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HomeMy WebLinkAboutZERKEL #2 LT 2Aerkel #,2 Lot 2A #017-421-32 SEP -a-2015 E2:11P FROM' 70:3437997 P.1'1 Development Services Department Building Safety Division i On -Site Water A Wastewater Program 4700 Elmore Rood P.O. Box 396650 Mark eegich Anchorage, AK 99507 mayor Eamuh e- rake [9071 N9-7904 Frump Installation Lag Well Drilling Permit Number. SW_(*��=��'yQ bated€Issue:I"_19- I Parcel Identification Number: 'r . 1j Property Owner Name & ai,tcy fit a5 5 y PUMP Iyastallation Date: CC � � 1 t; Pnmp Intake Depth Below Top of Well Casiug:34weer Pump Manufacturer's Name: Wit J +f a Pump Model: WT 07to Pump Sias I hp Adapter Burisi Depth: `Q feet Pitless Adapter Manufacturer's Nnme: 6.1(9 Pitless Adapter installer: tote Well Disinfected Upon Completion? [ Yes (-1 No Method of Disinfection: / l Comments: Pump Installer [Name: T R7 Vol Tre,47 Nil Attention. The pump installer shall provide a pump installation lug to the DSD within 30 days of pump installation. Municipality of Anchorage Page 'L- of —L DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: S W Ot 00 a PID Number: (91 —C4 21 —3 Z Nam"�c.c Wastewater System: ❑ New Upgrade .r � c2cr Address: ABSORPTION FIELD Prone: No. of Bedrooms: eep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Raring: O, f_ Total Depth fro Dl ngmalg /" GPDB Ft Lot: I Block: �7 Subdivision: ?-h 4L Depth Depth to Pipe bottom from On SMI grade: F0 Gravel depth ben♦eaglil T Kf k it ?_ Ft . t' Ft Township: Range: Section: Fill added above original rade: Gravel length: 7 Da 0 rO T Ft Ft. WELL: 0 New 0 upa:�� Gravel width: �� Numberoflines: /0 04"befee hilts: Ft Ft Classification (Private. A.B.C): Total Cased To: Total absorption area: Pipe material: FL Ft. t3t(a SO. Ft 303 Driller: Date Drilled: Static water Laval: Installer. Date ins/{,a1I ' �/e Ft. S tl.T 1r 3 Yield: Pump Set at: Casing Height Above Ground: TANK GPM FI. Ft, SEPARATION DISTANCES Septic 0Holding ❑S.T.E.P. To Septic Absorobon Lin Holmng 3ubtictPrivate Manufacturer, tkvi ItinoWeN Capacity in gallons: SQtJ From Tans FFNd Station Tank Se ,Linos Welt twlU _ (0014. ,4!� for Material: Number of Compartments: Watere (•f' LIFT STATION too fovt'f- kw'f LotSize `o (,{ 450 in gallons: Manufacturer. Line S0 Foundation t0 (,/ cot t. !. -tO E)t "Pump on/ level at: 'Pumpo at: High water alarm at: Curtain �( ,FF' / �T /�' �/� Pump Maka 6 Electrical Inspections performed by: Drain J� Remarks: BENCH MARK • Location DDesc gon: A 4 / '7 Y T c1e `� Fo.Lnill '-a n Assumed Elevatlomp /1 10 4<e ENGtL/ECA'C6VkbOF NXI A,- --gyp.••' �.s,�i oo.' Ft by: Mt'fwr�.�n YF4uYT Dates: Ist_46/a° I •*=49Tyyy .� :. V 2W. Inspections performed ... .. 2nd t Of MICHAEL N. ANDERSCN Department of Health and Human Services approvalfit f moi'. CE - 94 9 f•.z/�/v�. ��p. ! r Date Reviewed and approved by: 72-013 (Rev. "1) MOA 25 Permit No. SWO10009 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ZERKEL #2 LOT 2A PID No.: 017-421-32 EXISTING 1.500 GALLON SEPTIC TANK I DNERTER A C.%2 ADJACENT WELL C.0.3 C.0.1. 00 100' RADIUS THS1 It — — FRAME HOUSE \ 1 30 I I \\ I MONITORING TUBE ORIGINAL RENCH a \ C.0.4 i I � 1 10 ' ELL RADIUS I I I I I I 1 ASBUILT I SCALE: 1"=40' 1 V4& CM CU OF At .t0 14l /�. `�I•.• v.x �+ '••`f' �� Mq, flet n.r a � y' Cf I i s 49TH p//(� •,t� [Y[YYL LSOJ � ao �i • • • ...... YVYC I.li yY[R 11p[[ � , � •r �— m wl.[ 1[YtIY �„• MICHAEL N. ANDLRSCN �v CE 949 i ff • ZI3 v/ srolIcsrcnoN dt1•�)Fpp •• •`�;�.• N.1.5. 160 41.!• `, f^L� j ��• ••`'-.,I v6 CRND. PIPE MARK A B I ELEV. ELEV. TCO2 24' 8t' / 100.8' CO1 27' 82' / 99.8' 96.4 ' CO2 27' 82� 99.5' 96.4' MT1 106' B� 90.82 CO3 73 123.5 91.1' 87.3' CO4 10116' 1 t' S' 90.Sa 87.38 MUNICIPALITY OFANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343.4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SWO10009 Legal Description: ZERKEL #2 LT 2A / —13 —O/ / vsPact, 12.:00 N l— l3 — 0 / 2 vc ?,vsPEc7 3.• o�op..•. Date Issued: Jan 12, 2001 Expiration Date: Jan 12, 2002 Parcel ID: 017421-32 Design Engineer: 0088 Anderson Construction & Eng'g Site Address: 012515 RYA ST Owner Name: GENE ZERKEL Lot Size: 98980 SO. FT. Owner Address: 12515 RYA ROAD Total Bedrooms: 5 Permit Bedrooms: 5 ANCHORAGE . AK 99516-3370 This permit is for the construction of: Q Disposal Field F-] Septic Tank ❑ Holding Tank E] Privy El Private Well ❑ Water Storage All construction must 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 (1 BAAC72 ) and Drinking Water Regulations (18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. AT THE TIME OF CONSTRUCTION THE ENGINEER SHALL EXPOSE THE SEPTIC TANK AND VERIFY THE INTEGRITY. Received By: Issued By: Date: L o Date: / — /Z — 0/ Municipality of Anchorage �. Development Services DepartmentNil Building Safety Division L On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING 2 Parcel I.D. f71-421- Permit Number SW 0to-125— Propertyowner(s) 'r r�^e� �r� ( Day phone Mailing address (1) 1 2 S I 'a Mailing address (2) ApiraOIQ Rel; RL RSkA _Zip Code S9 i�L - 3370 Legal description (Lot, Block & Sub'd.) D�ZERkEL 1 fugplV/SIO,y Legal description Section, Township & Range) Lot Size 98 q.Ft. Number of Bedrooms 17 THIS APPLICATION IS FOR: Sewer Only Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: ElHot Tub 13Jacuzzi Swimming Pool 11 water Softening Unit ❑ Therapy Pool ❑ I certify that the above Information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Waiver Fees: Date of Payment: Receipt Number: 0j- 3--S Receipt Number: (Rev. 12100) Michael N. Anderson, P.E. Civil/Structural Engineering Services 4640 Shoshoni Avenue Anchorage, Alaska 99516 Phone 345-3377 Fax 345-1391 January 5, 2001 Department of Health and Human Services P.O. Box 6650 Anchorage, Alaska 99519-6650 Re: Lot 2a Zerkel Subd. To Whom it may concern: This is a request for a permit for the above location. The existing system is in failure and will not absorb any more waste water therefore a new test hole was excavated to the west of the existing trench. The soils were found to be sandy gravel and sandy silts with no water after the seven day monitoring period. The perc was completed in the slower loose silty sand at 7 feet and found to perc at 10 minutes per inch with a presoak of 5 hours. The new system will be designed with a slower perc of 16 to 30 minutes for additional capacity due to the short life of the previous system. A diverter valve will be added to allow the existing trench to be used in the future if possible. The existing tank will be inspected for holes during the installation of the new trench, if holes are found in the tank it will be replaced. The lot has an overall slope of 15 to 20 percent to the west and the neighboring properties will not be impacted for future development due to this new system upgrade. If you have any question please call me at 345-3377 Sincere is ael derson, P.E. MOUND OVER GRADE DESIGN CRITE IA: 5 BDR X 1 0 = 750 GPD —1 OR c �fl TER FABRIC SOILS 75010.6— 1250 SQ FT REQ'D 1250/1 0' SP TRENC 0 P 11' DE P SM 9' EFF CTNE 2.0' WIDE 70' LONG DRAIN ROCK 7.0' _ tg• n V I Off, EXISTING 1 GALLON EXISTING TANK TO BE SEPTIC TANK INSPECTED AND REPLAC D SEP 1 DIVERTER VALVE IF NECESSARY W I 1st THJy II F I ` 1sz � % NEW SYSTEM ````•� I `�� EXISTING i_�ii I I 1` HOUSE EXISTING HOUSE < I TRENCH --_ -'-_-_ D" I i EXISTING. ADJACENT fro ` WELL 100' RADIUS � I I i � I i EXISTING WELL , � 100' RADIUS I SEPTIC DESIGN PREPARED FOR GENE ZERKEL F.`7SIr1, 12515 RYA ROAD.•'•.:v `p;�• +� ANCHORAGE, ALASKA 99516 j !r.'49TIl �. •• •• ••�•�•�• PREPARED BY MICHAEL N. ANDERSON. P.E. 0- MICHAEL N. A:,D[RSCN 14250 N. GOLDENVIEW DRIVEr<i•. CC•94'9 a+p�,.�d,, (907) 345-3377 / FAX (907) 345-1391 ���`•n •' �` SCALE: 1"=60' JANUARY 5, 2001 �� "� THS1 1 1 1 1 I , _ L -I EXISTING 1.500 GALLON I SEPTIC TANK 1 � 1 � 1 I � 1 VALVE O O 1 1 1 MONITORING TUBE 1 � EXISTING PIPING 1 1 / 1 h 1 �1 1 � I 1 � 1 1 i 1 i ,,-EXISTING TRENCH 1 A.D.--IC1 1 I 1 1 1 SEPTIC DESIGN PREPARED FOR GENE ZERKEL 12515 RYA ROAD ANCHORAGE, ALASKA 99516 PREPARED BY MICHAEL N. ANDERSON, P.E. 14250 N. GOLDENVIEW DRIVE (907) 345-3377 / FAX (907) 345-1391 SCALE: 1"=20' JANARY 5, 2001 EXISTING HOUSE EXISTING WELL , 100' RADIUS,' OF q� 49TH • • ; ,•'fY/:::YL VO MICHAEL N. AADERSCN fc• CE 946 ."�j OF A4�xj ' '"h: ' (ENGINFERssEA417 �+ *:�49Lr \^ • ;k ..... e yMunicipality of Anchorage DEPARTMENT OF HEALTH 6 HUMAN SERVICES 0 V' MICHAEI N. n.no;a;cN :a 825'1' Street. Anchorage. Alaska 99502-0650 �••, C 9169 SOILS LOG — PERCOLATION TEST t,�►f�Frib�o,, ��,�`��.: PERFORMED FOR: C e`^� OT•r ri.P \ DATE LEGAL DESCRIPTION: luLo4-I Township. Range, Section: DEPTH SLOPE SITE PLAN IFEETI � ori •sic i 31 I Sag1y � rcvc t 4- 5, 61 7' 8 9 10 11 12 13 14 15 16 17 18 19 La04C, SAHa..y `1t I4 c(ta.1 Loc.se:r X0.11 G, WAS GROUND WATER J' o ENCOUNTERED? N IF YES. AT WHAT DEPTH? OepiA to War Aver MMWW4? 7J o wU Cut 7- l9 v 20 II PERCOLATION RATE Iminutevmcm PERC HOLE DIAMETER .1� TEST RUN BETWEEN L.s FT AND -7'0;.. FT :OMMENTS rI SG Ut'•e t7 1-rlen 4 S(O.�+'tr 1acic— PERFORMED BY: M t rl`O�I �I PALO /I I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE: ,/ 00 72-M (A r. 4,85I fi. DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division ~ ~/) ¢-~.~ 825 "L." Street, Anchorage, Alaska 99502, Telephone 264-4720 ~ / 7 - L/ Z / - ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~.,~ DISTANCES ~0 ~ E~ ~ ~ K ~ ~ ~ SEPTIC ABSORPTION Address TANK FIELD WELL "~ ~ ~.d , IZ ~10 I~ ~ ~.e(s) Perm,t NO NO el Bedrooms -- WELL / ?¢' /ff~ ~ 'J,~ ../~[~ 9~0 3 ~ V ,~ ~ LOT LINE Township, Range, Section ~8.BMit. T DIAGRAM (Sllow Ioc~bon si well septic syslem, property hnes, Ioundatmn, TANKS N ~ SEPTIC E} HOLDING / Matenal No. Si Compa~mems TYPE OF SYSTEM -- -I ~RENCH ~ BED ~ W. DRAIN ~ OTHER ~eptb to pipe bottom from ~ot¢l deptl~ from original grsde Fill added above original gr8de depth beneath p~pe WELLS % ~x ¢ PRIVATE ~ OTHER (identify) __ ~D' ~ ~ FT ~/ / __ FT -,1~' _ , _' REMARKS: -- ~ ~ ~¢ ~Micheel E, Anderson '~ 0 I~l~O ~ cedily Ihat this inspection was pedormed according Io alI~[~c ,% 4381 - E Health Depa.mem Approvnl: 7 ~ ~¢¢~¢'--~/~ _ Date:, 72~013 (3/85) post. Ir. brand fax ~ransnllttal r'nemo 7671 ~'~ .... ~om .......... ~NVI~ONMENTA WATER WELL RECORD STATE OF ALASKA DEPARTMI~NT OF NATURAL RE$OURES Division of 6eologiooI & GeoPhy,qool gurveyt FINISH OF WEE(,: E]o LOT' q Z~O~ PLOT I~LAZT .~- AB BUILT ~ Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMANSERVICES 82.5 "L" Street Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATEPERF LEGAL 2 4 5 6- 7 8 9 10 11- 12 13 14 15- 16- 17 18 19- 20- Township. Range, Section: SLOPE WAS GROUNO WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN PERCOLATION RATE ~.____~_ (rn,nu[e~,nc~) PERC HO~ DIAMET~ T~T nUN BE~E~ ~-- ~ AND ~' ~ m PERFORMED BY: ,/J~' ,t~ ~ ~ ,'~/~'/~f'7 I .~/~i~ ~ /~.I~6'~.~fl~ERTiFY THAT,THIS/.>/-.--/.~TEST WAS pERPOR~4ED mN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE- '[/~-f>[~O - 724308 (Rev. 4/8.5) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN.SERVICFS 82,5 "L" Street, Anchorage, Ataska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PEI LEGAL 1 5A~JoV 5 5~ 6 S 7 10 12 15 16 17- 18 19 20- Townsi~ip, Range, Section: 52~ 7-/2/,/ SLOPE SITE PLAN Zt _ WAS GROUNO WATER ENCOUNTERED? IF YES. AT WHAT OEP'TH;~ !_¢ pI:qFORMEO BY: --~P' ~ *'~-I::~c~ X ~- ~ I/~J(~'~"~'/~ Ii.~.. ~' ~J~ &;'~'~TIFY THAT THIS TEST WAS pERFORMED I" ACCOROANCE WITH ALL STATE ANO MUNICIPAL GUIOEI]N~S IN EFFECT ON THIS OATE. OATE; -- /'~'~/~'/¢'~/~ -- ANDERSON P. O. BOX 240773 Anchorage Alaska 99524 ENGINEERING 907 337- 8367 October 4, 1990 Municipality of Anchorage DFIHS 825 L Street Anchorage, Alaska 99501 To Whom It May Concern: The irnpact of constructing and operating water and wastewater systems on the subject property are expected to be minimal based upon the size of the parcel (2.5 Acres). The septic system and reserve area are both located nearly 200 feet from the closest well. Due to the nature of the soils there should be no effect to groundwater runoff as well. Please call me if you have any questions. Yours Truly, L. Wayne McFadden Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN.SERVICES 8?.5 "L" Street. Anchorage. Alaska 99502-0650 SOILS LOG ~ PERCOLATION TEST PERFORMED FOR: .~ ~_)~ Id~.~L= DATE PER~R~'~', ,: ~'"" ;~ .Y~/Z~,~/~ LEGALDESCRiPTiON:.~'.//t/~/~/ ~t/ ~1/~ flW~/,tTownship, Range, S~tion: ~ ZC T/Z~ ~l~ SLOPE SITE Pt~N 10 11 12 13 14- 15- 16- 17 18 19 20 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? PERCOLATION RATE -- TEST RUN BEI'~NEEN __ FT AND __PT ACCOROANCE WITH A~ STATE AND MUNICIPAL GUIOE~N~S IN ~FE~ ON ~IS ()ATE OAT~ .\ c~C~ / VACA~J'F LO 5-~pvt~ 5qsr~'~ [A~ ELL MUNICIPALITY OF ANCHORAGE ECONOMIC DEVELOPMENT AND PLANNING P.O. Box 196650 Anchorage, Alaska 99519.6650 PRELIMINARY PLAT APPLICATION OFFICE USE RECD BY: VERIFY OWN: A. Please fill in the inlormation requested below. Print one letter or number per block. Do not write in the shaded blocks. 1. Vacation Code 2. Tax Identification No. 11HP/1 1=1 3. NEW abbreviatb,cl legal"descr 'ption (T12N R2W SEC 2 LOT 45 OR SHORT SUB BLK 3 LOTS 34). ONION 10111101 1 1 111 ie 4. EXISTING abbreviatedlegal description (T12N 132W SEC 2 LOT 45 OR SHORT SUB BILK 3 LOTS 34) full legal on back page. 5. Petitioner's Name (Last - First) W 6. Petitioner's Representative mommmmm©m�mIBM mo©® mmmm I o Sol IN II != Address M516 iZYn ST(7_,Fik City /4tx.4Fya.nr State 4 - Phone it a rI-5-IQ) 01 Zip "1s1, 7. Petition Area 8. Proposed Acreage Number Lots 1111911 in 11111010 Address k -T-1 gt QA:Tiri S f u,_ Ct(Lr-t,,G _ City Phone8_:'A, - (O( n Zip C05; IS 9. Existing 10, Grid Number Number Lots 111 lmiimilloll � 12. Fee $ 350 _ 13. Community Council 11. Zone ,,IB1III B. I hereby certify that (I am)owner of the property described above and that l desire to subdivide it in conformance with Chapter 21 of the Anchorage Municipal Code of Ordinances. I understand that payment of the basic subdivision fee is nonrefundable and is to cover the costs associated with processing this application, that it does not assure approval of the subdivision. I also understand that additional fees maybe assess d if the Municipality's costs to process this application exceed the basic fee. I further understand that assigned hearing dates are entative and may have be postponed by Planning Staff, Platting Board, Planning Commission, or the Assembly due to ad{ttini ative r¢ap�ons. f /� Date: 02 e 0790 *Agents must provide written 20003 (Rev 6/69)1AOA-24 fLwGI_ 5U - LO jaC5j-Tj)j-jAjPj-3 X rxNW I4sG /4N W/4f`l WY4$ 5. Petitioner's Name (Last - First) W 6. Petitioner's Representative mommmmm©m�mIBM mo©® mmmm I o Sol IN II != Address M516 iZYn ST(7_,Fik City /4tx.4Fya.nr State 4 - Phone it a rI-5-IQ) 01 Zip "1s1, 7. Petition Area 8. Proposed Acreage Number Lots 1111911 in 11111010 Address k -T-1 gt QA:Tiri S f u,_ Ct(Lr-t,,G _ City Phone8_:'A, - (O( n Zip C05; IS 9. Existing 10, Grid Number Number Lots 111 lmiimilloll � 12. Fee $ 350 _ 13. Community Council 11. Zone ,,IB1III B. I hereby certify that (I am)owner of the property described above and that l desire to subdivide it in conformance with Chapter 21 of the Anchorage Municipal Code of Ordinances. I understand that payment of the basic subdivision fee is nonrefundable and is to cover the costs associated with processing this application, that it does not assure approval of the subdivision. I also understand that additional fees maybe assess d if the Municipality's costs to process this application exceed the basic fee. 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Z Z U m U W M m \"D P Vi f f G K K E d ego. - F ) a 3 S v C� N ti m° NZ p I U a � a a vec¢q Os - mw=+M1 � a M10 m m N 1014 y Np-- 0009 6 ° O LL? m \"D P Vi N _ IW119' ail /a0 30IG771H J11/laV38 40 stsve -/b 2' S v N ti h p - U a � a a vec¢q Os - m \"D P Vi ago- N J 0 0 0 moo 0 QP: o- Tv 2 U O 3 4 W W a Q: p N z m o ll! m o m m y J m G = ch d J m � J b . m c y Q Y k a u o F A O S - U a � a a vec¢q Os - ti U ti w Q°>UV OOw b mtim�o �a a „dam ¢ice'% n m F y u ya ` N. + o E u N\«�N&a a owq»am° pm>�dOC S�a`u,i N'i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # _ Complete legal description Location (site address or directions) EAST o,u Property owner Mailing address upper'< Day phone Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROC)MS: TYPE OF WATER SUPPLY: Individual well Cornmunity well Public water NOTE: If community well system, provide written confirmation from State ADEC '~t~st- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTF: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1191) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my'seal affixed hereto and as of the validation (late 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 invest, igation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and Stat~ codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /~z4 ~ =--l~.g~ .J ~-';~dG/,.3~'~-7z4,,)b Phone Address '~,, 0. EngineeYs signature M'3/'~-c~, C (~,..4~.~ ~----~ Date ?/'~/~/ J DHHS SIGNATURE _~ Approved for Disapproved, Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 DH HS 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. ~ Municipality of Anchorage ~,4~,,¢) Department of Health & Human Services · ~ HEALTH AUTHOR].T.Y APPROVAL CHECKLIST Legal DeScription: -,~P~J FY 4L¢~¥ A/~-¢ FY' A/H/~4~/ Parcel I.D. ¢/7~ ~'ZI A, WELL DATA Welltype P,.~/l/.47~ _lfA, B, orC, attach ADEC letter, ADEC water system number Log present (Y/N) ~/ Date completed Ib-ZZ-?O Driller Total depth_ -2~/ Cased to ~Z//Z~~"z~/~'~/~ Casing height Sanitary seal (Y/N) y wires properly protected (Y/N) ,~. z FROM WELL LOG Date of test /~- 2g-q¢ Static water level _ ~¢¢' Well flow ~' ~ Pump level N~T DE'f'E¢. ~'~, ~Gb_ AT INSPECTION g.p.m. '--¢ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I '7~' Absorption field on lot / Public sewer main f'~ ~ V -pul~lic sewer service line ; On adjacent lots ; On adjacent lots /'~6 _ Public sewer manhole/cleanout ~'l Petroleum tank Mo~_ b~ LoT WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~-Z.¢- ?/ B. SEPTIC/HOLDING TANK DATA Date installed /~2 ?- ¢~) Cleanouts (Y/N)_ ~/ High water alarm (Y/N) Date of pumping &/EW Nitrate /~, Other bacteria Collected by: _Tank size /,~'~) ~ Compartments Z_ Foundation cleanout (Y/N) y Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / ?~, ' __ On adjacent lots /~ ' ¢'- Foundation To property line //-/.,¢' Absorption field _ "~ / Water main/service line Surface water/drainage ,,V,~/~'g /,v' /,~,'~Z~IAT~ 72 028 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE N Date installed-'"----. Manufacturer Size in gallons ~ Manhole/Access (Y/N) "Pum~ "Pump off" level at Vent (Y/N) High water alarm level ~_~Cycles tested Meets MOA electrical codes (Y/N) ~ SEPARATIQN DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed Eength ~- 5' / ' Width 2. '5' Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating /2. ~ System type Gravel thickness ~ / Total depth Cleanouts present (Y/N) y Date of adequacy test NE I.~ ~'okl STR ~]d '~'/OM 0cT~,,~.~¢,¢' ~'~c,~ R-/-¢ / for __ ~'- bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water kl(~ IM On adjacent lots /¢¢/¢ Property line /¢o / To existing or abandoned system on lot tJo~JE. O~ /-o T Cutbank A/O~E l~,l A~E~t Water main/service line c~O/ Driveway, parking/vehicle storage area '~ ~ Curtain drain MOklE:_ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer's Name Date HAA Fee $ ,/ 7 ~-), ~--~ Date of Payment Receipt Number 72 026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number