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HomeMy WebLinkAboutFREEMAN LT 1S.0 08/28/2007 04:13 9072430742 Development Building AWPS, INC. Services Department Safety Division Oh -Site Water 4 Wastewater Program 4700 Brogaw Street • P.O. Box 196650 Markeeglch i Anchorage, AK 99519-6650 , Mayor www muni o•o/on�iTe (907)343-7904 PUMP Installation Log Well Drilling Permit Number: SW Date of Issue: Parcel identification Number: PAGE 02/04 Legal Description. - Property Owner Name Address: 20 pump Installation Date: Q 2 I O Pump Intake Depth Below Top of 'ell Casing: �YDfeet pump dlanufacturer's Name: Q % ,P l/ pn S -2 2 I Pump Model: Pump Size �?' hp Pitless Adapter Burial Depth: / feet Pitless Adaptor )Manufacturer's Nage: Pitless Adapter Installer: Well Disinfected Upon Completion? Yes Q No Method of Disinfection: Comments: I I Pump losta)ler Name: Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. .I I r, MUNICIPALITY OF ANCHORAGE (-', D. 4RTMENT OF HEALTH AND HUMAN SEI...CES ' Environmental Health Division 825 ••L" Street, Anchorage, Alaska 99502, Telephone 284-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES G' 92, IS ETtTO Addiess FROM PO 80K /I0363 An,A f}K 99Yy1 Pnonets) Permit No No a Bedrooms WELL 34E 36-68 F -o 44} 3 LEGAL DESCamTION LOT LINE Lot , block N� SObowrs,on F�aa ^a FOUNDATION Township, Range. Section AS -BUILT DIAG SAG & 20 r IL N R .� avdnvaway waler Dol TANKS F-F-T—r X SEPTIC ❑ HOLDING Munulaclurer Capacity In gallons An-hC a 11 V - O Material l No. of Compartments s TC! I IZ TYPE OF SYSTEM ❑ TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER Depth to pipe potion, from Total depth from original plane onginai grade FT Fm added above original place Gravel depth beneam pipe WELLS ❑ PRIVATE ❑ OTHER (Identify) t Installer t Date Installed (REMARKS: WELL GT to _ A (Snow location of well. septic system, property linesto etc) I Scale:4 R ENGINEER'S SEAL Inspections Perlotmed by _pant AECS SZf%vXAJ Dale / / 0 4-5 -SS' 'G�L�'! I - "✓t/bs-a�' • eerbly that this inspection was performed according a all u nd State ideltnei In dlect on this date. g—� ^b?' /o— 43 ealth DepaAment Approval 0� Date wta lyaot FT FT Gravel lengal Gravel width FT FT Total absorption area Distance between lines SO FTJ FT SFr" Number of tine5 6n rating Pipe material ssae" ti. r SO FT a 3034 Gt msialler Date Installed C"Is FX Sr- 066 9-s -8 s' WELLS ❑ PRIVATE ❑ OTHER (Identify) t Installer t Date Installed (REMARKS: WELL GT to _ A (Snow location of well. septic system, property linesto etc) I Scale:4 R ENGINEER'S SEAL Inspections Perlotmed by _pant AECS SZf%vXAJ Dale / / 0 4-5 -SS' 'G�L�'! I - "✓t/bs-a�' • eerbly that this inspection was performed according a all u nd State ideltnei In dlect on this date. g—� ^b?' /o— 43 ealth DepaAment Approval 0� Date wta lyaot r MUPQ I C I PAL I TY OF Ar4M"MFZAGF= DEPARTMENT OF HEALTH AND ENVIRONMENTAL,PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 OFV—S I TF= PERMIT NO: 850497 UPGRADE DATE ISSUED: 08/12/85 SEWI --- F:Z F�EFZMIT APPLICANT: CARLS EXCAVATING ADDRESS: P.O. BOX 110383 ANCHORAGE, A); 99511 CONTACT PHONE: 346-3568 LEGAL DESCRIP: SUBDIVISION: FREEMAN LOT: 1 SECTION: 20 TOWNSHIP: 12N RANGE: 3W LOT SIZE: 33000 4(SQ.FT. OR ACRES) BLOCK: NA' 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. 2. I 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.this or any adjacent or nearby lot. 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 M XB NE PV A LICENSED ELECTRICIAN. SIGNED •----- DATE: APPLICANT: CARLS VA�TIN`G sc� ISSUED BY _ �%l DATE: MUNICIPALITY OF ANCHORAGE:"', He_.:h and Environmental Prote Lon Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 ��//I' Ke INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM 1j NAME �OnA1RALE KID11h11:ING ADD RESS Rn y 11nu1Q5U0,?HONE �"I (c -.a LIZI LOCATION (�S'r 1% r -k D( LEGAL DESCRIPTION SEPTIC TANK: DISTANCE NUMBER OF FROM WELL 100 MANUFACTURER 5X1MSRL MATERIAL ((- COMPARTMENTS INSIDE LENGTH �C- INSIDE WIDTH VX(g LIQUID DEPTH ---ylk LIQUID CAPACITY GALLONS. TILE DRAIN FIELD: TOTAL LENGTH DISTANCE FRO" WELL 100( FOUNDATION a -D NEAREST LOT LINE 10� OF LINE (0'�" # of Lines D fSe- DISTANCE BETWEEN LINES A�`.Q TRENCH WIDTH IN. TOTAL EFFECTIVE ABSORPTION AREA -1(09 SO. FT. LENGTH OF EACH LINE DEPTH OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE -a -Q -IN. ABOVE TILE _C2 ---IN. SEEPAGE PIT: DIAMETER _OR WIDTH _. LENGTH- DEPTH Log Crib _Rings_ Crib Size: DIAMETER —DEPTH— DISTANCE FROM: WELL TOTAL EFFECTIVE BUILDING FOUNDATION_. NEAREST LOT LINE ABSORPTION AREA (WALL AREA) SQ. FT. Well C1ass:F��_ Depth: Well Distance To: Lot Line Bldg:�O+ Sewer Line: �-, Pipe Materials: Ptra r, C, # of Bedrooms: Installer: VLOiad&e VII Remarks: �n GATE _J__LZ?9APPROV EO .__ I_ ' • tom) _ _ - - - y - _ - GATE _J__LZ?9APPROV EO .__ Y'1 a r+l I C3 I P' FI L T'T � F H t-•1 C H � i-� t=i �t i E DEPARTMENTOF HEALTH AND ENVIRONMENTAL FGnTCTION fIl. Xl,�/� "- £25 'Ll�TP.EET, mr-HONSGE, A4:. 99- c,& Ls - IIlG11 264-4720 4cJELL FA t4 E7 C7 r4 I!FE GWCfz f'EFzt1I 11 PERMIT NO. C 7£0075 ) (i) [x ,% %L. �1ns7 1 I 1 !SI APPLICANT KLONDIKE KLIFF KONST. COX 2110 WASILLA i �J R 37EC1�"601 r LOCATION FOREST PARI: DR v� LEGAL L1 FREEMAN S/D LOT SIZE 33000 SQUARE FEES TYPE OF SOIL ABSOP,CTION SYSTEM IS: TRENCH r� MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT//R)= 330 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E>EowTh1= 1ZI ILE:4C37FlA= E•2 C3FZfA%•EFL DEF--r-H= CH THE LENGTH DIMENSION IS THE LENGTH (IF: FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EY,CAVATION CIN FEET). KECALJ I FRED> S~EFT I C Tnr-ji S12:1-_- 1 E+C+ c3nL_LC3,C-4- PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWG C �> I "ASF=`ECT I C]t.lE} nFzE FSE(pu I FzEO --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL; OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. f"EF2Ul I T E: & I FZE"> OECEMGEF-z 31r 1.227"V I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. '2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. '3: I UNDERSTAND THAT THE ON-SITE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED !ISSUED V3. 0 _ ^ © SOILS LOG MUNICIPALITY OFANCHORAGE / v DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ® PERCOLATION TEST Pouch 6650, Anchorage, Alaska 99502 276-2221 SOILS LOG — PERCOLATION TEST PERFORMED FOR:fILOA!OIICG IG L/ FF <O/J5T•• DATE PERFORMED: 8 — &• I — 78 LEGAL DESCRIPTION: G-enrT 1 lsurA ^—. SLOPE SITE PLAN 10- 11- 12 0 1112 5M 13- 14 15 16 17 t6 19 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT Z ame Ga GSovt DEPTH? f_-oiTow Or 47>rcay. S NO L O P E Reading Data Gross Time Net Time Depth to Water •' /Zea'—brown, ConduAn� Oomt 2- O 0 3 3 zl�a l sm,n I rri�n 4- s 5 5 Low moia fu re �undint 6 /5 Ll,S" 3 r S 7 . �oL40`iCn OIe lcwreulaf,on y�of- 8 0 9 10- 11- 12 0 1112 5M 13- 14 15 16 17 t6 19 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT Z ame Ga GSovt DEPTH? f_-oiTow Or 47>rcay. S NO L O P E Reading Data Gross Time Net Time Depth to Water Not Drop O Z.o" O zl�a l sm,n I rri�n • 5 " s /5 Ll,S" 3 r S �o3rrnn ✓ n 4-2-5 �5 20 -{ i41 UPERCOLATION RATE --:1 % mrn,An (minutasCnth) � �S TEST RUN BETWEEN —7 FT AND FT COMMENTS % Pi[O r •n '1•P s r�n�•Jnrrr��r/ ir• '< f-r�n�h ,i^m Phi �,•�/ •ln -7e.1 0 PERFORMEDBY: I-Awlaret T !'•.rP•J CERTIFIEDBY: ti DATE: '-A—.`•21�7f+ P ficpC. 1=KC. 72008 DY76I DAILY DRILLING LOG PENN JERSEY DRILLING CO. 2933 East 72nd Avenue Anchorate, Alaska 99502 344-2612 OWNER OF LAND .... DEPTH OF WELL---.— 0 .. . ....... kiSTATIC LEVEL OF WATER FT ........ . WELL SIT -IRT S5 VcellAkLRAW DOWN '7t GALS. PER'HIL .. .... .............. 7 ...... (D. -P ... N . ........... ... ........................... DATE—STARTED ...... H. -C=h- ..... -- )c DATE—ENDED ..... LlBkCh ...... .. 9-700 .. .............. ............ KIND OF CASING ..... 6../—/ ...... 6.4.ae—1 ...... uj.e../..cl J ...... . ........ KIND OF FORMATION: FROM ........... 0 ......... JT.TO._.... F 0, TO ........ I .. 5.6 ...FT-(./_. ........... FROM ...................... FT.TO . . .. .. .............. FT.clayish ... dljd.- FROM .... ............. ....... FT.TO ..... .............. ... FT -6 -and ... 1� . ....... FROM .......... CR ...... ... FT. TO ....... I. -S ......... FT.SrO.WD ... Oa..y FROM .......................... FT.TO ............. ... . ....... FT . ............. -Z70- ....... FROM................. . ....... FT -TO, ............ ............ F -r -.I -..Alp -l* ------------ FROM ..........................FT. TO ........... . ............. FT . .............. . ....................... FROM........I.: TO ..... 15.t/ .......... .... FR03L .................. .... FT.TO ....... . ............. . ... FT . ................ .................. FROM .......................... FT. TO...-..-..- . . ....... FT—claf ... . ............... FROM....................._... FT - TO ..................... . ... FT ....................... ....... ....... I FROM..... 5y ......... IV. TO. -71 ........... FT-6.and........._.....[....... FRO.'VL ....................... FT -TO ....... ... . ........... FT .............. . .............. .... FROM ....... 71 .... ...... FT. TO .... / ..Q.67 FROM ... . ............:........FT. TO .......................... FT . ............................ . FROM ..... /-Q.5 ........ FT. To .... LjR..5 ...... mb , OMP .. .... FROM .......................... FT. TO ..................... . ... FT . ....................................... FROM.......................... FT.TO ... . ................... . FT . .. ....... S. FROM ............. . ...........FT.TO .......................... FT . .................. . ................... FRO,,I .... LQ& _.......FT. TO.—L-S-a ... FT— L FROM ... ............. ....... FT.T0 ............. . ........... FT ............... . .............. . .. . ... FROM.......................... FT.TO ............. ........... FT . .......... ........ ....... ........... FROM.......................... FT. TO .......................... FT ............... ...................... MISCL INFORMATION: WcLL -;1-.-4- DKILLER-S NAME.L R M. 1— -.7cVl, .......... . ........ . ....... MUNICIPALITY OF ANCHORAGE ` • DEPARTMENT OF HEALTH & HUMAN SERVICES ' ' Division of Environmental Services On -Site Services Section . - - '` P.O. Box 196650 Anchorage.' Alaska 89519-6650 s. 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING " ParcelLD.p CIG- YIL-QL HAAp' r ,IiI� 99 7,4, GENERAL�INFORMATION. "'':. i^ • t =i -a l 1)'C r . .:.,..... Complete legal .descriptio n"�T'�,- ^$yr3t11�/t�itonl Location (site address ordirections) f/Z� ForL2GSr 61111dC Property owner' C�cr iL- (J Day phone :'35 —9303 - ,1 Ma(1(ng address ' p0. `13 ox �i19 �3 FhV t 402AG iQIL' '9'9511— /916 Lending ageTy Day phone :ct.--•— � tet..,. Mailing address Agenti' Day phone t y 7 ry �r _i _ ? :'Address., �•�.., .::.,.;-_. - -... .:.:.,.-.._ .. `. _ •-i . � `,(� z Unless otherwise requested, HAA will be held for pickup " +`':,; �' �._. ' _14_, , r 2.1='NUMBEROF.BED ROOMS. 3 4 - TYPE OF.WATER SUPPLY -^ - „ V : '.. w.1 .u. i...•i....N 1.-.ri:w ....—�. .. ....... .. ..-. .. ... e' 'w •-: .Y' '.4 4 Individualweli..._"...._Xx-X�•�t i�.� _ _.,ta<,> Community well -- ,, ' -- Public water , - ---NOTE: = If community well system','provide written confirmation from State 'ADEC attest - •" Ing to the legality and status of system Nit 4 -TYPE OF WASTEWATER DISPOSAL 1-7Individual on-site r r Holding tank l ` i Lt. Community 99 -site.,,!. . r I%.t 01- r. V. . *s.. Public sewer ....,, NOTE: = If community' wastemiatersystem,'provide written confirmation from State, ADEC " attesting to'the 'legality and status of system. 72-M (AW.1N7) Fm MOA F21 - - _ . . 5. STATEMENT OF INSPECTION BY. ENGINEER .,ice 1.. _:. 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 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 �r.lD�llSprJ tj16%iJcM- jrJL Phone 3`f`{'-LfSSI Address?r=i�'D,'CSbx 4:`2�07ij= 1' (,Hmn:aGE•. ''lL• 4SL� - -- Engineer's signature.- Date T Zo S yl ( y -- :. yYv^ i•,)Ti _�CIt=°s_-`.2fC f ID SYy i�';Y _i€. -'J';JIF�L=it {1�l{' Tt MI<haE. al 'Andn •on t• ty - 6 DHHS SIGNATURElogt - ` �f�F9 �'� .• � _�� Approved for bedrooms �`M.D.ws� - — 'ES ! y 1 � ._ • •DlsapproVed •,. _ .r_-5 �- rsi .» ..: r t -e i.xu=anJ11�W U i=T 1=v ti/ ti=t bJ�J= a:1 Y= n==rU Eue. 7J Conditional approval for bedrooms, with the followin sti ulahonsc a w•. '4, r. Z. f r •4 , -.;Additional Comments 5 \ x�,••• � `y t,�. ��• :,,.Date^] �0 9r ; ' �--, ` •,'.� _ ,cof ,:, L, y The Munic?palit)! k§ ndhorage Department of Health and Human Services (DHHS) Issues Health Authority ' '�Aperoval Certlichtes•based only upon,th... representations given in paragraph 5 above by an independent . ..., r. _ --. profess%rtalengineerregisteredin the State of Alaska. The DHHS does this as a courtesy to purchasers othomes . and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct in 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 • Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Ll" t, FruZ LM Ant Soli. Parcel I.D. A. Well Data Well type _P2t VAT"i= If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed 3 L$�7B Driller I�GNN �CfLS� y Total depth /T& Cased to �sL r Casing height Z Sanitary seal (YM) Wires properly protected (Y/N) FROM WELL LOG Date of test 312 g I7 Static water level -15' Well flow 7 g•p•m• Pump levell I k N ow SEPARATION DISTANCES FROM WELL TO: AT INSPECTION' /Zl9s 3.j 1 g.p.m. drNWO W,.f Septictholding tank on lot 1400 ; On adjacent lots �lOd Absorption field on lot i/DD ; On adjacent lots Woo Public sewer main /I JA Public sewer manhole/cleanoutg 14 Sewer service line N JA Petroleum tank N A WATER SAMPLE_ RESULTS: Coliform Nitrate • 10 M9 /L. Other bacteria Date of sample: A. 1/3 f'q 5 Collected by: A • 144Q.A L.1 B. SEPTICIHOLDING TANK DATA Date Installed '71 15 Tank size I, z.50 UAL . Compartments TiJ 0 Cleanouts (Y/N) Y Foundation cleanout (YM) YDepression (Y/N) High water alarm (Y/N) A] Alarm tested (YM) / q� Date of pumping 13 o Ig s Pumper. A PW.S 1•!ymr— SVGS. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ",\ _ \� /O r 7 10D >40 Well(s) on lot % 0 On adjacent lots Foundation r 1 r To property line Wo Absorption field 7$ Water main/service line 7 to 0 Surface water/drainage > /Do r 72-026 (593)•F nt CONTINUED ON BACK PAGE C. LIFT STATION /~/ A Date installed Manufacturer Size in gallons Manhole/Access Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION D. ABSORPTION FIELD DATA LIFT STATION TO: _%Fd?ffP off" Level at tested adjacent lots Surface water Date installed 12 ) z 8 Soil rating (GPD/Fiz) 3 1=T. 80 System type t;al Length /o Width 3 Gravel thickness 7b Total depth/t- Total absorption area 71-b F-77; U Cleanout present (Y/N) Y Depression over field (Y/N) Date of adequacy test 7/L Results (pass/fall) P,a 5'5 for —T N R�"E Bedrooms Water level in absorption field before test U After test D Peroxide treatment (past 12 months) (Y/N) A If yes, give date /`I % SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot � On adjacent lots 7/0 0 Property line /D 'X- To building foundation 7 ZD To existing or abandoned system on lot �48 On adjacent lots 7 SO Cutbank i 3 S Water mair Vservice line ? SO Surface water 7/00 Driveway, parking/vehicle storage area i50 Curtain drain /JonIG j1s*pdz_ AECS NAA /01151 SS I- ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in a%cMV7e date of this inspection. Signature � C_ Engirieer's Name,-' / ' l GI R CC. E � 6 C12 S p r✓ Date -71 z o �qS HAA Fee $ Date of Payment Receipt Number 72-026 rv63l• Back Waiver Fee $ _ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section CIM P.O. Box 196650 Anchorage, Alaska 99519-6850 343-4744 . CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # n110 — 11-':1- M 1. GENERAL INFORMATION Complete legal description HAA # W19Q,)Lnn Lot 1, Freeman Subdivision Location (site address or directions) 11220 Forrest Drive Property owner Chris :int. Linda La,, Day phone 345-9303 Mailing address Or) &X 111IL1 3 (2Ane hwer L, _ I `N3 Lending agency Mailing address Day phone Agent . Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: Four 3. TYPE OF WATER SUPPLY: Individual well XXXX Community well Public water 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 XXXX 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(P v.1/91) Frmt MOA921 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 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 Anderson Engineering Phone Address P.O. Box 240773 Anchorage, AK 99524 Engineer's signature & DHHS SIGNATURE Approved for Disapproved. By: Date 563-7155 7/3/95 cc ,N.Ichocl E. Andurwn ICr 4361-E Jas Conditional approval for bedrooms, with the following stipulations: Additional Comments 1uTir Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an Independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending Institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is Issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72Mm...+A+1 e.a ►ani DAILY DRILLING { ,t 0 LOO.. .0 7 ..... ; ,. -.. y -. >. q... /• rvrr. .11t �j1%if Fl�� _♦ / rnj { y �: 'PENN JERSEY DRILLING t r , ; r�' . 1 I .✓ r ri .r x - ..':.1i ' - ',+; j >. a \Y N. , ri�.rt i >Yi rt1! 5rt �' ♦ < , s. ..n y�� {�J� '••_- �n�. �� ,y��• r �.'.3�Y '..i' i i ♦ ;�tF �.-et.•� i. ty • • :.r Y .. J Y , X • ' \ MY ra.i ?Zta1 AnaM •• �� _ Amehoro , 1L�s.N1ll '7 t •.. C.. r\Aj 1." 1 AS 11 r , , • y ;� ,ti i ' f:t` •., •.a-' •r a. • I•MAIi OWN= OJiJ1ND C�i-4-'Y �rAKnrL� DEFISol�rai ' /sG{/ea' Ff04jrrz 1 x ADLRma_tluJLa+ +' f ill i-q1��j=/�s�•� ' C."ATW UVIOL Or NATii 1! �' 4 ` ` jf S X, ( l.y •-. _ �• . '<. .+, -/. ...'• :< S x•�r•TWra y 7�,ty ..•fix, 4 si.:• r.x. •. -.Y w � waw-aITK nw DOw11 n 1 r to �y f F/: ;.� �...1_l.ldJx t L� irr U?. dll iE>;"'.:7 M+• ..she' 'Y.'- ►•.e •• .' a . :4 r DA'iE--4t1'AiT'm i r1- . - .- ... .. .. :. rt .•.\c.. .,fie .,. DATE-IIfDm l312Gh `fig;_ /_9_�8 ` RM OFCASMO ►!:r {LeL�!l%�l�c _ KIND OrFOWMATIONt . c , . , _., ` i,a?ua,xt1> .,IoM CJ iT, To_�4_ _ E -r E�O.zC.N c (lSoi l n m 5 a—;; zo�!51a_ qM n, FROM _1T.+a- nslay�sh..d-L07 'FROM t ��� ,'r ,; n��_ ♦ :�t ; i,n... o.1ti rl ' i<� rot'0.� "n`•t'y x i•< . •.s � a - F! . • tIT� t '1 r•'C air •�• t . ARD .,'�N wi•+ � •'r for - - **.J�C�i� �r Y>"i .1s �tt ��•"�4 ;r�W �a Mr <"'1''i L14� -.r: x _ v r t r - <. 5"rr ,✓ i y . � M Y > y MPOYit47i r1 '�y.,M �t �. Ka J x ry �r J FR0�=1? Yo •S__�..�__._** �I..LL3iLI w .ws } r�>FRt11f e+�;.iknS�'ir T, � r.J� r1� "G• r' . y r r S t •t. r4 e. ti 'L t»r i�. •i;p'L.'t wr t � r,rCi " � ..-. ° Boli. � r � TO � •//y� �•r � /� • r_. t,y..,. ." Tw ilit/�fNly�Y'K'T>w y l;�r •�,( ..t�� t a - FROIL_`�.,1T. ib.w/-I•-�+.•..>./.411� 1--T!t.iKoY '!r.a.a' e'- +,I,+�.Jv �,..-'7•t• !� yY. .S t ,rn_ •. ! ,�r� r/• I t. -. ///n _ S ~ Y. rx t,r�,n •+r��r� n .5. t'yr1,M'tS,�''• Li t t'4J lWIR.�[.i�+. •V++�rV i�+..la7VFR/�Y M'•]•.4 )� �,�• '.j ''i„n �-•rc• 1� r rrr. ♦.-1^ ?.r ... • rl r'Y til\r+r- L �. 4t?k1� L'... w.. f . �.Cxl,l� el. s .�- n�+•:-�:•� _� ,�>•� t.* � � r y no►I _ b alg—". TO L 5-.%-,r C1a.Vg graLC l rsoY rr. TO �+ FROM- r*. To sT FRoY rr.TO MI/CLINFORMATIONt WcLL 4ta— • J DEIIIZR'8 NAM -La B_ _ CA ® Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: F26E'MAAJ --SOO • Parcel I.D. A. Well Data _ _.WeII type Piz),) 41r -c -It A. B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed 3 176 Driller R-94 U&M SCY Total depth /S(" Cased to 156 Casing height Z Sanitary seal (Y/N) r Wires properly protected (Y/N) Y FROM WELL LOG AT INSPECTION Date of test 3128 /7$ 717045 rn � g Static water level 75 r �'�• S r n o :2 f - rri O Ln Well flow 7 g.p.m. 3• g.p.m. S Pump levell V �r k n10 �J nl Uel K+U 0 H1 nl m n o SEPARATION DISTANCES FROM WELL TO: Z Septicrhokiing tank on lot >1001 _;On adjacent lots >100, Absorption field on lot >/0D r ; On adjacent lots >/0Dr Public sewer main V A Public sewer manhole/cleanout N/Q Sewer service line JV 14 Petroleum tank Al JA WATER SAMPLE RESULTS: Date of sampler B. SEPTIC/HOLDING TANK DATA Nitrate Other bacteria Collected by: Q. L)ARAt1) Date installed 9/RIR S Tank size h7-56 Compartments Tn Cleanouts (YM) Y Foundation cleanout (Y/N) Y_Depression (YM) High water alar (Y/N) Al Alarm tested (YM) AIJA Date of pumping X130 195 Pumper A P"s ' L�Ms SVCS. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: r %l04r > �0 Well(s) on lot �i�ab On adjacent lots Foundation To property line >10 r Absorption field > S r Water main/service line 7 �D Surface water/drainage >lODr 72-M rMn'Front _ __ _ . CONTINUED ON BACK PAGE NIA Date installed Size in Vent (Y/M 'Pump on' level Manufacti (Y/N) `ump oft• Levet at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot - On adjacent lots Surface water D. ABSORPTION FIELD DATA Date Installed, 4//z /78 Soil rating (GPD/F12) 33D BDaNt System type�mlGN Length %fir` Width 3 r Gravel thickness _—LDL—Total depth /&V /Z1• .,Total absorption area 76 h'>- a Cleanout present (Y/N) Y Depression over field (YnN) Date of adequaq test 7 L Results (pass/fa�) pA SS for �Oy fL Bedrooms Water level In absorption field before test O After test D Peroxide treatment (past 12 months) (YIN) /� If yes, give date - IV /A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: -- v Well on lot i/00 r On adjacent lots i/DO r Property Pure ID' • r , To building foundation ;1 710 To existing or abandoned system on lot /LA On adjacent lots > 50 Cutban k > 351 - Water main/service line >59 r r Surface water ADD Driveway, parldngtvehicle storage area > SD Curtain drain #AA �%slSs 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. .........V,r• Signature r n-7 • -V Engineers Name A41U)ACL. E 4PJsrRS0.J fr M�ha�.- ' •.• . 4' E. Anderson Date 7 J / C. HAA Fee $ 'Waiver Fee $ Date of Paymert Date of Payment Receipt Number �0 (, u/� .3 Receipt Number 72-026 CM- Brk n 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 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) /-0T i �x'ez�fffxl suB . Location (address or directions) (b)�' Applicant Name 4, GL �� ���` Telephone: Home477r r Business z79 71< Applicant Address (�L10' T *)eil 99 1G (c) Applicant is (check one): fending Institution ❑ ; Owner/bvilder�; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent 'E41-b"J12% Pre 'CeS, 1A0_- Ttrl lee 1\Qm Address 2702. Garnbe\\ Street. RQo2, AnchccaRe. AK 99503 Telephone .2'716'-17101 — (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family, Multi -Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual WelIX 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 ❑ 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. a Page 1 of 2 72-W501184) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ' 19 As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation of ds 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. i,� / Name of Firm& Q/✓i�t� 49&04'Ste' Telephone SG0/_50/C Address /7-Zo iJ 33d"Sa/TE B /fAlc'.'� IfZ 99503 Date DHEP APPROVAL `�' Approved for _( ad.� edrooms b _ to Approved �— Disappro Conditional 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 engineers work. Page 2 of 2 72-025 (1)/94) A. WELL DATA r' N eow) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 ' MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 1.r Legal Description: LO%� Well Classification >'Z111 12- If A. B, C, D.E.C. Approved (Y/N) Well Log PresentY N) Date Completed 3 - � Yield f 1 X-7 cSP� J, P Total Depth 6<0 Cased to INE Depth of Grouting Static Water Level n 7Z• y Pump Set At i Casing Height Above Ground Sanitary Seal on Casin (Y/ ) Electrical Wiring in Conduit(Y ) Depression Around Wellhead (Y& Separation Distances from Well: To Septic/Holding Tank on Lot //0 ; On Adjoining Lots /OV f To Nearest Edge of Absorption Field on Lot On Adjoining Lots Aly i fi To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot AIIX Water Sample Collected by �' ei/L_'l ; Date /0 Water Saml Comments B. SEPTIC/HOLDING TANK DATA Date Installed 9`5��7 Size �Z' No. of Compartments y Standpipes(Y N) Air -tight Caps ©Y N) Foundation Cleanou (Y ) Depression over Tank (19 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) — Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holdiny Tank: To Water -Supply Well //0 To Property Line Zo To Water Main/Service LineL Course •�/%} Comments Page 1 of 2 72-026(11/84) To Building Foundation$ 3, To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Results of Last Adequacy Tesf`t iTy % , Separation Distance from Absorption Field: To Water -Supply Well /e / i To Property Line To Building Foundation u t To Existing or Abandoned System on Lot A ; On Adjoining Lots 94 f To Water Main/Service Line ��� To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course 111114 To Driveway, Parking Area, or Vehicle Storage Area So Comments 0. LIFT STATION Date Insta /7 Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Dimensions Manhole/Access (Y/N) _ "Pump Off" Level at .�Vent(Y/N) PumpingZ7oi¢suring Adequacy Test. Meets MOA •• Check Permitted Bedroom Rating Against HAA Request •• I certify that I h/av a ed, v ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed GLS �� Date Company SCS MOA No. �s OL+ OF•A�s�f� Receipt No. t�y'�P•'• 617 Date of Payment ) ^ f —�� s A ••�;.t?Ttt �: Amount:$ LSn�tl 0Pwa' 6y C. Recd, No. 4231 fi Page 2 of 2 —Y AIS A-#14acid.. 72.026 (11,841 Soils Rating in Absorption Strata 330 Type of System Design DatElpstalled �'�L—%8 Length of Field Width of Field Depth of Field /y Gravel Bed Thickness 70 Square Feet of Absorption Area 7�/� Standpipes Presen (Y ) Depression over Field (Y© Date of Last Adequacy Test Results of Last Adequacy Tesf`t iTy % , Separation Distance from Absorption Field: To Water -Supply Well /e / i To Property Line To Building Foundation u t To Existing or Abandoned System on Lot A ; On Adjoining Lots 94 f To Water Main/Service Line ��� To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course 111114 To Driveway, Parking Area, or Vehicle Storage Area So Comments 0. LIFT STATION Date Insta /7 Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Dimensions Manhole/Access (Y/N) _ "Pump Off" Level at .�Vent(Y/N) PumpingZ7oi¢suring Adequacy Test. Meets MOA •• Check Permitted Bedroom Rating Against HAA Request •• I certify that I h/av a ed, v ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed GLS �� Date Company SCS MOA No. �s OL+ OF•A�s�f� Receipt No. t�y'�P•'• 617 Date of Payment ) ^ f —�� s A ••�;.t?Ttt �: Amount:$ LSn�tl 0Pwa' 6y C. Recd, No. 4231 fi Page 2 of 2 —Y AIS A-#14acid.. 72.026 (11,841 L MUNICIPALITY OF ANCHORAGE ,�r IW D1 DEPARTMENT OF HEALTH 6 ENVIRONMENTAL PROTECTION 825 L Street • Andwrspa, AWka 93501 NUMBER B -'SINGLE FAMILY ❑ One ❑ Four ❑ Other ENVIRONMENTAL ENGINEERING DIVISION ❑ Two ❑ Five Telephone 2844720 2-' Three ❑ Six 7. WATER SU my REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAC►(.ITIS$ ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1978. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY DIRECTIONS: Complete all parts on pope 1. Ineompleb retp, win not be procass d. Pleere allow tan (101 dotes for proaleirp. 1. ►Rt) ERT NER gir'INDIVIDUAL/ON-SITE" PHONE oir If system is over two (2) years old an adequacy test is required MAILIN ADOR NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATEDL 0.A60X o7//o PROPERTY RESIDENT (If different fydVn above) NE keezzler 2 8U.�c �R LLPHONE Uat)l& Gs>r!//C/rJ�Ci' io ani MAILING ADDRESS 3. LENDING INSTITUTION PHONE Aelme jels( Z0161'7 MAILING ADDRESS 'PIS REALTOR/AGENT Ix—Z,4. zl�n6 46r 4Z C'.6aGo MAILING AODR O S. LEGAL DESCRIPTION s /Jision STREET LOCATI N oeeczlel'e— W. 8. TYPE OF RESIDENCE NUMBER B -'SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY 2-' Three ❑ Six 7. WATER SU my IV INDIVIDUAL' ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1978. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM gir'INDIVIDUAL/ON-SITE" *elf individual/on-sits, give installation date If system is over two (2) years old an adequacy test is required 13 PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATEDL 72-01017/791 C. . P.4r 14 ---4 THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED .� TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED I SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED �/ Z4--% p INSTALLER ❑Septic Tank or ❑ Holding Tank Size: ..I 9)V0 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTUF!!;,L4,t4,j_ TOTAL ABSORPTION-AgEA 6 UY MATERIAL 1 k "F� 4. DISTANCES WELL TO: Septic/Holding Tenk Absorption Arm wer SeiM rpt of ne Absorption Aree to nearest Lot Line 5. COMMENTS APPROVED FOR 3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE 4—'0 i BY (Tile) LEGAL DESCRIPTION 72010 (Rev. 3/78)