HomeMy WebLinkAboutEAGLE CREST #2 BLK J LT 3AEagle Crest #2
Block J
Lot 3A
#050-293-94
.r11il�:i
ADDRE
LEGAL
DATE. - Started 1 o / xf Ended to,SSS
&rltofiph rilting lkx
DOC Co. aoa
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 6682759
PERMIT NUMBER
KIND OF FORMATION:'
DEPTH 01: WELL C
STATICLEVEL OF WATER Fr. / 3,ti-
r XjI & DOWNFT
GALS. PER HR 1/ro0
KIND 01: CASING
From Ft. to 3 Ft.
I.2Z^l
_
From
Ft.
to
Ft.
From Ft. to -_7 Ft.
6" ,,,^' r
i
'+,4u7=
From
1 Ft.
to
Ft.
From Ft. to-22—Ft.
From -
Ft.
to
Ft.
From�FLto Ft.
5P4..)0
�4'�°v-�-t
From
Ft.
to
Ft
From Ft. to Ft.
'��_�'�-'�^�S
From Ft.
to
Ft
From !S to 1 2 1 Ft.
I ! i rr i
'E. k t;'4 _
From
Ft.
to
FI.
�Ft.
i
From Ft. to Ft.
Si < i
-
Froia
Ft.
to
Ft.
From I =,t Ft. to c. Ft.
+641 Yinm
Ft.
to
Ft.
From FI. to Ft CC AY /0, r A From Ft. to Fl.
From Ft. to / C -'f Ft. .iN ^.4 ( 4c . 1 w.4r6,f'rom Ft. to Ft. P
A0 PZ O� paOt �10t
From Ft. to Ft. From Ft. to Ft. OE
From Ft. to Ft. - From Ft. to Ft.� 1 n 1C�a6
From Ft. to Ft. From Fl. to FI.V
From Fl. to Ft.— From FI. to Ft.
From Ft. to FI. From Ft. to Ft. _
From Ft. to Fl. From FI. to—Fl.—
From—Ft.
oFl.From Ft. to FI. From Ft. to Ft
MISCL. INFORMATION:
DRILLER'S NAME - ;, -
it
/ M U NIC IFS ALIT Y O F A N C H u R A G E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
ON—S I TE W ELL FIEF ZM I T
PERMIT NO: 850632
DATE ISSUED: 09/27/85
APPLICANT: LINDA LEASK
ADDRESS: P.O.BOX 771786
EAGLE RIVER, AK 99577
CONTACT PHONE: 562-2058'.
LEGAL DESCRIP: SUBDIVISION: EAGLE CREST 2ND ADD LOT: 3A BLOCK: J
SECTION: 7 TOWNSHIP: 14N RANGE: 1W
LOT SIZE: 10125 (SQ.FT. OR ACRES)
I certify that:
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
1. MOA will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set back:
distances from any existing well, wastewater disposal system or public
sewerage system on th s or any adjacent or nearby lot.
SIGNED ----------------- DATE:
- ------ -
APPLICANT: LINDA LEASK
ISSUED DYGo..--%%�o _----------- DATE: q-2�
--- -------------
7201r 4460 vtJ
Municipality of Anchorage
Development Services Department
! Building Safety Division
On -Site Water and Wastewater Program '
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 050 -?q'4 -q4 COSA# bgmo(o
Expiration Date: Co -.2 Lt - C
1. GENERAL INFORMATION
Complete legal description FARI F rR ST #2 LOT RA- RLOCK I
.. �: .. :... s,4 1.0.
Current Property owner(s) Craig Graff Day phone 696-2325
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: _3_
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ❑
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional
civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site
Systems 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 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 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—.Arclema—EngWzedng—&--SUDMYirLg In'- phone RAR -17q?
Engineer's Printed Name KENNETH M DtIFFUS Date
Engineers 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.
5. DSD SIGNATURE
_' Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checidist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
ON-SITE • :�'
WASTEWgTE�
-PRg
Arsenic Advisory
Maintenance Agreements
Supplemental Engineers Report
Other
By: Original Certificate Date:
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description- FA,LF rRFST #2 LOT RA RI O -K j
Parcel lD: 050-293-94
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID #
Date completed 10/1985 Sanitary seal (Y/N)Y
Total depth 169 ft. Cased to 169 ft.
FROM WELL LOG
Date of test 10/1985
Static water level 1 3 5 ft.
Well production 2 5 g.p.m.
WATER SAMPLE RESULTS:
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) _ 24 in.
AT INSPECTION
c
4.8 g.p.m.
Coliform 0 colonies/100ml. Nitrate 3.31 - mg/L Other bacteria 0 colonies/100 mL
Arsenic: mg/I Date of sample: 3/10/2008 Collected by: ArcTerra
B. SEPTIC/HOLDING TANK DATA
.Tank Type/Material Date installed _wank size
gal. Number of Compartments
Cleanouts (Y/N)—Foundation cleanout (Y/N)—Depression over tank (YIN)_
High water alarm (Y/N)—L--Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed _Soil rating (g.p.d./fe or,ft2/bdrm) System type _
Length ft. Width _ft. Gravel below pipe _ft. Total depth ft.
Eff. absorption area ft? Monitoring tube _Depression over field _
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test__n. Water added_ -4al. New depth—in.
Elapsed Time: min. Final fluid depth in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type)_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
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 10 0'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
Manure/animal excrete storage areas 10 0'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property tine Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
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. g' :• [> 5
l •.
Engineer's Printed Name KENNETH M. DUFFUS �f`%F0 PR 5S o
OFE
t
Date 03/20/2008
COSA Fee $430.00
Date of Payment 3/7- 06
Receipt Number 106271
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
f:
SCS ReEN
1080972001
Client Name
AreTerra Engineering and Surveying
Project Name/N
18708 Citation
Client Sample 11)
Outside Spicket
Matrix
Drinking Water
PN'SID 0
Sample Remarks:
All Dates/rimes are Alaska Standard Time
Printed Date/time
03/20/2008 13:30
Collected Date/rime
03/10/2008 8:30
Received Date/rime
03/10/2008 9:20
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Parameter Results POL Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic
Waters Department
Total Nitmte/Nitrilc-N
Microbiology Laboratory
Colony Count
Total Coliform
Fecal Coliform
ND
5.00
ug/L
EP200.8
C
(<10)
03/12/08 03/19/08
Mll
3.31
0.100
mg/L
SN120450ONO3-F
D
(<10)
03/12/08
LCP
0 col/100mL
SN1209222B
A
(Q00)
03/10/08
DLC
0 col/100mL
SM209222B
A
(<1)
03/10/08
DLC
0 cot/100mL
SN1209222B
A
(<I)
03/10/08
DLC
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH 6 HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel l.D.il 050-293-94
r
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA N
1. GENERAL INFORMATION
Complete legal description Lot 3A, Block J, Eagle Crest 12-
Location
2-
Location (site address or directions)
18708 Citation Road
Property owner Chris Benediktsson
Mailing address PO Box 4534, Eagle River, AK 99577
Lending agency
Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water _
Day phone 688-2287
Day phone
Day phone
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 . r
XXX. -:.,-
Public sewer
NOTE: if community wastewater system,'provide Written confirmation from State ADEC
attesting to the legalityand status otsystema
?2. M (A.. jt2q F.oM MOA F71
S. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
Investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system Is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. 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 in compliance with all Municipal and State codes,
ordinances, and regulations In effect on the date of this Inspection.
Name of Firm 5 & 5 ENGINEERING Phone6 '1 `i 7
Eagle River Loop Road No. 204
Address Eagle River Alaska 92577
Engineer's signature Date c7 ( q `%
1 R.NERT C. COWAN % f
6. DHHS SIGNATURE C"g'JI
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
M
FAWAW
tow
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an Independent
professional engineer registered in the State of Alaska.The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
Conduct Inspections or analyze data before a certificate is Issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineers work.
724)23(14+. A1) e.n MOA121
• - RECEIVED
Municipality of Anchorage MAR p9
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division IyuMQPAUTY X
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 349W?W"
Health Authority Approval Checklist
Legal Description: 1, O F 34 St jc J£ A G L4 C.i SS 7 0Z Parcel I.D.: 09 O- X9 3- 9 R/
A. WELL DATA
Well type f 4 r v H r 4: If A. B, or C, attach ADEC letter. ADEC water system number
Log present dqN) YC f Data completed i C I (i i
Total depth ) (' , Cased to N 8
Sanitary seal &N)
Date of test
Static water level
Well production
ES
FROM WELL LOG
/c/ gS'
WATER SAMPLE RESULTS:
1 3 S-
-Dk S
_ Casing height (above ground) r f.
Wires property protected 6�N) Y E S'
AT INSPECTION
3/',/clri
)3G
g.p.m. S. % -g-P.M.
Coliform O Nitrate a• 7 9 Other bacteria D
Date of sample: 3/'6/'12 Collected by: S & S ENGINEERING
11=4 EIIIII& KIM toup Road No. 204
B. SEPTIGHOLDING TANK DATA I U g Ll C_ S E w h Eagle River, Alaska 99577
Date installed Tank size Number of Compartments Cleanouts_(Y/N)
Foundation cleanout (YM) _
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Depression (YM)
Pumper
Soil rating (g.p.dAt2 or
High water
System type
below pipe Total depth
Effective absorption area ring Tube present (Y/N)_ Depression over field (YM)
Data of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth In old before test (in.); Immediately atter_ gal. water added (in.):
Fluid depth (ins) Minutes later: Absorption rate
Pe a treatment (past 12 months) (Y/ 4) It yes, give date
72-026 (Rev. 3196)•
D. UFT STATION
Date installed
Manhole/Access (Y/N) _
High water alarm level ar _
Cycle�,t
E. SEPARATION DISTANCES
"Pump on'
'Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons
"Pump ofP level at*
Septlatholding tank on lot
N /f1
On adjacent lots
N IA
Absorption field on lot
N 1A
On adjacent lots
Public sewer main
i
t
Public sewer manhole/cleanout
/ C,7 f
Sewer /septic service line
i
S-
Lift station
''� /'#
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation
Property line
Water main/service line Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION ON LOTTO:
Property line.
Surface water
Curtain draia-
F. ENGINEER'S CERTIFICATION
foundation
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
I certify that I have determined thru Held inspections and review of Municipal records
in conformanceV7wiffiVrA 71trol_
lines in efect on this date.
Signature
_ gd,sf4- C. Cva.g✓
Engineer's Name
Date __ `i f/ °► ry�
HAA Fee $ 3 ' D -D Waiver Fee $
Date of Payment 12—Z Date of Payment
Receipt Number 2•.._2- Receipt Number
72.026 (Rev. 3/98)'
;``�• IN me ere
ROBERT C. COWAN
CE•6$01 ;1r�
NAR -12-99 12:51 FROM -CTE ENVIRONIENTAL 5515331
CT6E Environmental Services Inc.
CT&E Ref.lr
Client Name
Project Name/#
Client Sample Ila
Matrix
Ordered By
PWSID
990874001
S & S Engineering
N/A
Lot 3A Blit J Eagle Crest M2
Drinking Water
T-297 P.01/0/ F-737
Client POA
Printed DateMme 03/13/99 12:29
Collected Date/Time 03/08/99 17:30
Received DatclTime 03/09/99 10:55
Technical Director: Stephen C. Ede
Released By
ALtorable
Prep
Analysis
Parameter Results PUL Units evrnoa Limits
Date
Date
Mir
Totat Cotifa m o cot/103r WS 9222s 03/09/09 KAP
aitrate•a 2.79 O.1C0 er_/L EPA 300.0 t0 man 03/09/99 03/09/99 SCL
• MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH b HUMAN SERVICES Aiih
�) Division of Environmental Services 99
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcell.D.# 050 7-55 94 ODO HAA# ui19�Q�R•�
GENERAL INFORMATION
Complete legal description Lot 3A; Htock J; EagCe C4est 02
Locatiori (site address or directions)
18708 Citation Road
Eagte Pivea, AK
Property owner Chnia Benediktaaon Day phone
Mailing address P.O. 4534 Eagte RiveA, AK 99577
Lending agency
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XXX
Day phone
Day phone
696-3939
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 XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
7=4125(R«.1/91) r�i MOAv11
S. • STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my'
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my invest!qation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S i S ENGINEERING Phone CCI y — ;Ln 7 cj
77074 Eagle River Loop Road No. 204
Address
Engineer's signature
Date '�'/.3r/C1s
OF
rA 'e l aOURT C. COWAN
`'r ; CE -8801
tt
6. DHHS SIGNATURE t+ ; :�.
�- Approved for —7 bedrooms.
6y:
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
mmir
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
724431Rw. 1,911 B� MOA @21
Municipality of Anchorage
.;, DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 o Anchorage, Alaska 99501 • (907) 3434744
C.
Date installed Tank size
Foundation cleanout (Y/N},
Date of pin Pumper—
ABSORPTION
umper_ABSORPTION FIELD DATA
Date installed Soil rating
Number of Compartments Cleanouts
High water alarm (YRJ) _
(g.p.d./ft' or ftr/bdrm)
Length Width Gravel thickness below pipe
. r•
Effective absoigitia-n area Monitoring Tube prescnto] l/
Date of adequacy test
Fluid depth in absorption ftcl
Fluid dcvt Minutcs
System type
over field (YRS
For bedrooms
test (in.); Immediately after_ gal. water added (in.):
Peroxide treatment (past 12 months) (YRJ)
(in.) Absorption rate =
If yes, give date
Health Authority Approval Checklist
Legal Description: LoT3A
i>t- -T Parcell.D.: 0SO 7-93 94
Don
7—
A.
A. WELL DATA
Well type If
A, B, or C. attach ADEC letter. ADEC nater system number A
LogprescntO
Date completed to -8S
Total depth LCA t
Cased to 1 Lrel Casing height (above ground)
t r +
Sanitary seal
Wires properly protected ON)
FROM WELL LOG ATINSPECTION
^
w
Date of test
-2.'t -Cis'
Static water level
13S r 1 5� t
Well production
2S, O g.p.m. .L
rn
@b.in.
t7
WATER SAMPLE RESULTS:
V; C"
o M
z
Coliform i>
Nitrate 2.\`t Other bacteria
0
Date of sample: a-2.5'- 9 5 Collected by: s i s ENGINEERING
17W4 Eagle River Loop Rad No. 104
B. SEPTIC/HOLDING TANK DATA �J gtJv L S E 4168- Eagle River, Alaska 99577
C.
Date installed Tank size
Foundation cleanout (Y/N},
Date of pin Pumper—
ABSORPTION
umper_ABSORPTION FIELD DATA
Date installed Soil rating
Number of Compartments Cleanouts
High water alarm (YRJ) _
(g.p.d./ft' or ftr/bdrm)
Length Width Gravel thickness below pipe
. r•
Effective absoigitia-n area Monitoring Tube prescnto] l/
Date of adequacy test
Fluid depth in absorption ftcl
Fluid dcvt Minutcs
System type
over field (YRS
For bedrooms
test (in.); Immediately after_ gal. water added (in.):
Peroxide treatment (past 12 months) (YRJ)
(in.) Absorption rate =
If yes, give date
D. LIFT STATION
Date installed
Size in gallons
Manholc/Acccss (Y/t)
"Pump on" level at* "Pump ofr, Icvel at"
High water alarm level at"
*Datum
cl
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot1I
b ; On adjacent lots ti
Absorption field
J`
on lot
A ; On adjacent lots
Public saver main
o o t;- Public sewer manhole%Icanout 1oby
Server /septic service line
ZS Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation
Property line Absorption Geld
Water main/service lin
mage Wells on adjacent lots
_ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Water main/service line
Surface water
D • , c storage area
C
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
1 certify that / have determined thru field inspections and review ofAfunicipal rec y�rl a ab �e s'1S`dNL are
In conformance with AfOA lfiL4 gui fines i Jfect on this date. r sti�tr/f
Signature Wit _ i � �. "' 0.
i . i
Engineer's Name 4.0 4.4 T C. Co t..A,✓ ? \ RO.ERT C COWAN W j
CE - 8801
C
Date �/3/ °l S' IsieN, N
HAA Fee S .300, OO Waiver Fee S
Date of Payment R-31=1 1�- Date of Payment
ReceiptNumbcr C>12(oD Receipt Number
Rev. 8/95 OSS: haa.wk.doc
CT&E Environmental Services Inc.
Laboratory Division
Laboratory Analysis Report
CT1E Ret.# 9S.]4]9.1
Y.acrix NATER
Client Sarple ID L]A aLK J LAOLS CREST 02
Client Name 4 G a ENGINEERING
Ordered By A. COWAN
project Name
Project#
PK3ID VA
S •npl• Remark•: SAMPLR GOLLECTESI HY% S.H.
WORK Order 19511
Printed Date 08/20/95 O 11%11 hra.
Collected Data 09/25/95 a 11%1S hre.
Reosived Data 09/2S/9S O 14:eS hre.
Technical Director STEPHEN G, EDE
Released
Allowable Ext. Anal
Oc Limits Data Date :nit
Results Qual Unite method
10...._..._..__..'""0_28.9•_
09/18/95 CMR
............................... 1.19 "A DPA 357.1
Sitrate-N
}
____...................................................................•.....UA a Dnavailable .......
' BeSpecial Instruction. Above KA • Not Analysed
r'. Be:e Sample Remarks Above LT a Less Than
. Vndeteeted, Asporred value is the practical quancit leatlon llnie. OT . Greater Than
. Secondary dilution. — — --
200 W. Poner Drive, Anchorage. AK 99519_1605562.2343 fax (907) 561 S301
e • OHIO. WEST VIRGIN!
cwlR(1NNIENTAL FACILITIES IN ALASKA, CALIRORNIA, FLORIDA. ILLINOIS. MARYlANO, MICHIGAN, MISSOURI, NEW JERSEY,
Z00 91£'ON ITZ1P69406 « E)JI1S31 '1l1D83 W07 £S%ZS 56/02/80
1
f �
MUNICIPALITY OF ANCHORAGE
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
Application Date Afay 10, 1986
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, supdivision, section, township, range)
Location (address or directions)
(b) Applicant Nameoda L Qad -KigPh Telephone: Home 1294-7676 Business
Applicant Address P.O. Sox 771796, Eaglo giypt, APasba 99577
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ® ; Buyer ❑ ; Other ❑ (explain); -
(d) Lending Institution /yoRTelephone �65�273
(e) Real Estate Company and Agent
Address
Telephone
2. TYPE OF RESIDENCE
Single-Familyt] Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well 91 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 ,
Onsite ❑ Public W 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 72-02501,e4t
rAl
n
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
1.1
As certified by my seal affixed hereto and as of the validation date shown below, I verily 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 o1 Firm S & S ENGINEERING Telephone b q491 -2—q7
Address SR B 196X
Date EAGLE RIVER, AK 99577 MAY 17 1986
DHEP APPROVV�ALj 63)
04,
Approved for ,CIA Je 12 bedrooms by �'
Approved Disapprov Condie I _
Terms of Conditional Approval
N3
CAUTION
R
A
A. 5h PW
Dale!
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
MUNICIPALITY OF ANCHORAGE (MO2..r
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAGE / T
DEPT. OF HEALTH aegal Descriptio L
ENVIRONMENTAL PROTECTION ZpC,£ cz c-rr l)
A. WELL DATA MAY 19 1986
Well Classification1-' %1 Y�.� B. C. D.E.C. Approved (Y/N)
Well Log Present 6m) Date Completed /,o - e S Yield
Total Depth' Z L'I I Cased to O Depth of Grouting
Static Water Level 13 5" Pump Set At 1A
Casing Height Above Ground /71 04 --Sanitary Seal on Casing&NT
Electrical Wiring in Conduit (ON) Depression Around Wellhead (Y4
Separation Distances from Well:
To Septic/Holding Tank on Lot �Lr' ; On #t ing Lots 4lA'
To Nearest Edge of Absorption Field on Lot A ; On Adjoini ots N /
19-
To Nearest Public Sewer Line oc> 1 ~ To Nearest Public Sewer
Cleanout/Manhole. • 1 � � 1 1- To Nearest Sewer Service Line on Lot
ZSI`
Water Sample Collected by S� S l N & ��10 Z AA -e- Date
Water Sample Test Results SF�tS f �Gc� 2y
Comments /Uu nrr
B. SEPTIC/HOLDING TANK DATA
Date Installed CY $GL Size
Standpipes (Y/N)
No. of Compartments
Air -tight Caps (Y/N)
Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) -;for
Holding Tank High -Water Alarm (Y/N)-16porary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Building Foundation
To Disposal Field
To Stream. Pond. Lake, or Major Drainage
Course
Comments pool-cz=' -wt, 6n! /O -/a -SS VaR t 1=rF uS S - 1 > `let,
Page 1 of 2
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design _
Length of Field
— Depth of Field
Grave Bed Thickness
Square Feet of Absorption Area Standpipes Present(Y/N)
Depression over Field (Y/N) pate of Last Adequacy Test
Results of Last Adequacy Test 1A_
Separation Distance from Absorption Field:
To Water -Supply Well _
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments —
D. LIFT STATION
Date Installed .
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at A "Pump Off' Level at
High Water Alarm Level at f' Vent (Y/N)
Tested for
Electrical Codes (Y/N)
Comments
•• Check Permitted Bedroom Rating Against HAA Request ••
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conf ormed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed 5 & S ENGINEERING Date !AY 17
CompanySR B 196X MOA No. a s- CIL' -s
EAGLE RIVER, AK 9957$ tact
Receipt No. i ; • ••.;�y+
Date of Payment S — 10I -&o 1 �9
S t .. ..
Amount: $ Cc
� ��', ••
MMA A. Shot.
CW. 1157.1
Page 2 of 2
72-026 (11,64)