HomeMy WebLinkAboutMOUNTAINSIDE VILLAGE BLK 1 LT 1Mountainside
Village
Block 1
Lot 1
#020-172-13
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241073
Work Type: SepticTank Upgrade
Tax Code Number: 02017213000
Site Legal Address: MOUNTAINSIDE VILLAGE BLK 1 LT 1 G:3439
Site Mailing Address: 17601 ROSEMONT DR, Anchorage
Owner: BELOY FAMILY TRUST
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
5/3/2024
5/3/2025
55422
❑ Disposal Field Q 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: (S�
Issued By:
J
Date:
Date: S 3 to z y
4
�- N C i�PA L11 TY OF A�m. cHoRA\ G
A
Development Services Department``
"�� Phone: 907-343-7904
On -Size Water & Wastewater Section Fax: 907-343-7997
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 020-172-13
Property owner(s) KIEL BELOY Day phone 907-227-5174
Mailing address 17601 ROSEMONT DRIVE *ANCHORAGE, AK
Site address 17601 ROSEMONT DRIVE *ANCHORAGE, AK
Legal description (Sub'd., Block & Lot) MOUNTAINSIDE VILLAGE; BLOCK 1, LOT 1
Legal description (Township, Range & Section)
Lot Size
Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
(N all that apply)
TYPE OF DWELLING:
Absorption Field ❑ Initial ®
Single Family (SF) El
Septic Tank 0 Upgrade [�(
(w/wo ADU)
Holding Tank ❑ Renewal ❑
Duplex (D) El
❑
Multiple Dwellings ElPrivy
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A 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: _02Z5 Waiver Fees:
Date of Payment: .SII/ZY Date of Payment:
Receipt Number: _ (j �cq,�g-yG Receipt Number:
Permit No. Ply 1075 Waiver No.
GADevelopment Services\Building Safety\On Site Water and WastewateAForms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241073, Curtis Townsend, 05/03/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241073, Curtis Townsend, 05/03/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241073, Curtis Townsend, 05/03/24
of
\\ MUNICIPALITY OF ANCHORAGE
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street. Anchorage, Alaska 99501 Telephone 264.4720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
Cee Ltnto/n
5-6 / /-2.2AUPGRADE
MAILING ADDRESS
co.� god A -c�3-
LEGAL DESCRIPTION
Mounfa.:s St CL Ur-//. L • / Sr. /t r//N /Z 3 L -i
LOCATION
KK �QM Ont
NO. OF BEDROOMS 4
DISTANCE TO:
Well�.
/2.(j
Absorption area
Dwelling
PERMIT NO.
690Z29
D Y
/O
ncil- s17
ZQ
~
ManulacturerC-f f't e �
Material S 7
No. of compartments Z
N
Liq, capacity in lqlons
IF HOMEMADE:
Imitle length
Width
Liquid depth
2 S
b Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J02
S=FQ•
Manufacturer
Material
Liquid capacity in gallons
o
-1
DISTANCE TO:
Well
114
Foundation
Acif-")
Nearest lot Ime
/ 3
PERM
� �O Z2. �
W.1 M Z
.
No. of lines
Length of each line s
Total Ipngth of lines
Trench width
Distance between lines
;: F W
2
-
$p
inches
AIA
c F¢-
Top of tile to finish grade �/.
Material beneadf tile /
Total of i absorption area
d
2 — 7
6 ineties
�-
Length
Width
Depth
PERMIT Nu.
W
t7
F-
d1
Type of crib
Crib diameter
Crib depth
Total eflec[ive absorption area
W
a
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
W i
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
Nr
PIPE MATERIALS
Dao 3'[
SOILTEST RATING
2 3/ '/6 �k
!.
INSTALLER
G's r X d' S / S.z
o
REMARKS
/h c pecfa 6 aar. Ma/t STfiS—�
gk
F
/ tri OLST
r
ek ti
41- 223 / 01 /L • 1h
11 F U `t- 1 •eRt �f O� t o Cf •� —
",
f
A
S
-
o
r
1
�
APPROVED -- DATE LEGAL -
72-013 (Rev. 3/781
0
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: �' CS L.0Ag- 11Jc--vvO7 DATE PERFORMED: 7 - / * Z35
L. + ( B I.e-h-1
LEGAL DESCRIPTION: '![ c.L404a:nS.'4t V, 111Township, Range, Section: ��•
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
OL ofItn(c s0i't
In 1`1 se I h Sa4d 7 4,rrtve 1
rh MaNSI-ftt " c"Ll't)
6kF -'-31101 I,( Id
h
WASGROUND WATER
OP ENCOUNTERED? q D
%,V 0CTlu`NcC1 S
IF YES, AT WHAT L
O
DEPTH? P
E
Depth to Water litter
Monitoring?, - Date:
,a .
SITE PLAN
■■■■■■■R■■
Grosa
Time
■■■■.■■M■■
Depth to
Water
QwMzMMMMwN
A-rfi
ONNNNERENE
ENNNOMENNN
NESENNEENE
If r5
EV92002r�MME
001100190r��1OWN
N.IIMME®OMMM
r
MENNE
REENN
MENEMMEEMN
/3-ZDf7 �L .. ajr y(xa 'H7 a4 0.. �;e -PvM cv�. f'All T.{� /�� tQ,/
� -C'14
Reading Date
Grosa
Time
Net
Time
Depth to
Water
Net
Drop
A-rfi
//33
Zc,o
If r5
TEST RUN BETWEEN 2 FT AND -2'4^ FT
r
./c
Tor+ -a
�'J- ''0 /O t:t n. -/[.i nv "L27 'Q'�/, (Sc,,'1 ty,r»„^f C•1/!'�
/3-ZDf7 �L .. ajr y(xa 'H7 a4 0.. �;e -PvM cv�. f'All T.{� /�� tQ,/
ryo7"SSl'/Ar—
PERFORMED BY:
Trs-s-0-2- 1 � TERTIFY THAT THIS TEST WAS PERFORMED IN
^
I Jet
h
(, U
ACCORDANCE WITH
ALL STATE AND
MUNICIPAL G-111114 NES IN EFFECT ON THIS DATE. DATE: 7
12.?I
o
.'
/O
203
2 0
-
ILI
(o
( 3
M
P
/22
(0
I4
20
/ �
•O/
PERgOLATION RATE 24 jritetutesnnch) PERC HOLE VAMP:
TEST RUN BETWEEN 2 FT AND -2'4^ FT
COMMENTS -5$'a'(
Tor+ -a
�'J- ''0 /O t:t n. -/[.i nv "L27 'Q'�/, (Sc,,'1 ty,r»„^f C•1/!'�
/3-ZDf7 �L .. ajr y(xa 'H7 a4 0.. �;e -PvM cv�. f'All T.{� /�� tQ,/
ryo7"SSl'/Ar—
PERFORMED BY:
Trs-s-0-2- 1 � TERTIFY THAT THIS TEST WAS PERFORMED IN
^
I Jet
(, U
ACCORDANCE WITH
ALL STATE AND
MUNICIPAL G-111114 NES IN EFFECT ON THIS DATE. DATE: 7
72-008(Rev. 4/115)
Al �17'G
( �z Ptrh 'f CS �" 14y1'i K-"7•jw'/ r/
r WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division Of 6e01091C01 a'Ge0PAysICO1 Surveys
Drilling Permit No.
LOCATION OF WELL (Please complete either la. to ar It.)
lo. Borough
h`ill�l.
(1A'u'11.i11i1or'1.:
Villy+r_
Lot
1
Block
1
Ib. 1/44th.
1—,f—,f of
Section No.
TuwnshlpN❑
B❑
flame* E10
w❑
M*rl Alan
It DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
S. OWNER OF WELL: r
Address: rr. Cmig Uncoln
Sheet Address end Area of Well Location
2. WELL L06 feelBlow
Burl*08
Malarlal Type Top eot:am
d• WEL -DEPTH: (final)
1 it.
B. DATE OF CQMPLET ON
7 — 2/ —,5
!iih 0.0 gravel t/ 1:;. adlk::'ltl:d i1tim. U 8
a. OCable teal U)Rolary ❑odea, E3 one
- .1 1- . •,.. in
❑Augv ❑J*/led ❑Bored ❑OtMr:
Ir'k''• drV 'r.111.1 11) 24
?.Use: Q Domsttla ❑ Public Supply ❑ Industry
❑ Irrlgatlen ❑ R08harq* ❑ tsmmerlael
❑ Lot Well ❑ Other:
(1.ty1itc1j ::i IL WAIna ul 40
1,• I 41) 46
lY'4it:ry, A11/t.["iU Rd :Alt 46 47
9. CASINO: ❑ Tpri�ded Welded
dlam. U In. td 44 11. Depth WeIgAI 17 Ibe./ll.
• 1 ,:.- •. 4 . ( !
dlam. In. 1 11. cloth Stickup ft.
9. FINISH OF WELLI
Typo: rxk DlamaUn
Blet/114.11 31308 Length:
Sae between f1. and n.
1-2 W1artiuq Ii'uu nxl: C 4r1 CI ft.
'
Backfilling Gravel pock
i:t (Sit ayl,inI frud rod: fi 1-1t'"165 fl.
31 11. 7 27 '
10. STATIC WATER LEVELI
❑ Above or U Below fond ourfaes Date
Equipment glad; dnt valve Iniler
a
/�•n �F.'T .
11. PUMPING LEVEL below lend *Urfa.* end YIELD
ft• after hr,, pumping_q•p•m•
It. alter 1108• pumplwv _e.p.m.
'l," y,,
12.GROUTINO Well Secured: ❑ Yoe n No
Malarlal: ❑ Nw/ Cement ❑Other:
•fn -Y(.,
IS.►UMP: (11 available) HP
Length of Drop Pipe ft. capacity q.p.n.
® Subs. ❑ Jet ❑ Centrlflcol ❑ other
14. REMARKS:
Bailed &Y: I'eacomY of 48 galloro
5 (five) Bdmltes aftarw d -i, a•9.5 CM. v--
16. WATER WELL CONTRACTORS CERTIFICATION: 'M x48141t
15. Water Temporal,,, _* ❑ p ❑ C
This well we, drilled under my jurisdiction and Ihla -soon I. Ir08 to in* 0081 Of my knowledge and be Uef;
1} -Bill lylllirt; 0). LV512 -
Registered Business Nom* Contract License Numbs,
Address. i7i'JiLN1z) 1 B''ei !)1)C J: `xff9
Signed: _ 1 ; ' �� oala• O. 9 ri"
Aalnortr*d Representative
e
Form 02•WWA (II/eq COPY DUlrlbutlon: WHITE- Stats 0003. ►INK•Orliter. CANARY -Customer
n r,
MU1+1 I Cr I F='r'�kE_ I -T-Y C3 F_ 1'4P4C;7--I C3;--Zd'-�C:3E_
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
C3 til — ^ITE- 8E= QJ E=1 i 14 . t -J =- S_'1_
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL, DESCRIP:
LOT SIZE:
MAX BEDROOMS:
850229
05/20/05
CRAIG LINCOLN
1911 LORE RD
ANCHORAGE, AK
5611222
SUBDIVISION:
SECTION: 11
55500 (SQ.FT
4
99507
MOUNTAINSIDE VILLAGE LOT: 1
TOWNSHIP: 11N RANGE: 7W
OR ACRES)
FLOCK: 1
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site.
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- -- -
I certify that:
1. I am familiar with the requirements for on-site: sewers and wells as Ot
forth by the Municipality.of Anchorage (MOA) and the Ctato of Alaska.
2. I will install the system in accordance with all MOA cedes and regulation_,
and in compliance with the design criteria of this permit.
Z. I will adhere to all MOA and State of Alaska requirements for -the set bac_;:
distances from an existing well wastewater disposal te„, or public
Y 9 , i s)'s
sewerage system on this or any adjacant or nearby lot.
4. I understand,that this permit is valid for a maximum of 4 bec:rocme and
any enlargement will require an additional permit.
IF A'LIFT STATION IS INSTALLED IPJ AN AREA COVERED BY MO^ BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST FE ODTAINED; (2) AC-E:UILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (7) THE
ELECTRICAL W7,K MUST Br DONE B' LICENSED ELECTRICIAN.
SIGNED ( DATE:
lll///111
APPLICANT: GRAIL COLN
ISSUED BY ^ DATE:
-- -- - --- _ - -- ----------- --- -- 65.-1_-----
T F-< C ^.E C 1-1
=- L ID
ttit _ . ID!!F"* r, I hl
DEPTH TO PIPE BOTTOM (FT.)
4.0!/
4.0
4.0
GRAVEL DEPTH (FT.)
6.0 ✓
0.5
3.5
TOTAL DEPTH (FT.)
10.0 LQO
4.5
7.5
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
2.5 1
50.0a�
220.0
41.0
5.0
65.0
GRAVEL VOLUME (CU.YDS.)
70.1
:>3.5
48.2
TANK. SIZE (GALS)
1,250.0 **r
4450.0 *
1,250.0 ►
SOIL RATING (SO.FT./BR)
150 —,g3(
150
150
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- -- -
I certify that:
1. I am familiar with the requirements for on-site: sewers and wells as Ot
forth by the Municipality.of Anchorage (MOA) and the Ctato of Alaska.
2. I will install the system in accordance with all MOA cedes and regulation_,
and in compliance with the design criteria of this permit.
Z. I will adhere to all MOA and State of Alaska requirements for -the set bac_;:
distances from an existing well wastewater disposal te„, or public
Y 9 , i s)'s
sewerage system on this or any adjacant or nearby lot.
4. I understand,that this permit is valid for a maximum of 4 bec:rocme and
any enlargement will require an additional permit.
IF A'LIFT STATION IS INSTALLED IPJ AN AREA COVERED BY MO^ BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST FE ODTAINED; (2) AC-E:UILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (7) THE
ELECTRICAL W7,K MUST Br DONE B' LICENSED ELECTRICIAN.
SIGNED ( DATE:
lll///111
APPLICANT: GRAIL COLN
ISSUED BY ^ DATE:
-- -- - --- _ - -- ----------- --- -- 65.-1_-----
PERMIT NO:
DATE ISSUED:
AP'P'LICANT:
ADDRESS:
/� • �--�-�-c-�-sem--,
ML "I C; 1 F --'n L, I TY MJr f-i"f--1-4C3r-,:j-':C;=
DEPARTMENT OF HEALTH AND ENVIRC^JMENTAL PROTECTION
025 L STREET, ANCHORACE, AK 99501
264-4720
C] Jni Sa I T E E�3 [= tAJ =-- F2 Z< L1.I E -Z !_ L- Fes' F-- F-< C'1. I -
CONTACT PHONE:
LEGAL DESCRIP:
050229
05/20/05
GRAIG LINCOLN
1911 LORE RD
ANCHORAGE, AK 99507
5611222
SUFDIVISION: MOUNTAINSIDE VILLAGE LOT: 1 BLOCK.: 1
SECTION: 11 TOWNSHIP: 11N RANGE: "W
LOT SIZE: 55500 • (SO..FT.
OR ACRES)
MAX BEDROOMS: 4
Listed below are the options
available to you
in designing
your septic
System. Choose the option
that best fits your
site.
TF:ChICF-1
nr-]D
-
- -
- W _ FiF:n I P4
DEPTH TO PIPE BOTTOM (FT.)
4.0
4.0
4.0
GRAVEL DEPTH (FT.)
6.0
0.5
.5
TOTAL DEPTH (FT.)
10.0
4.5
7.5
GRAVEL WIDTH (FT.)
2.5
20.0
5.0
GRAVEL LENGTH (FT.)
42.0
:,0.0
54.0
GRAVEL VOLUME (CU.YDS.)
^S.1 `
C0.2
40.0.
TANK SIZE (GALS)
1, 50 ;� �rx/
1,250.0
SOIL RATING (SO�.FT./BR)
25
1.^_5
105
- -r --- --
TANK MUST HAVE ATLEASTT- — --
A.,S
'M _ ---
- - - - - - -
I certify that: _
1. I am familiar -with the requirements for on-site sewers and wells a:; set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
�. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
. I will adhere to all MOA and State of Alaska requirements for the sct back:
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent'or nearby lot.
4. I understand that this permit is valid for a maximum of 4 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK' MUST DE DONE BY A LICENSr--n ELECTRICIAN.
SIGNED DATE:
APF•LICANT: GRAI LINCOLN
ISSUED BY
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
'9
9
10
11
12
13
14
15
16
17
18
19
20
COMMENT
PERFORMED
72.009 (6/79)
-;x �'[� • SOILS LOG
MUNICIPALITY OF ANCHORAGE /
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION,
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
fI
a
�r y ��• n . I
G
W6 P.
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
DATE PERFORMED:
Zkck
FYtgi4
Woommmm
MMMKWOMM
M■■■■■■■■
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
r
r
PERCOLATION RATE
Municipality of Anchorage
• ^- Development Services Department
Building Safety Division
On -Site Water and Wastewater Program `
4700 South Bragaw St. s' `•
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 I.D. 0 ZO .1.72 - 13 HAA # •0,15W44
1. GENERAL INFORMATION Expiration Date: 12 - / .21- 0 5"
Complete legal description _Loi f, 13/e,e-4 / Lfou^76P^.r.cdc 41*11o9e_
0
Location (site address or directions) 1"7d0 if >?oJ ear 0^/ D,:, .e
Current Property owner(s) TO Rn F 1<00" 13o0/L, Day phone' 3 y6 -
Mailing address
Lending agency
IT6ol Roves onl be -;.+e ji_cloro�P Atc 9eS /6
Day phone
Mailing address
Real Estate Agent H#chac l D,_eve•e. Ctn/2/ 2 s8 -SBoo
Day phone_ 23G _-17`7 Z
Mailing Address W2_0 w. re"C4*i00e 40-- A,. . '➢9 e0 T
Unless otherwise requested, HAA will be held by DSD forpickup. pl eore_ ctrl/ rucr/ A* a 1`ric4«e/
2. NUMBER OF BEDROOMS: y� nroe.Pt Z70-777% u�Ae^ H11.4
IS 2 S6�S6cc� n c k - ae
V.1,
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual On-site tz
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 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 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. (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 ora .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
ht my i that the ation-
based on procedures outlined in the Health Authority Approval Guidelines for this application,
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 fromor
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,`rdiinrances,
and regulations in effect at the time of installation. Niw wafer N1fY P/'
Name of Firm
-fdffoP T�cl7n:�«/ Str✓:moi Phone 3 ys'� T 6
Address /HS30 Ectio SFS /!^h^ Ao�t. '}k 475�� f2 wos
Engineer's Printed Name TJ,eo coo 7=• N�+a Date Serf _
5. DSD SIGNATURE
✓ Approved for _LJL__ bedrooms
Disapproved.
Conditional approval for
A4 4N
4;
o.
49LH e
1 „, �: tiEODORE F. MOORE
CE 3559
�. •. . a
bedrooms, with the following stipulations:
c*:
„1. WATER
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 1 �-- 0
By:'
(Rev 01A2)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST'
Legal Description: Lo / ! afcacte I 1`tvelr JQIVC/of Village Parcel ID: 0 Z -1? 2
- /3
A. WELL DATA
Well type P✓ % If A, B, or C provide PWSID # = Well Log (Y/N) Y
Date completed 7/2-7 /6.f
Total depth 16 ft.
Sanitary seal (Y/N) Y
Cased to *17___ft.
FROM WELL LOG
Date of test 7/ Z7 / 8s -
Static water level 10 ft.
Wires properly protected (Y/N) Y
Casing height (above ground) 2 Y In.
AT INSPECTION
S/2.6/or
y-3 ft.
Well production !. s g.P.m. y 9 9 P.M.
WATER SAMPLE RESULTS:
Coliform 12colonies/100 ml. Nitrate 2. S6 mg./I. Other bacteria _e5 colonies/100 mi.
Arsenic: mg./I. Date of sample: _2__/8 I*r Collected by: - F 14mr>t/oi 71,c,4 Stie
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material .S e/!tr C / Sf•e /
Date installed W -a 2 / 8 s
Tank size i_ zsy gal. Number of Compartments _*Z_ Cleanouts (Y/N) Y
Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N. A
Date of pumping_S/27 Ion Pumper NorH,lova(
C. ABSORPTION FIELD DATA
Date installed '7�2 s bf Soil rating (g.p.d./ft' or ft�/bdrm) 2 t/ �� System type 71-C,.C4
Length 9 ! ft.
Width ?
ft. Gravel below pipe _d— ft.
Total depth _J_ ft. Eff. absorption area 1092 ft2 Monitoring tube Y Depression over field _M
Date of adequacy test S 126/G Results (Pass/Fait) P� For 9 bedrooms
Fluid depth in absorption field before test �p in. . "Pr
NWater added7t9 gal. New dethk3 P &,sn.
Elapsed Time:/'Fd min. Final fluid depth %r. L in. Absorption rate >= 6G�d.
9 P•
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date N• 4.
D. LIFT STATION /J. A -
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
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/hft station on lot = t 20 • On adjacent lots t JC!
Absorption field on lot = t t 2 On adjacent lots > t C►G —
Public sewer main /v• A Public sewer manhole/cleanout ALA,
Sewer /septic service line >_ =sem— Holding tank N A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 16 r Property line = 04' Absorption field /of
Water main N• 4•
Water service line > to' Surface water > 14
Wells on adjacent lots > too
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
' .nt Building foundation 20 • Water main N• �•
Property line 13 np � 9
Water Service line —>te' Surface water 7 t�+o • Driveway, parking/vehicle storage 5 ,
Curtain drainN9 ^�ffi Wells on adjacent lots -�_4"0 •
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 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 '714i0,dafg
Date ,JV 2 7—
HAA Fee
Date of Payment
Receipt Number
(Rev. 12/01)
Waiver Fee $
"at.,
�:• TPS" •��ti��'
�o •u.H oo• 'o .
. MEOOORE F. /40ORE j JV
C:-3589 r �.
Date of Payment
Receipt Number
J0kvA
Municipality of Anchorage
• Development Services Department
Building Safety Division :.
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O 20 — 1T Z - 13 HAA # 0 DACI
Expiration Date:
1. GENERAL INFORMATION
Complete legal description f 1, L{/oc4 1� Moan iarnsra/Q (/�//cryo -C iQ
Location (site address or directions) 17 d O D cr -; 4L
Current Propertyowner(s) To, AA t k,," 13cotA Day phone 3YB-o>s'?
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
176G I /{otemCAA Dr,,.t, A^cA or� _ A&r 995 r,(
Day phone
f=S 6/7 Day phone
Unless otherwise requested, HAA will be held by DSD for pickup. P l Bolt Ca I/ &C. ne ; k, m boo lA
2. NUMBER OF BEDROOMS: y svd-ozS3 whtn 11,4,4 viar/y
&I- rick -'V
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
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
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my 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. l further verify that based on the information obtained from the
Municipality of Anchorage files ,and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
NameofFirm Flcrl•/rip TieAnrral SCrvrrO/ Phone 3•IS-13S'S-
Address /Y536 J96 Aa Sf.,p^cam aCfi
�,
Engineer's Printed Name TAeoe?o7 � rcoo•e Date ►taI - 2-00-C,
Or F`l tp�,
ty�i ; •' �ENGINEER'S
' 49T -1<f< �,:STAMP
.......•«e.•.•ee.uee ee.d
5. DSD SIGNATURE •g STM ODONE F. MOON£
�,,•.
CE -3589
Approved for bedrooms. *,•• ,••••��•..��
Disapproved. °i3 m';"tl�.v
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist x
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By:14K Original Certificate Date: — 9 — 0_5
(Rev 12/00)
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 AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 110 e/0[k 1, Pic, &A *4,A•ride 14//a4., Parcel ID: 020 - 1T 2 -/3
A. WELL DATA
Well type l�� i If A, B, or C provide PWSID #
Date completed 7(_27 ISS- Sanitary seal (Y/N) Y
Total depth f6S n.
Date of test
Static water level
Well production
Cased to N 7 n.
FROM WELL LOG
7 / 2'T / 8 5
9•S 9—
p.m-
WATER SAMPLE RESULTS:
M
Coliform O colonies/100 ml.
Arsenic: <aon.S mg./I.
B. SEPTICIHOLDING TANK DATA
Nitrate 2.9/ mg./I.
Well Log (Y/N)
Wires properly protected (Y/N) _Y
Casing height (above ground) _'in.
AT INSPECTION
S•/ ze / of
-t- 9 -13 -m -
Other bacteria _ 0 colonies/100 ml.
Date of sample: 5716/0.r Collected by: FIa /*io 7--w-A S—c
Tank Type/Material _ Yeon h c I Swt/ Date installed _ 7/2-2./65
Tank size 125'U gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (YIN) _' Depression over tank (Y/N) N High water alarm (Y/N) N. A
Date of pumping -5127 /of Pumper Nor YLAmoa
C. ABSORPTION FIELD DATA
Date installed 712-2- 145T Soil rating (g.p.d./ft2 or n2/bdrm) 231 -2L System type TQC^e 4
Length 91 n. Width 3 n. Gravel below pipe n.
Total depth 13 n. Eff. absorption area 1092 n2 Monitoring tube Y Depression over field N
Date of adequacy test S-/ Z(/ OS Results (Pass/Fail) Poixt For�' _ bedrooms
29„ s.l 1 Y7 -:s
Fluid depth in absorption field before test 'b" Water added779 gal. New depth d rin.
10
Elapsed Time: 1`7min. Final fluid depth H,s/ in. Absorption rate >= iGd g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date N• A.
D. LIFT STATION V. A.
Date installed
'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 station on lot - 12a'
Absorption field on lot
Public sewer main N
Sewer /septic service line > 2..f
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots > 160
On adjacent lots > 16Y '
Public sewer manhoWcleanout N • A.
Holding tank N • A.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 15' r Property line - / Z' Absorption field /0'
Water main N • A. Water service line > 10 ' Surface water > 1410'
Wells on adjacent lots > 100 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line t3' 1•Building foundation = 20' Water main ".A
Water Service line > /o" Surface water > 100' Driveway, parking/vehicle storage 1=1157'
Curtain drain Noni Sain Wells on adjacent lots > /oa
F. COMMENTS
in.
A+ `te.
^
G. ENGINEER'S CERTIFICATION
.••••.*.
I certify that 1 have determined through field inspections ander
JQ �T}I
review of Municipal records that the above systems are in
*f
all" ...,i.., 6
conformance with MOA HAA guidelines in effect on this date.
see....
Engineer's Printed Name eo dr, rt F •/`t ao rC
�t.....e......e......
is „%nr000rt_ f• uocRC a
_-rA
Date MaY 3 / ZUGS'
C
J
nt. �••.....•• �S
HAA Fees `tr 60 Waiver Fee $
Date of Payment — Date of Payment
Receipt Number Receipt Number
(Rev. 12/01)
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SCS Ref.0
1052780001
Client Name
Flattop Technical Srv.
ProjectNamt/N
LI. BI. MountainsideVillaae
Client Sample ID
L1, B1, Mountainside Village
Afatrtx
Drinking Water
:ror bor bavr
All Datesffimes are Alaska Standard Time
Printed Datelllme
05/27/2005 14:59
Collected DatcMine
05/182005 12:56
Jiecelved Date/Time
05/19/2005 12:58
Technical Director
Stephen C. Ede
- si
Sample Remarks:
EP 300.0 - CCV for nitrite recovered high outside of acceptance criteria. Nitrite was not detected in the sample.
Allowable Prep Anatysb
?ammeter Results PQL Unita Method Container ID Limits Data Date Init
natal- Department
Haadnas as CaCO3
4etals by ICP/HS
Silicon
Private Individual Analvsis
Aluminum
Antimony
Arsenic
Barium
Cadmium
Calcium
Chromium
Copper
Iron
lead
Magnesium
Manganese
Chloride
Phosphorus
Fluoride
Potassium
Nitrate -N
Selenium
Nitrite -N
Sodium
160 5.00 mg/L SM202340B D 05/20/05 0520105 TK
3990 200 ug/L EP200.8 D 05/20/05 0525/05 TK
20.0 U
20.0
uglL
EP200.8
D
05/20105 0520/05
TK
1.43
1.00
ug/L
EP200.8
D
(<-6)
0520/05 05/20105
TK
5.00 U
5.00
ug/L
EP200.8
D
(<-50)
05/20105 05)'20/05
TK
37.2
3.00
ug/L
EP200.8
D
(<-2000)
0520105 0520/05
TK
0.500 U
0.500
ug/L
EP200.8
(«5)
05/20/05 05/23/05
TK
50800
500
ug/L
EP200.8
D
05/20105 0520105
TK
1.00 U
1.00
ug/L
EP200.8
D
(<-100)
0520105 0520/05
TK
15.5
1.00
ug/L
EP200.8
D
(<-1300)
OS/20/05 0520105
TK
250 U
250
ug/L
EP200.6
D
(<-300)
05/20/05 0520'05
TK
0.599
0.200
ug/L
EP200.8
(<-15)
05/20/05 0523/05
TK
8050
50.0
ug/L
EP200.8
D
05/20105 0520105
TK
2.20
1.00
ug/L
EP200.8
D
(<-50)
0520/05 0520/05
TK
10.2
0.100
mg/L
EPA 300.0
(<-250)
05/26N5
1JB
200 U
200
ug/L
EP200.8
D
0520/05 0520105
TK
0.100 U
0.100
mg/L
, EPA 300.0
(<-2)
0526105
1JB
500 U
500
ug/L
EP200.8
D
0520/05 05/20105
TK
2.41
0.100
mg/L
EPA 300.0
B
(<-10)
05/18/05
JIB
5.00 U
5.00
ug/L
EP200.8
D
(< 50)
0520105 032OM5
TK
0.100 1.)
0.100
mg/!.
EPA 300.0
B
(<-I)
05/18/05
110
8630
Soo
ug/L
EP200.8
D
(<-250000) 0520/05 0520/05
TK
6-c7-06: •: s6PM:
SCS Ref.0
1052780001
Client Name
Flattop Technical Srv.
ProjectName/M
I.I. BI. Mountainside Villaac
Client Sample ID
Ll, B I, Mountainside Village
%fatri:
Drinking Water
:907 6616301 . 3/ 7
Ali Datea/11mes are Alaska Standard Time
Printed Datefrime
0527/2005 14:59
Canceled Date/time
05/182005 12:56
Received Datdr6ne
05/192005 12:58
Technical Director
Stephen C. Ede
Allowable Prep Analysis
.'aran><tcr Resins PQL Units Method Container to Llmiu Dam Date Uit
Private Sndividual 1lnalvain
Silver
Thallium
Sulfate
Zinc
Total Dissolved Solids
Nickel
HCO3 Alkalinity
CO3 Alkalinity
OH Alkalinity
Conductivity
PH
Alkalinity
Total Colifoms
1.00 U
1.00
ug/L•
EP200.8
D
(<a100)
05120/05 05/10/05
TK
1.00 U
1.00
ug/L
EP200.8
D
(o-2)
0520/05 0520/05
TK
30.7
0.100
mg/L
EPA 300.0
(<-250)
0526/05
11B
111
5.00
ug/L
EP200.8
D
(o-50001
0520/05 0520105
TK
220
10.0
mg/L
SM202540C
C
(o-5001
0525/05
KP
2.00 U
200
ug/L
EP200.8
D
(o-100)
0520105 0520105
TK
133
10.0
mVL
SM2023203
C
05/1&43
KP
10.0 U
10.0
mg/L
SM20 2320B
C
05/18/05
KP
10.0U
10.0
mg/L
SM202320B
C
05/18/05
KP
335
1.00
umhos/cm
SM202510B
C
05/18/05
KP
7.80
0.100
PH units
EPA 150.1
C
(6.5.8.5)
05/18105
KP
133
10.0
mg/L
SM202320B
C
05/1&05
KP
0
coVl00mL
SM209222B
A
(o-1)
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8UNVETOR'1 CERTIFICATION
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uru 1.n yl••er CTI ,w �e MOUWAIL1510C VILLAGE 50001J1410u
B SSE, EPPS 9 POTTS
2220E, DDM. AVE.
1�'„•1A SN -sea ANCHORAGE, ALASKA 99507
wwer• kML 104Lt• 1"•SO' 9.1 Ne.e.
Loa era ..r s.Mr/ID/io ru 6A• Oe•I.
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MUNICIPALITY OF ANCHORAGE Alk
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES Aimz
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. # 1"2 7c/7— -;7-7--Z -S " HAA # ,Z % W._;,
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) I -760 / fioremon f Dom,
Pronertv owner _� oce 7h2 n/lso� ___ _ DAv phone 56Y — (S3G
Mailing address I Qo>< lr'L73� 4,1cye
� ,rbc 9951/
Lending agency Pen''Sti lu i"ro'fy!V:9 Day phone
Mailing address
Agent N. A. — rc,. Senle b.. Gwne, Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: y
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
RECEIVED
MAY 19 1937
Municipality of Anchorage
Dept. Health & Human Services
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. .
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(R"A/91) Pml MOA121
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm_- f`lcrfiaP Tec.Ai;eca/ SPiv'.rv� Phone 3YS-13-rs—
Address MY30 actio YAO 4/)char cz4 ,¢cr 9,7s-
-7,
Engineer's — T� �r 5;)4.-o-� Date s'/ 0/97
6. DHHS SIGNATURE
t
Approved for Wr' bedrooms.
M
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate Is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72M31p«. 7N�) Baa MOA.21
��
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501• (907) 343-4744
-P,
Health Authority Approval Checklist ���
Legal Description: L.F Q/1.r 1� nau�k r r.dt U;1roPam1I.D.: G
A. WELL DATA O
Weli type f r� "I -c. if A. B, or C, attach ADEC letter. ADEC water system number N• A.
Log pmt (Y/M Y Date completed 7/
Total depth 16S Cased to H -1. Casing height (above ground) 30 "
Sanitary seal (Y/M
Date of test
Static water level
FROM WELL LAG
7/27 1 a
70'
Well production 9. S� g.p.m.
WATER SAMPLE RESULTS:
Wire properly protested (Y/M Y
AT INSPECTION
.'//2/97
S. 2y '+ 9 -p.m.
Coliform f9
co 1 / / u 0 m z
Nitrate 1,7/ !U /-e Other bacteria
Nw a reporAvf
Date of sample:
5'/ 12 / p 7
Collected by: F /u t/eP 7 -0 -CA
Sv c
B. SEPTICIHOLDING TANK DATA
Date installed 7 / 8S� Talc size 1260 g Number of Compartments 2 Cleanouts (Y/M Y
Foundation cleanout (Y/M Y Depression (Y/M N High water alarm (Y/M N• A
Date of Pumping S/ 13 / 9 7 Pumper No e M l ao d
C. ABSORPTION !r'IEIA DATA
Dau installed 7 / S S Soil rating (g p.d./fi or ft%drm) 31 a' System type Tnn ch
136W—
Length SS' 33 D' Width 3' Gravel thickness below pipe 7 2 ` Total depth 12-6 " S E ' H. T
S/li/P7
Effective absorption area 1092 0' Monitoring Tube peaent(Y/N)Y Depression over field (Y/M N
Dau of adequacy test S/ 12 / 9 7 Results (Pass/Fail) Patr For Y bedrooms
a" W. h.7', -es'" w 1+.T.
Fluid depth is absorption field before tett (in.); go" Se Immediately atter747 gal. water added (in.):Sb ''F " SF
I a S. 4 w rn.7.
Fluid depth tits "SE (ins.) Minutes later: /18 Absorption rate e _ ? COo a p.d.
Peroxide treatmem (past 12 months) (Y/M Non 2 keno ft— If Yes. give date N.
D. LIFT STATION N. A•,
Date installed Size in gallons
ManholelAooess (Y/N) "Pump on" level at' "Pump off' level at*
High water alarm level at' 'Datum RECEIVED
Cycles tested
E. SEPARATION DISTANCES MAY 19 1997
Municipality of Anchorage
SEPARATION DISTANCES FROM WELL ON LOT TO: Dept. Health & Human Services
Sepudholding tank on lot 120' : On adjacent lots > too
Absorption field on lot 1 I Z' ; On adjacent lots > 100,
Public sewer main 14. A. Public sewer manhole/cleanout N• ti.
Sewer /septic service line > Zs-" Litt station
SEPARATION DISTANCES FROM
TANK ON LOT TO:
14. A.
Building foundation I S-' Property line —, I z I Absorption field 140,
Water main/service lint > 10 , Surface water/drainage > 100' Wells on adjacem lob > 1c'0'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building bmdation 13' (i2e- ,oW. rV-) Property Line -ee Water main/serviceline > 140,
Surface water > 100 • Driveway. parldngNehicle storage area s'
Curtain drain Nona seen Wells on adjacent lots �> 1 v o '
F. ENGINEER'S CERTIFICATION.'�`
(:i !i ?.1,
I cerofy that I have determined thra eld Inspections and review ofMimicipal recoedaidt •' • `f
in conformance with MOA NAA guidelines in effect on this date
0tr s ; r; i <•: :` ; . ,
Signature Tut
y
Engincer's Name Ttiao oda-e F � cr co-
'. r: �oo „r .
Date may Ip /997Y`S•.
•... Y
• "T`r1'.7,'. �4". tie
HAA Fee S 300 f -e Waiver Fee S
Date of Payment 7 Date of Payment
Receipt Number Receipt Number
7r'
Rev. 8/95 OSS: haa.v)k doc
MUNICIPALITY OF ANCHORAGE
• Department of Health &Human Services
DIVISION OF ENVIRONMENTAL- SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel l.D.# O2n-10a -Q., HAA# VAQc?Cr-G01R
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Li R1MoyNTAiN6mc VILLA E
Location (address or directions)
17(601 ROSEMONT DR ANCHORAGE
(b) Property owner CRA16 t CARTS LINCOL N Telephone: (home) 3qS- 3992 Business S61 -1227 -
Mailing Address 17601 ROSEMONT DR.
(c) Lending Institution N 13A Telephone 2S7 -3Y3Y
Mailing Address Pb",0, 7-02 yAnds
Ah
995-10
(d) Real Estate Company and Agent PAULA
HERN boN
A REMAX
Address 2600 CORbovA I AA_ ch� C hk 99.f0?
Telephone 2 76 -2761
(e) Mail the HAA to the following address: (or check here K if hold for pick up.)
List contact person and day phone number below:
T£b OR CHRIS 31/3-- 13S`
FL ATToi? TECH Svcs
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 -sited Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 IS". 7i8a) Page 1 of 2
5. 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 effect on the date of this inspection.
Name of Firm _Ela Fltip % cchnira/ Scrl«r Telephone 3 YS- 13SS-
Address /YS 30 Ectie SY.- AncAonay
Date Tfx�k, 1Z. 1990
0, A44-9
....................... a
T:!i0:)0RE F.:100RE
CE - 3537 �•••^,iv,�
�. Pr'c:si�n•� �
6. DHHS APPROVAL
Engineer's Seal
Approved for La edrooms by eLZ `U rac Date
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
22-M (Rn.7/W) Book Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744 ��
Legal Description: Li, RI MALNTA/4cl0e, V7LLASF
A. WELL DATA
Well Classification PR 1 vATP If A, B. C, D.E.C. Approved (Y/N) N -4 -
Well Log Present (Y/N) ES Date Completed -7/27I85- Yield 7.8+6PM MEAS.7110190
Total Depth I(og—Cased to 'q7 Depth of Grouting 94 -
Static
-
Static Water Level 337 Pump Set At LINK
Casing Height Above Ground 27 Sanitary Seal on Casing (Y/N) YES
Electrical Wiring in Conduit (Y/N) YE5 Depression Around Wellhead (Y/N) No
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ^ 124 r ; On Adjoining Lots �!/00
To Nearest Edge of Absorption Field on Lot a I ly ; On Adjoining Lots >100'
To Nearest Public Sewer Line 7roo I To Nearest Public Sewer Cleanout/Manhole /oo'
7
To Nearest Sewer Service Line on Lot ^ /O$
Water Sample Collected by FLATTof TECO SVC S ; Date -71 10/10
Water Sample Test Results -CyJ" JQ cfo�ty - O cu('16' r /ruo.� C 1.2 6. r a .r�f+7.Ec M
at 7.8;4
Comments CnNSTA1IT PVMPINL, OF 1785 6ALL014S A SR026HT THE LEVEL OF
-rHE WATER 1N THE WELL To 131 FEETy BL*T N0 Lo WE R,
B. SEPTIC/HOLDING TANK DATA
Date Installed sz Size 12SO No. of Compartments
Standpipes (Y/N) SFS Air -tight Caps (Y/N) `IES Foundation Cleanout (Y/N) YES
Depression over Tank (Y/N) No Date Last Pumped 12/1/89 ROTO-Z'OvtFtr
Pumping/Maintenance Contact on File (Y/N) 'N .A• ; for rl.A -
Holding Tank High -Water Alarm (Y/N) N • A • Temporary Holding Tank Permit (Y/N) A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well SZ -114 To Building Foundation 1-7
To Property Line To Disposal Field 10
To Water Main/Service Line ^ lo0l
To Stream, Pond. Lake or Major Drainage Course } 100
Comments
72-M (Rev. 7/88( Front Pagel of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorp]tion Strata 231 q'$Dem Type of System Design Ncd
Date Installed /�2 /SS Length of Field ql i33 1 +S8
Width of Field 3 Depth of Field 9 - to
Gravel Bed Thickness 6
Square Feet of Absortion Area 972 v' Statndpipes Present (Y/N) YES
Depression over Field (Y/N) NO Date of Last Adequacy Test 110 o
Results of Last Adequacy Test ADFOvATF FOR 4 BDRM
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well ` Ily To Property Line 13
To Building Foundation b To Existing or Abandoned System on
Lot _ N.A. ; On Adjoining Lots '7 So
To Water Main/Service Line 65 To Cutback (if present) H /1
To Stream, Pond, Lake, or Major Drainage Course - /oo '
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION NONE
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 guidelines in effect on the date of this
Inspection..,
OF A
Signed cCtic—.+,� ,� 4ek
Company—F_( Mc e Tcth.i,,r..f .<i•W1c•,V ic��'' ••9s�e
�gi Engineer's Seal
Date Tu (y l3 /990 i ...:......................
MOA No. 90 —o /9 e.�.�."0"........
•f:..�}lte
nL T11 ODORE F. A1001?e _ d►�`
CE -3539
Si
n Y
Receipt No. - a a otl ILl Receipt No. _� x'34
Date of Payment — 71- t S+ -Ra Waiver Fee: $
Amount: $ 1-1O, 01�N Date of Payment
72-M (Rw. T/BB) Ba<w Page 2 of 2
w.
MUNICIPALITY OF ANCHORAGE n
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720 �t
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot block• subdivision, section, township, range)
/•toun'"(4%.)-%a� t/�f)a4e. j3/QC/': / Lot / Se</r 7•ii,vX'sar
Location (address or directions)
y -
(b) Applicant Name Crct%g "L'^c0hh Telephone: Home 3yyo/JZ7' Business `T- 221_
Applicant Address A `f / A/ _31r4 H vt Q 7' O
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Buyer ❑ ;Other ❑ (explain);
(d) Lending Institution it A R- Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family Multi -Family❑ Other
Number of Bedrooms 4
3. WATER SUPPLY
Individual Well 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 DISPOSAL
Onsitex 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
72-025014A)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 3 .
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Healtfi
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 f r, < ;^` Telephone 5 G f S'0 4/d
Address A n r% A k
Date
6. DHEA
Approveded for for V �� bedrooms
Approved Disapprc
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 professional "
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
72-025 011") "
MUNICIPALITY OF ANCHCRAGZ
^ ^ DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PRCTECTICN
HEALTH AUTHORITY APPROVAL (HAA) 851
CHECKLIST - FEBRUARY 1984
284-4720
Legal Description: 01Oun
1�-/!,vR3W re( It
A. WELL DATA
Well Classification ��^`esf'� If A, E. C. D.E.C. Approved (Y/N)
Well Log Present A) Date Completed :7-Z ? -,9S Yield y' S GPM, 'r
Total Depth / e S � Cased to 4 * ✓ Depth of Grouting —'
Static Water Level 30 Pump Set At —
Casing Height Above Ground 2' S Sanitary Seal on Casing 6?N)
Electrical Wiring in ConduitR/N) Depression Around Wellhead (Y/O
Separation Distances from Well:
Adjoining Lots G !00
On Adj
To Septic/Holding Tank on Lot ! � 8 9
To Nearest Edge of Absorption Field on Lot �4 : On Adjoining Lots C T- /00
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
_ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
".. r ; Date —/in,// �, -r
Date Installed -7-22-431 Size �Z ��✓ No. of Compartments �'•/ pva
StandpipestqN) Air -tight Cape" Foundation Cleanout �l)
Depression over Tank (Y161 Date Last Pumped —
Pumping/Maintenance Contract on Fite (Y/N) ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank: ! 7 -
To
To Water -Supply Well 7- To Building Foundation
To Property Line /9 -` N' To Disposal Field !O
To Water Main/Service Line �' i ! O To Stream, Pond, Lake, or Major Drainage
Course 10,7- /00
Comments
Page 1 of 2
72-026(11164)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata .2'6/ of /% Type of System Design 7-i (I<Gli
Date Installed - - 2.2 - B Length of Field __ � / a 3+ -A r 41 r
Width of Field 3 Depth of Field —10
Gravel Bed Thickness 6
Square Feet of Absorption Area 9 t1. O Standpipes Present
Depression over Field (Ylep Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well / Z Y `'� To Property Line
To Building Foundation _
Lot
To Existing or Abandoned System on
On Adjoining Lots GT 30
To Water Main/Service Line G 7-10 To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area /$� 7D Irrvc c%; rrw,.rY
Comments
D. LIFT STATION
Date Installed .
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) _
Comments
Dimensions
Manhole/Access (Y/N)
'Pump Off' Level at
Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Icertify that checked,veytied,orconformed toall MOA and HAA guidelines ineffect onthe date ofthis inspection.
Signed 7Z 11 t"=- Date
Company MOA No. s t
Receipt No. -c! '�Yq fa ( r
Date of Payment —) D -a 9 8 r-5
Amount:$ (05ta-
Page 2 of 2
72.026 (11,84)
C.
G Reid,
225I.E
Seal