000�/J�ogoDo 000 00a... og000 .. a 6Aft1E -�. AUSMAP! L4 4© ° °CE PROmMTYm-Ii&NI,Srsasl MSI VIM.VI®,Inc, Gidm. Ms 0117 1 To Orhr PFO.\E TOLL FREE I&M M tea.. OF c ;o �vo-a ogry e� Municipality of Anchorage 19 °° °°°°°/°/ I°'°,°000'o/ego a� DEPARTMENT OF HEALTH & HUMAN SE=RVICES �� qG I U ague°( 825 "L" Street, Anchorage, Alaska 99502-0650 eADus V. nusmrml ° SOILS LOG —PERCOLATION TEST '�©�� °° 1393 PERFORMED FOR: -t'I f'IL- DATE PERFORMED: LEGAL DESCRIPTION:_Lo-4 VlitL 2 PAetc 14ILv, Township, Range, Section: DEPTH1 Go SLOPE SITE PLAN (FEET) I / 1 j 2_ 3 4- 5- _ 6 7 d . O 8 y o " 6 10 o - 11 12 C9 13 J 14 til 15- 16 5 16 — HAND P20 pR.0 2 17 18- 19- 20- COMMENTS 81920 COMMENTS WAS GROUND WATER ENCOUNTERED?�'� S IF YES, AT WHAT I 0 �- o DEPTH? I?'•S P E Depth to Water Atter ) Monitoring? 12' Date: Reading Date Gross Time Net Time Depth to Water Net Drop 8.24- 2 r7 � �• 0,,,.. b b r I 37d X11 M.j w I '' 5 V4 - PERCOLATION RATEI' C3�3 (minutes/inch) PERC HOLE DIAMETER I TEST RUN BETWEEN IS FT AND FT PERFORMED BY: N te'Ap'o 1, Y]A.Vkl, - - y` CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) �1 .�J op GI- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Ok7r"""� 825 "L" Street, Anchorage, Alaska 99502-0650 ® ®so oBu�i�CGo¢e°°°°°� Q o erVtLe V. AUSMAN SOILS LOG — PERCOLATION TEST ®® W. CE, 1393 q; A/ PERFORMED FOR:�,�InXLU Lt.r,-rz�_ DATE PERFORMED: LEGAL DESCRIPTION:_ Lo -r 4 "Jl-K Z Gae'.- Township, Range, Section: DEPTH ELI i.i I SLOPE SITE PLAN (FEET) sue'v. I I I- I I 1- 2 3 _ � U 4 =a ,o 5 o 6 7 8 9 10 it 12 13 14- 15 16 17 18 19 20 COMMENTS 0,-2,9 VAQA\/� WAS `JVD i,J� L1QckUFil� WATER ENCOUNTERED? J S IF YES, AT WHAT -- L O DEPTH? p E Depth to Water Aller _ Monitoring? — pale: Reading Date Gross Time Net Depth to Time Water Net Drop 9- 7-4 2 n d _Zr 5'�z to t, " PERCOLATION RATES (mmutes/mCh) PERC HOLE DIAMETER w I v TEST RUN BETWEEN �_ FT AND -(,2 ---FT PERFORMED BY:CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 'Pi- ?-A - I 72-008 (Rev. 4/85) 4' polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258.2419 JOB L.O r Y7 OGK. 7 l7LafZ1k SHEET CALCULATED BY CHECKED BY OF DATE �' _13— )"L - DATE PRODUCT I(SfyBSAEaOMI IPadlzdl ®mlrc.Smlon,AVs. 01471 To IMMOLEIOLLIhEEIG MM polarconsult alaslca, Inc. 1503 West 33rd Avenue a Suite 310 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258.2419 JOS /"LCrP_K- �.rv�PTIL•. F --r 4 nc,kZ YAe�F4aL<, uI SHEET NO. L OF !� CALCULATED CHECKED DATE to—I'-92— DATE a�aoucrewi Is�reksrwelaosi lemaEal08�=�mam�.66ss.mVLioomn vxoiierouraee itmuss,¢a �ne%eee0eee 49 2,eeee ooy�Loe • • V. e'e Je. a o o Joo ooue® 5- .. EARLE V. AUSMAN d_ CIE - 1393 ff c a� 0�!'iUfE5514Cf�� ¢n G�,..L-Gly( nt.A. P�R.F- PIPre--.�F1oll�£ora ln� l�•T_. 5O.r�F.i (-�(�l.T:. a�aoucrewi Is�reksrwelaosi lemaEal08�=�mam�.66ss.mVLioomn vxoiierouraee itmuss,¢a �ne%eee0eee 49 2,eeee ooy�Loe • • V. e'e Je. a o o Joo ooue® 5- .. EARLE V. AUSMAN d_ CIE - 1393 ff c a� 0�!'iUfE5514Cf�� ¢n JOB c.LllanV- ' twits . LuT4 BLK 2 0",y-Mtui s polarconsult alaska, Inc. SHEET NO. � OF 4 1503 West 33rd Avenue • Suite 310 CALCULATED BY DATE 4-i-97 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258.2419 CHECKED BY DATE SCALE _ DUCT N61&j� WEI,)NSI (0a )t4 gTic .0rYon EW 01171 To OILer PUPOTE TOLL FREE 1 POO225bk0 e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: 7FR0MI9 i C4))DL(5 C -DATE PERFORM LEGAL DESCRIPTION: L- T `� / �lo�k-� r (Ar;K fILLS Township, Range, Section: `rlZ N - / SLOPE CITF 1 2 3 4 5 6 7 S 9 10 11 12 13 14 15 16 17 18 19 20 ,OMMENTS cq ¢aJC-A— <j(?^JFv" WAS GROUND WATER ENCOUNTERED? 5 IF YES, AT WHAT L DEPTH? p E Depth to Water After Monitoring? N/6: gate: �(� tae A EARL E V. AUSAMN - d „ CE - 1393 / T. Reading Date Gross Time Net Time Depth to Water Net Drop P2F.S;s�c,e l \1'.210 o vy 2 t%S n PERCOLATION RATE ' — (minutes/Inch) PERC HOLE DIAMETER 1,0 TEST RUN BETWEEN 2_ FT AND 1!� FT PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALI, STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE. S /V'A'L 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR:_-it(LomE C49c)LE CLAtKK DATE PERFORM LEGAL DESCRIPTION: Lo -t �� 7 WloLkZ r P44 Rltcj Township, Range, Section: T12 DEPTH SLOPE SITE (FEET) pQ_/�, i� I I 1 2 3 4 5 6 7 8 9 10 it 12 13 14 15 16 17 18 19 20 ,OMMENTS 5\� LT2AV✓--L. CAnR-t>� SAi.l D Stt-,T� c'\2gVl; WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT L DEPTH? IP r� O P E Depth to Waler Alter -- Monitoring? `" Dale:2- ��ooeoeao o r• , eeoe;e. . I f ....... . e..eeae . ... EARLE V. AUSMAN rn V ,, �r4;ai. - R3 Reading Date Gross Time Net Time Depth to Water Net Drop P21�/cal` 11'.31 d LP3? 2'•0l 30 1 `1 sl 1/t I�oo lo'r % Its — 1ib PERCOLATION RATE (00 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 2 FT AND Z,S FT PERFORMED BY: z�I i�\G��r �. `V6Ut.- CERTIFYTHATTHIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 71123IRi/ 72-008 (Rev. 4185) Municipality of Anchorage P.O. BOA 196650 ANCHORAGE, ALASKA 99519-6650 (907)343-4200 T2RRWMW9t Tom Fink, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES January 8, 1988 Corwin & Associates 4790 Business Park Boulevard Bldg. E Anchorage, Alaska 99503 Subject: Lot 4 Block 2 Park Hills Subdivision #1 Permit #870039, On-site Sewer Permit A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1987. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well. and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. Effective January 1, 1988, a new fee schedule is in effect. When re -applying for a new permit, the new fees are; $90.00 for an on-site sewer permit; $50.00 for a well permit; $140.00 for a combined sewer and well permit. If there are any further questions, please call this office at 343•-4744. Sincerely, G 4Rober W. obinson Program Manager On-site Services RWR/ljw enc: Copy of Permit Iwo 1-Q 149][q . �'A., wov p R "v^ V7SI ON 14111 � I-;X-INSTAW. D|PARlMENT (/F / 111 AN)> E:NVI1 PROTE[]IOM 825 L STREET, ANCHONAGE AK 9950l , 264-4720 LD HvIl_3. 1 111-1 Q. WUHAM7110; I 1� lln� IIAI M 31 H PERM[� �L/: 87O�39 D�T� ]5JUED: 04/01/87 APPLICANT: C ARtolH & A8 to C CTATE3 ACU�E�S: 4710 TRIG IIII �N PMRK HIM). PLPG E ANCHORAGL, AK 9?5O3 CONTACl PHU�41..: 561-6151 DESCI zlP: SUBDl;ISInN: PARK H[LLS SUDD. #1 LOT: 4 2 SGWIION: 31 TOWNSH!P: 1.' �N K(1NGE: 3N LOT 61ZE: 4OK A[�E�;) 1 AX 9DRUUM'I ars the opLions availab1e to you in desigping you/septic system. CUorse How option that hesi fzts your site. I h 0 W IWUC 4 -U W W H 3 UJ 13 F 14 AL W 11 OEP!H TU FlP|8CjTlHPI ([l 4.0 4,0 4"V GRAVEL DE17,T|| (1:TO 0.5 3,5 T;TAL DEPTH (In 7, 0 4.5 7.5 GI �AVEL WIDTH (FT5 0,0 5.0 GRA;EL LENGTM (FT63'0 Sol ,o 34.0 Ok'AA[L VOLUM. (CV,Y0G.) 2W 2R,P 40.0 TANK SM (GALS) 1,250"0 ** 1,250,0 ** 1,2"0.0 ** SOIL 111ATIN8 (HUM ./M 125 1T5 125 MUST 1 14YE AT LEAST TWO COMPARTMENTS ---------------------------------------- [ certz+y that: fam1\iar wiW thc requirements for on -silo sewers and wells as set WrLh hy the Pluricipaliiy of Anchorage (MUM and the Mate of Alaska" 2 I wil1 inUall the system in acco/`dance with all MOA codes and regulatirns, and in compliance with I.ke design criteria rF this permit" 3, I `vi)l adhOre to all MOA and 131.11te of Alaska requirements Ior Lte set bact il is1ances ; rom any existing well, wasLewater :isposal sysLem or Puhl1c seweI on Ufis o/any adjacent or nearky l"t� 4 l undersiand Mal Lhis permit is valid for a maxi/mnm of 4 bedrooms and *ny pnlarliemwL °i1l require an addi0.ional perm1k lF� 1,T1 1 3 FRED B� 110('l8UILDI�G C�DE�, 1111:1,1(�) AH 011ST DE V8TAI4111); (2) M-1,1111JLTD WlLL NOT s6 R SPFCTlUN SEPOCTo AND 03> TXE ELB�TROCAL WD EClRICTAN. AlGNEK DATE: __/__��_-___..... _ A��LlC�NT: � �AlES —�, (ENGI,NEER'S u Municipality of Anchorage a DEPARTMENT OF HEALTH & HUMAN SERVICES 0 2 p e 3 4 0 n O Q 5 A 6 r• n 7 o O 8 c 0 9 0 10 0 0 O 11 0 0 O 12- E/4 D 13 14 15 16- 17 81920 18- 19- 20 rH.IM135 "k &I i hT /&Jrzorr� WAS GROUND WAT ENCOUNTERED? S IF YES, AT WHAT L 0 DEPTH? p h E Depth to Water Alter (/ 3 Monitoring? {% Dale: q. Rea Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE 825 L Street, Anchorage, Alaska 99502-0650 fTF, , -._ c,�..-�- —//SOILS °`` c �l`. Cc 1I ` I� �19Y-Ii IP?l 'tl —I� LOG — PERCOLATION TEST�i °• ""I" r:o. ce._• ss Z FT AND ��� FT I �? SS.:I. 4.T. � raQV� A PERFORMED FOR: J(- rYr//r- 1' nrtS�rit4vr\ DATE PERFORMED':'�elJ_./"I(i�; "ill I Yom( 1 I LEGAL DESCRIPTION: Tial ✓� I II y:V V I'I' I "1 Township, Range, Section: i 72\'; = FQEPTH� A SLOPE -T -n SITE PLAN F 0 2 p e 3 4 0 n O Q 5 A 6 r• n 7 o O 8 c 0 9 0 10 0 0 O 11 0 0 O 12- E/4 D 13 14 15 16- 17 81920 18- 19- 20 rH.IM135 "k &I i hT /&Jrzorr� WAS GROUND WAT ENCOUNTERED? S IF YES, AT WHAT L 0 DEPTH? p h E Depth to Water Alter (/ 3 Monitoring? {% Dale: q. Rea Date Gross Net Depth to Net Time Time Water Drop PERFORMEDBY: `�t1"�-�" `'��-'y lam_ I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN T E THIS DATE. DATE: �-1 PERCOLATION RATE tminutes/inch) PERC HOLE DIAMETER 1I ` I� �19Y-Ii IP?l 'tl —I� (TEST RUN BETWEEN U II, . FT AND ��� FT I �? SS.:I. 4.T. � raQV� A PERFORMEDBY: `�t1"�-�" `'��-'y lam_ I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN T E THIS DATE. DATE: �-1 Al, ItRroA 1�1a9(Uld bOr 1� I ,s 4IVER SYSTEM LOCATION PLAN G. Lor DLOCK SUBDIVISION �.v�/P/i/`�. SECTION/ TOWNSHIP/ RANGE q'p "-t y 9CALE� NOTES THE ACCURACY LOCATION OF EXISTING ' PROPERTY CORNERS, WELLS, AND SEPTIC DRAWN BYE SYSTEMS INDICATED 19 NOT E%ACT. .,• , NORTH ��'1/ DIMEN31OPI3 IHOICATED HAVE BEEN DETERMINED BY USE OF CLOTH TAPE AND J n , NOT BY SURVEYING TECHNIQUES. cl co J. PREPARED FORS 1. �nq Bets SHEET '� Of of Anchorage POu d 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNO WLES, MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit B: 840406 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 4 Block 2 Park Hill Subdivision #1 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-•4720. Sincerely, Keith E. Bandt�sor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 Y'!JNIi_'IPAL.ITY OF ANC:P- "qGE DEPARTMENT O "IF_ALTH AND ENVIRONMENTAL F. JTECTION 825 L_ STREET: AN H��RAGE, HEC •99501 i 720 14 IE L_ d_ I:" F✓ K� r•9 I" _i.. PERMIT NO: 840406 DATE ISSUED: 05;'30/84 APPLICANT: THOMPSON CONST. ADDRESS: 1048 W. INTERNATIONAL AIRPORT RD. 119. ANCHORAGE, AEC 99502 CONTACT PHONE: 561-2484 LEGAL DESCRIP: SUBDIVISION: PARK HILI... #1 LOT: 4 237 SECTION: 34 TOWNSHIP: 12N RANGE: 314 LOT SIZE: 48820 (SO.FT. OR ACRES) MAX BEDROOMS: 4 LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING SYSTEM. CHOOSE THE OPTION THAT BEST FIT:= YOUR SITE. DEPTH TO PIPE BOTTOM (FT.) GRAVEL DEPTH (FT.) TOTAL. DEPTH (FT.) GRAVEL WIDTH (FT.) GRAVEL. LENGTH (FT.) GRAVEL VOLUME (CU. YDS. ) TANK SIZE (GALS) SOIL. RATING (SO. FT. /BR) 4. N 4. O S, 4_1 5 119. 0 +: + 49. 5} 237 Fj 1= C- 4. _ °4. 0 A 5 4. 5 26. 0 51 0 49. 1 :L, 2501. g xw 220 BLOCK: 2 YOUR SEPTIC 4. 0 _. 5 r. L 5. 0 103. 0 76. 2 `37 GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS <NOT EXCEEDING 75 FT. EACH) TANS: MUST HAVE AT LEAST TWO COMPARTMENTS CERTIFY THAT: 1. I AI'9 FAMILIAR WITH THE REQUIREMENT'S FOR ON—SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALIT''r OF ANCHORAGE CMOA) AND THE STATE OF ALASKA, 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS. HNC, IN COMPLIANC':E WITH THE DESIGN CRITERIA OF THIS PERMIT. —. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL. SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 4 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES., THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; C2) AS—BUILTS E4ILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK NI_IST BE DONE BY A LI(;ENSED ELECTRICIAN. SIGrJkID DOTE: 3/ ------- AP'P'LICANT: THOMPSON CONST. G ISSUED Lr'r'DATE : — — ❑ SOILS LOG LLt 6 Z _ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION O PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-0720 \� SOILS LO.E.QCOLATION TEST PERFORMED FOR: rArK HIDATE PERFORMED: 3-23-82. LEGALDESCRIPTION: Te57- WOUG a S 1 4r w+ 15:3•{'ro. D—E P -T -H-1 SLOPE SITE PLAN VF (a" 14Urn US FroxEr_+ +0 2 `,12 ' I I I P I 2 3 4 5 S'�"y C)raOELUL, SAnID 6 73rowwl I f''loi-,jrr, DtM SC 'I. 1'hore gr4v&L tk AN, ,'uHht�J LE. 7 INd Ic.a+�5 SM 8 0 10 it 12 13 14 SAOp (; rowwlr moi�r 16 17 I-IArdCr DQILI Iraq AT 18 WAS GROUND WATER S ENCOUNTERED?E' S O P IF YES, AT WHAT E DEPTH? 12. 'I -1 -SZ Reading Date �L�A7 Net Depth to Net Time Time Water Drop rrF nprL Jnr • b.. a 0U Groul.10 iz I 3 3 '• I '• 2 5 �' �/e 4 �7/ � S •• 0-7 I :50 (o'2 S C�� rJr 1:4 �3 Ilo y ILP Reading Date Gross Net Depth to Net Time Time Water Drop rrF nprL Jnr • b.. a 0U Groul.10 iz I 3 3 '• I '• 2 5 �' �/e 4 �7/ � S •• 0-7 I :50 (o'2 S C�� rJr 1:4 �3 Ilo y ILP s44111 20 .S -O p cjraveul r ?�rowwl ,O CY PERCOLATION RATE_ TEST RUN BETWEEN (minutes/inch) � I _ 4 /¢ FT AND S � FT COMMENTS r(lnp+k rrF nprL Jnr (r, 51/11, 2"r2rr P.bo VP Groul.10 PERFORMED BY: 72-008 (6/79) CERTIFIED BY: DATE: 2■ rll!�" Municipality of Anchorage • -� Development Services Department ° Building Safety Division, / On -Site Water and Wastewater Program a ° 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. 0f7 - INZ-l7 HAA# nl� / (paa0�{(D Expiration Date: 1. GENERAL INFORMATION Complete legal description '1_ot'/, Block 2 Park /�rl/t� iFdo(frun # / Location (site address or directions) I`/6rl Park *Itr Drive - Current Property owner(s) Vc c fo rr cc M cz lonl Day phone 2Y — 67f 7 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address lyo'gl Park */Ir Drive. A-rck, Ak 99S/,< US A A Day phone FS 60 Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: y 3. TYPE OF WATER SUPPLY: Individual Well El Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ER 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 Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of Installation. Name of Firm Flu blor- %actin (�aI Ser'v<<U Phone Address Engineer's Printed Name 5. DSD SIGNATURE Jz Approved for .Y_ bedrooms. Disapproved. r� Date 2/12/02 U.�.s7w.y Ali Ct.� +,F+.� •, } ►f.ENGINEER'S ti STAMP 7•Jeeese•H.•.•..•.. •.•i.r•-• J . 7HZOJORE F, ::OGRE u •' Cc - 9539 r: ' ate'•...•.•.••• ',;,cv V.7 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist x Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: �.,/ (GJ �c`— Original Certificate Date: — 3 -02- (Rev. 1b00) Municipality of Anchorage • Development Services Department Building Safety Division ` Onsite Water & Wastewater Program 4700 South Bragew St. P.O. Box 196650 Anchorage. AK 995196650 www.cl.anchorage.ak.us (907) 343-79W HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: La f Y/ B/ k Z PA H. //s S lb �(dn # 1 Parcel ID: 0/ 7 — 1 Y Z -17 A. WELL DATA Well type ,�v_f. If A, B, or C provide PWSID # _ Date completed S/ 17/V Sanitary seal (YIN) Y Total depth l0 6 tl. Cased to JAI—ft. FROM WELL LOG Date of test 3 / 17 / 9 3 Static water level 7 `✓ ft• Well production 1 2 9•p•m- WATER SAMPLE RESULTS: Coliform O colonies/100 mi. Nitrate 0. Z26 mg.A. Well Log (Y/N) Y Wires property protected (YIN) Y_ Casing height (above ground) I Z in. AT INSPECTION 2/ I /O'Z 77 ft• d.O g.p.m. Other bacteria O colonies/100 ml. Date of sample: 2 / I / O 2 Collected by: F &r yop TeChnica/ Ser✓ 4 •J B. SEPTICIH022111REITANK DATA (S Of Ca,919 ell/ on &&< k) Tank Type/Materiai Sef fic / S141/ Date installed to / ZS / 7-e Tank size I Z.SO gal. Number of Compartments 2 Cieanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N• A. Date of pumping B/ ZZ /0/ Pumper Nor hhlanvC C. ABSORPTION FIELD DATA Date installed f o / Z3/P3 Soil rating (g.p.d./ftp or ft2/bdrm) 1!!pa(/ksSystem type Tri t 14 Length SW ft. Width 2 ft. Gravel below pipe IV S ft. (►+,r. u.faa& 79" 60./J +' See W 6w) Total depth 9 ft. A Elf. absorption area SA (tr Monitoring tube Depression over field N Date of adequacy test Z/1102 Results (Pass/Fail) Pats For Al bedrooms Fluid depth in absorption field before test _Q_ in. Water added$ gal. New depth O in. Elapsed Time: — min. Final fluid depth O in. Absorption rate >= 6O0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Nave k..o ovn If yes, give date N• W. y 'lie frvAch no,,hp, 7rtl^,- eAhrn,,rlS SY" repo r !rd S+nt�r/ a/eP h% D. LIFT STATION N• A, Date installed `Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump ofr level at _ in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankfliR station on lot too ' Absorption field on lot 170 . Public sewer main W. A Sewer /septic service line '> 2S Manhole/Access (YIN) High water alarm level at Meets alarm & circuit requirements? On adjacent lots > 100 ' On adjacent lots > 100 Public sewer manhole/deanout Al. 4. Holding tank N• A. In. SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation Z Y ' Property line 3S ' Absorption field �S Water main > ZS' Water service line > ZS' Surface water > too Wells on adjacent lots > r00' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Yo' Building foundation 100 ' Water main > ZS•' Water Service line > 2S' Surface water > 10o' Driveway, parking/vehicle storage > SO ' Curtain drain None SQP7 Wells on adjacent lots > fyo 0 F. COMMENTS At cl1ctw.rxrr-4 &r . 00-n RoNb, Y4t2r it alai( k l rn[ ctocwn G. ENGINEER'S CERTIFICATION t %e Stp hL Y0,7 0 Fluccu Fecv- *s f* I certify that I 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. Engineer's Printed Name "TAeoclore F ncror< Date 2 /12 /0 z HAA Fee $ 3'7S- �- Waiver Fee $ Date of Payment Receipt Number (Rev. 12/00) Date of Payment Receipt Number Q s" X14y mlott4c 4&";0 if awe- no} nk to ffts"-NIA LN A, 1`✓• •.•.•...j T�♦ yr't C,9Tk`'k,� ' 1 • A .4AR.. .. K l r . TH_ODORE F. A7OORE : t CE -35894f.......... .. �-� </1 l t t LOT 5 .. :•S'cRaaK-MPt1-tv, • Bpl;aMror— l� f saw` a� LOT 4- ggta2o 0. 5`eltc. 'r,17e Oar V� D`rilra/ 6?0� �'L �Krf[� fVT �i �J NOTE: Thu is AO—f O- Sep He S14rrncep pe T>` efPP ea f /a. 4 e Mt srE-c Gf 4n 0 t tvthoie _�z�swZ PLOT PLAN AS BUILT X SCALE L =4o GRID '5051 JOB No. 1 Mona@t1h o Limit� R Sy 1731 George Bell Circle o o Anchorage, Alaksa 99515 (907) 345-6476 1 Hereby certify that I have surveyed the followin described pMorl Lot + Block 2 , Pa2l< t-41�t s sub., aor� Na ��� OF, A< q �♦ Li,K 1QPdY tlf._ Recording District, Alaska, and that the improvements situated b thereon are within the property lines and do not encroach onto the property i'�R adjacent thereto, that no improvements on the property lying adjacent thereto / C-1: f Ttl 1. 1 encroach on the surveyed premises and that there are no roadways, transmission �,,,,,,;,,• lines or other visible easements on said property except as indicated hereon. ih Kennciii G,`,nny • • • •' 1 Dated this the ?$ f Day of EME" . 1924__, at Anchorage, Alaska �•, IS 5202 l t .7 It is the responsibility of the owner to determine the existence of any easements,�sN............ ,t�'` Municipality of Anchorage • Department of Health and Human Services Division of Environmental Services On -Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLE FAMILY DWELLING Parcel I.D. 4f 2- (�t HAA# l f -t=0%8 Expiration Date: 1. GENERAL INFORMATION Complete legal description [-o h- 4f (5Z-ycp' - Location (site address or directions) Iq &s( Pag k b ((i! Or Current Property owner(s) a+v( 1<, Day phone 3,4 5 71 5 Mailing address Lending agency Mailing address Real Estate Age Mailing Address Day phone Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: "I 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 1P Individual On-site (� Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Department of Health and Human Services (DHHS) 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) 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. -_-025 Rev. 01 001' 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address Engineer's Printed Name 6. DHHS SIGNATURE // Approved for _ bedrooms. Disapproved. Conditional approval for Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Phone 2i4 -f S--3 ,. cy-"wr Date bedrooms, with the following stipulations. Maintenance Agreements Supplemental Engineer's Report Other By: /i„/� _1z lamOriginal Certificate Date: 3 - 2 C -O a Expiration Date: � - 2 e - CD D Reissue Date: 75-025 (Rev. 0 1;00)' Municipality of Anchorage i� L CE I VE a • Department of Health and Human Services Division of Environmental Services flQ�R 072000 On -Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 MUNICIPALITY OF ANCHORAGE. 9 ""^"IMF.NTAL SERVICES DWI` www. c i. a nc ho rag e. ak. u s (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: (-n fi '"0 i3 v Ilrn���l (� yI Parcel l.D.: 017-14 2�1 A. WELL DATA Well type fir. ale If A, B, or C provide PWSID # _ Well Logue Date completed 57gT Sanitary seal Wires properly protected _� Total depth 16,4ft Cased to 104 ft Casing height (above ground) (2- in. FROM WELL LOG FM1►&W*&1r.P►I Date of test 22 pa Static water level ft _ 7 If ft Well production/ _g.p.m _ 7— g.p.m yhSu�,� C� �.�e Wetl tat lZejfw7 WATER SAMPLE RESULTS: P F 1 Ut sq Coliform _colonniie,,s,/11000.��I Nitrate _� mg/I / ther bacteriac lonies/100 ml Date of sample:_ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material . Ar Date installed 10(2')Iy �e ( Tank size LI SX) gal Number of Compartments Z� Cleanouts _Foundation cleanout . Depression over tank _7,( High water alarm !� Date of pumping 'Z 1440 Pumper /4a o- Fh� nnd. C. ABSORPTION FIELD DATA Date installed A4242— Soil rating (g.p.d./ft2 or ft2/bdrm) (f 2-- System type 1 eeP f rrnrI7,_ Length St ft Width _2—ft Gravel below pipe "V7 ft Total depth 4 ft Effective absorption area!F,10 ft' Monitoring tube Depression over field N( Date of adequacy test z a') ou Results (Pass/Fail) �Jti sS `� For 4(_ bedrooms Fluid depth in absorption field before test 0 in Water added X60 gal. New depth O —in. Elapsed Time: 114yV min Final fluid depth O in Absorption rate >= (obd g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Jq - If yes, give date _ 72-026 (Rev. 01/00)` D. LIFT STATION Date installed Size in gallons "Pump on" level at in " o " level at in Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank//s? ion on lot /190 14 On adjacent. lots High water alarm level at in Meets alarm & circuit requirements. I o?) (-/- Absorption field on lot too I % On adjacent lots / fkj t --- Public sewer main r`� A Public sewer manhole/cleanout , Sewer /septic service line 100 Holding tank /V SEPARATION DISTANCES FROM SEPTIC/FJOLal G' TANK ON LOT TO: Building foundation 22 �- Property line 20 % Absorption field . 4f D -I- Water main �— Water service line I bo t -�- Surface water /o C) (>< Drainage / 0 r7 1* Wells on adjacent lots 100 (4 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 2L�1 f Building foundation 221 Water main Water Service line 1(901+ Surface water /00 (-� Driveway, parking/vehicle storage Curtain drain e— F. COMMENTS G. ENGINEER'S CERTIFICATION Wells on adjacent lots /001+ I certify that I 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. Engineer's Printed Name Mt,rkw.e( Axk,r- 4vrt Date _ 'I/r HAA Fee $ Date of Payment 2;,)-7 ,J D7) Receipt Number 72-026 (Rev. 01/00)' Waiver Fee $ Date of Payment Receipt Number IN EP, �Zzcs ®4 yon•° MICHAEL N. ANDEMN•;. !p MUNICIPALANCHORAGE DEPARTMENT OF HEALTH &HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ft O (7-j- `-f Z HAAS_ Q2�gI-kC)()LI, 1. GENERAL INFORMATION Complete legal description Location (site address or directions) _ _I`f (9S/ Por hti �; ( (5 Of- ( ?S 0? Property owner G6Vje-a" Stromc(:c(ar(�, _Day phone Mailingaddress I`�Sl Lf)'\MbAc_(0 �\ , (?AAIB Lic�'J'Csn Lending agency Day phone Mailing address Agent . Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 1�'/!j NI Xi'!tb'31L144_lul:47D]RU01-ni4 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 (Rov. 1/91) Front MOA 921 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 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 &Wc0., SVS Phone 2�q— ogoZ Address q�DLsnx. ,'gZo?_7 A u Ate, (69S/&( Engineer's signature Date 49th CE -8749 6. DHHS SIGNATURE x Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: WTlr, Date 2 — AO — The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rev. 1/91) Back MOA 01 a Municipality of Anchorage Department of Health & Human Services A HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Po6-1k�t6 , K 01&k- Z Parcel I.D. 0l -?-/(-/2- !? A. WELL DATA Well type P Lv wt e- If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed !!0/ ti's Driller � 1 12; h e Total depth f 6 (0 Cased to I (9(0 Casing height _ Sanitary seal (Y/N) e Wires properly protected (Y/N) y % z < 3 FROM WELL LOG AT INSPECTION z Date of test Static water level i� e L- � lin N p r m T Z Well flow I Z g.p.m. _ g.p.m.m co �O r O C Pump level o" SEPARATION DISTANCES FROM WELL TO: z Septic/holding tank on lot /o � ; On adjacent lots / UC9 Absorption field on lot (?v / ; On adjacent lots /0(3 1 - Public sewer main Public sewer manhole/cleanout N/J Sewer service line Petroleum tank h� o h �- WATER SAMPLE RESULTS: Coliform -0� Nitrate Other bacteria �— Date of sample: I Z h D( u 3 Collected by: e(A e 4 � e["h B. SEPTIC/HOLDING TANK DATA Date installed -51 4 3 Tank size —1 '? ° u 5 Compartments Z- Cleanouts (Y/N) "-d c'S Foundation cleanout (Y/N) 4'C' 5 Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping %( ' w - Pumper _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot SOS —On adjacet.,;ots /yn Foundation �U To property line zr Absorption field�a0 Water main/service line Surface water/drainage /00 72-026 (Rev. 719 1) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gal o Vent (Y/N) High water alarm level Meets MOA electrical codes (Y. SEPARATION DI Well on Manufacturer Manhole/Access on" level at E FROM LIFT STATION TO: D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Date installed 0 T {-gt Soil rating /12- System type ' - r Ph r% ' Length S 7 Width 2 Gravel thickness 1/2 Total depth S / Total absorption area 5-( 3 t t_, Cleanouts present (Y/N) C� -e S Depression over field (Y/N) 711Date of adequacy test Results (pass/fail) �, ( -,- �D for Peroxide treatment (past 12 months) (Y/N) _—L� C) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot j 7 O / On adjacent lots /o D f Property line 'e �7 z+/ To building foundation /Od To existing or abandoned system on lot N w On adjacent lots /Dom Cutbank /on 4 Water main/service line LVM Surface water / CO c Driveway, parking/vehicle storage area (00 + Curtain drain /-1/� E. ENGINEER'S CERTIFICATION bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this:inV10ction. ®Ai ��� ty�t-�E Signature � -V Engineer's Name szz3vaw P'SPP ur.)o,v <a � � ......h«�« Date I _ ZLt L( o5 S �...�.,,..... 19� iSteven R Pannone. .��Q CE -8149 aye HAA Fee $ J 0 0I Vv c Date of Payment z Receipt Number 2s6c4? 72-026 (Rev. 9/91( Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number