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Home My WebLink AboutEAGLE CREST #1 TR A LT 22Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 201322 PID Number: 05030329 Dwelling: ❑t Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑E Upgrade Name HAGEDON ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19530 THIRD STREET ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 3 - GPD/SF JTotal - Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade - Ft. Gravel depth beneath pipe - Ft. Subdivision Block Lot EAGLE CREST #1 TRA LT 22 Fill added above original grade _ Ft. Gravel length - Ft. Township Range Section Gravel width - Ft. Beds: Number of Lines - Distance between lines - Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line - Ft2 1 - Ft. Well 92 - - - +25 TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water +100 _ _ _ Material POLYETHYLENE Number of compartments 2 Lot Line +10 - - - NA Foundation +10 - - _ LIFT STATION Manufacturer Capacity Gal. Remarks old tank demolished per code TANK REPLACEMENT ONLY Alarm location Electrical installed by PIPE MATERIAL House to tank 3034Tank to 3034 drainfield Installer GUARANTEED SVCS Drainfield existing CO/MT3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspection151 8/20/20 nd 8/21/20 Location and description I BOTTOM STEP AT DECK 3 4,h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date l 'low. j �. •:949 . . .... ...... .. Septic System ��' UHARLES G BALZARINI / �F�iJ Approved ,� Date Q� p p bAW CE -13854 ..��c��r �� i F,0 pROFES Note: this does include SIONP� approval not well permit requirements. (Rev 05/02/18) 8/30/20 s� AN Municlpallty of Anchorage l)°parc, P.O. Box 196650 a 4700 Elmore Road Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Department On -Site Water and Wastewater Section x x x x VARIANCE/'WAIVER REVIEW x x* x Waiver#: WR060011 COSA#:OSC201483 Permit#:OSP201322 PID#: 050-303-29 Legal Description: Eagle Crest #1 Tract A Lot 22 Engineer: C&M Engineering Applicant: Promise Hagedon Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved. The approved separation distance is 92.0 feet. See engineer's waiver request for justifications. This is a reissuance of a waiver approved in 2006. A new HDPE tank was installed and well water samples are favorable. This waiver approval applies to the existing septic tank only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ■ ................. ■ ■ .. N 0 M 0 ... 1 ................... ■ ■ ■ ........................ a ■ 1 Waiver is Granted: X Waiver is not Granted: Date: C= I 1-2 0 9-0 Approved b : Pp Y Name of Reviewer .............................................................................. 1 **** VARIAN C EMAIVE R REVIEW **** C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 8/31/2020 RE: Proposed Septic System to Well Waiver for Eagle Crest #1 Tract A Lot 22 Dear Reviewer, A new polyethylene septic tank was recently installed at the above property. Upon completion of the asbuilt survey, it was observed that the new tank encroaches upon the required 100’ separation distance between it and the well. The house location between the well and septic made measurement of the 100’ well radius difficult and the tank was installed in the incorrect location. We are requesting that a waiver be approved for a distance of 91’ between the tank and the well. The waiver may be justified for the following reasons: • The new Polyethylene tank is not subject to corrosion and is unlikely to leak. • Topography would prevent effluent from traveling towards the well. • Nitrate levels are low (0.285 mg/L) • The separation between the well and the old tank was previously waived to 92’ • The well log indicates a clay layer starting at a depth of 220’ which is above the static water level. Thank you for your time in reviewing this request. Please do not hesitate to contact me at 907-854-5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 8/31/20 CHARLES G BALZARINI CE-13854 R E G ISTEREDPROFE S S I O N A LENGINEER08/29/20 Lot 22, Tract A Eagle Crest #1 17,820 Sq. Ft. +/- 19530 Third Street 2 Story Wood Frame House S89° 58' 40"W 132.00 S00° 11' 00"E 135.00N00° 11' 00"W 135.00N89° 58' 40"E 132.0014.01 4 . 2 40.13 6 . 326.12 2 . 1 W SSSS S S OHU OHU OHU T T G E33.638.239.7 30.0 R.O.W.GRAV EL DRIV E W A Y GRAVEL SHARED DRIVEWAY 100' WELL RA D I U S SEPTIC COVER LOT 21 LOT 40LOT 39 ℄ THIRD STREET ℄ HILLCREST LANEEDGE OF ROAD EDGE OF ROAD 10' UTILITY EASEMENT PROFESSIONAL SEAL Date:Frontier Surveys, LLC Project No: 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 As-Built Survey of: www.frontiersurveys.com Frontier Surveys, LLC I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on Plat:Grid:Ordered By: 907.460.1686 - info@frontiersurveys.com This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. August 27th, 2020. Legend: Scale 1" = 40' Lot 22, Tract A Eaglecrest Addition No. 1 Charles Balzarini 20-431 8/27/2020 63-70 N/A Gas Meter Electric Meter/Outside Power Deck Septic Telephone Pole S G E Overhead Utility T Tel. PedestalWater Valve General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft.STA T E O F ALA S K A49 TH ROYEVRUSDNALLANOISSEFORP DERE T S IGER Pierre M. Stragier NO. LS-9812 08/31/2020 W 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 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201322 Work Type: SepticTank Upgrade Tax Code Number: 05030329000 Site Legal Address: EAGLE CREST #1 TR ALT 22 G:0055 Site Mailing Address: 19530 THIRD ST, Eagle River Owner: HAGEDON PROMISE Design Engineer: C&M ENGINEERING SERVICES This permit is for the construction of: Effective Date Expiration Date: ��rcnt S 0 Q f+ U• Dcparttrtent Lot Size in Sq Ft: Total Bedrooms: 8/18/2020 8/18/2021 17820 ❑ 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: Date: Issued By: n,f ,rte R �t lU(�'U' Date: 0;2 0 3 MUHMPA UTY OF ,, HCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION rRf Parcel I.D. 050 303 29 Property owner(s) HAGEDON Day phone Mailinq address Site address 19530 THIRD ST Legal description (Sub'd., Block & Lot) EAGLE CREST #1 TRA LOT 22 Legal description (Township, Range & Section) Lot Size 17,820 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank 0 Upgrade F1 Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑`' THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees Date of Payment: Receipt Number: Permit No. � ado cm (b- 8iR2O�2a 0"t G�yt> SP2013zZ Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment ServicesTuilding Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 8/15/2020 RE: Proposed Septic System Modification for Eagle Crest #1 Tract A Lot 22 Dear Reviewer, The above referenced property is currently served by a 3 bedroom septic system installed in 1980s. The 1000 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1000 gallon (MIN) HDPE tank constructed and installed in accordance with MOA requirements. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 8/15/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201322, Rebecca Carroll, 08/18/20 tewate- F*END A, CLEANOUTANC I / /ASP201322, Re • C2r�dll • MONITOR TUBE / * TH .•* �J Z TEST HOLE { .. .... ......f(� 0.5% \ SLOPE INDICATOR , , , • , ,r ... ...... CHARLES G BALZARIM � �r+�'c��•, CE -13854 ,,•��`�� / \ i srF- • . , gig, iza . • ��'`_� THIRD STREET ' WELL I SEPTIC AREA \ / ' 100' WELL RADIUS NEW 1300 GAL HDPE SEPTIC TANK \ / W/INSULATED RISER / \ AT FIRST COMPARTMENT INSTALL PER MANUFACTURER'S \ AND MOA REQUIREMENTS / \ 100' WELL RADIUS / \ 3 BR HOME DRIVEWAY 100' WELL RADIUS DECK / EAGLE CREST#1 TR. A \ / LOT 22 NEW DOUBLE / CLEANOUTS EAGLE CREST#1 TR. A �DEMOLISH EXIST. TANK EAGLE CREST#1 TR. A LOT 23 PER MOA REQUIREMENTS LOT 21 \ -- � SEPTIC AREA CONNECT TO EXIST. TRENCH. CHECK LINE FOR BLOCKAGES 10' UTILITY EASEMENT EAGLE CREST#1 TR. A EAGLE CREST#1 TR. A EAGLE CREST#1 TR. A LOT 38 LOT 39 LOT 40 (NO DOCUMENTED SEPTIC AREA SEPTIC AREA SEPTIC AREA 100' WELL RADIUS / FLAG 100' WELL RADIUS PRIOR SEPARATION DISTANCE NOTES: TO STARTING CONSTRUCTION � THE PROPOSED SEPTIC IS GREATER THAN: \ 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 0 15 30 SCALA 1" = 30' 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION LEGAL DESCRIPTION: EAGLE CREST#1 TRA LOT 22 C&M ENGINEERING SERVICES OWNER: HAGEDON I DATE: 8/15/201 REV: I DRAWN: CBJ REF - 907 -854-5558 SITE PLAN ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT No. of compartments ~ Manufacturer ---4 ~ capacity in gallons IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well ing PERMIT NO. Manufacturer Material Liquid capacity in gallons Well Foundation I ~, Nearest I t line/ Length W~Oth epth PERMIT NO. Type of crib Crib diameter Well DISTANCE TO: DISTANCE TO: Suilding OTHER SOIL TEST RATIN~ ] INSTALLER foundation Driller Sewer line Nearest lot line Septic tank 72-013 (Rev. 3/78) DEPARTMENT O['-HEALTH AN~) ENVIRONMENTAL F~TEGTION · °-.' 825 L STREET, ANCHORAGE, AK 995wi ~.~_~5~ " 2(34-4720 ~'~.~ o~. ONIS ITE SEWER ~ WELL PERM I T PERMIT NO: DATE ISSUED: 850519 0&/18/85 APPLICANT: ADDRESS: CONTACT PHONE: % S&S ENSINEERINS CURTHESS.CONST. SRB 19&-X EAGLE RIVER, AK 99577- ~94-2979 LEGAL DESCRIP: SUBDIVISION: EAGLE CREST LOTI 22 SECTION: 7 TOWNSHIP: 14N RANGE: 1W 'LOT SIZE: 17820 ' (SQ.FT. OR ACRES) MAX BEDROOMS: A Listed below are system. Choose the option DEPTH TO PIPE BOTTOM (F~.) GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL WIDTH (FT.) GRAVEL LENGTH (FT.) GRAVEL VOLUME (GU.YDS.) TANK SIZE (GALS) SOIL RATING (SQ.FT~/BR) the options available to you that best fits your TRENCH &. 0'" 10.0'~ '18. ? 1,000o0 ~ in d'esigning your septic site. BED W. DRA I N 4.0 4.0 0.5 5.5 4.5 7.5 18.0' 5.0 55.0 45.0 22.0 51.9 1,000.0 ** 1,000.0 ** 151 151 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certify that: 1. I am familiar IF A THEN (1) AN ELECTRI~-~ERMIT AND INSPECTION MUST BE OBTAINED;~ (2) WILL NOT BE APPRO~D WITHOUT AN ELECTRICAL INSPECTION REPORT; AND .ELECTRICAL WORK~UST B~NE~BY A ~ICENSED ELECTRICIAN. APPLICANT:' %[~E ~G CURTHESS CONST. · ISSUED BY with the requirements for on-site sewers and wells as set forth by the Municipality o~ 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 set back distances ~rom any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. I.understand that this permit is valid for a maximum of 5 bedrooms and · any enlargement will require an additional permit. LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES~ AS-GUILTS (5) THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street. Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PER~OR~EO ~OR: (~.uc----r' LEGAL DESCRIPTION: 1 2 3 -4 9 -~10- 11 13- 14 15- 16- 17- 18- 19- 20- COMMENTS bi.ri A. Sharer No. 1457-~ PERFORMED BY: 72-008 (6/79) ~---$01L$ LOG DATE PERFORMED: ri PERCOLATION TEST SLOPE SITE PLAN .ASO.OUN..ATER ~)o ~ E ENCOUNTERED? IF YES. AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Waler Drop PERCOLATION RATE ///~ (minuteslinch) /, TEST RUN BETWEEN FT AND FT Durbin :D . bng CO, Time Drill Lo~I Casln~l I "'~u"~""'~Mile 1.2,'Lucas'"~'"'""~IRo~ P.O. Box 871~8 WaslIla, AI~La 99687 (~7) ~ 376-:"~J, Name: S;)cci;..1 K Co:'~struct~ un AddresS~o X City: E~gle ;~ivar, /,.K Job Location:LOt ~2t Tract At Ea~le Crest Crew: R.Durbin/S.Zsclwricsen/R.I,e~;er Date: June ~, 175~ ~ Notes: ,.el.,. cased ?66 f includin %':elded on for fill) Static w;;ter level: 26~ ft. su~fl ce Depth Well Lo~ 0-/3 ~11 8-l~ Sand" ~ .~.,o and 1~0 ft. lavel left %o sit overnight: ~ fL. ,ole in AH 1~0-~0 Sand and gravel %.~th ~0-21~0 Brov:n cloy ~0-%72~ Bro%vn elm3 ?ith so:~le gravel ~72-; 31 ;~ost].y ?:~avel Subd. fro~.~ ft, UMIC Y\ LT Y OF H C H 0 -, G E�� s�•. `, Development Services DepartmentPhone: 907-343-7904 ; On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 05030329 Certificate of On -Site Systems Approval Expiration Date: be e 1 , ao';�' 0 1. GENERAL INFORMATION Complete legal description EAGLE CREST#1 TR A LOT 22 Location (site address) 19530 TH I RD Current property owner(s) HAGEDON Mailing address Real estate agent Day phone Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) k ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Z Private Septic El Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: O '� l� 1��Distance: I a t Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 6 6 0 Date of Payment Receipt Number COSA# OSC)o Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm C&M ENGINEERING Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE ySystem #1 Approved for v3 bedrooms. System #2 Approved for bedrooms Disapproved Phone 8545558 Date 8/30/2020 :-No_ � OF A/gsl�1 *: 49 TH •.* i• %J �? rJJ . CHARLES G BALZARIKI ., CE -13854 OpROfESS\*' A� Conditional approval for bedrooms, with the following stipulations: OF WATER AND WAS Tj7T�T BY � � �/V_�, 6 &x7c—W Original Certificate Date: o The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA Checklist blue sheet X Nitrate Advisory Arsenic Advisory Other COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA ______________________ Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: EAGLE CREST#1 TRA L22 05030329 11 1 +3.7 1985 NA 286 286 0.285 +12 C.Balzarini 7/19/20 258 7/19/20 0 Sept/PLASTIC 0 NA, new plastic septic tank TRENCH 1985 7/19 3 15.5 50 8 450 60 1440 50 450 NO NA ✔ COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to:(Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S 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.8/30/20 92 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ New Poly Tank Installed ✔ MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LOT ff T/tctc.t A EAGLE CREST S[IBPXI/XSXON Location (address or directions) 19530 Ttt~c~ S.t.,ze.e,t, E,,~I~' R.i.u~,-A~ 9957? J~ f. Pa~c2~ ~ (b) Property owner Mailing Address 19530 (c) Lending Institution . · G.U.A.C. Mailing Address Telephone: (home) 694-1635 Business E,,~t.e l~ue~, AK 99577 Telephone (d) Real Estate Company and Agent Address 16600 C¢,t~-~_J-~-d Telephone 694-4 (e) Mail the HAA to the following address: (or check here,~', if hold for pick up.) List contact person and day phone number below: $ & $ ENGINEERING Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Familyr~] Number of bedrooms _~ 3. WATER SUPPLY Individual Well ~ Community ri Public ri Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOS~'L On-site EX 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 I 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. Address //~ .o ~ ~'"~..~/~' /~. Date Telephone 6. DHHS APPROVAl. Approved'Dr ~' · Appr0v'ed ' ~ bedrooms by Disapproved · Terms of Conditional Approval Conditional 11 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health AuthorityApproval · 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 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. Page 2 of 2 'Well Classificaiio~ Well Log Present (Y/N) ¢ Date Completed Total Depth~l Cased to~Depthof Grouting . Static Water Level ~ ~ .~ ' MUNICIPALITY OF ANCHORAGE (MOA) Health Authority App~;0val (HAA) CHECKLIST -'FEBRUARY 1984 343-4744 Legal Description: If'~,, B. C. D.E.C. Approved (Y/Ni Yield .~. Pump Set'At Casing Height Ab0v.e Ground Electrical Wiring In Conduit ~q'N ) SEPARATION DISTANCES FROM WELL: To Septic/He,rd+rig Tank on Lot I 'OO To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Sanitary Seal on Casing~N), ' ' Y~ Depression Aro{Jnd Wellhead (Y/,~ ~ ; On Adjoining Lots ~ ~)O //OO ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ~U/~ lO'+ C~-~? t'k~,c.r ~.~.,~ ; Date ¥ - :-- _ Comments B. SEPTiC/HOLDING TANK DATA Date Installed ~Size StandPlpe. s (Y/N). "~. Depressi~)~ ~v~r 'l:ank (Y/N) / ~,¢x:::) No. of Compartments Air-tight Caps (Y/N) ~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) · Foundation Cleanout (Y/N) Date Last Pumped ~ ~')/IPl ; for ' ' 'Temporary Holding Tank Permit (Y/N) A]/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation ~ ~" · '~ To Disposal Field ~ / To Water-Supply Well To Property Line To Water Main/Service Line To Stream. Pond. Lake or Major Drainage Course comments' ~'"'~"l"Z'~5 72-o~ (,.,. ?/.) F,~, page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (~ / ~-- Width of Field . ~,l/O s* Square Feet of Absortion Area DePression over Field (Y/N) Results of. Last .Adequacy,. Test SEPARATION DISTANCE FROM ABSORPTION FIELD: Length of Field Depth of Field ;~ ' . ~;;~'Gravel Bed Thickness ~-~ ~ -- Statndpipes Present /~ Date of Last Adequacy Test / To Property Line ! O * To Existing or Abandoned System on Adjoining Loi~ ' .'~ Q ~ ~ TO Cutb'ack (if present) T(~ Water-Sbpply Well To Building Foundation" · Lot i ~ . ~ To Water M~in/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comm. e'nts Do LIFT STATION~ . . ' . Dateln§talled'....~~_,,~/~. (-' '' , .Dimensions Size in Gallons .... ~" Manhole/Access (Y/N) "Pump On" Level at '"'~,_ "Pump Off" Level at High Water Alarm Level at "~,_Vent (Y/N) Tested for '"'~,~mping Cycles during Adequacy Test' Meets MOA Electrical Codes (Y/N) ~ - Comments *'Chec'k Permitted Bedroom Rating Against HAA Request'* I certify that I have checked, venhed, or con[ormed to a MOA and HAA guidelines In effect on the date of this inspection. ~ ~ ~ · Compan;/~c) Date Receipt No. °'~'/ Date of Payment Amounts Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 .CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS ~0~! BY SABLE foz Work Ozde: I [4405 Date ~eport Printed: 3UN 29 89 ! 08:58 PWSID : Collected e ~s. [ecatved SUN 27 89 e [6:00 hze. P~esezve~ ~ith :AS Client Name Client Acct P.O.! VERgAL ~eq ! Analyste Completed: Ser'~ ~epo~te to: Special ADEC Chemlab ~ef t: 5986 Lab Smpl ID: I Matztx: WATER Allowable Paramete~ Teete8 gesult/Urdte Metho~ Limits NITR~TE-N ~3(0.10) ~]1 gPA 351.2 [0 Sample SA~Lg COL~ECT£O B! ~3S. EOUTINE SAMPLE. Eema~ks: Tests Perfo£med See Special lnstxuctionl Above UA-Unavailable None Detecte~ '" Sea Sample Bema:ke Above Not Analyzed LT-tese Than. CT-Gzeatez Than 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 J~yLt. z~tq.q I~r 1987 GENERAL INFORMATION (a) Legal Description (include lot. block, subdivision, section, township, range) Lot ~; T¢,,c,t A; E,tR~ C¢~.6t $,,bd. lui6ion Location (address or directions) (b) Applicant Name ~omP. qc~..~q Telephone: Home Business Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder ~, Buyer []; Other [] (explain); (d) Lending Institution G~'~AC Telephone Address ',' '"' (e) (f) 99577 Real Estate Company and Agent Address ~,0, ~qX, 771699. Ea_at.~ Rluee.. A&[6h.a Telephone 694-5500 ~e HAA to the following address: S ~ ~ ENGINEERING 17034 Eag~_ ~'u~_~ Lnop Rnad~ S~- ~04 orE. ed bF Con~e ~ TYPE OF RESIDENCE Single-Family'l~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well D( Community [] Public I-I 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 OnsiteF]' Publicl-I 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 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 flies 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 Telephone ~' ~ .4~_ ~ ~.~, ~ Address S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Date "'.w:~ R:..~-, A~o.~ 99577 Approved for ./'"~'~'~/_ ~ bedrooms by: . ate -~,-'~ ~ Approved ,,.,./~,_. Disapproved 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 engineer's work. · Page 2 of 2 · ;'~-o=5 u ~/~ 'v; ~ I~UN;CIPAU~y OF ANC~,~,[,C. IPALITY OF ANCHORAGE (MOA) CEPT. OF HEAL~'~ri~t~3~H AuTHORiTY APPROVAL (H~) ~l~O~m~ P~OTE~/CQHECKLIST - FEBRUARY 1~ ~7~ L~al D~ription: ~ ~ RECEIVED A. WELL DATA Well Classification Well Log PresentON) Total Depth ~- ~' / ~' Cased to ~-~ ! · Static Water Level ~-, ~' ~- · Casing Height Above Ground ~'/E°~P ·· Electrical Wiring in ConduitON) Separation Distances from Well: To Septic/H'~ Tank on Lot To Nearest Edge of Absorption Field on Lot If A, B, C, D.E.C. Approved (¥/~ Date Completed ~ -- ~ -- ,~'..5" Yield Depth of Grouting Pump Set At G4 ~" Sanitary Seal on CasingGN) Depression Around Wellhead (Y,~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line 5(~.z'' To Nearest Public Sewer Cleanout/Manhole ~'~· , To Nearest Sewer Service Line on Lot Water Sample Collected by ~' · t ,~ ~'~'/,f/~a'~,,~; :Date //Z 5'/ Water Sample Test Results ~.~ --.'.'~/~'~' .~,~ c: ~ ~ ~.- ~.. ~ Comments B. SEPTIC~TANK DATA Date Installed Standpipes {~)N) Depression over Tank (Y(~) Pumping/Maintenance Contract on File (Y/N) ~//zt/ ; for Holding Tank High-Water Alarm (Y/N) /J'~/~ Temporary Holding Tank Permit (Y/N) Size No. of Compartments Air-tight Caps ~N) Foundation~leanout(~N) Date Last Pumped Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Comments To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026{t1/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed [~../'~ ,5'- Width of Field z~.o t~ Type of System Design /~,'~'~ Length of Field ~ ~ ~pth of Field ~O Square Feet of Absorption Area Depression over Field (YO Results of Last Adequacy Test ~'/ Separation Distance from Absorption Field: To Water-Supply Well /' Oo i To Building Foundation ~.'~D ¢ '~ Lot ~//~ To Water Main/Service Line ~ O ¢ 4-- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Gravel Bed Thickness Standpipes Present Date Of Last Adequacy Test /U~/,~/ //~f~'5"' '-'""- To Property Line To Existing or Abandoned System on ; On Adjoining Lots TO Cutbank (if present) AJ//41' 5-0 ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions ///~//,~.ump Off' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify Ihat I h__a.v_e. ~ J-~..v e r i f i ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection S & S ENGIHP..P. KIH~ / / Comp,~IieRj~''AIasEI99S77 MOANo. /~'6''-~00 --~ Receipt NO. ~ O C~ r -'(~,~-- Data of Payment Amount: $ Page 2 of 2 72-026 411,64) 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 ~-~~~-- GENERAL INFORMATION (a) (b) {c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name .~.~A Applicant Address J ? ~ 0 ~ Applicant is (check one): Lending Institution I'-I; Owner/builder I'-I; Buyer I'-I; Other [-I (explain); Telephone: Home ~'~gf'~ ~'~,'7~,_ Business {d) Lending Institution -{.'[O,l~l,d?_,_~ ~ Telephone Address {e) Real Estale Company and Agent __E=..7_{, -' 13 3.3 Telephone (I) Mail the HAA Io the following address: TYPE OF RESIDENCE Single-FamilYt~ Multi-FamilyI-I Number of Bedrooms Other WATER SUPPLY Individual Well,,,~ Community I'l Public I-I Note: If community well system, must have written confirmation from Ihe Slate Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ Public 1'3 Community I-I Holding Tank I-I · N o't'e: II corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 ~,2-o~5 ,,,~) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal altixed 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 verity that based on the information obtained Irom the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or ~Nastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the dale of this inspection. Name of Firm "=~~' Address / Date Approved ~.~. Disapproved Terms of Conditional Approval ~'~'~-'t..t' ~")., Date Conditional 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 ol 2 72-025 (I t/84] WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 /~UNIClEAUTY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION m~A¥ R C i.VED Legal Description: ~ If A, B, C, D.E.C. Approved (Y/N) Date Completed ~/-~- J/~'~ Yield ~-'~'~ Depth of Grouting NO I~ I~ Pump Set At ~-.~' .~tt ~" Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) Well Classification Well Log Present (Y/N) Total Depth ~ Cased to Static Water Level ~, ~i~_,_,_,_~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot J I O To Nearest Public Sewer Line ~~ CleanouVManhole ~..0 i,J ~--. Water Sample Collected by Water Sample Test Results __ Comments ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Date B. SEPTIC/HOLDING TANK DATA Date Installed ~ ~/J~"' Standpipes (Y/N) Ta~'O Depression over Ta~k (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course Size Air-tight Caps (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: IOO No. of Compartments '~' '"// Foundation Cleanout (Y/N) Date Last Pumped t~,l~-- ~/e~ ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ~ ~ To Disposal Field ~ To Stream. Pond. Lake. or Major Drainage Comments Page I of 2 72~26(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation '~' ¢~ ' Lot /',,.J TO Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design r'~--~E/~ f---~ Length of Fietd Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line I ~ J' To Existing or Abandoned System on ; On Adjoining Lots f ~ + To Cutbank (if present) ~ O~%~ ~ D. LIFT STATION NoNI . Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (WN) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments Page 2 of 2 *° 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. Signed ~ Date ~" L~.~ Company MOA No. Receipt No. "-~.~ '~...:~,c~ I Date of Payment ,r~'. ~ .'~'~ ~'~-~,~.. Amount:$ ~ ~W?4~ ~-'~ ~ Engin~r's~al .... . DEPT. OF EN¥IRONMF~NTAL CONSERYATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA qg501 BILL SHEFFIELD, GO~RNOR Telephone: (907) Address: 274-~533 Pws i.n. To Whom it May Concern: According to records on file in this office the ~C~,t~- E~f~ck~_,~-,r7 ~'-~/~ ' Water System is in compllance with the Stale Drinking Water Regulations --~yeD~tPx4 ~p~,/c. Stncerely~.~~. 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 GENERAL INFORMATION (a) Legal ~_..escription~_~ ~.. (include~_~.~ ~-.'"7"l°t' block, subdivision,~t, section,~.,~, ~- Z..~"t°wnship' ra~.~ Location (address or directions) (b) Applicant Name -,~'/¢~'/ ~/'Z..-/~---~/f' ' Telephone: Home Applicant Address (c) Business Applicant is (check one): Lending Institution I-1; Owner/builder~[~; Buyer r-I; Other r'l (explain); Lending Institution ~/.J' ~F Telephone (d) (e) Address Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Singl~-Family~ Multi-Family D Number of Bedrooms '~ Other WATER SUPPLY Individual Well~l~] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting fo the legality and status. 4. SEWAGE DISPOSAL · On$ite~ Public [] Community [] Holding Ta~k [] Note: If community well system, must have written confirmation from the State Department.hr Environmental Conservation attesting to the legality and status. Page 1 of 2 ~,~25 o~.s~) 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 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 flies 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--~m~,~ Telephone Address .... Date ..... ...... _ DHEPAPPROVAL - , · Approved for /~-~,) bedrooms by Approved "~ Disapproved ; Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of HeaIth and Environmental Protection (DHEP) issues Health Authority Approval certificates based eo~ely 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 d~ 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 (11/84) HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ~N~r,~r.~ ~'[CT~JI~ALTH AUTHORITY APPROVAL (HAA) WELL DATA Well Classification Well Log Present~)N) Total Depth ~ Cased to Static Water Level '~--(~'Z~· Casing Height Above Ground Electrical Wiring in Condui'<:~N) Separation Distances from Well: To Septic/l~ Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole e'3- Water Sample Collected by Water Sample Test Results Comments CHECKLIST - FEBRUARY 1984 264-4720 Legal Descripti n' ~.-o-r If A, B, C, D.E.C. Approved (Y/N) Date Completed [·')" ~- ~ Yield ~ Depth of Grouting Pump Set At Z3f- ~, '~ Sanitary Seal on Casing ~)N) Depression Around Wellhead (Y~ ''~ ; On Adjoining Lots I ~ t.~' ~ ; On Adjoining Lots I ~ t To Nearest Public Sewer To Nearest Sewer Service Line on Lot I~) I-1~' B. SEPTI~ANK DATA Date Installed ..~/~,.~" Size / ~ No. of Compartments ~ Standpipes ~)N) TM Air-tight CapstaN)~ Foundation Clean(~ut ~;~N)~,~ Depression over Tank (Y~) '~ Date Last Pumped /,,~-~,.,3 Pumping/Maintenance Contract on File (Y/N) /O ~ ; for Holding Tank High-Water Alarm (Y/N) rO//~. Temporary Holding Tank Permit (Y/N) ~/~' Separation Distances from Septic/~ Tank: To Water-Supply Well ~ ~ ~ To Property Line tO I.~ To Water Main/Service Line Course i'D/~ To Building Foundation ~ ~' To Disposal Field ~ · To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026( C. ABSORPTfON FIELD DATA Soils Rating in Absorption Strata Date Installed ~ !~::~ ~" Width of Field ~ o Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Founda~jol Lot A To Water Main/Service Line i~'~L ~,~, Type of System Design Length of Field ~ Depth of Field [ ~ Gravel Bed Thickness r'/~. Standpipes Present ~) Date of To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~ ~ I"~ TO~ Cutbank (if present) /5/,,4 Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed lo all MOA and HAA guidelines in effect on the date of this inspection. Signed '~ ~' ~.~E_~GJ~N~,&EF,~C~ Date ~/,?-.'~ /~ f - cor~ a~ '.aW ~.V.E~.~,S.;~ ~ ..... /~,~ ~ ~ Receipt No. ' ~R~5 ~ Oat. o~ Paym.nt %-~5 Amou.t: S A~,O~ Page 2 of 2