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Home My WebLink AboutSAMPSON ESTATES BLK 1 LT 9mpson Esta Block 1 Lot 9 #051-822-27 Municipality of Anchorage o_A~, · Development Services Department .-."_="!, .= ..'. Bu~I,o s~/O~o. On-Site Water & Wastewater Program, 4700 South Bragaw SL p.o. Box ~o/~oo. ~K 905~6~0 www.cLanchorage.ak, um (907) 343-7904 Page I of 5 On-Site Wastewater Dispocel System and/or Well Inspection Report Permit Number:, SW010073 PID Number:, 051-822-27 No~r~:DENNiS BOUWENS Wastewater System: 1:3 New · Upgrade 23912 GOLIATH DRIVE * CHUGIAK, AK ggS&7 ABSORPTION FIELD Ph°ne:(907) &S&--75;~8 5 II~.p Trench mSh~llow 'ranch 1:3Bed DUound LEGAL DESCRIPTION = '~ o.& ~/~ ~ 9 1 SAMPSON ESTATES 4 - 5 .. 5.0 - - - 0 - 1.0 rL 76 TOTAL (MIN.) WELL: [] New [] Upgrode 2.5 rL 1 ~.. ~ ~ 760 ~... D 5054/ F-810 ~ CCC CONSTRUCTION 4/20-21/2001 SEPARATION DISTANCES .s. pu= ~.o~=~ ~s.T.r,~. ~O~.r To SapUC Ab~ier~dfl°n StouonUft HoldlngTanks~.~/~'~° PREMIER PLASTIC 1000 weft 100'+ 100'4- - - 25'+ PLASTIC 2 s~,o=o wot., ~oo'+~oo'+ - - - LIFT STATION ~..,o~: oxc~ '~V, ,~ o%c,~lo~ct BENCH MARK BOTTOM OF PATIO DOOR THRESHOLD I~'"'~ ~'-'~' 100.00 i ......... ......... 3rd 4/2,/2001 L.~7.J, ~fr~ ! A. b~ess...' Department of Health and Human Serv~es approval . ~ ',..'. ~ ....-' ~[V.e~' .......... ~eviewed and approved by Dote: /I/-X~L': o~. (~v. P~M~N~'~ AS BUILT DRA~G p~,~ N~ SW010075 - 0,51-822-27 GOLIA'~ ~N~ 1000' ~ON ~ / SEP~C TANK DBL1 17.8 17.5 DB~ 18.4 18.7 - USED ~ A RESE~ FD 18,5 19.1 C01 11.0 18.7 - MT1 11.4 18.7 -- C02 52,1 -- 24.9 MT2 ~1,6 -- 24.3 MT3 ~4.6 -- ~7.6 I ~SI~ B~TER & WASTEWATER ~ CONSULTANTS. INC. ' ~R~ FOR: PHONE NUMBER: a~[ NUMBS: ~ .. * I DENNIS BOUWENS (907) 688-7538 2 OF SAMPSON ESTATES SUBDIVISION; LOT g, BLOCK 1, AS-BUILT OF SEPTIC SYSTEM UPGRADE ,..~,.o.~.,: AS BUILT DRAWING $W01007~ - 051-822-27 ~ R~ G~E = 96.3 + I~RT OF BUNG' / F~MIEE~C ~I~JsO~oBUNO- n~ G~E Mf ~ = 97.0-9B.0~ . ~ ~ORIGI~ ~SI~ WATER & ~STEWATER ~ DENNIS BOUWENS (907) 688-7338 2 OF 3 ~[ OF ~: PROFILE AS-BUILT OF SEPTIC SYSTEM UPGRADE MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Apr 19, 2001 Expiration Date: Apr 19, 2002 Permit Number: SW010073 Legal Description: 'SAMPSON ESTATES BLK I LT 9 Design Engineer: 0041 AK Water & Wastewater Consultan' Owner Name: DENNIS S. BOUWENS Owner Address: 23912 GOLIATH DRIVE CHUGIAK, AK 99567- Parcel ID: 051-822-27 Site Address: 023912 GOLIATH DR Lot Size: 40668 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail requirements specified tn 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 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 MAXIMUM DEPTH OF THE ABSORPTION TRENCH AT ANY POINT SHALL BE NO DEEPER THAN 10 FEET ~,FROM ORIGINAL GRADE. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewafer Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (~07) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-1~-~7 Permit Number 5 ~/O/OO 7~ Properly owner(s) DENNIS BOUWENS Day phone 688-7338 Mailing address (1) 23912 GOLIATH DRIV~ * CHUGIAK. AK Mailing address (2) N,/^ Zip Code 99567 Legal description (Lot. Block& Sub'd.) LOT 9. BLOCK 1: SAMPSON ESTATES SUBDIVISION Legal descripUon (Section, Township & Range) Lot Slze 40--~5~~ Acres/~ Number of Bedrooms THIS APPUCATION I$ FOR: Sewer Only E]~ Sewer and Well Sewer Upgrade · Well Only E]~ water storage THIS PROPERTY CONTAINS: Hot Tub Swtmmlng Pool Therapy Pool Jac~ r~,l ~E] Water Seffenlng unit I certify that the above Information Is correct. I further certify that this application Is being made for a Single Family Dwelling and is in accordance with applicable Municipal codes. ALASKA WATER &: WASTEWATER CONSULTANTS~ INC. Permit Fees: ~3~ Date of Payment: Receipt Number:. Waiver Fees; Date of Payment: Receipt Number.. ALASIG WATER & WASTEWATER CONSULTANTS, INC. April 9, 2001 Municipality of Anchorage Development Service Department Building Safety Division On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Reft Septic System Upgrade for Lot 9, Block 1, Sampson Estates Subdivision To whom it may concern: The existing 3 bedroom house is served by a private well and septic system. The existing septic system consist~of a 1000 gallon septic tank and a deep trench type drainfield. The existing drainfield will not pass an adequacy test and must be upgraded prior to the sale of the house. A test hole was excavated north/northwest of the existing septic system in the area of the proposed septic upgrade. The proposed septic system will be designed around the 30 foot radius of this test hole. We are proposing that a new 1000 gallon septic tank be installed in the same area as the existing septic tank and a deep trench type drainfield be installed. Comments regarding the proposed design are summarized as follows: 1. SOILS: See the attached Icg which shows the soil classifications, groundwater monitoring, and the percolation test results. It is our opinion that due to the overall appearance of the soils, an application rate of 0.6 gallons/day/ft: should be used. 2. TRENCII DESIGN: a. Percolation Rate: 4.4 minutes/inch b. Allowable Application Rate: 0.6 gallons/day/ft2 c. Number of Bedrooms: 3 d. Design Flow: 450 gallons per day e. Minimum Absorption Area: 750 ft2 f. Total Depth: 11 feet (max.) g. Effective Depth: 6 feet h. Width: 2.5 feet i Minimum Length: 64 feet total length Effective absorption area = 768 ft2 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Wcbsite: akwwc.com 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 4. TOPOGRAPHY: As can be seen on the topography notes, the area for the proposed upgrade is on a 1 to 5 percent slope, running from approximately north/northeast to south/southwest. The slope does increase towards the south of the proposed and existing drainfield to approximately 25%. I am unaware of any adverse impacts this installation would have on adjacent wells or septio systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. amess, P.E., M.S. NOTE: ,4ttached is a site plan drawing, a design drawing, a topography site plan, a soils log, and a 7 page construction specification letter which are all part of the design package for this septic system. 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.cora ~ (~ D~, P~E 2 OF2) O~WN ~: .~ ~ ~. J.LM. ~.~4 ~z.~..g ........ DENNIS BOUWENS 688-7~38 SAMPSON ESTATES SUBDIVISION; LOT 9, BLOCK 1, ~[ OF WORK: SITE P~N FOR SEPTIC SYSTEM UPGRADE I X · ~o~ o~.~. ~v,~ ~ ~ r r J.LU. ~SI~ WATER & ~VASTE~TER ~ONSULTANTS. IN~. OENNIS 8OUWEN5 (gO7) 688-7~8 SAMPSON ESTATES SUBDIVISION; LOT g, BLO:K 1, DESIGN OF SEPTIC SYSTEM UPGRADE ~%~- CONSULTANTS, INC. .so,L Loo- .E.CO T,O. TEST PERFORMED FOR: DENNIS BO~S DA~: 4/5/2~1 ~e~J ~ OR~,CS IT[ST HOC[ ~ I FILL ' I T SW HH ~ ~ ~ - SM OH - , HOUSZ-- ~;"' ] ~ / fJJlJl DEPTH TO DATE GRO~DWATER PRO~ ~ ~ g-- rSITE P~ J I' = I00' ~o-- SH/HL [~ IIIII WITH SOHE GRAVEL NET TIHE WATER LEVEL NET DROP 11 -- DATE RE'lNG CLOCK TIHE (HINGES) RE'lNG (INCHES) 12 -- 4/6/2001 I 3:35 ~ 6' 2 3:45 10 3' 3' 13_ 3 3:45 6' 4 3:55 10 3-1/8" 2-7/8' 14-- 5 3:55 ~ 6- 6 4:05 10 ~- 1/4" 2-3/4" 15-- 7 4:05 ~ 6- 8 4:15 10 3-1/2" 2-1/2' 16-- 9 4:15 ~ 6' 17 -- 10 4:25 10 3-3/4' 2-1/4' 11 4:25 ~ 6- 18 -- 12 4:35 10 3-3/4" 2-1/4' 19-- PERCO~TION ~TE 4.44 (HIN./INCH) PERC. HOLE DIA. 6' (INCHES) TEST R~ BET~EN 7.0 ~. ~D 7.5 20-- COHHENTS: PERC-HO~ W~ PRE-SO~ED FOR 4+ HOURS. RECOMMEND USING A 0.6 ~PU~ON ~ DUE TO ~E 0~ ~P~CE OF ~E SOI~. PERFORMED BY A~ WATER · W~ATER I. JEF~ ~ O~NESS. CE~ T~T THIS ~ ~ERFORMED IN ACCORD~CE WI~ ~ ~A~ ~D MUNICIP~ OUIDEUN~ IN E~ ON ~IS DA~: ' I DEPTH TO DATE GROUNDWATER DRY 4/5/2001 i~- ~ 4/~il/2001 ,-- MUNICIPALITY OF ANCHORAGE ," '~ DE~ iTMENT OF HEALTH AND HUMAN SER~,_ .ES ~"~. · Environmental Health Division ":~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES C tX¢'~"' -'~t~¢-f'~-~--,r- ~ SEPTIC ABSORPTION WELL ~ .... TANK FIELD Phone(s) Permit No. No. o, .~oo~. WELL Township. Range, Section AS-BUILT DIAGRAM (Show Iocatron o~ well, septic system, property hnes, foundaUon, I ~ ~ ~ ~ I~ ~ d ...... y, waterbodms, etc.) TANKS i O' ~ SEPTIC ~ HOLDING Capacity m gallons Material No. el Compartments TYPE OF SYSTEM ~TRENCH ~ BED ~ W. DRAIN ~ OTHER Depth to p~pe bottom Item Tolal depth from original grade original grade I ~ FIll added above original grade ~ Gravel de¢lh beneath pipe~ FT~ Dist .... bet .... lines Total absorpt~o Installer 3ate Installed ~ WELLS PRIVATE ~ OTHER (Identify) Class~ficahon (A,B.C) ' Total ~epth F~ Cased to REMARKS: SE B ] 96X , ~ ........... ' , cedily that Ibis inspeclion was pedormed according to all Municipal and Slate guldeunes in eilec[ on (his aaf~: ' 72-013 (3/85) I F'ERM I"[' NO: DA'TE !SSUED: ' AI:::'P L :i CAIxl]': ADDRESS E'.r_:H'4TAC]" Ft--18NE: DEF:'ARTMEN, ,2F 1.4EAL.TH AND ENVIRONMENTA,.. PROTECTION 825 L STREET, ANCHORAGE, AK 99501 26zt,-47:~C) Iii60 148 05/30/86 CLJR ].- I::' I ERAT T B[]X' 15000 ~2.9 WASILLA, AK 376-6786 99687 LEGAL. DESCRIP: SUBDIVISION~ SAMPSON E!~;TA]"ES SEC]"I (:}hi: 3 TOWNSH I P: 15N L.E}T SIZE: 4()668 (SQ.FT, OR ACRES) MAX BEDRO[]MS: L.C}T: 9 BI,.,,OCK: ! RAIqSE:: t....ist(F.,d bel.'::w,~ ar'e t. he options available te you in designing your' septic system. Choose the option tha'L best £its youm site,, DEF'TH TO F'IPE BOTTOM (F:'T.) GRAVEL DEF"TH ]"OTAL DEPTH (FT.) GRAVEL WIDTH (F"l". GRAVIEI.... LENGTH (FT.) GRAVEl... VOLUME (CU,, YDS,, ) TANK S]:ZE (GAL. S) SOIL.. RATING (SQ.F'T. /BR) 4 ,, 0 4.0 4. ,, 0 7 ,, 0 0.5 3.5 1:l.. 0 4.5 7~ 5 2. '.!.5 24.0 5 ~ 0 58 ,, 0 45.0 87 ,, 0 '~'? 40. :3 40.0 64.5 1,00C), 0 ~.~ ]., 0C)0, 0 -:-~ :[, 000.0 .~.~. 2.68 239 2,68 ~.~{' GRAVEL. I....ENGTH > '75 FT. RE(;!LI]:RES MUL. TIPL.E RUNS (NOT EXCEEDIIqG 75 F:'T. EAC'H) '~'~' TANI< MUST HAVE AT LIEAS]" TWO COMF'AIRTMENTS ]: cer't:i. ['y 't:.hat: 1. ]: am fami].ial* with t. he Pequ:i. pements fc:m on-~ite sewer's and wells as set foi-t.h by the Mun:i. cipali-ty of Anchor'age (MOA) arid the StaLe o¢ Ala~ka. 2. I will. ins'La].], the system in ac:coi-danc:e wi'Lb all MOA cc](::tes ar'~d f'e~jLt].atic)r'is~ and in cc)topi, lance wiLh the design c:pJ.'LePJa c)-[' Lh:i.s pePmit,, :];. I wi].i adher'e to) al.I. ~'ffJA and State c)f a].asl{a r'eqLtir'ements fcH'" the set back distar't~:es f'pem any existing (,~e].l, t4as't:.e~.~a'Lef' disposal system of public sewer'age system on' this o~~ any adjacent ~r near'by lc)t, 4,, I Lu]cter'stal]cl that tlnis pePmit is raj. id for' a maximum c~f 3 }]edPoeriis and any enlar'gemer'r[, w:i.].], r'equJ. Pe an addJ. tic)r'fal pepmit,, IF:' A LIF]" S'TATIOf~} IS INSTAL.LED IN AN AREA COVERED BY MOA BIJILDING CODES, 'THEtq (1) AN ELECTRICAL F'ERMIT AND IIxlSF'EC]"tON MUST BE OBTAINED; (2) AS-BUILTS WtL. L NOT BE APPROVED WITHOUT AN EL. ECTRICAL. INSPECTIOiq REPORT; AND (3) THE ELECTRICAL. WORK MUST BE DON!E BY A L. ICENSED EI...ECTRICIAN. AF'F:'L. Z CAN]~ CURT l::'I ERATT P.O. b,..,X 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TOt~,iY ~ t ,~ '"OR OEPARTMENT OF HEALTH & HUMAN SF. RVICF. S January 10, 1986 TO: Permit Applicant Subject: Permit # 850302 Lot 9 Block 1 Sampson Estates Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. 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 ~f th~ 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 documentatiod. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of'Permit DEF'ARTMENT £]~ ~EALTH AND ENVIRONMENTAL F ITECTION 825 L STREET, ANCHGRAGE, Al.,:: 99501 ~ 64-47~0 [}N-.--~'~ I 'T'E SE_"WER F'ERM ~ 'f F'ERM I T NO: [)ATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: MAX BEDROOMS: 850;502. 06 / i 4/85 RAY PELLITIER SHASTA CONS]", INC. .?.00 W 34 AVE, SUITE ~900 ~E~ ANCHORAGE, At.'.; 99505 274-0156 SUBDIVISION: SAMPSON ESTATES SECTION: 5 TOWNSHIP: 15N 43560 (SQ.FT. OR ACRES) :.....; LOT~ 9 BLOCB.~: 1 RANGE: iW L..~sted below are the options available to you in designing-youn septic' system. ' Choose the option that best fits your site. DEF'TH TI] PIPE BO'f'TOM (F'T'.) GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL. WIDTH (FI",,) GRAVEL. LENGTH (F:'l".) GRAVEl,_ VOLUME (CIJ. YDS. ) TANK SIZ. E (GALS) SOIL RATING (SQ.F'T. /BR) "I-REENC]~-~ .BED W. DR~-~/I J'~ 4.0 4.0 4.0 6. o 0.5 3.5 lO.O 4.5 7.~ 2.5 25.0 5.0 83.0 ~* 50.0 107.0 *~ 50.0 46.3 79. ~ 1,000.0 ~..~ 1,000.0 *~ 1,000.0 ~* 33 1 274 331 *"~' (-]RAVEl,.. [,.ENGTH > '75 I::T. REQUIRES MULTIF'LE RUNS (NOT EXCEEDIIIG"- * .... '," 75 I='T. EACH) ~.~:'~. 'f'ANK MUSI" [lAVE .A'I" LEAS]' TWO CONF'ARTMENTS I c:ertify that: 1.. I am familiar with the requirements for on-site sewers and wells as set. forth by the MuniciPal:ity of Anchorage (MOA) and the State o~ Alaska. 2. I will instal~ the system in accordance with all MOA codes and regulati'ons~ and .in compliance with th~ design criteria o¢ this per. mit. · 3. I will adhere to ali MOA and State of Alaska requirements for the set back · distances from any existing well', wastewater disposal s,ystem or public sewerage system on this of any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum o¢ 3 bedr~ooms and any enlargement wili require an additional permit. IF A LIFT STATION tS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (].~ AN ELECTRICAL PERMIT AND INSF'ECTION MUST BE OBTAINED; (2)"AS-BUILTS WILL NOT BE APPROVED WI]"HOUT AN ELECTRICAl_ INSPECTIO~ REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. APFLICANT~'ELLITIER SHASTA COI'4ST. INC.' ANCHORAGE, ALASKA 99502-0650 (907) 264-41'11 TONYKNOWI~S (~ ".:.. '.i '"" MA YOR ,: . b DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit ~: 840853 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 9 Block ~ Sampson Estates Subdivision 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 o Bandt, Supervisor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 DEPARTMEIqT OF HEALTH Alq~ ENV~RONIflENTAL F:'ROTECT~OIq 825 L SI"REET~ At~ICHORAGE, At< 9950 264-4720 PIERMI T NO: DATIE ISSUED~ APF'I. I CAi',IT: ' AD!)RESS :. CONTACT PHONE: I....EBAL DESCR IP-" LOT sIZE: MAX BEDRO[]MS: 8408 ',53 10/05/84 .SHASTA CONSTRUCTION 200 W 34TH ~556. ANCHOIRAGE, Al.::] 995()3 ,?~68= 8'725 SUBDIVISI'ON: SAMPSON ESTPf't'ES SECTION: 3 TOWNSHIP 40668 (SC-~ F']". OR ACRES) ,~LOM .... i LOT ~ 9 R ' ~ "- RANGIE .~ ;I. W Listed be].oN ai-e ~.h~, · ~* ' ' ,}p~].ons availab!e 'Lo y(]u in de, signing your sep'L:i.c .... [] .... 6:'Lha9 optJ. C]l't that best fits ¥' -":"~~" 'TO BOTTOM 4,, 0 4 ,, 0 ,.)E.F , F,. F'IF'E (F'f'.) 4~ 0 GRAVEl._ DEF'FH (F'T.) 6.0 0,,5 3.5 TOTAL ..... I II-, (FT.) J. 0.0 4,,5 7.5 B,~E.I_ WIDTH (FT.) ~ 5 GRAVEL ,_I:,IGTt, (FrT.) 83,, 0 *.x- 50.0 107.0 *~. GRAVEl... VOLUtdE. (CLI. YI)S,, ) 5(). 0 46.3 79.3 TAI'dK SIZE (GALS) 1,000.0 .~e~. t~00C~.0 ~'~' 1,000.0 '?~' SOIL RATING (SQ,FT,,/BR) 331 274 33:[' GRAVEl_ LENGTtq > '75 t::]". REQLI]:I:IES MUI..TIPLE IRUNS (NOT IEXCEEEDING 75 FT. EACH)' TA,.h... MUS]" H~VE AT LEAST TWO CDMI .~-,,,!IIE.,'.IF..~ I ceptify that: ' I am familiar' ~.~ith 'Lhe r'equivements l'c!r' ,'.:p,.-..site ,:se~er's and we].ls as ~iet foP'Lb by the Mur~ic::i~pal:i. ty c)f Anchor'age (MOA:, and 'Lhe StaLe of Alaska. 2, t Nil]. ins'Lall the system in acc:,:3r'danc:e with all MOA c:(2des and r, egu].ations, arid in compliance with 'Lhe design cr'itevia of this pe:.,r'mi'L. .T.';. I Nil]. adhere 'Lo all MOA and State o,~' Alasl.::a r'equil-emen'Ls'¢cu" the se'/ back distances ¢vom. any existing welt,., C/~astev¥,a'(.c4'r' disposal, sys'Lem of pub1:i.c set^;epage system on 'Lhis cu~ any adjac:ent ov near-by ].o'f..,, 4,, I understand that this per'mit is valid £o~~ a maximum of 3 bedr'ooms and any enlar'gement will pequive an addi.'Lional per'mit, IF A [...IFT STATION IS II'.ISTALI_ED IN AN ARIEA COVERED BY MOA BUI[...DIIqG CODES, THEN (1) AN E:LilE:I]TR]:CAI_ PERMIT AND INSPECT]:ON IflUST BE OBTAINEEI); (2) AS-BUILTS I, gIl.:.LNOT BE APPROVED WITHOI.JT AN ELECTRIC~L INSI:'!ECTION REPORT; AND (3) TI"'IE~: EL. ECTRICAL WORK MUST BE DONE BY A LICENSED ELECTF/ICIAN. AF:'F'LICANT: SI'"IA3'f'A [~ISTRLICT PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: LEGAL DESCRIPTION: 2 3 4 7 8 12 14 17 20- ~/Nr,..A_PCbr-~ ~--~TTownship, Range, Section: ~--~ il VtJ' t '~"~ ~ SLOPE SITE PLAN WAS GROUND WATER ~) ENCOUNTERED? iF ES, ATWHAT DEPTH? ~ Deplh to Water A~ , Monitoring? Date: Gross Net Depth to Net Reading Date Time Time Water Drop I .¢.Z~-~4. l?.,,r ,/., Z !~; 1v/~ ,'~ o 5'9" Z-..;'..I PERCOLATION RATE Z w7 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN~ FT AND FT COMMENTS ~ "}"~- Wr'b~' ~m""'~rs'2'""A~ y"'~ ~ // } PERFORMED BY: :~ ~~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIDEL, ATE. DATE: MAY 2 8 1986 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST [] SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: ~--~-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16 17 18 19 2O SLOPE SITE PLAN l 11 COMMENTS WAS GROUND WATER ~.~0 SL ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop / /~/',~,,~,-/ , ,, / ~ O *~/~ PERCOLATION RATE 3 '2 (minutes/inch) TEST RUN BETWEEN ~' FT AND ~ FT PERFORMED BY: ,~/~ ~ CERTIFIED BY: 72-008 (6/79) "'~"WA'fER WELL RECORD STATE OF ALASKA OEPAR.TMENT OF NATURAL RESOURES Division of GooIogicol & Geophysical Surveys W e 11 .#' t Gravel~ clay~ silt --Gi-~a~'~-~N-TF~Jb-u j-gi'e r ~, m o i si Gravel~ silt, sand i--Gz~V~ 1~-~ ~ni-d--d ry o- -F' 're-7 -~ o I 38 ---C;" .... '[ ..... 3md -_is-i--'?- 7o / 77 Gravel, silt, v/a'ber I72 I ¥ CASING: [] Threaded E] Welded ~,o~.. 6 ,.. ,o 181 diam.__ ..... in. fo_____ ff. Depth SIIch*p IO. ST&TiC k?,tTER LEVEL: ft. ___.Z/__. / O Above or ~ Belo~'¢ land surfuce 9ate fl. otter ~hr$. pumping ....... q.p.m. .... fi, offer ..... hfs, pumping -- g.p.m. I~.GROUTINO Wall 6rouled: ~_._] Yes [] t,~eteriol; [~ Neat Cement [j Other: 1%~./f, 16. WATER WELL CO,NI'RACTOR'S CERTIFICATIOff: ' 15. ~,R;ter Tarnporcture ...... o [i~ F ~ C Mareuson l}rilling A.A 5385 .k~=O. t~ox ~/O~C)4 ~Jaad_e Rive:c, Product;ion oJ:' 15 GN,I · Municipality of Anchorage .... Development Services Department. Building Safety Division On.Site Water & Wastewate{'pr°gran~", ' ' "' 4700 South Bragaw SL' p.o. Bo~,~96650A~.~rage, AK 99519..6650. · ~ ' 'www.d.anchomge.ak. us ; (907) 343-7904. · . CERTIFICATE OF HEALTh· AUTHORITY A_PROVAL 'FoR; 'SINGL E'FAHILY DWEI LING" -' Parcel I.D. ' 051-~2-27 1. GENERAL INFORMATION Complete legal description ESTATES SU~O~S~O~ kOT 9~ ~LO¢~ ~ . Location (slte address or dimctions) 23912 GOLIATH DRIVE * CHU(~IAK, AK 99567 Current Property owner(s) Mailing address Lending agency ' Mailing'address Real Estate Agent Mailing address DENNIS BOUWENS Day phone 23912 GOLIATH DRIVE * CHUCIAK~ AK 99567 Day phone 688-7338 [ORI HACK~BERGER wf O'~lqAUlC PROPER~£S Dayphone 3111 C STREET * ANCHORAGET AK 99503 727-4444 Unlesso~erwlsemques~e~l-lAA~llbeheldbyDSDforpick~. 2. NUMBEROFBEDROOMS: 3 3. T~PE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding ~nk [] Community On-site [] Public Sewer [] 'i'he Muntclpality of Anchorage Development Services Department (DSD) Issues Ce~ficetos cf Health Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered In the State of AJaska. Ce~ficates of HeaIth Authority Approval are required for the tcansfer of title (except between spouses) for proposes served by a single family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Ce~ficates 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 eld. (Certificates may be reissued for a period cf up to one year with valid water samples.) Ce~ficetes are valid for one year for pmper~es served by Class A or B wells or a public water system. The Municipality cf Anchorage is not responsible for errors or omlssions In the professional engineer's work. 4. S.TATEMENT OF INSI~ECTiON BY ENGiNEEi:~'~*.~ *: ':~ ** p $ ge,on,' sed on procedu s omiined /n Hea h ' · . ~ ~at ~e.~-~ ~t~ su~ a~ ~ dis~l ~ ~(am) ~, ~ ~ ad~. mr ~e. num~ &f ~s and ~'of S~ I~i~t~ h~ln: ~:1 ~ ~ ~t ~ ~ ~ ' / *:. .' lnf~ag~ ob~ln~ ~m ~e Munld~l~ of ~ge fll~ and ~ mY ~fl~'~ lns~, ~" ., . on-site ~ter su~ ah~ ~ste~t~ di~l ~em is(em) In ~ ~ ~1 ~e Mun~ ~ . and ~te ~es, o~ina~s, and ~ulaU~s In e~ at ~ time of Ins~l~., " * *-, ' · '~" Name of Fi~., ~ WATER ~ W~T~A~R C0NSULTA~S. INC.: Phone~.. 537-6179 Address . 01 DE~RR ROAD. SU~ 2B * ANCHO~CE. ~ 99504 " Engineers Commen~: ...... : ' ' ' In conducting this e~aluaUon, AWWC, I~c. attempted to prmfde a thorough, . consdon#ous engineering analysis of the system In accordance w~h ADEC and MOA ' DSD Guidoflnea & Regulations. The reposed results described the pedormance of the system under the conditions encountered at the Ume of the test, and eaparaEon di'~ancos measured to readi~, Idenfffiable features. The operational Efe of all wells and s~uptfc systems depend on the Iocal soils condition, groundwater levels that may .. cruets during the yeat, and the water usage of the faml~, being een~d by the system. These conditions are outside the conYol of the evaluator of the system. Satisfactoty teat results do not guarantee future pedotmance of the system, ~or do they guarantee ~at · them are no hidden defects or encroachmon~s. AWWC, Inc. can therefore not provide any v,,arren~y or fufure eattmate of how long the sYStem will c~nttnue to meat the operatfonal requiremen~s of the ADEC or MOA DSD. The content of this report IS to¢ the sole benefit of tho ovmer listnd abew. Any reliance upon or use of this repot by any other person or parly Is not au~hodz~l, nor will lt confer any legal right wha DSO SIGNATURE L~ Approved for .~ bedrooms. Disapproved. Conditional approval for __ Attachments: HAA Checldist SepUc System Advisory Well Flow Advisory Manltenance Agreements Supplemental Engineer's Reo~t Olher Odglnal Certificate Date: Municipality of Anchorage Development Services Department On.~ Wa~er & Wa~valm' Rogram 4700 ~xdh B~ ~'t. P.O. Box 106850 Allcllotage. AK Og519-6&,~0 WELt. DATA Well type PmV^~ Date completed Totel depth 181 HEALTH AUTHORITY APPROVAL CHECKLIST SAMPSON ESTATES SUBDMSIONi LOT 9~ BLOCK 1t Pa~elID: 051-822-27 IfA, B. ore provide PWSlI~ N/A 11//9//84 ~mltery seal (Y/N) YES Casedte 181 fL FROM WELL LOG Date of test 11/9/84 Stetlc water leval NOT GIVEN fL Well production 15 g.p.m. WATER &N~PLE RESULTS: Coliform .~_ colonies/lO0 mi. Nitrate1''2' ~) mg,/L. Date of Mm. pie: 4./19/2001 Collected b~. SF. PTIC/HOLDIN(~ TANK DATA Tan~ Type~ate~al PLAS~C Tank size 1000 gal. Number of Compmlmente 2 Depression over tank (Y/N) NO Pumper Soil rnUng ~ ft¥odm~) o.6 Foundation deanout (Y/N) YES Date of pumping NEW ABSoRFnON HELl) DATA Date In~ed well Log (Y/N) YES ~ properly pm~ {Y/N) YES Casing belght (above ground) 12'+ AT INSPECTION 3//23//2001 170 5.0+ AWWCI INC. In, Date Installed 4//20-21//2001 Cleanoute (y/N) YES High wster alarm (Y/N) Leng~ 76 TOTAL 'lt. ~ 2.5 fL ,ocmqup::,~ EfL absorption ama 760 ~' IVlonltodngtube YES Fluid deplh In abeoq~on tleld before test - In. Water added - gal. Elapsed Time: - min. Finallluld depth - In. Absorption rate Any reJuvenallon rant (past 12 mo.) (Y/N & type) - System M)e DEEP TRENCH Gravel below pipe 5 fL Depresalon over llald NO For 3 bedn3oms - in. g.p.d. New depth If ye% give date .fL g.p.m, (:~ colonies/lO0 mi. D, UFT STATION ,D~ate Imte~ed Size In gallons ~ Pump on' level et in. 'Pump off' n. I~gh water -lan~ level at In. ~ Cymes testsd Meets alarm & drcuIt requirements? E. SEPARATION DISTANCES SEPARATION 01STANCES FROM WELL ON LOT TO: Septic tenl~ 8tetlon on lot 100'+ AbsorpUon field on lot. 100'+ Public 8ewer main N/A Sewer/se~c sen4ce line 25'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundalion 5'+ Properly line 5°+ Water main N,/A Water ~eMce Une lO'+ We~ on adjacent lots, 100% SEPARATION DISTANCE FROM ABSORPTION F1ELD ON LOT TO: Property line lo'+ B~Ing foundaUon 10'+ Water sewlce line 10'+ Sue'face water 10o'+ Curtalndraln NONE KNOWN We~s on adjacent lots. 100'+ F. COMMENTS On adjacent lots 100'+ On adjacent lots 100'+ PuI~c sewer manhole/deanout Holding tank N,/A Absoq~on field 5'+ Surface water 100'+ Water main N/A Driveway, perking/vehicle storage 50'+ G. ENGINEER'S CERTIFICATION I certify that I have determined ~hrou~h field InspecUons and review of Municipal mcorrls t~at the above systems ere In cordlxznance with MOA HAlt guldellne~ in effect on this date. Englmmr~ Pdn/~ed N~me J~.F~,EY A. GARNESS HAAFee$ ~00 . O0 Oate of Paymant Receipt Number, ~/0 Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE : ,- . . ~,~ 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 Complete legal description Lot 9; Bi0ck'*l; -Sampson Estates Location (site address or directions) 23912 Goliath Drive ~;tChhgiak,::, AK Propp~6wner::i:'t'::,-Michael Dennis Day phone 688-4253 ~-).~ ':.: ........ ,*:.,.:,:.. ,;-..:> _ MaJlir~g,'a~ldr, ess *~*.?.0o Box'670532 ~hug~aA, AE 99567 cenoing agency,.' ............. Day phone ~.ailjng address '~ ; · Day phone Add~s~-... · ....~ . Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3" 3. TYPE OF WATER SUPPLY: , . NOTE: If community well sYStem, provide Written confirmation from~tate ADEC~attest: ' lng to the legahty and status of system.. ~ ~':' ~ [~,~ <:~ "~"'/ '- ' :- NOTE:' -If ~om~UnitY ~a~t~'~tei syste~, p~)de'~ritten"co'nfirmat~n from State ADEC · : '~'. ' '-. '-attesti~t~ thb'iegafity and statUb of Syste~. 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 thi inspection. S & S ENGINEERING Name of Firm !7n_?~ ;~ffl,, R;wr Loop I~oacl No. 204 Phone ~ Eagle River, Alaska 99577 Address / /? ?~ __~ , Engineer's signature ~¢~~//..~-~. _ . . Date DHHS SIGNATURE · /~ Approved fo~ -~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional 'Cbmments The Municipality of Anchorage Department of"Health'and Human Services (DHHS) issues Hea th Authority APproval Certificates based o~ly upon th~ rePreSentations given in paragraph 5 above'by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduc~ 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 NlUNICIPN.r]¥ OF ANCHOY. AG.~ ~NVII~NMENI'~ SERVICES MAR Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Health Authority Approval Checklist /..~-r =fL ~,Loc~ t ~ ~A,,4~'5-~ ParcelI.D.: 06~'1- g'~.;Z--77 Well type Log present Total depth Sanitary seal (~'N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed I I - =1 - ~ ~ Cased to /81 Casing height (above ground) Wires properly p~otected t~)'N) FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: AT INSPECTION g.p.m. Coliform /2Y Date of Sample: ~/~/q"/ a. SEPTIC/HOLDING TANK DATA Nitrate Date installed ~ ~'~1 '~;~ Tank size Foundation cleanest Date of Pumping C. ABSORPTION FIELDDATA Date installed Length ~ Width. Depression (Y/~ / m~),/L. Other bacteria ' Collected by: $ & $ ENGINEERING 17034 Eagle River Loop Road, No. 204 Eagle River, Alaska 99577 Number of Compartments ' "~ Cleanouts (~N) "/E~ /J o High water alarm (Y/rD System type. 3"~_NcH I Total depth Pumper Soil rating (g.p.d./fF or{~'~ Gravel thickness below pipe bedrooms Effective absorption area' BIZ ~' Monitoring Tube present (?~N). '/~ Depression over field (Y/{~) Date of adequacy test -~. -'Z ~ -'l'~ Results ([~/Fail) P,~S.c For Fluid depth in absorption field before test (in.); ~'~ Immediately after~ gal. water added (in.): Fluid depth ~1 (ins) Minutes later: /~ ,~,,~. Absorption rate = g.p.d. Peroxide treatment (past 12 months) ~ l~og~ ~=x,~J If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* ~ ' E. SEPARATION DISTANCES Size in gallons "Pump on" level at* ~r~p off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: I Foundation '7 Property line I o ~4- Absorption field Water main/service line /o ~- Surface water/drainage ,/oep 14- Wells on adjacent lots t SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '~.O '4- Building foundation '7-~ Water main/service line lo 14- Surface water ~o~ ~' Driveway, parking/vehicle storage area Curtain drain ¢o¢e . ~¢0¢¢ Wells on adjacent lots ~ ~ ~ .... ; ~.~ I certi~ that l have determined thru field inspections and review of Municipal recor~~ ~re in conformance with MQA HAA guidelines in e.cron this date. Signature HAA Fee $ '¢~ (J-Z~ , ~ Date of Payment ~ /'/~' 7 Receipt Number ,¢~-~%---~ ~&~-~.~'-~/~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650, Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~)~.~ \ ~ ~3 ~}~, - ~.,"-'~ NAA# 1~ ~'~c\ ~ 1. GENERAL INFORMATION Complete legal description Location (site add'ress or directions) 23912 Go~a~h Property owner Mailing address Tom' O' Brien Day phone 2916 Dome Pt. Cr., ~(¢KinneY, Texas 75070 Lending agencY Mailing address Day phone Agent Virginia Kohfield - RE/MAX OF EAGLE RIVER Day phone 694-4200 16600 Centerfield Drive, Suite 201, Ea~le River, Alaska 99577 Add ress Unless otherwise requested, HAA will be held for pickup. 3 ',4 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. NOTE: 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Holding tank Community on-site Public sewer If community wastewater system, prov!de written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev. 1/91) Front MOA #21 ')~JOM s~eeu!bue leUO!SSeloJd eql u! suo!ss!uJo Jo s,loJJe JO~ elq!suodseJ lou s! eS~Joqouv ~o /9,!l~d!o!un~ aq.L 'penss! s! @l~o!Jpaeo ~ eJo~eq ~,ep eZXl~U~ Jo suo!~oedsuj jonpuoo lou op SH NC] ~o seeXold LU~] 'slUeLUeJ!nbaJ e~,~,s pue leJepe~ u!~eo/g,s!jss ol JepJo u! suo!jnl!jsu! J~u!puel J!eql pu~ SeLUOq ,tO sJes~qoJnd ol Xse~ noo e se s!q~, seop SHHO eq.L '~>lSSIV,to m, e1S @ql u! pSJE~7,$!l~SJ Jeau!~ue leUO!SSe,~oJd ~,uepu@d@pu! u8 Xq e^oq~ g qdeJl~ed u[ UeA!6 suo!lelu@seJdeJ eq~, uodn XlUO peseq sel~o!j!~e0 leAoJddV ~,!Joqjnv qlleeH senss! (SHHC]) seo!/ueS ueLunH pub qlleeH jo iUeLU~BdeQ @5sJoqouv 1o X~!led!o!unlAI eq.L s~uetuwoo IBuoR!ppv :suop, Blndp, s 6U!MOIIO~. eq~ q:HM 'sLuooJpeq Joj IBAo.JddB IBUO!l.!puo0 'peAoJddBs!a euoqd · swooJpeq ~ JoJ peAoJdd¥ /!~ ~I:Irl.LYNglS SHHa 'g eJm, Bu6!s s,Jeeu!Su=l sseJppv wJ!_-I jo ewBN 'uol~oedsu! s!ql ¢o elBp eq~ uo ~qejje u! suo!lBInSeJ pub 'seouBu!pJo 'sepoo elB1S pub IBd!o!unlAl lie q~!M eOUB!IdLUo0 U! S! Lue~sXs IBsods!p Je~BMe~s~M ~o/puU Xlddns ~elBM e~!s-uo eq~ 'uop, oedsu! pub uo!~Bl~!~se^u! XuJ u Jori pub sel!J eSB~oqouv jo ~!lBd!a!un~ eq~ LUOJJ peu!B~qo UO!~BLUJO~U! eq~ uo peseq ~Bq~/,jpe^ ~eqMn~ I 'u!eJeq pe~Bo!pu! e~m, onJ~s jo edX~ pue s~uoo~peq jo ~equJnu eql ~oj m, BnbepB pub IBUO!~ounj 'ejBs s! Lum, sXs IBsods!p Je~BMe~sBM Jo/pu~ Xlddns ~elBM e~!s-uo eq~ 1Bql SMOqS uo!~Bo!ldde lenoCddv/qpoq~nv q~lBeH s!q~, jo uo!~Bl~!~se^u! ~ua ~,Bq~ XJHe^ I 'Moleq uMoqs e~Bp uo!~ep!lB^ eq~, jo sB pub o~e~eq pax!jiB FBeS XuJ Xq pe!j!laeo sV I:I:I:INHDN:I AG NOIJ. O~dSNI 40 .LN=IIN=I.LyJ. S Legal Description: A. WELL DATA · Well type ~---'\V/~.~ Log present ~N) Total depth Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Sanitary seal Date completed [I¢ ,c:~_ 6,¢)f~ Driller ~//~'4/~[j~C~/~ Cased to I ~:~1' Casing height ~,~L FROM WELL LOG Date of test II ~ ~ ~'~ Static water level Well flow J Pump level Wires properly protected~l) y g.p.m. AT INSPECTIO~uNiCtPALtTy OF ANCHORAGE 1 -- ~ ~ - ¢~c~RoNMENTAL SF~RVICES DIVISION SEPARATION DISTANCES FROM WELL TO: Septic/.h~_!d!r~g tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ~ ~:::~ ~ ; On adjacent lots [ ~c:>f Jr- Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~'/~[ ~. ~;:) (-~ Tank size \ ~ Compartments ~ CleanoutsCN) '~ ' Foundation cleanout (~'N) ~ Depression (Y/<I~ P,J High water alarm (Y/N) ~ Alarm tested(Y/N) '---' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onl°t \~ . Onadjacentlots ~ ~:::~:~,1 j~ Foundation "7t To'property line [LO -Jo Absorption field ~' Water main/service line I Surface water/drainage \(::~::> ~ 'lc' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date inst', Manufacturer Size in gallons "'"'~~ Manhole/Access (Y/N) Vent (Y/N) "Pump on~ "Pump off" level at High water alarm level ~ ~..~s tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water Soil rating "7~t.~ ~ ~/"/~ System type Gravel thickness "~ ' Total depth Cleanouts present4:C~N) Date of adequacy test D. ABSORPTION FIELD DATA Date installed ~"' ~1 Length '~'~P' Width ~' Total absorption area ~1 Depression over field (Y~ Results ~2~/fail) Peroxide treatment (past 12 months) (Y/N) for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~ ~ On adjacent lots I ~ t'4' Property line '~/¢ To building foundation To existing or abandoned system on lot On adjacent lots .~::>t..~ Cutbank h,[O/,~ Water main/service line Surface water I ~c>t4- Driveway, parking/vehicle storage area Curtain drain 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. Eagle River, Alaska ~577 ....... Engineer s Name ~ ~,,,.~,,,~ HAAFee$ /~ oO , Waiver Fee: $ Date of Payment Z~ ~- ¢~ ~ Date of Payment Receipt Number ~'-~ ~ -(~ / ¢¢) 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 Application Date GENERAL INFORMATION (a) Legal Description (include~division, section, township, range) Location (address or directions) (b) Applicant Name 7"'.,,,¢~ x~'"~ Telephone: Home Business ~-~'"'¢ Applicant Address ~42' oc-'..~''' ~--¢~.z..--~c.r,¢~_./..~ ('~~--~' . ~ -- (c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain); (d) Lending Institution _~-..~_?~.~.-~ ~lephone (e) Real Estate Company and Agent ~/~ ~ lephone (f) ~ the HAA to the following address: 2. TYPE OF RESIDENCE ~ Singte-Family~(' Mult~amily [] Other Number of Bedrooms ~ 3. WATER SUPPLY" individual Well~r' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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 PROVIDII~,.~ INSPECTIONS, TESTS, FILE SEARCH, DA, A AND INFORMATION 1 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. Name of Firm Address Date Telephone DHEP APPROVAL Approved for ''/'/~ Approved bedrooms by ,~/~ ''~' ~¢//'~'""-~ Date -~z _ / ¢ - ~, ~ 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 MUNICIPALIIY OF ANc/''~:~- - MUN-I~IPALITY OF ANCHORAGE (MOA) DEPT. OF HEAL~ ~ E~IRONMENT~ PROT~H AUTHORITY APPROVAL (HAA) CH C US - JUL 1 1 198[ Well Classification Well Log Presentd~,~ Total Depth //~/ ~ Cased to Static Water Level _/~ ~ '" Casing Height Above Ground Electrical Wiring in Conduit Separation Distances from Well: To Septic/Holding Tank on Lot I~ A, B, C, D.E.C. Approved (Y/N) Date Completed ////-' '~'-'~/' Yield /'~/ ! Depth of Grouting Pump Set At /,7~ '~ ~' Sanitary Seal on Casing4~r Depression Around Wellhead To Nearest Edge of Absorption Field o'n Lot // To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed ~"'~ ~ _Z:5(~ Size ~.O~O No. of Compartments ~ "* .:. Standpipes ~ Air-tight Caps~/~ Foundation Cleanout~.N')' Depression over Tank ~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ' ; for "---- Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /~::)/-) I~- To Building Foundation r/ ! To Property Line /42 ~ ~- To Disposal Field '~-'" To Water~M. aiWService Line --~ ' ~ To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (-Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /42 Z~ To Building Foundation Lot ""'/'~ To WaterM~ln/Service Line ~o r .~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~ Depth of Field Gravel Bed Thickness Standpipes Present 4~4~) Date of Last Adequacy Test r,7 To Property Line To Existing or Abandoned System on ; On Adjoining Lots .'~'~ / To Cutbank (if pre,sent) 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) "Pu/Cnp Off" Level at / x' // Vent(Y/N) //",-/ /. Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that.J have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed :)lc I~ 19o,~ / , -- Company ~GL- - MOA No. Date of Payment Amount: $ , · 1~ '~' Page 2 of 2 72-026 (11/84)