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HomeMy WebLinkAboutSEIDLER #2 BLK 5 LT 3Seidler #2 Block 5 Lot 3 #050-081-61 Municipality of Anchorage a° Development Services Department Building Safety Division On-Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Pagel of 1 www.cLanchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: PID Number: 050.081.61 Noma: Wastewater System: ❑ New ® Upgrade Address: 12117 Luaene Drive,Eagle River 77 ABSORPTION FIELD Phone: Number of Bedrooms: 14 ® Deep Trench D Shallow Trench 0 Bed D Mound 0 other: LEGAL DESCRIPTION Soil Rafing: Total Depth from original grade: GPD/FP Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: 5 3 Seidler No. 2 R. FL Township: Range: Section: Fill added above original grade: Gravel Length: Ft, Ff. Well: [:1 New El Upgrade Gravel width: Number of lines: Distance betweenlines: Ft. Ft. Clasalgcadon (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: Exist' Private R. I Rf. W 3034 PVC Driller: Date Dulled: Static Water Level: Installer: Date Installed Ft. JR's Pump ng 9/1/2009 Yield: Pump Set at: Casing Height Above Ground: GPM Ft. Ft. TANK SEPARATION DISTANCES ❑ septic ❑ Holding ❑ S.T.E.P. ❑ Other: To Septic Absorption Lift Holding ublic/Private Manufacturer: capadty: From Tank Field Station Tank Sewer Line Exist'g 1000 Gal. We" Material: Fiberglass Number of Compartments: 2 Surface Water LIFT STATION Size: Manufacturer: Lot Line Gal. "Pump on" level at: "Pump ofr level at: High water alarm M:Foundation in. in. in. Curtain Drain Pump Make & Model Electrical Inspections performed by: Remarks: Replaced perforated pipe in drainfield with new pipe. Old pipe was BENCH MARK Cast Iron and corroded closed. installed new 3034 pvc perforated Location and Description: pipe. Connected to exist'g Double Clean-out at the outlet of tank & Assumed Elevation: 100.0 Ft. Monitor Tube. No change in lay-out. Engineer's Stamp tam Inspections performed by: PANNONE ENG. SVC, LLC Dates: 1' 9/1/2009 2nd 9/1/2009 OF 44"1StiI`♦ Development Services Department Approval ���P�E : �,.•' ;�♦♦ •°: ♦♦ Conditional Approval Date: if49 THr 0 j♦ Steven R. Pcnnone� •� ♦ CE 8149 i ♦♦1�•��� Reviewed and approved by: Date: ��4t` a/ - SS`s` A* 1 GREOR ANCHORAGE AREA BOROGH X. Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM t� NAME ��'«� �OR1/3r9��J' MAILING ADDRESS Sle 2F�-�CGASfe A.' .A PHONE LOCATION., elt �, /✓ ' LEGAL DESCRIPTION J_-Q,L0ek S/� SEPTIC TANK: DISTANCE j NUMBER OF FROM WELL MANUFACTURER �� MATERIAL /`���G COMPARTMENTS— INSIDE OMPARTMENTS/ INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY -4-6-110 GALLONS. TILE DRAIN FIELD: *�,�, �O /+ / ` r TOTAL LENGTH DISTANCE FROM WELL�FOUNDATION Z ! NEAREST LOT LINE +SOF LINES 147'7-5 / NUMBER OF LINES DISTANCE BETWEEN.LINES TRENCH WIDTH L IN. TOTAL EFFECTIVE i ABSORPTION AREA - SQ. FT. LENGTH OF EACH LINE FILTERDEPTH OF DEPTH: TOP OF TILE TO FINISH GRADE �� MATERIAL BENEATH TILE IN. ABOVE TILE W' IN. WELL: hle TYPE /Z. lio CONSTRUCTION S✓>��tJ r�fDEPTH ..�0 DISTANCE FROM: BUILDING��`` NEAREST s NEAREST SEPTIC / SEEPAGE i FOUNDATION l�0. , LOT LINE Z Z SEWER LINE , TANK OOO, SYSTEM - 260 , CESSPOOL, OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: CAS % .-QO UJ I td jleef� P�- LOT SLOPE: Form EQ -032 poQft{' DIAGRAM OF SYSTEM 37\92 APPROVED �rT��w jp Yele S G.A.A.B Tv, _ 9 2,(D CL.rn GRE* ANCHORAGE AREA Bo*GH ICS-Ir{{{lO5 ,geII' IjI�I''I7�gT; DEPARTMENT OF ENVIRONMENTAL QUALITY FERMI n3330 "C" REET ANCHORAGE, ALASKA 99503 Iulf7/�/ F 1 A JY//I(//eLj/J TELEPHONE 274-4567 SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT NAME OF APPLICANT INSTALLATION LOCATION f-1 MAILING ADDRESS 3 3�, It7�� -1IE LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK v E]E.PA�GE PIT DRAIN'rrr6D OTHER , TYPE AND SIZE OF FACILITY TO BE SERVED /\y. p " '� 5;b' 3' FINANCED THROUGH /0 TO BE INSTALLE BY SOIL TEST RESULTS OTE: THIS PERMIT P NOT VALID WITHO T �QIL TEST COMPLETION DATE ANTICIPATED /}�^ FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS r FOUNDATION TO SEPTIC TANK 61 FOUNDATION TO SEEPAGE PIT DRAIN Frl!: SEPTIC TANK TO SEEPAGE PIT WALL S-- I rpm � �T . SEPTIC TANK. SEEPAGE PIT DRAT Par,n TO NEAREST LOT LINE. WELL TO SEPTIC TANK A01 ' SEEPAGE PIT /©O DRAIN FIELD ,OD ALSO CONSIDER AREA WELLS. _ WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD r ,,/rr��I SEPTIC TANK,/��, SEEPAGE PIT /p0 DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ONSEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. kr�� GRAYEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. G.A. .B. OR ICE6 ED OEBIGNER_ I CERTIFY THAT 1 AM FAMILIAR WITH THE REEQ',U IIR'EMEENN71TSAOOF GREATER ANCHORAGI DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE `L" [ q APPLICANT'S SIGNATURE FORM O.EQ-076 \REA SIZE TYPE , • 1 O Et E GEOTECHNICAL & DEVELOPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 - 694-2774 or 688-2280 Russell Oyster - Earl EHrs 694-2774 2280 Soils & Foundations - - - Land Development SOIL LOG Performed for: Name: �7<' Tel. No. � ` �? r� Nailing Address: R � " 55�, ,�fe�rc Legal Description: _ 1.._.0-< 3 �tct°5�77 Depth (feet) Soil Chiracteristics 2 SP �` ceca3 z,p 3 V41LY L�Sai ZG]t� Ca-4A�J:f� 1�>`v , 4 5 6 7? Gc7,a,/+..te 4-P1,1=1 a' V �j Caa 1C�a g 10 12 I Gn-c"N- S zy Ground Water Encountered: Yes No v"If yess what depth Proposed Installation: Seepage Pit Drain Field comments: _ � cr svcL Qv�evzza�t t,c:sr,<2 Performed by: Date: \R � v -r. "3)JS 7 Drilting log Dy . A & L DRILLING COMPANY BOX 47, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2586 OWNER OF LAND Sf��/ E .L 0 M APA DEPTH OF WELL y; T L. r , From Ft. to Ft. From Ft. to Ft. QO 6 J ®2. O /e+f 4/ From - Ft. to Ft. ADDRESS &iff 1FL 2 I� O ei< From Ft. to Ft. STATIC LEVEL OF WATER FT. LEGAL DESCRIPTION� LI�c�Lp� DESCRIPTION" r!1cL �9.A:SZ.DRAW-D,OWNFT. Ft. -26 DATE. - Started 9 3 �- % V Ended J n /6�— �w GALS. PER HR . Sd_ PERMIT NUMBER. Ft.— KIND OF CASING d Ft.— From KIND OF FORMATION: Ft. to From Ft. to�Ft: y; T L. r , From Ft. to Ft. From Ft. to Ft. QO 6 J ®2. O /e+f 4/ From - Ft. to Ft. From ZeFt. to!7N Ft. &iff 1FL 2 I� O ei< From Ft. to Ft. From/ Ft. to !& Ft. 40f- O e From Ft. to Ft, (4� Fmm ,O /V Ft tn074 1. F# p jie r /'-r >u-j4Q -f6� 8`/�. F«..... c. From�Ft. to -2-C-940 Ft. 4 From c'0 Ft. to•Z�_Ft:,,A From-2�Ft. toC ! LFL From—Ft toFt From Ft. to—Ft.— From—Ft. oFt._ From Ft. From Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to - Ft. From Ft. to Ft._ From Ft. to Ft. From Ft. to Ft From From—Ft. Ft. toy Ft:_ From Ft. to Ft. From Ft. to Ft._ From —'Ft. to—Ft.— o Ft._FromFt. From—Ft. to Ft. From Ft. to Ft.— From Ft. to Ft.— From o Ft. to—Ft.— Ft.— From Ft. to— o—FromFt. From—Ft. to . From Ft. to_ From - Ft. to— MLISCL.INFORMATION: f n e 4d DRILLER'S NAME e- c �� f / i/ Municipality of Anchorage O • �� Development Services Department o=x a � Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St, P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorace.ak. us (907)343-7904 CERTIFICATE OF HEALTH Ai1THORi i Y APPROVAL FOR A SINGLE t-AMILY MELLING Parcel I.D. 050-081-61 HAA#_ :Lq C Expiration Date: `�L/ 3 — O 3 1. GENERAL INFORMATION Complete legal description Lot 3; Block 5; Seidler S/D Location (site address or directions) Current Property owner(s) Mike Fallon _ _. Day phone Mailing address L- .} L LK Lending agency Mailing address Real Estate Agent Mailing Address Kathy Olmstead 16600 Centerfield Dri Unless otherwise requested, NAA will be held by DSD for pickup. Day phone Day phone_ 694_4200 ,le Rive AK 99577 ,41`. e� 9-11910 3 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY.' TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site )UX Individual Water Storage ❑ Individual Holding tank !] Community Class Well ❑ Community On-site [] Public Water System ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSDI Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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 an -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. (Certificates may be reissued for a period at 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 ornissions 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. Glome of -Firm --S&S Engineering - Address 17034 N. Eagle River Road, Eagler River, Engineer's Printed Name Robert C. Cowan, P.E. (907) 694-2979 AK 99577 { Date 8 / // A 3 5. DSD SIGNATURE 1 xarM Z. cbt'°AR � : a -mol _ Approved for 3 bedrooms.? Fps';•,• „,'',; Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: �����/� G�/. �D C Original Certificate Date: 8-13-03 (Rev. 01M) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AU I rl'ORI T Y MPPRV VAL 5-Vf-IEIF',LI0ST 3 yVOJl;a Legal Description: I Parcel ID: 675-0 - (08 (--(,1 A. WELL DATA Well type '-!�E v If A, B, or C provide PWSID # Date completed 14 75- Sanitary seal (YIN) J Total depth '30 J ft. Cased to �iF `�E �L�inl r -'i ru /�Date of test Static water levelft. Well production 0.0 g.p,m. WATER SAMPLE RESULTS: Coliform colonies/100 mi. Nitrate L, mp�/�/g.//,l.. Arsenic: = mg./I. Date of sample: T/! (I 3 B. SEPTIC/HOLDING TANK DATA l�l``I Tank Type/Material �� JL I fe e b A G L4.i f Tank size GC)j gal. Number of Compartments j Well Log (Y/N) _ Wires properly protected (Y/NJ Casing height (above ground) ) E3"T in. AT INSPECTION 2l D� 25 ft. 4 0 _ g.p.m. Other bacteria __I_ colonies/100 ml. Colle5t GINEERING 17054 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Date installed /C Cleanouts (YIN) _ Foundation cleanout (YIN) Depression over tank (Y/N) °"! High water alarm (Y/N) Date of pumping Pumper J-12 50V! f L lotCM %fir N G- C. ABSORPTION FIELD DATA Date installed b5—'•/'e Soil rating (g.p.d./ft' o Z/bd t System type 2 Length ?i5 ft. Width 3 ft. Gravel below pipe ft. Total depth— B_^! . Eff. absorption area '?(L_Cft2 Monitoring tube _� Depression over field Date of adequacy test Results (Pass/Fail) f�65s For 3 bedrooms Fluid depth in absorption field before testL4 in. Water added4Aal. New depth in. Elapsed Time: &0 min. Final fluid depth 3-3- in. Absorption rate >= 5Z) g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 0./ If yes, give date `I N SU L_A-T-*'-" D. LIFT STATION Date installed � A" "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons _ "Pump off"level at _ in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift stafit6n on lot 1049 Absorption field on lot 100 1 Public sewer main S er /septic service line �S� t Manhole/Access(Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots !fl0 r1— On adjacent lots 100 /�— Public sewer manhole/cleanout dv///19- Holding tank SEPARATION DISTANCES FROM SEPTIC/HBI:-BMG TANK ON LOT TO: Building foundation r- Property line Absorption field_ S 4 -- Water main 4.J A Water service line 19— Surface water �oO rr fi Wells on adjacent lots 10t7 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 1 1] 'e Building foundation 10 -1- Water main r4 I r l Water Service line (D e- Surface water ( (0 O 4- Driveway, parking/vehicle storage 1 Curtain drain LNtr 4 0-W J Wells on adjacent lots _ /00 4- F. COMMENTS G. ENGINEER'S CERTIFICATION _., . 1 certify that I have determined through field inspections and review of Municipal records that the above systems are Jr conformance with MOA HAA guidelines in effect on this date. �,,. .. _... ....... ..:`.. !r! ROBERT C. COWAN Engineer's Printed Name a /}riiZT �- CywA ✓ `?'�pcc 8801 Date 103 E`er.., ............. HAA Fee Date of Payment 37f_�` 5�lta-lo3 Waiver Fee $ Date of Payment Receipt Number d 3 17 Z Receipt Number (Rev. 12/01) 0 �tO c�6= ti N87°ssas F iso.00 ASBUILT-NO CORNERS SET THIS DATE. SEWARD I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE, FOLLOWING DESCRIBED PROPERTY: = 5 sEie�e p sriBO va, t torte �� f AND THAT NO ENCROACHMt`NTS EXIST EXCEPT AS DATE: INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- vci2s� VISION PLAT. UNDER NO CIRCUMSTANCES SHOULDANY BOFFENCE DATA BE DFOR LNESNOR FORESTABLSHNG �N- [D: ARY LINES.RAWN= oaf OF A A, %. I Duene Merk Sewerd •' ��°r LS -6918 Municipality of Anchorage • Development Services Department 4icroq� Building Safety Division �On-Site Water and Wastewater Program TY 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 LD. D,rO- O'9 G, / HAA# 14P 0/0'4 Expiration Date: / i -2 y- 0 / 1: GENERAL INFORMATION Complete legal description Lot 3 Block 5 SEIDLER SUBD. fit Location (site address or directions) 12117 Lugene Ln Eagle River, AK 99577 Current Propertyowner(s) Mike & Theresa Rosso Dayphone 694-3.63/740-8136 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup."���,�,jl e Ghrl 'v /;z 7 wi 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site X❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 engineertegistered 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 S&S Engineering, Phone 694-2979 Address 17034 N. Eagle River Rd Eagle River AK 99577 Engineer's Printed Name Robert C Cowan P,11:, Date Av&il J7, 2001 5. DSD SIGNATURE _� Approved for 3 Disapproved. Conditional approval for bedrooms. OF ROBERT C. COWAN /I CE -8801 a1kk lFi' . bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: dee� G J PJ_.e� Original Certificate Date: (Rev. 12100) Municipality of Anchorage U e( 1• '''° Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995196650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �' 3(L Oex_ � 1 y/L *Z Parcel ID: QS'0 — O $1 6 A. WELL DATA Well typevrl VA -T& If A, B, or C provide PWSID # = Well Log (Y/N) Date completed/ Sanitary seal (Y/N) AK5 Wires properly protecte!(Y/N) t Total depth ::FQLft. Cased to LoLft Casing height (above ground) Z in. FROM WELL LOG AT INSPECTION Date of test `/ / 13 �D / i Static water level X18 ft. Z 51 ft. Well production t"/• 9 -P.M. "F 9•P•m• WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate aL •.X-7 mg./i. Other bacteria 0 colonies/100 ml. Date of sample:8 6 D i Collected by: 5& 5 ENGINEERING Xc Al CA 17034 Eagle River Loop Road No. 204 B. SEPT CIHOLDING TANK DATA Eagle River, Alaska 99577 Tank Type/Material I S Date installed no17-5- Tank S Tank size /000 gal. Number of Compartments Cleanouts (Y/N) AS Foundation cleanout (Y/N)" Depression over tank (Y/N) High water alarm (Y/N) ^/ bate of pumping Pumper J Q IS C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./flz orf dr ) 00 System type / ,94r=�C Ff Length VS ft. Width ft. Gravel below pipe (0 ft. Total dept h�ft. Eff. absorption area�fe Monitoring tube Depression over field O Date of adequacy test 3 0 / Results (Pass/Fail) rf(-55 For -�S bedrooms Fluid depth in absorption field before test 3 '11f)(4 Water added626gal. New depth4Q in. Elapsed Time: bo min. Final fluid depth3z.7in. Absorption rate >= -415�6 g.p.d Any rejuvenation treatment (past 12 mo.) (Y/N & type) //D If yes, give date -* i#VSWLA-T&:5 * * M0Nr7p;e/0'i5- TU/3,61- IS 2- /0//:57A40&7- D. LIFT STATION Date installed 7atiln "Pump on" lev Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (YIN) "Pump off" level at _ in. High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank) Ottoh on lot too'-/- Absorption oo -/- Absorption field on lot 100 t Public sewer main ^4 A, r S ,,ev ver /septic service line ✓! � On adjacent lots /00 r On adjacent lots /00 r'% - Public sewer manhole/cleanout ^f A Holding tank A//`4 SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 5 F Property line JAbsorption field S Water main - 1A Water service line f Surface water X00 /r Wells on adjacent lots /Op rr SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line f'� r Building foundation /0 Water main N % Water Service line /0 r4- Surface water /00 Driveway, parking/vehicle storage Curtain drain NGYV& 4 LPW)/ Wells on adjacent lots X00 /70- F. t F. COMMENTS G. ENGINEER'S CERTIFICATION 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 t0 OpERT C . e Owgw Date HAA Fee $ '3 O0. L y Waiver Fee $ Date of Payment 8 / r -7 1110 f Date of Payment Receipt Number 001 T6 7 Receipt Number (Rev. 12100) A�1 R0EZRtF0ftWAN � 0^ CE -8801 ?` a MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL Nl Ci(f7 I 1 %c�l OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date -,it•-) - e_Z - £34', 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lor 3 (�r nca S� l�LE 2 Location (address or directions) (b) Applicant Name iy ffccS Telephone: Home O `¢ -3Z(03 Business Applicant Address _51e2_ E3 o,< z 3 e f (c) Applicant is (check one): Lending Institution M-/ ✓ /builder ❑ ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution �7� Lf i U6}L Telephone Address — (e) Real Estate Company and Agent _ Address /y 0 Telephone (f) -Meit the HAA to the following address: S & S FNGlNErDjbjG EAGLE RIVER, AK 99577 2. TYPE OF RESIDENCE Single -Family a_ Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY j Individual Well lLls Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISP SAL Onsite Cc 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) 5. ENGINEERING FIRM PROVIDMINSPECTIONS, TESTS, FILE SEARCH, DRA AND INFORMATION 0 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 S & S ENGINEERING Telephone 6�?q-2Jl71r Address hilt ki TVhX Date EAGLE RIVER, ABC 99577 �ffe Approved for( % bedrooms by Approved S[_ Disapprove 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 professionaf 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) 0 0 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) MUNICIPALITY OF ANCHOR)QMECKLIST - FEBRUARY 1984 CEPT. OF HEALTH & 264-4720 ENVIRONMENTAL PROTECTION � Legal Description: or 1✓ OCT 2 1 1986 5`�'�`G� 5�� z A. WELL DATA RE EIVED Well Classification If A, B, C, D.E.C. Approved (Y/N) Nli4 Well Log Present &/N) Date Completed % "/!�e -;6 Yield 0. 5 °� f Total Depth ?(o/ Cased to Depth of Grouting Static Water Level !0 Pump Set At Casing Height Above Ground Electrical Wiring in Conduit&N) Separation Distances from Well: Sanitary Seal on Casing&N) Depression Around Wellhead (0) To Septic/Holding Tank on Lot le e� F ; On Adjoining Lots ZCXJ.4 To Nearest Edge of Absorption Field on Lot /co'f On Adjoining Lots /Oc)14 To Nearest Public Sewer Line Cleanout/Manhole r — To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by S+5 ; Date /0 -zt 8 C Water Sample Test Results 'sP'-n S%Af? Comments B. SEPTIC/HOLDING TANK DATA Date Installed /Oy7�—?S Size lcv(r>0 No. of Compartments StandpipesvON) Air -tight Caps OM) Foundation Cleanout (Y& Depression over Tank (Y& Date Last Pumped /b - L3"A4f� Pumping/Maintenance Contract on File (Y/N) HJPr ; for Holding Tank High -Water Alarm (Y/N) 1-4/A Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well /yo F To Property Line /Or+ To Water MaW/Service Line �yr� Course H/A Comments Page 1 of 2 72-026(11/84) J To Building Foundation To Disposal Field K/ ff To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /cc #/xu Type of System Design C44 Date Installed DC7 Length of Field 2 S Width of Field Depth of Field c5 Gravel Bed Thickness & Square Feet of Absorption Area 3C>0 0 Standpipes Present ®/N) Depression over Field (Y(4 Date of Last Adequacy Test /C2 'Z(s' BG Results of Last Adequacy Test a2 Separation Distance from Absorption Field To Water -Supply Well (Oo�-r To Property Line /D -f i To Building Foundation Z / To Existing or Abandoned System on Lot hrM ; On Adjoining Lots 30 f To Water Main/Service Line 1014 To Cutbank (if present) "IA To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons K/Q Manhole/Access (Y/N) "Pump On" Level at 7 .'Pump Off" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments *' Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certifSt&a51 PpYGJt4Ee ffiWed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. SignecSR g 196X Date l_o12 /e Ir CompLAMP MER_ AK 99577 MOAN U—OrO3 Receipt No. r fl n0 Date of Payment /O 2� Amount: $ 65-- iMllfdldPMJ3Y OF ANcH,);_G= DEPT. OF HEALTH 3 WRONMENTAL PRORC: r;iy Page 2 of 2 72-026 (11/84) OCT 2 71986 REE EIVED k:. •• •eoe •fie `�� En SJ�* 6� �VG66\� ••'Ai rye, 14£T•e �",sj? ya a `�l"mrp ��pRQFE5S1ti�\, s a • 5. LEGAL DESCRIPTION DATE RECEIVED �l INSPECTION APPOINTMENTS �` tiG i j TIME TIME TIME DATE DATE DATE Lid,/SINGLEFAMILY ❑ One ❑ Four ❑ Other ``` `l INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH 8, ENVIRONMENTAL PROT ECTLMIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 • OCT 6 1981 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 R E C E ID REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER j� PHONE INDIVIDUAL/ON-SITE** ) ��! � YEAR ONSITE SYSTEM WAS INSTALLED. MAILING ADDRESS 7 7 PROPERTY RESIDENT (If different from above PHONE 2. BUYER / PHONE MAILING ADDRESS ?0,&x cc// LZe '4'276,2 3. LENDING INSTITUTION PHONE A) 17) FAQ _�17"7 - SS -S& MAILING ADDRESS ( - 0 4. REALTOR/AGENT/ 'LGCvli PHONE ""av -IJLl�/Gt/ �Yv1 --, sL-L/ZN, '�GI.`_JSS MAILING ADDRESS 5. LEGAL DESCRIPTION 6L= t,6ti 2 tiG i j STREET LOCATION 6. TYPE OF RESIDENCE - NUMBER OF,BEDROOMS Lid,/SINGLEFAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY EO Three ❑ Six 7. WATER SUPPLY $?f INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** ) ��! � YEAR ONSITE SYSTEM WAS INSTALLED. ❑ PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ ",SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE 'r5THREE ❑ FIVE ❑ OTHER " ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM 1. INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: / L E n If Tank is homemade give dimensions: SOILS RATING - TYPE OF TANK MANUFACTURER, TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS 1�4_'APPROVED FOR - BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE y B� 72-010 (Rev. 6/79) I MEET . 1? P.4 LToR � 1 PLI17 nc nwtx.nT- !1111 11•� i r `s N, Cirtfl -:-, ENVIR !, r. DUVIREt,;E ro lr l i L, /� 0� AP 3 J RtC /.iLVED k REQUEST FLP,Afri;QV,'Lt il,r:tV:ah;'` tJAIRri 1'i -Iv !iII',GiLI iN a-4 1-1W -7 i DIRECTIONS Conpl,ie all D is unn,w1. i ... 1. PROPER IZ OWNEft Lombard, Stephen C. and Caroline Y. -- 694-3465 TOM, I_ING AD.fif'SS---—_-- Star Route Box 233-E, Eagle River, Ak. 99577 - ---- — -- PFi OI'ERTY F LSIDGNT 0I ...... Same I 2. 6L.IYER t i1c _ Gorski, James M. and Susan E. 333-7190 MAILING F,DDF; ESS 2200 Glacier, Unit 103, Anchorage, Alaska :___— 3.—iE{d_iJlNG ihS7lTUl lOi --- Peoples Bank & Trust Co 279 7511 MAI LI f!G ADUF' ESS Pouch 7-007, Anchorage, Alaska 99510 - — -- 4. PEE"LT0s1/+CEN1 Dynamic Realty (Clarence King) 279-7611 MHI LING ADDRESS 501 West Northern Lights Blvd., Anchorage, Alaska 99503 5. LEGAL DESCRIPTION Lot 3, Blk. 5, Seidler Subdivision - -- Unknown (Contact Clarence King C Dynamic Realty for information) 6 TY(Y OE RESIDENCE U (_ix F - I_� FINGLC F4.M1LY !)� C7 MUI_TILLL IAN1iL 7. WATEi; E'.UFPLY -- G INDIVIDUAL` ❑ COMMUNITY L PUBLIC UTILITY S, SeV'NUE DIJPOSAL SYST U11 xl I NDI V I DU4 UON-M-1-1 0 PUOLIC UTILITY Otho! t:C LI I & A Itss rx is ov!i I?t y.u,0 is.q'IIe6 NOTE: TH E I N SP E CT 10NY'-EMU31 ACCU.It I'd'f .).. _.%_��..1 _.� � %( t `<�r•, i�I 3i.{i}I.-LS=D 72-010i3/7E) ��V f Vhf l✓� -�^ J CA Sr; rr, ONLY w ---------- NI N N I 6 f - - - ---- ----------- 1 V C F D R s j C, 1 V CONID'� FIONAL /l!'PI 11) 1 s p f N L) I V 1 D -7.`.L/OH SITE'C rJ' M-11, Y Qo U� 0 i ,Wj 72-010 NP-, 31721 13 F D R s CONID'� FIONAL /l!'PI A 1 U� 0 i ,Wj 72-010 NP-, 31721