HomeMy WebLinkAboutSPRING HILLS ESTATES BLK 1 LT 13Sp ing Hill
Estates
Block 1
Lot 13
#015-051-51
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEAI..TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
I DISTANCE TO:
I~ ~ Manufacturer
~ [Liq. capacity in gallons
l Man.racture,'
Absorption area
Inside length
Dwelling
Dwelling
Material
Widt ~
PHONE /',~N~W
~2: I DISTANCE TO' Well
Length of each line
F ~. '~'p of tile to finish grade~
.L ,.% G,
Length Width
---~ Clas~ Depth
~: I DISTANCE TO: Building foundation
Foundation
Total length of lines
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
, NO. OF BEDROOMS ,'
PERMIT NO.
No,~of d~mpartments
Liquid depth
PERMIT NO,
Material Liquid capacity in gallons
Nearest lot line
Trench wid~o~ 0 inches
inches
PERMIT NO.
Distance between lines
Total effective absorl~tion ar~ea
PERMIT NO,
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorpt on area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
~-NST~L LER '
REMARKS
APPROVED
DATE
LEGAL
72-013 (Rev. 3/78)
Well Owner DOUG
M -W'- DRIL'.ING, Inc.
P,O. Box 10-378 * 10300 Old Seward Highway
(90i) 349-8535
ANcHoRAGE, ALASKA 99511
DRILLING LOG
Use of Well Dot~e,utic _
Location (address of: Township, Range, Section, if known; or distance main road
Lot 13 Block 1 Spring Hills Estates
Size of casing_ 6" Depth of Hole
Static water level 137 it.
Screen ( ); Perforated (
Describe screen or perforatio~
Well pumping test at ~ gallons per (~5~)
of drawdown from static level.
Date of completion__February 3, 1984
149 feet Cased to 149.10 {eet
(below) land surface. Finish of well (check one) open end (:.,DC(
).
None
(minute) for 1 hours with 1007
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
);
0 .TO 2
~..TO
4 .TO 12
12 .TO !7
17 TO 65
65 TO fie __
q~ .?O.
:].38 .TO.
.~O.
.~O.
~.~O.
.~O
~ .~O
.~O.
Casing stiekup
Brown silty gravel
Sand ~ gravel - Loose
Brown sand
Bro~ silty ~ravol
_ Gray silty gr~vel -~ (dam?)
Bro;a~ silty gravel - (damp)
Gray silty gravel - (damo)
,,~at erbe arin~6 gravel
C~icat~ No's. 814 & 9~3
3 -- CONTRACTOR
MUNICIPALITY OF ANCHORAGE
Department ' Health and Environmental rotection
825 ~ Street, Anchorage, AK. ~.501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~
WELL AND/~ 0N-SITE SEWER PERMIT
Location: Phone Number:
Type of Soil Absorption System Is:
Trench: ~(~ Drainfield: Seepage Bed:
Maximum Number of Bedrooms:
Lot Size:
Holding Tank:
Soil Rating(sq.ft/br) ~
The Required Size of the Soil Absorption System Is:
The length dimension is the length(in ~eet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(H~LDI-N6) TANK SIZE = /~-~-C~ . GALLONS
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the 'type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a cor0nlunity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the res~denqe is remodeled to include more that ~be~rooms.
Ap p~l i ~'a~t~ ' U
Date: // ~',B ~ (:~:~ /--~
SWP/024 (1/81)
SOl LS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchnrage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR: //'~ ~.~ (/f c,
-~- L/ ,. /',//
· ~G*,_ DESCRIPT,ON: -:,~.'"'~ ~ ~..?
1
SLOPE
1[
20
COMMENTS
DATE PERFORMED: /
SITE PLAN
WAS GROUND WATER
ENCOUNTERED? , v
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
,~ FT AND FT
CERTIFIED BY:
Municipality of Anchorage
Development Services Department
Building Safety DMslon
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(so7) 343-79o4
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Expiration Date:
parcel I.D. 015-051-51
t. GENERAL INFORMATION
01o
Completelegaldescdption SPRING HILL ESTATES; LOT 13, BLOCK 1
Location (site address ordirecflons) 9801 SPRING HILL DRIVE
Current Property owner(s)
Mailing address
' Le'n~ing agency
Mailing address
Re~.l Estate Agent
Mailing address
MICHAEL LLrrZ & LISA GERTSCH Day phon~
9801 SPRING HiLL CiRIVE~ ANCHORAGEt AK 99507
· Day phone
346-1344
CAROL BUTLER ,/ REMAX PROI~ERT1ES Day phone
Unless othen~lse requested, HAA will be held by DSD for plckup. '
:: . , ..:
2. NUMBEROF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Indivldual Well ' ·
Individual Water Storage r-~
Community Class Well
Public Water System. r-1
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Indivldual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department iDSD) Issues Certificates of Health Authoflty
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer registered In the State of Alaska. Certes of Health Authority Approval are required for the transfer
of title (except between spouses) for properties sewed by a single family on-site westewater 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 proparlJes sewed 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 proparties served by Class A or B
wells or a public water system. The Municipality of Anchorage Is not respons~le for errors or omissions In the
professional englneefs work.
Note: Alaska Water and Wastewater Consultants, Inc~ shall be paid $1110.00 at, or prior
to closing for the enginesdng sen/ices provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As cer~fied by my seal affixed hereto and as of the velMation date shown below, I verify that my
Investigation, based on procedures outlined in the Health Au~ Approval Guidelines for this application,
shows that the on-site water supply and/or wastewatsr disposal system Is(am) safe, functional and adequate
for the number of bedrooms and lype of structure Indicated herein. I further verily that based On the
informaffon obtained from the Municipality of Anchorage files and from my Investigaffon and Inspection, the
On-site water supply and/or wastewator dlsposel system Is(are) In compliance with all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of Instaliaffon.
NameofFirm ALASKA WATER &: WASTE'WATER CONSULTANTS, INC. Phone
357-6179
Engineer's Pdnted Name J£~<EY A. (~ARNESS, P.E. Date I
Engineer's Comments:
In conducting this evaluaffon, AI444/C, Inc. attempted to provide a Ihon~h,
consclenfous englneedng ana~ of the aystem ln accordance wtth ADEC and MOA
DSD Guldelines & Regulaffons. The reporl~I results descttbed the penbnnance of the
operaltonal requlremen~s of the ADEC or MOA DSD. The content of lh~ report ls for
5. DSD SIGNATURE
,,Vp,'ov tor ,'oom. .
Disapproved.
Conditional approval for __
Attachments:
HAA Checklist
Septic sYstem Advisory
Well Flow Advisory
Manitanance Agreements
Supplemental Engineer's Reort
Other
Orlglaal Certificate Date: ~E'%- ~.. Z ' ID I
Municipality of Anchorage
Development Services Department
8-~xling Safety 13Maon
On.S~ Wat~ & Wastewater Program
4700 6outh Bmgaw St.
HEALTH AUTHORITY APPROVAL CHECKLIST
SPRING HILL ESTATES; LOT 13, BLOCK 1 Parcel ID:
Legal Description:
.4. WELL DATA
Well type
Date completed 2/3/84.
Totaldepth 149 lt.
Date of test
Static water lewl
Well production
WAFER SAMPLE RESULTS:
If A, B, or C provide PWSlD~ N/A
San~aw ~ml (Y/N) YES
Casedto 149 It.
FROM WELL LOG
2/3/84.
137 lt.
5 g.p.m.
015-051-51
Coliform ~ colonies/100 mi.
Date of ~ample: 5/9/2001
B. SEPTIC/NOLDING TANK DATA
Nllmte I '~ mgJl_
wen Log (Y/N)
W]ms prepaY/pmtacted (Y/N)
Casing height (above ground)
AT INSPECTION
5/7/'2001
186 It.
7.1 g.p.m.
Y
Tank Typa/Matadal
Tank size 1250 gal.
Foundation cleanout (Y/N) YES
Date of pumping 5/7/2001
C, ABSORPTION FIELD DATA
STEEL
Number of Compartments 2
Dapmsslon over tank (Y/N) NO
Pumper
Fluid depth In absorption tlald before test 0 In.
Elapsed Time: 5. min. Finallluld depth 0
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
18+ In.
~'tsmtype SHALLOW TRENCH
Gravel below pipe 42'
Dap _m_~_ _~!on over flald NO
For 4. beqmoms
New depth 1 In.
6OO+ g.p.d.
If yes, give date
Date Installed 11/7/e3 Soil rating ( .g~_.d::~r ~rodn~) 85
Lang~ 40 f~ Wlolh 5 lt.
Totaldep~ lo+/- lt. Eff. absorption ama 370 ft~ Monttoltnglube YES
Date of adequacy test 5/7/2001 Results (Pass/Fall) PASS
Watar added 741 gal.
In. Abeoq~on rata >=
NONE KNOWN
Date Inste~ed~ 1/7/~
C~anouta (Y/N) 'fT_s
High water alam~ (Y/N) N/A
A+ HOME SERVICES
AWWCt INC.
D. UFT 8'rATION
Date Inst~ed Size In
'Pump on' level et in. 'Pump n. High water amen level at ~ .In.
~ Cycles tested Meets alarm & olrcult requirements?
8e~¢ tenUIItt etet~on on lot
Absorpfion field on Iot~
Pub~ sewer main
8ewer/espt~o esrvtce Iina
E. SEPARATION DISTANCES *CENTER OF WELL
SEPARATION DISTANCES FROM W',q l ONLOTTO: TO EDGE OF ST1
'102.1'
100'+
N/^
25'+ Holding tank
SEPARATION OISTANCE$ FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundaUon ,5'+ Property line 5'+
Water main N/A Water seMce Bna. lO'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION Fl~-~n ON LOT TO:
Property line 10'+
Water esndce line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
On adjacent lots. 100'+
On adjacent lots 100'+
Public sewer manhole,~cteanaut
N/A
N/A
A~otpflon field,
Surface water. 100'+
Driveway, pa~dngNehlcle atorage ~o'+
· G. ENGINEER'S CERTIFICATION
Building foundaUon 10'+ Water main
Sun'ace water 100'+
Wells on adjacent ~
I cerbfy ~at I have determined 6~gh field Inspec~ns and
review of Municipal recoils that the above ay~ern~ are In
conformance ~ MOA HAA guidelines In effect on this date.
Date
JEFFREY A. GARNESS
Waiver Fee $
Date of Payment
Recelpt Number.
i~Y-15-0t I$:1~ Fi~-
,d~K CTIE Environmental Servlce~ Inc.
T-660 P.OZ/03 F-939
1012400001
AK Water & Wastewatcr Consultnn~ Inc.
Sprin; Hill ~states
Lot 13 Block 1
Drlnldng Water
CF& £ Rcf.~
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID 0
Sample Remarla:
Client
Printed Date/Time 05/15/2001 13:33
Collected Date/rime 05/09/200 ! 16:08
Received DateJTlme 05/09/2001 16:55
Technical Director Stephen C. ;'de
Released B ~'~~
Nitratc-N
I
Units Med~d
AHoweble Prep An~l~sis
Limits Date Dste Init
0.500 mg/L EPA ,100.0 (<I0) 05/09/01 SCL
Xtcrobiolo!p/' Laborai:ory
To~al Coliform 0
0 col/100mL SMI$ 92220
05/09/01 KAP
MUNICIPALITY OF ANCHORAGE
DFPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environm.ental 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
Ocli.../ _ ~.-.,/ x~ NAA # ~ ~c~"-~ ("-'j~..L.\c\
GENERAL INFORMATION
Complete legal description
Location (site address or directions) c~' ~'O /
Property owner
Mailing address
Lending agency
Mailing address '~'
Agent ~._~,~__tz- U~+ ,-~--F-~/~ .~T~- ~~
Address ~ ~ "~" %~5 %~ "~ ~0
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
~r-N
Day phone
Day phone "7~:Z'~-~i//
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system,
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 further verifythat 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 A!¢,sk~W~.te{ & /~~ Phone
/84'7i ~ ,krid~r/ ·
Address ~
/ ,~ ~ ~',/ ~
Enginee¢ssignature ~~d~,, ~ ,rV ,/ %~ ~~1~
bedrooms.
DHHS SIGNATURE
'×~' Approved for
Date 7,/2/,/~'¢':q-
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
72~25 (Rev. 1/91) ~<~ck MOA ¢Y21
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
Municipality of Anchorage AU6 0 7 1997/ --
DEPARTMENT OF HEALTH & HUMAN SERVICES_
Environmental Services Division R ~ C E IV E
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
~-~-~ Total depth
Sanitary seal (Y/N)
Health Authority Approval Checklist
~ I <:~¢_~ /4 (j~- Parcel I.D.:
Date completed
Cased to
o/5"--
If A, B, or C, attach ADEC letter. ADEC water system number
casing height (above ground)
4~ S¢.e. IC~¢i4-- ~ FROM WELL'LOG
Date of test
Static water level ( ~'~
Well production
g.p.m.
Wires properly protected (Y/N)
AT INSPECTION
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Absorption rate ::
If yes, give date /~/
.g.p.d.
Fluid depth ~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Effective absorption area ~'~"~ Monitoring Tube present (Y/N) "'//. Depression over field (Y/N) __
Date of adequacy test ~/2-~'-/.~'~' ResUlts(]'ass/Fail) /O/~.¢ ~ For ~
Fluid depth in absorption field before test (in.); ~ Immediately after"]"G'Tgal, water added (in.):
Soil rating .~4~d./fF or fF/bdrm) ~"-- System type
Gravel thickness below pipe ,E~ Z/~
Total depth
bedrooms
Date installed- tl/?~)/
/
Length ,~ Width
SEPTIC/HOLDING TANK DATA
Date installed, I/-7/~ ~ Tank size
V Depression (Y/N). J~J High water alarm (Y/N)
Foundation cleanout (Y/N)
Date of Pumping ~/)'~-/~:~/~ Pumper
Number of Compartments ~2.-- Cleanouts (Y/N) Y
O,gL-~ / F~'~
/, .~' ,~, ,14~2' Other bacteria
Collected by: ~,-u~-5~;4 tccA.-~,¢~ ~
High Water alarm~t~~-~'*'*''*~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~O'Z,
Septic/holding
tank
on
lot
:T~'t~-~V--- On adjacent lots
Absorption field on lot
Public sewer main
Sewer/septic service tine
On adjacent lots
Public sewer manhole/cleanout
Lift station
tO0/4-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~{ '~' Property line ,~0 ~- Absorption field
Water main/service line I~)~- Surface water/drainage IE~/j,. Wells on adjacent lots
are
LO0/+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ¢,~"'/- Building foundation ;¢q-O/4'" Water main/service line /0/~'
Surface water [ O0 t.(,_ Driveway, parking/vehicle storage area
Curtain drain NO ~6:. ~.~ouyt,J Wells on adjacent lots /~0 / ¢'
ENGINEER'S CERTIFICATION
/ certify that/have detgr//'nine~t~/~fie/d inspections
,n conformanc~ ~/~gui~e/ine~s in effect on this date.
Signature
Engineer,sName,, u ~~~
Date
HAAFee $ ~ ~7~ ,¢7~)
Date of Payment ¢1.~/~ ?
ReoeiptNumber ?JD~2-~- _(~'~/~*~//)
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
30'
bJ
FROM ; ALASKA WATER 8~ WASTEWATER PHONE NO. : 907~85246 Au@. 11 1997 lI:26AM Pi
CT&E Ref.#
Client Name
Project Name///
Client Sample ID
Matrix
Ordered By
PWSID
974054001
AK Water & Wastewater Services
Lt 13,1~k 1 Spring Hill Est
Lt 13,Bk 1 Spring Hill Est
Drinking Water
Sample Rmnarks:
Client PO~
Printed Date/Time 07/30/97 12:29
Collected Date/lime 07/25/97 10:35
Received Date/Time 07/25/97 1.3:1.5
Tech,i~al Director: Stephen C, Ede
gitrat~-N
Totel coliform
ResuLts PQL
1 .~8
0
Allowable Prep Analysis
Units Method Limits Date Date [ni~
0,100 mg/L SM18 4500-NO3F 10 max 07/~6/97 JEJ
co[/lOOmL SM1B 922~B 07/25/07 T~4U
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
GENERAL INFORMATION
Complete legal description
Lot
Location (site address or directions)
,9801 Spring Hill Driv6
Property owner
Mailing address _
Lending agency
Mailing address.
Agent
Address
Cheryl Sims
C/O REAL ESTATE SUPPORT SERVICES
8200 Humboldt Ave. S. Suite 204
Da, y~phon.e, ,, .~4~71~70
Minneapolis MN 55431
Day phone
Day phone
Unless otherwise requested, HAA will b? h/etS"for pickup. .
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
NOTE:
lng to the legality and status of system,
If community well system, provide written confirmation from State ADEC attest-
TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX×
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
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 inves!i_gation 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.
Address s & $ ENGINEERING_ ·
Engineer's sig natra,tel~ Date
? : ~ ~,,: .~ , :..-, ,,
Se
DHHS SIGNATURE
,//~ Approved for , ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: / Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Bsck MOA
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LoT-IS /~y,.& I E;,P~IfJG I-IlO. L_ Parcel I.D.
A, Well Data
Well type F~ (~ If A, B, or C, attach ADEC letter. ADEC water system number
LogpresentCN) ~ ~ Date completed ~/;/~ ~ Driller
Total depth I¢~/~ Cased to [~, ~0 ~ Casing height
Sanitary seal.N) ¢~ .Wires properly protecte~)
FROM WELL LOG AT INSPECTION o~
Date of test L ]3]7G I/~%/ PG-
Static water level /~ 7' / ?P '
Well flow ~' g.p.m. ~' ~
g.p.~
Pump level1 U~ ~P ~o~
SEPARATION DISTANCES FROM WELL TO:
Septic/l'u=tdm~tank on lot
Absorption field on lot
Public sewer main
/o0
/ oo '¢-
Sewer service line
; On adjacent lots_
; On adjacent lots / CO ry_
Public sewer manhole/cleanout
Petroleum tank /Jo ..z~ ~-
WATER SAMPLE RESULTS:
Coliform O,/r/C~ ~
Date of sample: / / Zo /
Nitrate //, ~ "~/Z Other bacteria
Collected by: /~'~_~-,~(',~/¢LJ~---,/~TC-C'~k-)(~ _
B. SEPTIC/.H~TANK DATA
Date installed _///9/ F''}
Oleanouts(~.) ~_;
Tank size
Foundation o eano l
Compartments ~
Depression (Y~/L~O
High water alarm (Y(~) ,,k,)O
Date of pumping /0/Z.~/ ~Z
Alarm tested (Y/N) /k-)///)¢
Pumper _7~/4/zi('_~ /Z~a~/~//~
SEPARATION DISTANCES FROM SEPTICCPrOL-DllqG"-r'ANK TO:
Well(s) on lot /~L3 ¢~ On adjacent lots (/~.~-~
To property line /'(~) ~-/~ Absorption field .~ /¥~
Surface water/drainage / ¢_2¢.~
Foundation
Water main/service line
72-026 (3/93)* Front ¢OO~ D~ ~/O~1 ~ /S~~& T A~ %~ a F~~CONTINUED ON BACK PAGE
C. LIFT STATION /-,iof-..J~
Manufacturer
Manhole/Access (Y/N)
Vent (Y/N)__~ ~~evel at ____
~[~eht sWl~lt~)rAa le~ re cmt i i~ lc o d e s (y/N )
SEPARATIO~STATION TO:
_~.~gp4et'~ On adjacent lots Surface water '~.~
D. ABSORPTION FIELD DATA
Date installed
Length '~¢'0 / Width
Total absorption area ~(-~
Date of adequacy test /
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/~)
Soil rating (GPD/F¢) P~-
Gravel thickness
Cleanout presentC~) '-~E'~¢
Result~ail) ~
System type /A/'/D~
Total depth /0
Depression over field (Y~)~
for /-1~ (/~o°'~ ~) Bedrooms
Aftertest
/UJo,-'LJE'' /'~/L)oud/-J Ifyes, givedate
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~..~0
To building foundation
On adjacent tots
Surface water
Curtain drain
On adjacent lots //~)~--~ ¢¢'~ Property line
To existing or abandoned system on lot /C)o,z~
Cutbank A~Yz~r.'c~'-- /9'L~,J~-~/"q']-Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEERIS CERTIFICATION
I certify that I have checked,~~onformed to all MOA and HAA ~
Signature ~
Engineer's Name S,~GINEER ~l~r~ ) [,~
Date ,S~^ .... IN, O ~
Eagle River, Alaska 99577
guidelines in effect
? . ';
inspection.
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
01/25/94 09: 30 CT:~:E ENU I RONHENTIqL LAB '.:-;ERU l CE'3 1,10.46,5 ~O.T
chemlab Ref,~
Client Sample ID ;£,13 B1
Matrix :WATER
Commercial Testing & Engineering Co,
Environmental Laboratory Service~ ~e,~.~,~,,.~v~:~m~,~f~-~,~.~~~
REPORT of ANALY~ 5633 B Street
:94,0323--3 Anchorage, AK 99618.1600
~PRING HILL E'gTA~S S/D Tel: (907) 562-2343
Client Name :$ & 8 gNG£~&~RIN6 WORK Order :75143
Ordered By ~R, SMAFER Report Completed :0!/25/94
Project Name : Collected :01/20/94 ~ 15:00 hr~,
ProJ~ct~ : R~cetved ~01/20/94 ~ ~5~35 hr~
PWBID .UA Technical B~.~ctor:~g~H~N,C. EDE ~
Sample Remarks: ROUTINE SAHPLE COLLF. CTEI] BY t S,S,
QC Allowable Ext. Anal
Parameter Results Qua]. Untt~ Heth(~ Llmit~ Date Date Init
Nitrate-N 1,2 ~g/L EPA 353.2/300.0 10 01/23, C~
* See Special Instruot].ons Above UA = Unavailabl~
*~ See Sample Remarks Alx}ve NA = Not Analyzed
, U = Undetected, Reported value is the practical quantification limit. LT = ~es~ Than
~,D ~ Secondary dilution. GT ~ G~eater Than
Member of tl~o !~S Group (8o~i~t~ G~n~ral~ d~ Surveil!an¢~) ....
ENVIRONMENTAL FACILITIES IN A~ASKA. COLORADO, FLORIDA, ILLINOI~. MARYLAND, NEW JERSEY, OHIO, UTAH. W~BT VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
O/~ ¢~'/- ~"~/ HAA# /~/-~L_ ¢ ~ O,~-'~ ?
Telephone: (home)G'qg"3?ff<¢ Business
Location (address or directions)
(b) Property owner Cr'v¢l
Mailing Address
(c) Lending Institution ~'~/ Telephone
Mailing Address
(d) Real Estate Company and Agent
Address ~O~ '~ ~,
Telephone
(e) Mail the HAA to the following address: (or check here [], if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well I~'
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
'Conservation attesting to th legality and status,
4. SEWAGE DISPOSAL
On-site~ 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.
72-025 (Rev. 7/88) Page 1 of 2
;~ to ~ olSed
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leAoJddv leUO!l!puoo jo SLUJeJ.
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lees s,Jeeu!6u:]
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description: L
A. WELL DATA
Well Classification ~RIVSTL~
Well Log Present (Y/N) ~/ ff~_ Date Completed 2.
TotalDepth~ '~l" Casedto ",'/$1¢ Depth of Grouting
Static Water Level I ~D'
Casing Height Above Ground _ ;~'7 u
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot IO'7
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line "2/oo'
To Nearest Sewer Service Line on Lot ,~.
If A, B, C, D.E.C. Approved (Y/N) ~.~,
Yield ---7'&' Gp~ flE'~'.¢ ll/.1./q~
Pump Set At '-~18~'
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots /O~f
~' ! I~- ; On Adjoining Lots I ~ q'
To Nearest Public Sewer Cleanout/Manhole ~ IOO
I/
Water Sample Collected by FLATTOP -r~¢# 5'~'~S. ; Date
Water Sample Test Results .5~'~-¢..'¢,¢~¢fo~ - O c~t~.,[-'c~'~/"toOmt.j
Comments buRtNG WECL F~o~ TES~ o~ ~/2o/7o STEAbV
[2 ~'~
Air-tight Caps (Y/N)
_
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarrn (Y/N) ~.,~ ·
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
I
To Water-Supply Well {
To Property Line ~> -Co/
To Water Main/Service Line ~ (0_O¢
To Stream, Pond, Lake or Major Drainage Course ~/OO
Comments
No. of Compartments .2.
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit(Y/N) N.~,
To Building Foundation
To Disposal Field _ .5-
I~SP, ~z~P o~' T
B. SEPTIC/HOLDING TANK DATA
Date Installed I\/'7//~.~ _Size
Standpipes (Y/N) "/
Depression over Tank (Y/N)
72-026 (Rev. 7/88)Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
/8 p/~ ~4 Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Stalndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well '~ 112-
To Building Foundation ~.~ 2. 5' '
Lot N, ./+,
To Water Main/Service Line '~ '70 /
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments -k ENb etON,tTO~ '-ru[~E ExTE~.I~)5
To Property Line ~-o/ ~'~¢~ ins?. ¢¥P.
To Existing or Abandoned System on
; On Adjoining Lots '7/0o '
To Cutback (if present) kt~A.
'TO I0~ ~£z. oL, v, C~lgowNb L¢V£L . Ok/,qgTe
D. LIFT STATION ~ ./~.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA
inspection.
Signed ~"¢'~
Company
Date II
MOA No.
Receipt No. E>~ '~'~ ~ ~_____~C/:::~.--~"")
Date of Payment//- ~''(¢
Amount: $
72~026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
ffect on the date of this
Engineer's Seal
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D, #92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order I~ 30257 Date Report Printed: NOV 19 90 @ 14:46
Client Smaple ID:LI3 B1 SPRING HILLS EST, W.SIDE It.B,
PWSID :UA
Collected NOV 16 90 O i3:50 hrs.
Received NOV 16 90 0 14:18 hrs.
Preserved with :AS REQUIRED
Client Name : FLATTOP TECHNICAL SRV
Client Acct: FLATTOT
P.O,9 NONE RECEIVED
Req ~
Ordered By : TED MOORE
Analysis Completed :NOV 3.9 90 Send Reports to:
Qboratory Supervisor .~TEPHEN C./~DE 1)FLATTOP TECNNICAL SRV
Special
Instruct:
Chemlab Roe 8:904879 Lab Smpl ID: I Matrix: WATER
Allowable
Parameter Tested Result Units Msthod Limits
NITRATE-N 0,94 ms/1 EPA 353.2 10
Sample ROUTINE SAMPLE
Remarks: SAMPLE COLLECTED }IY TED MOORE.
Tests Performed
None Detected
Not Analyzed
See Special Instructions Above UA=Unavailable
See Sataplo Remarks Above
I,T-Loss Than, gT=Greater Than
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL ~]ALTI-I
DEPAR'i~IENT OF t{EALTH AND ENVIRONbIENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Telephone -- Iiome
Applicants Address_:4.Zt_.~_:::~_,,,i_~W:~,._~::,.,~flj,_j~li~/) ,," ......... ';'L~,,,~ /~1~,. ~..~,_ ~2~' ~V
(c) Applicant is (ehec~ one)Lending Institution ~7 ; Owner/builder [:~! ;
Buyer ~ ; Other i-iii (explain);
(d) Lending Institntion Telephone
Address
(e) Real Estate Co. & Agent :/~Slf't'4__ ·
Address Q-i~ ~- ~.;13 .....
Telephone ~j,~_ t 9- J i
(f) biall the I~ to the following ~dress:
2. ~Type of Residence
Single-'Famil y
Number of Bedrooms
3, Water
Individual Well
Multi-Family
Other (describe)
Community ~ff_~ Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
s__e w a g e_ Dj s_2o__s__al_
Onsite ~ Public ~ Community -~7 Holding Tank :~--:
Note: If community well system, must have written confirmation from the State
Department of Environmet~tal Conservation attesting to the legality and status.
[Page 1 of 2]
Engineering Firm Providinji_~n_s__pections~ Tests, File Search! Data and Info,matk~: ::
As certified by my seal affixed hereto and as of the validation date showa helou~
verify that my investigat:[on of this Health Authority Approval shows that the
water supply and/or wastewater disposal system is safe, functional and ~equat~ for
the number of bedrooms and type of structure 'indicated herein. I further verify
based on the infomnation obtain~ from the ~micipality of ~chorage files and frm~
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance ~[th all Municipal and State codes, ordinances, and regula
tions in effect on the date of this inspection.
Name of Firm /~f-~ ~ ~.~.~ ~ Telephone ~'.~ ~, C~ q~
Date ............. =~,~ ....... ,~ ,.,,~.,,
~ ~ C~r ~.. ......
(ENGINEER SLAL) ~o ~ ............ ~ .......... · ....
DHEP Approval ~ }% [6,'ofC. ~aic;, .Ir.
Approved _~_ Disapproved ~__ Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTH()RITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PIJRCILRSERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EblPLOYEES OF DIIEP 1)0 NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MHNISIPALITY OF ANCIIORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-1. 9~84
MUNICIpALllY OF ANCI4ORAG~
DEP'[. OF HEALTH &
ENVIRONMENTAt- pRO'I'ECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Log P~esent ~)N)
Total Depth * (~9~ Cased toe~...l '
Static Water ~1 ~.. ~7~ ~ ~t At
Casing ~ight ~ G~nd %, ~.
Elec~ical Wi~ing in ~nduit ~)
~p~ation Distan~s f~ ~11:
To ~ptic~[oldin~ Ta~ on ~t
To ~a~st Ed~ of ~so~ption Field on ~t
To Nearest ~blic ~ Line ,
Clean~t/Ma~ole ~ ~
Wate~ Sable Collected By
Wate~ S~le Test ~sults
If A, B, c~ C, D.E.C. Approve .~)
_ Date Ccmpleted~ 2- 3 - loc . . Yield ~%pm
Depth of Grouting. ~
Sanitary Seal on Casing Y~__~
Depression A~ound Wellhead (Y_~ &JO
; On Adjoining Lots
; On Adjoining Lots ~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed~ti-_q-~3 Sizew /OOO,~¢% No. of Cc~mpa~tr~nts~2-
Standpipes ~N) ~ Ai~-tight Caps
Depression ove~ Tank (Y/N) Date Last P~ped
Pumping/Maintenance Contract on File (__Y~
Holding Tank High-Wate~ Alarm ~ AJ~. Temporary Holding Tank Permit
Separation Distances from Septic/Holding Tank:
¢
To Building Foundation ~ I%.~
To Disposal Field ~ ~-/
To'Stream, Pond, Lake, cz, Majo~ D~ainage
[Page 1 of 2]
C. ABSORPTION FIELD [IRTA
Soils Rating in Absorption Strata
Date Installed x I{ - q - ~3
Width of Field %~ ~ ~
Square Feet of Absorption A~ea ~
Depression over Field (~ ~0
Results of Last Adequacy Test ~ ~
Separation Distanc~ f~om Absorption Field:
To Water-Supply Well C~? (oo~ To P~operty Line
Date of Last Adequacy Test
Type of System Design
Length of Field ~ ~0I
Depth of Field wq.~'-~,O'
Gravel Bed Thickness iL %z"
Standpipes P~esent ~N)
To Building Foundation ~ ;lq' To Existing or Abandoned System cn Lot ~ ; On Adjoining Lots ~r ~o~'
To Water Main/Service Line ~ To Cutbank(if present)
To Stream/Pond/Lake/o~ Major D~ainage Course ~
To D~iveway, Pa~king A~ea, o~ Vehicle Storage Area fg' (¢~ ~6~
STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Corm~nts -
Dimensions
Manhole/Access (Y/N) --
-- "Pump Off" Level at ~
Vent (,.Y/N) --
Pumping Cycles cluing Adequacy Test.
Meets MOA
** Check Permitted Beclroc~ Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA
on the date of thisAnspection.
Signed~~ .~~ Date ~QD~~
Company y~. ?--~ ,.~'_ MOA NO.~>~ ~.
KB1/d5/s
[Page 2 of 2]
2-15~84