The URL can be used to link to this page

Home My WebLink AboutSEACLIFF BLK 3 LT 3eacliff Block 3 Lot 3 #011-221-45 ' Municipality of Anchorage Page of 2 - DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report %S— O ZG Z PID Number:--� Permit Number: Name: JAc/� /'o2TE2 Wastewater System: I? New ❑ Upgrade Address:ABSORPTION /34/70 f/E2N DIR 4nNr-l4 ?11574 FIELD Phone: 3�5 2 ys No. of Bedrooms: y - �6eep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: /�'2. Total Depth from original grade: 9 5 GPD . Ft. Lot: Block: Subdivision: Depth to pipe bottoah from original grade: Gravel depth beneath pipe S.S. Ft. Ft. Township: Range: Section: / S, Fill added above original grade: Gravel length: S/ w Ft. Ft. WELL:❑New ❑Upgrade Gravel width: v 3 Number of lines: / Oistsnce between lines: • Ft. Ft. Classification (Private, A.B.C): Total Depth:Cased To: Total absorption area: Pipes material: /'v/3 tr / C' Ft - Ft. .5-/0 SC. Ft. Driller. Date Drilled: '- Static Water Level: Installer. L A YO ✓a+ C o ✓1 5 "C Date installed: IAJ O U/ o is' — ^- Ft. o Yield: Pump Set at Casing Height Above Ground: TANK GPM -' FL I Ft. SEPARATION DISTANCES 0-Teptlo ❑ Holding D S.T.E.P. TO Septic Absorption tin Holding PubliaPrivate Manufacturer. 4 NG /4 Capacity in gallons: 12-50 From Tank Field Station Tank Sewer Lines Material: - Number of Compartments: Well +?_00 +ZOO _ - - S%EEL Z Surface - - - LIFT STATION Water +/oo .+too Lot r 1 Size in gallons: Manufacturer. _ Line "30 , Z5 — — "Pump on" level at: "Pump off" level at: High water alarm at: Foundation-- - - - — Curtain - - - _ Pump Make Electrical Inspections performed by. Drain BENCH MARK Remarks: Location and Description: /fon?E Yt7 /3E 8v/r:% /N Nw Ca2 63 133 TE19CG Ff— Assumed Elevation: /ODS p Ft ENGIt#�E�;S��EI�L p, Dates: 1st Inspections performed by: - 2nd Department of Heal and U7 JServic approval res Fof r w/L Reviewed by: fns Date: 6614, r, V., ; �� and approved 72-013 IRev. 9191) MOP. 25 �J Permit No. % S - o 2 2 Page Z' of 7 - Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report egal Description: 6o7-3 &_3 SEAac ir- PID No.: 6 A 39S sZE�3rf2, Tye 2-013 A(1193) /4A) l/lEu.) 51 t w odd 96, / Z 56 �rl Sepfi tt'S /lc:f3r42 EG = oa�o w w ; r- 7cg M�v3EoR i `a %J o J............ _j x......_�........ ��............. I- I..............o s �/ENK %,-�T�rZS I ZY /�GGeSS a............................ _�....._J ............ .s........ -..... .._..... ._........... .................................... i................................. . 39S sZE�3rf2, Tye 2-013 A(1193) /4A) l/lEu.) 51 t w odd 96, / Z 56 �rl Sepfi �nry B. Wilson :01 Buddy Ferner Dr 1chorage, AIC, 99516 %7-346-2000 Constructing Engineers, Inc. Engineers, surveyors SOILS LOG — PERCOLATION TEST PERFORMED FOR: " PtGk12D `z - C 2 GATE PERFORMED:i LEGAL DESCRIPTION: L 3 B S6ACL( FF Township, Range, Section: 112..E DEPTH SLOPE SITE PLAN (FEET) O " SILTS I i I I I 3 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15• 16- 17- 18- 19- 20 - t^� 1 -LJ LAJ 5—% 7'(+tr.1 _5AA-)9; G-)t,J LAYElZS WAS GROUND WATER ENCOUNTERED? !1 IF YES, AT WHAT DEPTH? _ Depth to Water Atter Moid"ing? !late: L Reading Date Gross Time Net Time Depth tO Water Not Drop i0 `K Z k4. u n I I PERCOLATION RATE 2 (minutesnnchh) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND ( FT COMMENTS /C1iIov%aJ.e✓G 4--05 -4-o vtvt sojt o-4 'Mtu/d-ty4-ti a.pe, Vct,--t a.5 Q,+ 84- 5191 ti pjwc- , PERFORMED BY: t oos j , ►u C) I 14A N CV1('5 OIJ CERTIFY THAT THIS TEST WAS PERFORMED IN '7—ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE 9G PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES j nYY\ P.O. BOX 196650, 825 "L" STREET, ROOM 502 q ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW950262 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:PORTER JACK H OWNER ADDRESS:9332 ENDICOTT ST ANCHORAGE, ALASKA 99515 PARCEL ID:01122145 LEGAL DESCRIPTION: SEACLIFF BLK 3 LT 3 LOT SIZE: 13050 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 9/07/95 EXPIRATION DATE: 9/07/96 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. 02210awAmpl RECEIVED B ISSUED BY: DATE • 9"I% �_'1. DATE • / ' - laf I I 15A I I 1 it PROPOSED I 2 DEEP TRENCH 14A i (UNDEVELOPED TEST PIT REPLACEMENT LOT 3 N 13A 4 M HOUSE az 12A I I I I 4 I I I IIA I I I 5 NOTE: AREA SERVED ;�Y PU6LIC WATER, NO WELL WITHIN 200' OF LOT 3, 6LOCK 3. ALL SEPTICS WITHIN 100' OF PROPOSED SEPTIC ARE SHOWN. LEGEND O SEWER LOT AREA = 13,050 SF EASEMENT LESS SE72)ACKS, DRIVEWAY AND HOUSE FOOTPRINT = 7,545 SF AVAILAaLE FOR SEPTIC SYSTEM SEPTIC SITE PLAN �4, Rl LEGAL: LOT 3, BLOCK 3, SE.ACLIFF SUED.;? s IN NW 1/4, 515, T12N, R4W, SM ALASKA GRID 2424 Do k OWNER: JACK PORTER PHONE: 345-7245 DB�a p:Y8.s.9}8�9 90�OAC6G aOS�/q� Al NA"v.9 Py eCi. iAq7 S£• a�9�"y yF� DATE: 5/19/95 SCALE: 1' = 100' : nG 3a'm+ Ffi i <, �x$j 17 CONSTRUCTING ENGINEERS 346-2000��+�°'°' 9601 6UDDY WERNER DRIVE ANCHORAGE, ALASKA 99516 LAfT:IMww�D nTKD nwn ABSORPTION SYSTEM DESInN DETAILS DEEP TRENCH SYSTEM MOUND SURFACE HOUSE CLEANOUT V TO 4' FROM FOUNDATION WALL SEPTIC TANK 1250 GALLON CLEANOUTS SEPTIC TANK OPPOSING CLEANOUTS�� SOLID PIPE CLEANOUTS 25' 25' MONITOR TUBE O I PERFORATED PIPE / INSTALLED LEVEL PLAN VIEW = SCHEMATIC NTS BEDROCK OR IMPERMEABLE LAYER SECTION (END VIEW) NTS SCOPE: NEW ABSORPTION SYSTEM FOR A FOUR 14) 6EDROOM HOME. GROUND LEVEL NATIVE SOIL BACKFILL A6SORPTION AREA CALCULATIONS: 4' SILT BARRIER N =600 GPD CAPACITY SOILS RATING AT PROPOSED SYSTEM = 1.2 GPD/SF MINIMUM SIZING = 600/1.2 = 500 SF TRENCH WALL AREA 0 5'2' GRAVEL OVER PIPE PROBABLE IMPACTS TO AD7ACENT LOTS; AS SHOWN ON THE SITE PLAN, DEVELOPMENT OF THE WELL AND SEPTIC SYSTEMS FOR THIS LOT WILL HAVE NO SIGNIFICANT ADVERSE EFFECTS ON THE ADJACENT PROPERTIES: A. WELLS r a 6, WASTEWATER SYSTEMS 4' PERFORATED PIPE W AND (PERFS DOWN) 0 5. fpy�AN DEGIC'DETAIL w ( GRAVEL »> ` c., ruati c, % ref E r w � z r � z_ v SEASONALLY HIGH _ GROUNDWATER TABLE BEDROCK OR IMPERMEABLE LAYER SECTION (END VIEW) NTS SCOPE: NEW ABSORPTION SYSTEM FOR A FOUR 14) 6EDROOM HOME. THE SYSTEM, WILL 6E A DEEP TRENCH WITH 5' OF GRAVEL 6F -LOW THE PIPE. A6SORPTION AREA CALCULATIONS: MINIMUM REQUIRED: 4 BEDROOMS X 150 GPD/6EDROOM =600 GPD CAPACITY SOILS RATING AT PROPOSED SYSTEM = 1.2 GPD/SF MINIMUM SIZING = 600/1.2 = 500 SF TRENCH WALL AREA LENGTH = 500 SF/10' = 50' PROBABLE IMPACTS TO AD7ACENT LOTS; AS SHOWN ON THE SITE PLAN, DEVELOPMENT OF THE WELL AND SEPTIC SYSTEMS FOR THIS LOT WILL HAVE NO SIGNIFICANT ADVERSE EFFECTS ON THE ADJACENT PROPERTIES: A. WELLS 6, WASTEWATER SYSTEMS 0. RESERVED SPACE / SURFACE AND SU6SURFACE AND D. DRAINAGE fpy�AN DEGIC'DETAIL f LEGAL: LOT 3, 6LOCK 3, SEACL IFF SURD. IN NW 1/4, 515, T12N, R4G4 W, SM ALASKA RID 242 »> ` c., ruati c, % ref OWNER: JACK PORTER PHONE: 345-7245 01 DATE; 6/15/95 SCALE: NO SCALE i 4 F afyy3 ♦ .i{ -ti G% V iP _ P'.T CONSTRUCTING ENGINEERS 346-2000r,ta€ R. 9601 BUDDY WERNER DRIVE 2 OF 3'� ANCHORAGE, ALASKA 55516 nn♦TTmww♦ono T'o nwn ♦, Dry H. Wilson v � 1GIH "b43* 01 Buddy Warner or W, Ohoray.� AK, 99516 7-146-2000 constructing is •°• Engineers, Inc. a s� ou..aaoeoeoxeeteoseagoet w Engineers, Surveyors $a. r33a.E o �� SOILS LOG -- PERCOLATION TEST 6E '�®e JUne $g' PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: f3-3 $C AC L (FF Township, Range, Section: 1 �, N 2 9 17 - c` S DEPTH SLOPE N L1.1 ' , S I S (FEET) j 1, O 2 r SITE PLAN 1 2 3 4 5 6 7 8- 9- 10- 11 12 13 14 15 16 17 18 19 20 COMMENTS S (LT S — l0 ,5r4u p� C7 to 4 ✓, G C�w�Sw /D- /s5 5Ar ki D sK) WAS GROUND WATER ENCOUNTERED? N Q PERCOLATION RATE Pfl - les inch) PERC HOLE DIAMETER S TEST RUN BETWEENAND 3 Y" FT PERFORMED BY: e0JV0% A10 HA L(jlL j tj/ll -- h h n Municipality of Anchorage Development Services Department Building Safety Division \_ On -Site Water and Wastewater Program 4700 Bragaw, Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-221-45 1. GENERAL INFORMATION Complete legal description Seacliff Block 3 Lot 3 COSA#_ of/ 1)4b'h Expiration Date: O 7 Location (site address) 9332 Endicott Street, Anchorage, 99515 Current Property owner(s) Wayne Goetz & Cheryl Graves Day phone Mailing address same Lending agency Day phone Mailing address Real Estate Agent Mary Tutterow/ Dynamic Properties Day phone 261-7682 Mailing Address 3111 C Street, Suite 100, Anchorage, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site 0 Individual Water Storage ❑ Individual Holding Tank ❑ Community Class A Well El Community Or -site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems AooroyaL(GOSA)-based_nnty-uponlhe-representaGons-g'even-ln-paragraph4-byan-Independent-professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and maybe reissued with new water sample results. (Certificates may be reissued for a period of up to one year wftti 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. ET 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 Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage 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 Finn Watkins Engineering, Inc. Address P.O. Box 110443 Anchorage, AK 99511-0443 Phone (907)349-1851 Engineer's Printed Name Cindy W. Ellis Date August 16, 2006 5. DSD SIGNATURE Approved for 4 bedrooms. Disapproved. Conditional approval for bedrooms, with the following Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By Original Certificate Date: -s ' 9 ' 0 �o (Rev. „NS) Municipality of Anchorage • Development Services Department Building safety Division On -We Water & Wastewater Program 4700 Bragew Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.oryonslte (907)343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Ssac if Block 3 Lot 3 Parcel ID: 011-221-45 A. WELL DATA Well type A If A, B, or C provide PINSID i _ Wel Log (YIN) Date completed _ Sanitary seal (YIN) _ Wires property protected (Y/4) Total depth 11. Cased to R. Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test WA WA Static water level n. i ft. Well produclon 9.p -m. i 9.p.m. WATER SAMPLE RESULTS: Conform WA colonlash00 mL Nitrate mg1L Other bacteria coloniet/100 mL Arsenic: _ mgfl Date of temple: _ Collected by: B. SEPTICIHOLDING TANK DATA Tank TypslMaterlal Steel Septic Tank Date instated November 10, 1995 Tank size 1250 gal. Number of Compartmernts Cleanouts (YIN) Yea Foundation desnout (YIN) Yes Depression over tank (YIN) No High water alarm (YIN) WA Date of pumping July 17, 2006 C. ABSORPTION FIELD DATA Date Installed 11/10/95 Sol rating Pumper Northland Pumping (g.p.dJe or fftdrm)1.2 System type Deep Trench Length 51 ft. Width 3 R. Gravel below pipe 5 1 ft. Total depth E._6__& Eff. absorption area 510 ftp Monitodng brbe Yes Depression war Held No Date of adequacy test July 17, 2006 Results (Pass/Fan) Pass For 4 bedrooms Fluid depth in absorption field before test 0 in. Water addednl .3 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 ti. Absorption rate >• 800 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 1L type) No 11 yet, give date D. LIFT STATION Date Installed N/A Size in gallons 'Pump on' level at _ in. 'Pump ofr level at _ In. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAiR station on lot Claes A Well Absorption told on lot Public sewer main Sewer /septic service line Manhole/Access (YIN) High water alar level Meets alarm b droit requirements? On adjacent krta On adjacent lets Public sewer manhole/deanout Holding tank Animal containment areas Manureianimal excrete storage areas SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 19 Property One30_ Absorption Held V Water main 100'+ Water service One W+ Surface water IW+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property One 20+ Building foundation 20+ Water main 1110'+ Water Service One W+ Surface water I W+ Driveway, pwMngNeWe storage 70+ Curtain drain WA Welts on adjacent lots 200'+ F. COMMENTS: O. ENGINEER'S CERTIFICATION I codify that 1 have determined through field inspecdons and review of Munidpal records that the above systems aro in conformance with MOA COSA guidelines in effed on this date. Engineer's Pdnted Name Cindy W. Ellis Date Auaust 25.2005 COSA Fee S Waiver Fee S Date of Payment Receipt Number (Rev. 11105) Date of Payment Receipt Number 491 �V.` Ejua Von I C04 TZ2 2 c im lz tj I/V 0' UNDER NO CONAIUSTNIC13 SHOULD AN A9 -SUIT K U110 FOR cmm*=w w F4R ESUMUSHWG BOUNDARY OR FEWM:UNES. THE SURVEYOR TAXES RESPONS13LITY FOR THE INFM TRANSACUS MR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OWA SCAUMM mrlureT SURVEY TYPE A♦�IIAT DRAD06GE ASPhALT �T... W�... "m FOUND !RBUUR WOO FENCE EiM CONCRETE ® "ASSUMED aV- KETAL FENCE wow CEO( .. PLOT PLANS & LOT SURVEYS ir is THE RcspoNsimuTy OF THE euuDm OR ETMNM pfam To ONLY THOSE 0"OVEWENTS ABOVE GROUND AND VISIBLE WALL BE CONSTRU"ON. TO VERIFY PROPOSED BUILDING GRADE RELATTVE SHOWL MClC$. VAXL.S. SEPTIC CIZANOUTS. SIDEWALKS DMVEWAYS. TO FINISHED GRADE AND LMUTY COKWM)ONS AND TO 097111111" MMATE LOCATION. ONLY. SNOW THE ICOSTENCE OF ANY EASENEMM COVENANTS OR RESTRWfUMFROU BEING SUN AND LOCATED. WHICH 00 NOT APPEAR ON THE RECORDSUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. SURVEY CERTIFICATION Prepared by E. Johns MAT PLAN Robert Jr. k!"A'S's'06c. 'd %N Profes slonal Lcm Surveyo' 542 C'12 AW - ANCHORAGE, ALASKA *0501 V'. = 301 ll.t w SS.' H.e Plat FU Ma Uro by O.Ad by: %ft'll l REJ au� may. ia Grid; lw.a2,.6 2_4?4 ANA- STRUCTUOIC AS 4121—S -MAT L L.0 P.'evU= --m LOT 3, BLOCK .L SEAC�rc.,:.-Lv..L �vDvxoION."', % I Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. D//-ZZI-q S 1. GENERAL INFORMATION Complete legal description L Location (site address or directions) HAA #_(q„ Expiration Date: > SG&CLIFG sig ittt� Ryw ENDICo„ %j 5 rt,4 Current Property owner(s) J A c-(, 1+ PO 2 i k IZ Day phone 2 qS I / 1 `/ / Mailing address 9332• 67rU0fC.0 71 5 i 11-N C- If A- V, -295/S'" Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: {..00 Z 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site 10. Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System Public Sewer i ❑ The Municipality of Anchorage Deve!opment 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 seat affixed hereto and as of the validation date shown below. I. verify that my Investigation, . based onprocedures 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: l 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 CofJ57Ruet /1JL)�1JGireUEE2S Phone `2DoO Address 9(oof 3Ugp� et7CrL (uc?!2 2 -, Engineer's•Printed Name f E (f it9lt-501ij Aate 4,it, I lk MC2-Fr,/�f� G '%*7.4 410 'SV �_� -� ..... •iwwl.ew !10.1772 E r P r�w •l •i11M �,' 1t�i7 fi ` � 5. DSD SIGNATURE d� '�..�.,...•• �� _fG Approved for ._ % bedrooms. gaL�ONAL+ Disapproved. Conditional approval for bedrooms, with the following stipulations: ttttt(t(Ifrrl///��i Slt . �'SKOEAdiri�i ON-SITE � YVn WASTEWATER Additional Comments JO`•�' �i�JJI�� q • �� 111: Jllll)� Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: (Rev. 12'00( Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw Sl. P.O. Box 196650 Anchorage, AK 89519.6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L3 ii 3 S EA C L I TrF Parcel ID: A. WELL DATA Well type _ Date completed _ Total depth If A, B, or C provide PWSID # Z t9 ygSWell Log (Y/N) I Sanitary seal (Y/N) _ Wires properly protected (YIN) i Cased to __ft. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform colonies/100 mi. Date of sample: B. SEPTICIHOLDING TANK DATA ft. 9.p.m. Nitrate mg.A. Collected by: Tank Type/Material 5 e P t 1 544 Tank size 17- S70 gal. Number of Compartments 7 - Foundation Foundation cleanout (YIN) Y Depression over tank (Y/N) Casing height (above grow AT INSPECTION ft. g.p.n Other bacteria Date installed 11-7-5 Cleanouts (Y/N) Y High water alarm (Y/N) Dateo(pumping 1dj30,00 Pumper 2SAAC-5 'i %IMpWL) SeR�)GE sNC. I C. ABSORPTION FIELD DATA Date installed 11-15* Soil rating (g.p.d./ft= orf12AxIm f'Z System type 7EEP I IZEN LN i Length -S ft. Width ft. Gravel below pipe J/ — ft. 5 I Total depthy— ft. Eff. absorption area,110 It= Monitoring tube Depression ov�e1r field IJ Date of adequacy test Z ( Results (Pass/Fail) For 7 bedrooms I Fluid depth in absorption field before test 0 In. Water addedA00gal. New depth Z in. �I p 0 �{ if-, Elapsed Time: 9 min. Final fluid depth _ in. Absorption rate >_ !i DO g.p.d. I Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) A� If yes, give date Tioia +o a-kd w ;~ir -K ( 0 e1n q +4* -,r LV '+'_ V- D. LIFT STATION -A) 00;E Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access(Y/N) "Pump air level at _ in. Cycles tested High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: AJ o W trC t- e AJ f-O�i Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: r r r Building foundation ! o !;7- erty line 3 V Absorption field f S M Water main .01/00 Water service line f b O Surface water i X00 f r r Wells on adjacent lotsfir~ ADO • G e r S 'Do � j o r /4 A r/&r ry E LG$ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ' 1 • Property line 1 S Building foundation 4-7- S Water main + / D f7 Water Service line t 7 S Surface water + 10 t? Driveway, parking/vehicle storage i Curtain drain /' 1 dO r Wells on adjacent lots -h,Z o O r 00AX.; F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspedkns and t 49ilt P% review of Municipal records that the above systems are in ' " conformance with MOA HAA guidednes in effect on this date.*1J. Engineer's Printed Name N' %i /1iI L54�✓ `+ �./ Date 5/ Z g, HAA Fee $ 3 ID Date of Payment Receipt Number 3� (Rev. 12100) Waiver Fee $ Date of Payment Receipt Number In. Parcel I.D. # MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES_ M�1 Division of Environmental Services - On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 22/- L%5� HAA# VMSL. LLLL-i 1. GENERAL INFORMATION Complete legal description G / / 2 /✓ Location (site address or directions) % 3 2- 7,-7- 5 C --S i 0/f-1 0/--) � Property owner G / 0 iz 7 L �� Day phone Z 3 - 3 Mailing address 1 '3 3 2 L AlD/G O% ( S % 14 NC f{ % 957S 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. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev.1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of FirmCONS j ,, L G� /� S Phone 3 LIG — Z D O c> Addressle Engineers signature , ,7 r _ Date- 6. ate 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for Additional Comments By: bedrooms. bedrooms, with the following stipulations: DateZZ — 12 — 9L _ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Rack MOA #21 MUNICIPALITY OF ANCHORAGE [NVIRONAIENTAL SERVICES DIVISION Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESN®V Q 1996 Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 34W E I V E D Health Authority Approval Checklist Legal Description: I— 3 5 3 S L 4G L I F Parcel I.D.: o 5- A. A. WELL DATA ,J Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Total depth Cased to Casing height (above ground) Sanitary seal (YIN) Wires properly protected (YIN) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. 9 -P.M. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTICS TANK DATA Date installed I I — q J� Tank size I Z —5 D Number of Compartments Z Cleanouts (Y/N) 1 Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N) Date of Pumping N L: 14J Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2 Z System type [�jstj _ Fl 9 S Length 5 Width � Gravel thickness below pipe 5 Total depth . / Effective absorption area .5 D 5r- Monitoring Tube present(Y/M ! Depression over field (Y" Date of adequacy test 104 " N 61,C) Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test (in.); — Immediately after — gal. water added (in.): — Fluid depth — (ins.) Minutes later: Absorption rate = Peroxide treatment (past 12 months) (Y/N) N If yes, give date D. LIFT STATION AJO Date installed Manhole/Access (YM) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off' level at* Gv ATC2 SEPARATION DISTANCES FROM WELL ON LOT TO: 1—veJ6/C wc--& Septic/holding tank on lot AJ14 ; On adjacent lots A-�111 Absorption field on lot 1-1114 ; On adjacent lots IV14 Public sewer main NIA Public sewer manhole/cleanout A --IM Sewer /septic service line A114 Lift station N114 SEPARATION DISTANCES FROM SEPTIC/I4@f9Q0 TANK ON LOT TO: Building foundation * / 0 Property line -�L -3 n � Absorption field s Water main/service line flo O Surface water/drainage 'Ye/00 Wells on adjacent lots �� a SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Z 5' , Water main/service line S ' Surface water -4 /00, i Curtain drain /Od Driveway, parking/vehicle storage area -,4 7 5 - Wells on adjacent lots -fi 40 D _ Property line 4 / S- F. F. ENGINEER'S CERTIFICATION 1 certifv that 1 have determined thru field inspections and review of Municipal rec0Z in conformance with MOA [L4A guidelines in effect on this date. y �C-) Signature �---�� Engineer's Name GOADS% L:�%G lZs, Fa AJ Date 64,-11 6,:5i a HAA Fee $ 3 of) e zm Waiver Fee $ Date of Payment �� /C -r Date of Payment Receipt Number � �� Receipt Number Rev. 8/95 OSS: ltaa.wk.doc leering Se- I Hera