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HomeMy WebLinkAboutWYNTER PARK #1 BLK 1 LT 8Wynter Park Block 1 Lot 8 #051-491-45 MUNICIPALITY OF ANCHORAGE On-Site Water& Wastewater Program - PO Box 196650 4700 Elmore Road V Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 http://www.rnuni orglonsite elm!.mien t I)NA On-Site Wastewater Disposal System Permit (o-1(7- / 7 Toru( Permit Number: OSP171086 Effective Date: 5/16/2017 Work Type: SepticTank Upgrade Expiration Date: 5/16/2018 Tax Code Number: 05149145000 Site Legal Address: WYNTER PARK#1 BLK 1 LT 8 G:1361 Site Mailing Address: 24145 PARK DR, Chugiak Owner: KAPOLCHOK GEROGE M Lot Size in Sq Ft: 23092 Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Date: Issued By: 4' �y'yirr_ Date: MUNICIPALITY OF ANCHORAGE I TM Community Development Departments ` Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-491-45 Property owner(s) GEORGE M. KAPOLCHOK 529-6689 Day phone Mailing address 1007 WEST 3RD AVE. STE. 200, ANCHORAGE, AK 99501 Site address 24145 PARK DR., CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) WYNTER PARK #1 BLOCK 1 , LOT 8 Legal description (Township, Range & Section) Lot Size 23092 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) [ ] (w/wo ADU) Septic Tank [ Upgrade Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE !WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 21 Waiver Fees: Date of Payment: 6II6/i 7 Date of Payment: Receipt Number: 00 2(5.- 1 , Receipt Number: Permit No. Dsef LOgtp Waiver No. Permit App_9-1-12.doc �RCTEI ARCTERRA CONSULTING, INC 212 E. 5151 Ave,Anchorage,AK.99503 `. 1 Office(907)868-3791, Fax(907)868-3793 •i�S(/LT�'G ,M l May 15, 2017 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Septic Tank Upgrade Permit—Wynter Park #1, Bl, L8 The owner has requested we proceed forward to obtain a septic permit to upgrade the failed septic tank. We propose to decommission the existing 1000-gallon septic tank per code and install a new 1000-gallon tank in the same location to serve the existing 3- bedroom house. The adjacent lots are served by the Class "A" Dawn Water System. There is no surface water within 100' of the proposed tank. We do not expect there to be any adverse effect on adjacent lots by the development of this tank. If you have any questions, please contact me at 868-3791 / FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Brent M. Western .Owner's Representative Attachments: On-Site Sewer Application 20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX (907)868-3793 • `\ MUNICIPALITY OF ANCHORAGE , til . DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION r ENVIRONMENTAL ENGINEERING DIVISION 825 L Street-Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PI O FerNEW D .cit,I -`-( ..,,C.: _Cl c]+� __ (97 74 f f ❑UPGRADE MAILING AEIB SS L /Yr'` � ��-Z/A/4 5 /2 LEGAL DESCRIPTION • LOCATI•N NO.OF OEDROOMS 5. / ) 77,,_6.c) ,6'/kr} - 3 W Absorpt- n ar. e / Dwelling / , PERMI 0_ Y DISTANCE TO: 10 Pea q _ -S /S 7 w2Q Manufacturer nts s ig `- ±‹.3ial ^r-,L. No.of compartments •, Lig, ap ctt in lions Inside length Wi�Cth` r Liquid depthIF HOMEMADE: 6 i 0 dr d x DISTANCE TO: Well /t/ Dwelling PERMIT NO. 0Zz T? Manufacturer Material Liquid capacity in gallons w U DISTANCE TO II Foundation�� Iii Nearest lot Ilne / PERMIT N? c1. L Lt� z No.of lines/ Length oL it lilte Total lerig�l�2f lips Trench wid Distance between lines /\f P 1,J -Cinches 1.. Top of the to finish grade to f ' Material beneath the Total effactj agar a 77^ inches 1.7 Length Width Depth PERMIT NO, w 0 -- --- -- 4 H Type of crib Gib diameter 1—Crib depth Total effective absorption area wa A Wellto Iluilding foundation Nearest lot line DIST NCE TO: -j as Deptlt Didier Distance to lot line PERMIT NO. rite-s_77r, Septic tank Absorption area 2017 SEPTIC TANK UPGRADE: Decommission existing septic tank per — __12 ..)(./t4 V,/)�c9 ---m dI�l N code& install new 1000-gallon septic tank and two post-tank cleanouts per -- t /_____ code, maintaining 5'+ from foundation & - , existing field,and 10' + from water line. NOTES _ ______________0_60S4 - ' iI N - 1. No wells on adjoining lots are — within 200'of proposed tank placement. 2. No surface water noted within J 100' of proposed tank placement. 3. Locate& mark key box and water _ ' �(7 ?LI ^rf line prior to construction. 4, r 1 f PA's--K- ' )-z APPROVED -*fl% c BATE �� i� a: SRO 1961 ... � �1. ,....1 rf trate 111VER ALASKA ' 31:' �,iie►�.-.__ f'H. 644.,E -_ref• V/ 7/g.(1.10181 72-013 (Rev.3/78) � 8 • (it) LOT 26 LOT 25 culli EN, 83 53'9�•� 2017 SEPTIC TANK UPGRADE: NOTES 1. No wells on adjoining lots are Decommission existing septic tank per within 200' of proposed tank code&install new 1000-gallon septic placement. tank and two post-tank cleanouts per 2. No surface water noted within code, maintaining S'+ from foundation & 100' of proposed tank placement. existing field,and 10' + from water line. 3. Locate&mark key box and water line prior to construction. N LOT L 10 OT 8 u; LOT 9 lJ CV O O 0 ; W• pp 34.0 0 25.0I Q 0 _ O • • ill t �_ an 25.0 s 0• IAN IL)1:1:-..;:i:',.:it:....•,....• 4L • ��G.� 't ti b N80.09.3311,, . • 111.64 C. '49fi ••7•�,. i •Mia' Jokola a; PARK ••• L 939 •' +' DRIVE -�— Ash• 7 Sri t y C...I.,`d�,AF ',O Mart: TAS ORIYM(.IS NOT TO ISE 100011IE0 FOR USE ISA PLOT PLAR• "t • :!•fir::': -r r f:g:—A• - t EFELLIS 0M MOLES R L r,....,r:,..oa•.ertr M doimi , LECENO. SET flt0 oroarA.+. U•.e..tr•e.M Gni Aaw.r.4«rv1►r rv,radw.A F/F7F 11ItMO, !/r M0 A L I S E A V OL 1 V A fence b wl Aro+r M M r.c vd.d. 4". a "MI' "S.M."- .K""1 wilt, PUOENTIAL JACK WHITE land.*nA Aroww.trKA.N'. rr AAeA Ares M•«+1r OA t T PI a • [ XCx d{i i 4 z i rt rt t 34. 1 .n.tNctlen r 1.r«tdi rw•-1 Fn... MCI. —r---A _ _ Q Lant2E1 SINt�EY CEA AF1GlTtON: ILII �►e.wow:: • - � **On end 6.4P1 I, a►r..rrn r.M.n A�.r.n aAW Kr00 11C. . n6.... Arat...racrlr br.d.•.110641.001,110641.0110641.001, ..A1 0A- •..T- �I.anra.moat Aar ewe M1«. CPI AWL.. -LAND & CCNSTRUCTON-SullvEYORS-PLANNERS-ENCJNEERS AS---aLit LT OF: 6[61.4.ocwT saat ./77,c1,4:tiro.- 6 6 ANC/1 12AM, ALASKBENSON A 95503 9J 200 5503 (507)56 5291 LOT 8, BLOCK 1, 'E s'• 2IMS 'Ar= 30' '}"' WYNTER PARK SUBDIVISION 2005-L-2Q1A eAr3 p"�;°'`, ' " "" '°` NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTFCTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 (:)N-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION ~oc~,o~ ~ / ~ Z-C6-~ ~1J~ . ~o. I wcJ I Absorpt~n a~ 1~ I Dwelling . Manufacturer J J Ma~eTial Inside le~ -.. Width~ -- Liquid depth Foundatiol ~-~ _~z~ Total le~t).~f lilies Dwelling PERMIT NO, Material Liquid capacity in gallons Nearest lot line JO / Trench wid Material beneath tile PERMIT IN ~ ~ Distance between I I es ~ERM T NO. OTHER SOIL TEST RATING INSTALLER REMARKS Depth Total effective absorption area Nearest Jot fine Distance to lot line PERMIT NO, Septic tank Absorption area(s) APPROVED 72-013 (Rev. 3/78) ....... = .......... DEF"RRTMENT OF HIZFILTH FIND ENVIRONMENTRL PROTECTION 825 L STREET., RNCHORFIGE~ FIK 264-4728 PE'RMIT NO: DRTE ISSUED,: 8404~5 Ce.,, h~,,- 04 FIF"PL I CFINT: DJ. RE~,. L:L NTFIuT PHONE: :, ,-..; S ENG'"G. ..,Rb :L_. e,,,, EFIGLE RI',/ER., RI'{ 694-29?9 D & 1"3 ..ON=,TRUCTION 'SL9571:' LEGRL DE_,bRIF. LOT =,I~E: f'IFl~.~ bEDROOMS: SUBDIVISION: W"r'NTER '- F HRK LOT: SECTION: ±0 TOWNSHIP: ±SN RFINEiE ,=_:.09~ (SQ. F'T. OR FIE. RE:=,) 8 iW E.,LOL. I'..: t '- ~gLI IN DESIGNING YOUR ':': ' ~' LISTED BELOW RRE ]'HE EPTION:, RVRILFIbLE TO _,EFTIL. _,N =,TEM. C:HOOSE THE OPTION THRT BEST FITS '-fOUR _ Ii E. T IR E: 1'-.! C: H BEE:. DE::PTH TO PIPE [::OTTOM (FT.) 6. 0 6. 5 6. GRAVEL DEPTH (FT.) 6. 0 8.-5 ;2. TOTFIL DEPTH (FT.) fl.2. 0 7. 8 8. GRRVEL WIDTH (FT.) GRRVEL LENGTH (FT.) ~2. QR~VEL VOLUME (CLI. MBS. > J,.9. 2 21. 4 24. TRNK SIZE (QRLS) 1,000. 0 SOIL RRTING (SQ. FT. ,."'BR) ** TFINK MLIST HFIVE FIT LERST TWO COHPFIRTi"IENTS I CERTIFY THRT: i. I FIM FRMIL. IRR WITH THE REQUIREMENTS FOR. ON-SITE SEWERS AND WELLS FIS SET FORTH b'-F THE MIJNICIPFILIT'¢ OF RNCHORFIGE (MCR) FIND THE S'FRTE OF' RLRSKR. 2, I WILL INSTRL. L THE S'¢S'FEM IN RCCORDFINCE WITH FILL MOFI CODES RND REGULFITIONS, RND IN COMPLIRNCE WITH THE DE:SIGN CRITERIR OF THIS PERHIT. .?.. I WILL RDHERE TO FILL MOR FIND STRTE OF RLRSI<R REQUIREMENTS FOR THE SET BFICK DISTFINCES FROM FIN'¢ EXISTING .NELL, .WRSTFI.4RTER DISPOSRL S'?STEM OR PUBLIC SEWERRGE S"?S].'EM ON THIS OR RN"r' RD..TRCENT OF.". NE:RRiB~' LOT. 4. I UNDERSTFIND THFIT THIS PERMIT Iq VFILID FOR R i"IFI,:'~IMUM OF Z. bEDROOMS FIN[) AN'T' ENLFIRGEHEr,IT WILL REL.':!UIRE RN RD[:,ITIONFIL PERMIT. IF' FI LIFT STRTION IS INS'TFILI.ED IN RN FIRER COVERED BY FIOFI BUILDING CODES., , THEN ('..:L) RN ELECTRICRL PERMIT FiND INSPECTION MUST bE ObTFIINED.~ (2,) R--;-bUILTS' WILl. NOT BE FIPF'ROVED 1.4ITHOUT FIN ELECTRICRL INSPECTION REPORT.~ FiND (2) THE ELEC:TRICRL WORK MUST BE [)ON[:' EW FI LIC'.'ENSED ELECTRICIRN. RPPLIC:RI"~T: C/'O S '& S ENI3"O. [:, & FI C:ONSrt'RLh::.TION¢ I_,.=,UE[. b'¢ [:'FITE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HFALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Abska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG ~"c/o ¢.3,3 PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: ~/~ ~ 1 ~'~- F ;'"// 2 3 6 7 8 9 11 12 13 14 15 16 17- 18- 19- 20- COMMENTS PERFORMED 72-008 (6/79) ,¢' / ENCOUNTERED? IF YES, AT WHAT E DEPTH? ' - ' I_1 I I '"Ffi-/l ¥1 L_J Reading Date Gross Net Depth to Net Time 'Fime Water Drop /,_,/'/ PERCOLATION RATE ~' - ~ (minutes/inch} TEST RUN BETWEEN FT AND FT [tE~SSE, EPPS & iKTI'fS 222.0 F2%ST 88 AVtiNUE AN(~KARAGE, AK 99507 (~7) 349-6451 WATER WELL TEST LC~.ATION: Client's Nan~: Address: DRAW GALLONS G~NS FIELD METER DOWN TIME GPM VOLUt~ TOTAL MON I'DDR LEVEL [~EADING ~ ~ 3 y- b-~)o 5-0 ~ q~_ .... 9',~/,U ,~pO / aOo , 9°- c~:q7 lo-~ q :~q __ i O° -- i o',_~9 i.O~'- (l:z~ -_ __ ii2 Production Rate: GPM 24-Hour Capacit7 Gallcns 3,401 C STREET. SUITE 1334 ANCHORAP~E, ALAS~<A 99503 STEVE COWPER, GOVERNOR 563-6775 -Fo hlhom It May Concern,' Accor. dinq to the records on ¢ile in this o¢¢ice, the __~'2~__u~)_~ k,°9-~c ~.9 ._ .......... Water System is in compliance with the qfafe o¢ Alaska Orinkinq Water Requlations, RC;K:s~ Sincerely, Envir(eCFmental Field OFFicec • • Municipality of Anchorage 0 - On-Site Water and Wastewater Program mil 1 i (907) 343-7904 s CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-491-45 Expiration Date: JO-2 i'-( 1. GENERAL INFORMATION Complete legal description WYNTER PARK#1 BLOCK 1, LOT 8 Location (site address) 24145 PARK DRIVE, CHUGIAK,AK 99567 Current Property owner(s) GEORGE M. KAPOLCHOK Day phone Mailing address 1007 WEST 3RD AVENUE,ANCHORAGE,AK 99501 Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual Individual Water Storage ❑ Holding Tank ❑ Community Class A Well ® Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: __Xg41 / / -,,d/ i Date: COSA to be released to the engineer,unless othe,l e/quested by the engineer. COSA Fee $ (v Waiver Fee $ Date of Payment Lb f3i/(' ' Date of Payment Receipt Number (3-q6 gab Receipt Number COSA# 65C1716-7.Q Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 Firm ARCTERRA CONSULTING,INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER,AK 99577 Engineer's Printed Name KENNETH M. DUFFUS 10/18/2018 Engineer's Comments:This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface,changes inland use,local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments,deficiencies or discrepancies exist. I f. �?�� OF' AL \ d * 4 9 LI f\ * 6. DSD SIGNATURE ± KENNET M. Oe System #1 Approved for 3 bedrooms. ',, 7i6 > I 11 n!%. - /i c� System #2 Approved for bedrooms. \ °iwnorTs,10 Aar Disapproved. \��+ Conditional approval for bedrooms, with the following stipulations: 'i yr /vi,L V g ON-SITE -) • WATER AND o WASTEWATER , OGRAM -Art SER\I\c' --_. Original Certificate Date: / - I-L 9 The Municipality of Anchorage Development Services Division (DSD)issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: • COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory • Well Flow Advisory Other • COSA blue sheet 10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist# of_ Structure served by this system _ Certificate of On-Site Systems Approval Checklist Legal Description: WYNTER PARK#1 BLOCK 1, LOT 8 Parcel ID: 051.491-45 A. WELL DATA—CLASS A Well type A If A, B, or C provid- SID# 211431 Well Log (Y/N) Date completed Sanitary s- (Y/N)V Wires properly protected (Y/N) Total depth ft. Ca -i to ft. Casing height(above gro •:) in. FRO i 1 ELL LOG AT INSPECTION Date of test Static water I- - ft. ft. Well p uction g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic: ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 6/6/2017 Tank size 1000 gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping Ivi IPJ Pumper dy---• C. ABSORPTION FIELD DATA Date installed 6/22/1984 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 _ System type DEEP TRENCH Length 32 ft. Width 2.5 ft. Gravel below pipe 6 ft. Total depth 12.5 ft. (Measured 5/10/17) Eff. absorption area 384 ft2 Monitoring tube Y Depression over field N Date of adequacy test 5/10/17 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 49 in. Water added 470 gal. New depth 54 in. Elapsed Time: 1440 min. Final fluid depth 47 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at_in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES -PUBLIC WATER WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10'+ _ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway,parking/vehicle storage 10'+ Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 200'+ 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 COSA guidelines in effect on this date. , OF 44 \ Engineer's Printed Name KENNETH M.DUFFUS j��� � 1 Date 10118/2018 * 49 TII /\11. # KENNETHmay_ COSA canary sheet_2-6-15.doc I .5 71 6 • 4.. \111/4 .116:111.- bPAD Ess MUNICIPALITY OF ANCHCRAGE DEPARTMENT OF HEALTH & HUMAN SERVICES r)IVlSlON OF ENVIRONMENTAl. SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITF SEWER AND WATER FACILITY 264-4744 REcEtvED JUN 2 Application ()ate GENERAL INFORMATION [MUST BE COMPLETED PRIOR TO SUBMITTALt (a) Legal Description (include lot, 3lock, subdivision section, townsmp, range) Location (aaaress or directions] ixff-lN PAF~t~ D~I~L=~ (e) (b) Property Owner J~'/'"J/v//Oi Telephone: Home.~ Business (c', Lenmng ~nsmuuon__~ ~~ Telephone Mailing Address '~ ~ ~ , (d) ~.. ,~t.~. Comp.ny..~ Ag~n~ ~ ~ d~ ~/ ~ ~~ Address ~ -~~~ .--~-~ / ~ ~ ~ ~. Z~ephon~ ~Z~" ¢~ ~ ~ ' Mail the HAA to the followina address: or: Check here ~ if hold for Dick UP. List contact person eno aay phone number below. TYPE OF RESIDENCE Single-Family ~J~ Number of Beerooms. WATER SUPPLY [] Community,',~ Public [] Individual Well Note: If comm unity well system, must have written confirmation from the State Department of Enwronmental Conservation attesting to the egality and status SEWAGE DISPOSAL Onsite~ Public [] Community [] Holding Tank r- Note: If community well system, must nave written confirmation from the State Department of Environmental Conservation attesting to me legality ana status. Page -i of 2 72-025 IR~v 8/861 Fronl ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 effeot on the date of this inspection. Name of Firm ~ ~¢'~ ,/~¢/'~ ~¢~;T~"7"~ Telephone Address ~'~'~O ~ ~''T/~/ ~' Date ~ -A~,¢-- DHHS APPROVAL Approved for 7 r;'bedrooms by Approved '~- Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Department of Health and Human Services fDHHS) 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 DH HS 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 cedificate 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/Rev 8/86) Back J~ ~N 22 1988 RECEIVED MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4744 WELL DATA Well Classification Legal Description: Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleaoout/Manhole Water Sample Collected by Water Sample Test Results Comments .~- Rrl V, ¢p Lo? ~ ? B, LOC/rZ / If A, B, C, D.E.C. Approve N) Date Completed Yield _ Depth ot Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SFPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) ~J(~ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course +'[ % Size /~O(~).~g~ No. of Compartments __ Foundation Cleanout (Y/N) _ Date Last Pumped 1'7 ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field -,-Io (r~om l>r. evlo~ r~eo~T) To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026 fRev 8/861 Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test /~© 5'AT/~ FAo'TO~ ~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well COI'TI~di~IT~ U JELL TO Building Foundation ~--'~-/' Lot -/~'/~) ! ; On Adjoining Lots To Water Main/Service Line '-/'/(~ / (?Ec'rzL-~UODJ)¢ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course -~1~/ To Driveway, Parking Area, or Vehicle Storage Area '4-' /'O / To Property Line To Existing or Abandoned System on w/O Comments LI F'C~.TIO N Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Oil" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that ~/~lt~e,t h ecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date of Payment ~ - ~ -~ ~' 42~,~ ? % Amount: $ / ~' A~ Page 2 of 2 ~'~K~NIC~PALtTY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEM~TH DEP~RITI,~NT OF HEJg~T}I AND ENVI. RONI~NTAL PROTECTION A2PLICATION FOR HEALTH AUTHORITY g2PROVAL CERTIFICATE 1. General Information Application Date _~~ ...... Legal Description (include lot, block, subdivision, section, township, range) Location (address o~ direcRions) (b) Applicants Name Applicant is (check one) Lending Institution (d) Lending Institution ~ __/%.d ~ >J ~? T~hone Address (e) Real Estate Co. & Agent Address Telephone (f) M'gi'l the t~kA to the followln§ address: T.~.e~o f. Residence Sin§la-Family [~ Mul,:i-Famil y Number of Bedrooms Other (~describe) Water pMp_p_lj[ Individual Well Z~ Community Note: If community well system, must have written confirmation from ~he State Department of Euvirommental Conservation attesting to the legality and status. Sewag~eDis_~ No~e; If community well system, must have writ~en'corrfirmation from the State Department of Environmental Conse~a~ti~n! ~tl~e~ing to the legality and status. [Page 1 of 2] 25. ?n_~j~ineerin~. Firm Providing Inspections, Tests, File Seai;ch, Data and Information As certified by my se~L affixed hereto and as of tho validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water snpply and/or wastewater di,,~posal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein.. ~ further verify that, based o~l ~he information obtained from the Municipali~'y of Anchorage files and from my investigation and iaspecgion, the on-site water supply and/or waetewater disposal system is in compliance with all Municipal and State codes, ordinances~ and regula- ~ions in effect on the da~e of this inspection. Name of Firm Telephone Approved for/,~_%~_bedrooms Approved ~'~ Disa By :ondi tion~3. Terms of Conditional Approval CAUTION THE MUNICIPALITY OF A!~CHORAGE DEPAR'~IENT OF HEALTH AND ENVIRONb~NTAL PROTECTION (DHEP) Is.quE8 HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEbYC- ATIONS GIVEN IN PARAGR~H 5 ABOVE BY AN INDEPENDEIf~ PROFESSIONAL ENGINEER REGISTEtLED IN THE STATE OF ALASKA° THE, DREP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CER%I~IN FEDERAL AND STATE REQUIRE~ biENTS. F~PLOYEES OF DtlEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. I~ MUNICIPALIT~f OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE, PROFESSIONAL ENGINEER'S WORK° RR4/eJ/D18 [Page 2 of 2] A WELL DATA Well Classification Well Lo9 ~resent [Y/N) Tota Depth Cased Static Water Level Casing Height Above Ground Eleetrical Wiring ~n Conduit (Y/N} Seoaration Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorotion FiekJ on L.oi To Nearest Public Sewer Line Cleanout/Manhole Water Samele Collected by Water Samole Test Results Comments MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALFPt OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION APR 3 264-4720 Legal Des, cr[p~ion: f A'. B. C. D.E.C, Approved(C¢/.N) Date Completed Yield Deplh of Grouting Pump Set At Sanitar)¢ Seal on Casing (Y/N) ~, Around Wellhead(Y/N) On Adjoining Lots ; On Aaloining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date B SEPTIC/HOLDING TANK DATA Date Installed ~--c.).-) .-~ V' Standpipes J~) Air-tight Caps (~,LN) Depression over 'rank (~/~ Pure oink/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm [Y/N) SeParation Distances from Septic/Holding Tank: To Water-S~ oply Wel ~':'~ ~-,,~ ~,~ To Property Line ~_.~(..~ I 'f- To Water Main/Service Line /E:~ Course Size /O 0 ¢~ No. of Compartments Foundation Cleanout (~N) Date Last PumDea //-..f/,!/~, : for _ Temporary Holding Tank Permit (Y/N) _ To Building Foundation /~ ' ? To Disposal Field "-'~-~! '~' To Stream Pond, Lake, or Major Drainage Comments Page ' of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Width of Field ,-~E) Square Feet of Absorption Area Depression over Field ('~N~ Results of Last Adequacy Test Separation Dislance from Absorption Field: To Water-Supply Well ~o To Building Foundation ,.~-/ Lot .,,Ay,/,,4.). Type of System Design Length of Field ,-¢,~Z / Depth of Field Gravel Bed Thickness _ Standpipes Present'N) Date of Last Adequacy Test To Property Line /~) / To Existing or Abandoned System on ~'./(-/¢~/-~> ; On Adjoining Lots ~'~,'~ / ''/'' To Water Main/Service Line ,/O ! '/- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~y~_~.~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certif~ tJ).a[J I~.a~¥~ ~P4;;~?.~,_yerified or conformed to all MOA and HAA guidelines Receipt No. ~%c~q c5 I Date of Payment /-~ ' ,~ - ~ ~- Amount: $ ~ ~, ¢~ Page 2 of 2 72 026 (11/84) in effect on the date of this inspection, ][}EPT. OF ENVIRONMENT,'~L CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA gg501 BiLL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom it May Concern: According to records on file in this office the ~ Water System is in compliance.with the State Drinking Water Regulations Sincerely,