HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 11 MUNICIPALITY OF ANCHORAGE
D[/"~RTMENT OF HEALTH AND HUMAN SER ES
%. ' Environmental Health Dlvislon
825 "L" Street, Anchorage, Alaska 99502. Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
..mo DISTANCES
WELL
^.d,~FROM -'"'~C.~ TANK FIELD
I
.5
-%- . FOUNDATION ,.%-
TANKS
1~ SEPTIC 1-] HOLDING
TYPE OF SYSTEM
[~:TRENCH [] BED D W. DRAIN I-"1 OTHER I
z.~, SQFT; ' /~/n FT ~,,r.
WELLS
'~ PRIVATE [] OTHER Ildentifvl
REMARKS:
Inspections Perto, mea by
r.a~le River Engineering Services
I ~, ~ cedJfy Ihat this inspection was pedormed according to all
72-O13 (:~85)
MUNICIF'ALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
'264-4720
ON--SITE SEWER & WELL PERMIT
PERMIT NO:
DATE ISSUED:
850687
10/21/85
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDR0OMS:
SHUMWAY GRAIG/MARY
P.O. BOX 1481
EAGLE RSIVER, AK 99577
694-4181
SUBDIVISION: EAGLE RIVER HTS.
SECTION:.7 TOWNSHIP: 14N
10852 (SQ.PT. OR ACRES)
5
LOT: 11 BLOCK: 2
RANGE: 1W
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site.
TRENC;4 BED W. DRAI~4
DEPTH TO PIPE BOTTOM (FT.) '4.0 4.0 4.0
GRAVEL DEPTH (FT.) 8.0 ,0.5 5.5
-TOTAL DEPTH (Fl'.) 12.0 4.5 7.5
GRAVEL WIDTH (FT.) 2.5 19.0 5.0
GRAVEL LENGTH (FT.) 28.0 * 56.0 50.0
GR'AVEL VOLUME (CU. YDS. ) 22. I 25.4 57. 1
TANK SIZE (GALS) 1,000.0 ** 1,000.0 ** 1,000.0 **
SOIL RATING .(SQ.FT'./BR) 148 152 152
** TANV MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am familiar with the requirements for on-sit~ 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 ~ith all MOA codes and regulations.
and in compliance with the design criteria of this permit. .
5. 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.
4. I understand'that this permit is valid for a maximum of 5 bedrooms and
any enlargement will requi~e an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
]'HEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT'BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
ELECTRICAL WORK MUST BE DpNE BY A LICENSED ELECTRICIAN.
SISNED' . . J/ ~.,~., DATE.
.............. ]_ _
APF'L I CANT: SHUMWA~¢~ GRA I G/MARY ~/ -
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~/'~,~'~
LEGAL DESCRIPTION:
~/- ~',,,~, ~,,,~,~.,"/
~ Cz e' Township, Range, Section:
SLOPE
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
2
4 '~.,:
5
7- ' ~ ' I 1%&~ I I I I I
9- ~' ~. ~
I0 - "' ~*~ ~--~ ¢~ WAS 6BOUND WATERENCOUNTERED?
- - DEPTH?
12 ~ ,~ E
· · " ~ni~ing?
13 . .~
14 '; ~,
15 ./ ,~
PERCO~TION RATE ~ (m~nul~mch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FTAND ~ FT
16
17-
18.
19.
20-
COMMENTS
P. 0. gl~ 7732~4 I ~..,~,e;~,,,-.-~,-- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE A~*r~ICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
· McKay Well Drilling
P.O, Box 557
Wasilla. Alaska 99687 [.
Phone 376-5058
We,,Owner ~"~;J¥ ~//'/~ ~'~ ~ ~ .
· Well Location/"3 ~/~?//, /~/,/~,~a'~,, [/.~ . .
· ~/]?/g /~,*uc-/c- //~/,/~
Size C~ing ~/' Depth of Hole /'P ~'
· S~tic Water Level, f~t Wel~ Test /~
Date of Completion /0 ' ? ~ - ~ ~'
Phone *
cesta to /~, ~--
Gal pe,r Minute for '/
. feet
Hours
AUTHORIZATION.TO DRILL
I hereby authorize McKay Drilling to p~roceed with the abo,ve WOrk./[~ayment shall be made in
the ~oUowing ~nanner: ,'~
· . ,. ~.' / ~ ,
.Balan~ d~ upon ~mplet~on. ~, ~P ~ , } /
In the event it is n~es~w t0 insitute le~l proc~dings to coll~ any amounts due on th~s ~h-
tmct,'l agr~ to ~y an addltio~l sum of fiE~n p~?en~ (15%) of the. original ~ntm~ pri~..
Plus att~rpey's f~s, and co~ for I~al pro.dings. '* .: '
Da~'e
Na~e
· ' Addri~ss
RECEIVED
· ~ MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services MAY 0 7 1999
On-Site Services Section ~UNICIPALI'i~ O1: ANCHOP.,a. GF-
P.O. Box 196650 Anchorage, Alaska 99519-6650 i~NViRON,,VL~.t,~AL$[P, VICI[$DIVI$1ON
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~,50-281-$0 HAA#
1. GENERAL INFORMATION
Complete legal description
Lotll, Block 2, Eagle River Heights
R
Location (site address or directions)
· Property owner
Mailing add~ess
Sarah DeSanto
10219 Wildwood
Eaqle ~V~r, Ak 99577
Day phone.
102~9 Wildwood, Eagle River, Ak 99577
696-1137
.4.
Lending agency
Mailing address
Agent /~"- Av'~';/
Address I~'°°
Unless otherwise requested, HAA will be held for pickup.
NUMI~ER OF BEDROOMS: 3 ·
TYPE OF WATER SUPPLY:
Individual well x
Community well
Public water
~ay phone
Day phone
~=.~[~ ip~,% ,.~v-. ~'q~"-/q
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site . x
Holding tan. k.. ·.
Community on-site
· ' ~" Public sewer
· NOTE: If community wa~tew'aier system, provide' written confirmation from State ADEc
attesting to the legality and status of system:
STATEMENT OF INSPECTION BY ENGINEER
As certifie, d 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 invest, igation 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.
Nam'e of Firm' '~ ~-e.~le-.~ [ "~, ~.
Address
Engineer's signature
DHHS SIGNATURE
· ["/' Approved for '7"//'//~,~"~bed~ooms.
Phone ('~o~
Date ~"'
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to pumhasers 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 error~ or omissions in the professional engineer's work.
· .. RECEIVED
MAY 07 1999
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SE~4~,y ~, Af~a%~al
.. Environmental Services Olvtsion ~qVIIIOI,~N. I,ERYI~ DIV~ION I~i
825 L Street. Room 502 · Anchorage, Alaska g9501· (907) 343-4744
Legal Dcschpfion:
A. ~ DATA
Be
Co
Health Authority Approval Checklist
Lotll, Block 2, Eagle
Well t.vpe private
Log pmseut (Y/N) Y
Tot~der~h lO5 '
Samt~..; seal (Y/N)
050-281-30
If A. B. or C. attach ADEC letter. ADEC wat~' system numbe~
Date completed 1 0 - 2 9 - 8 5
Cas~m 105 '
Y
FROM
10-29-85
Niuate
Date of lest
Static water level
WcU production
WATER SAMPLE RESULTS:
Coliform [~
Date of sample: ~. %. o~o}
SEPT~CAIOLDING TANK DATA
Y
Fe,,-d~!on cleanout (Y/N)
Dateot'Pmnpmg ~", 7'
ABSORri'tON F11~.n DATA
· I)ate installed lllllS5
~ 29' Width'
Wires properly protected (Y/N)
AT INSPECTION
4-29-99
63.7'
GT6GPN
CoH~by: SCuar: Gilbert
Soflm!ing (g.p.d./ft~o.rf~Axirln), 152 Sy,~e~n .tTpe deep trench
30" Oraw, ithlckncssbclowpipeS, ( 9 6 " to~ ~ 138"
F_.ff~fix,~absoll}fiona.v~a 4648f MoMtofiflsTobopre~tttff]N) Y Depfessionovzrfield(Y/N) N
Date of adc~Hacy t~l 4-29/99 ReSuJts (~aSs~ail) Pass For 3 bedrooms
Fluiddeptbinabsorpfionficldbefomtest (m.); 52.75~fla~atelyalter 45~.wa~radded (in.): 69"
Flu~ddcpth 52.75 "(ins.)lvl!n,~Tcs lam.: lO0 Absorptlonrate = 6- ,fa~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) a; if yes, gt~e date a;/~t
Dateiastafled 11/1/85 Tanksiz~ /.O00 Npmh~ofComparlmcots 2 Cleanouts(Y/N)__
Depn=ssion (Y/N) ~ High water alarm
LiI~ STATION
Dale installed
Manhole./^ _ _n:e~s_
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Sizc in gallons
"Pump on" level at*
*Datum
"Pump off' level at*
Public ~ver znnnhole/cleanout
R~. 8/95 OSS: htm, wk.doc
La station ~/a
SEPARATION DISTANCES FROM SEPTIC~OLDINO TANK ON LOT TO:
Building foundation 1 0 ' ~ line 2 7 ' Absorption field
Water m~ed_se_r~_~_...U_ne__ G T 2 ~Suffacc waterldmin~ge no ev.~adjaccntiots G ~ I O 0 '
SEPARATION DISTANCE FROM ABSORPTION iq~l .n ON LOT TO:
Bldldhlg fOUlldalJon 1 8 ' Wage! rain/service line G T 1 0 s
Surface water no evddonco Driveway, paflfing~ehlcle storage a~a
Cm~aindtain no evidence WcllsonadJaCentlots GTIO0' Propertyline I0';
ENGINEER'S CERTIFICATION
I ceftin, that I have determined thru field inspections and remew O. IMunicipal reco~l_~.t~]ao_eb~l~i~jcl~H are
in conformance with MOA HfL4 guiflelmes in effect on als date. ,~'..~'2 L'a'~-'T,,',-Is '
Sisna e -- .-~.. ,..
".-..- -
Waiwr Fg= $
Da~ of Payment
4' to center of trencl
Receipt Numb~
Septic/holding lank on lot 1 1 2 '
Absofl~tion field on lot 1 1 4 '
Public sewer main
Sc'wer l_?u_*c_sc,vic= linc a ~ 8 0 '
SEPARATION DISTANCES FROM WELL ON LOT TO:
; On adjacent lots GT1 O0 '
: On adjacem Iota GTIO0 '
Lot1..1, Block 2
Eagle River Heights (10219 Wildwood, Eagle River, 99577)
Homeowner - Sarah DeSanto
TAX ID 050-281-30
4-29-99
Well and Septic Adequacy Test (HAA)
WELL TEST
A four hour test was conducted using an acoustic well probe and 20 GPM capacity
water meter.
Total depth of the well was 105' below grade. Static was found to be 63.7' below
the top of the well casing.
1,470 gallons were pumped at unrestricted flow rates that varied between 5.6 and 7
GPM.
Level in the casing dropped 11' from 63.7' to 74.7'during the first hour of pumping
and stabilized. Level remained at 74.7' below top of casing during the remainder of
the test.
Recovery was 100% in 2 hours.
RESULTS: YIELD WAS IN EXCESS OF 6 GPM. Well satisfies the MOA
requirement for a 3 bedroom house.
Lot11, Block 2
Eagle River Heights (10219 Wildwood, Eagle River, 99577)
Homeowner - Sarah DeSanto
TAX ID 050-281-30
4-29-99
Well and Septic Adequacy Test (HAA)
SEPTIC TEST
The septic test was begun at 12 noon on 4-29-99. The 3 bedroom residence was
unoccupied during the test and recovery. All cleanouts were in place: 1 at the
foundation, 1 for each compartment of the septic tank and one monitorlcleanout at
each end of the trench.
The trench length was 29' with 96' of sewer rock below the invert. At the beginning
of the test the static level in the trench monitor on the north end of the trench was
52.75" above the bottom, which allowed 43.25"of remaining capacity below the
invert.
Flow was added to the monitor at the south end of the trench at an unrestricted flow
rate that varied between 5.6 and 7.5 GPM. 870 gallons were added during the 2
hour and 14 minute flow period.
The level in the north monitor rose 25.25" during the flow period. During the first 8.5
hours of the recovery period a drop of 22' was recorded, which represented 87%
recovery of the 870 gallons added. Recovery of the 870 gallons was 100% in 20
hours. However, the required 450 gallons was absorbed during the first I hour and
40 minutes of the recovery period.
RESULTS: System satisfies the MOA requirements for a 3 bedroom house.
(The test was conducted with more than the required number of gallons to insure
that the absorbsion would take place in the upper unused portion of the trench)
· MAY-0?-Gg 11:06 FROU-CT[ EN¥II~0~HTAL $6t5301 ?-564 P.03/04 F-506
CT&E Environmental Service& Inc.
C"f&£ R~.~
Client Name
Project Name/m
Client Sample ID
Ordered By
PWSID
Sample
991798~0!
SO Tcchmcal
Eagle R~ver Heights
tot 1 Blk 2 E~le lurer Hts
D~-g Waler
0
Client ~
Primed l~te/Tlme 05/06/!,~ 16.15
Colleeted Date/Tbne 05/02/99 12 UO
~.~eived ~e~e 05~3/99 09 US
T~ ~ur: ~ephen C. ~e
Atto~a~te pre~ A~atySiS
~lt$ ~etflo~ LImitG Date Date Init
Toter ¢otfform
0 eot/TO~ SK18 9222B
2.2~ 0.500 mg/k EPA 300.0
Io max
0S/03/99 r.~P
gs/o.~/99 0S/0.3/99 scl
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # {"~-?-~'~- - .~%~ ' ?"~, ''''~''' HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 10519
Property owner F.~r~/, R t ~,~ ,~_ R~'~,.i~,~t~.~
Mailing address ov~.6~.~ O/C[IVA~/A
Day phone
e
Lending agency
Mailing address
Day phone
Agent .l,~n~. H~,?~ ('~FAT[AI~IO ~EA~TV
11411 O.t.d G.t.e.m,t Hi~t'u, uccV
Address E~gt~ R,/_v~. A~a~Jz~. 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: $ XI
TYPE OF WATER SUPPLY:
Individual well Y,X
Community well
Public water
NOTE:
Day phone 694-91
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 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 ~ & $ Ei, iG;i, iEE~iN~,
Address '~7c~ ,'. '~.:.~!e River L~p Road
Eagle River~ Alaska 995~
Engineers signature
Phone
DHHS SIGNATURE
~ Approved for //~'~Jbedrooms.
__ Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in 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.
Municipality of Anchorage ~i~
. Department of Healtt3 & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~'~" ~\ "~-'~L..\/--, ~
A. WELL DATA
Well type'~'~--\~.~'~;' If A, B, or C, attach ADEC letter.
Log present~C~N) "~ ~
Total depth I ~
Sanitary seal~) ~
ADEC water system number -
Datecompleted ~C>-''7'-~5- ~ Driller
Cased to \ ~:x-~ ' Casing height
Wires properly protected (~)
FROM WELL LOG
-. ~ ~'
Date of test
Static water level '
Well flow' IQ
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ I''Z''~
g.p.m.
Absorption, field, on lot
Public sewer main
Sewer service line
; On adjacent lots ~ ~::~1 ~
Public sewer manhoi:e/cleano~t ' I~ /~-
Petroleum tank ~ O~'--~,-
WATER SAMPLE RESULTS:
Coliiorm '~ Nitrate \- ~ ~ ]'~
Date of sample: ~)'" I"~-~¢~'Z" Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date Installed / ~ '" I'- ~:~
Tank size
Compartments
High wa!er'al.arm (Y/N) '"-"' Alarm tested (Y/N) I,''
Date of pum~3i~ .... ;~'" J"7 - ¢=J~'' Pumper,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot "' ' ~''Z'''t' :
Topropertyline" ~' ~
Surface water/drainage
72-026 (Rev. 7/91) Frc~t
Foundation cleanout~r~N)~ ;-.~al -~ ~ ;)~D~);~'{~ion (V,41~
On adjacent lots
Absorption field
~ 4:::::~ Jr" Foundation_ ~
* ~ ~ ....... Water'm~in/servic~e line
· CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed
Size In gallons
Vent (WN) '
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
sEPAR,~TION "' ' : .... ' "
DISTANCE FROM LIFT STATION TO:
Well on lot '" On adjacent 10ts
D. ABSORPTION FIELD DATA
Total absorption'ar?a
Depression over ii;Id
Results
Peroxide treatment (past 12 months)
Manufacturer ' ' · '
Manhole/Access (Y/N) ' '
' "Pump off"levelat '
Cycles tested
Surface water: '
Gravel thickness ' {~ Total depth
.Cleanouts pres. e.nt,~rCN) -y
Date of adequacy test
for '
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellonlot ' / i'''~'~ On adjacent lots ~ ~ Jr P~ropertyline
To building'foundation - ~ {~1 ,, ,
To existing or abandoned system on
On adjacent lots .~1~ Cutbank //[' Water main/service line
Surface water__ --~ c::~:>t ~' Driveway, park,ing/vehicle storage area
Curtain drain
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 ~nspe~tion '
· .. ~. . . __,,~, ..~.,~'~',~.~,.~. , ~
Signature 17034 Ea:!e RIv~' LeeP Read No. 2~4 -~5~;." - '~'"7~.~..el, '
Riel',
,,,,_,,. ~,, .. ,......= .-... ~ .~
, · .~, ~ ·
, '. , ;. , , . ~"¢.~,."'.;,_.._ .__.__...., ',o,* ~'~.,,. ,
. .~.l ~n. ¢,--'~' -
HAA Fee $
Waiver Fee: $
Date of Payment W / /2 / ¢~- , Daieof Payment '"
Receipt Number c>~.~-~--~
Receipt Number
72-026 (Rev. 3/91) 8~Ck MOA21
CHEMICAL & GEOLO,G,I..CAL I, ABORATORY
A DIVISION OF CO &'IIdI~.'RCIAL TEoTINO & ENGINEERING CO. ~
,I~MUNICIPAMTY OF ANCHORAGE ~
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECT!ON
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date June
GENERALINFORMATION ~
(a) ~galDescription(includelo~block, subdivision, section, township, range)
l,n~ 11 Rln~k ? Es[le Rivep height~ TlhN RlW Sec.
Location (address or directions)
23, 1986
(b) Applicant Name t,~-~v gh~m'~y Telephone:Home
Applicant Address ~,,, lti~l ~.;~['lP R-IvPt-: A'lagk~.
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution N/A Telephone
Address
(e) Real Estate Company and Agent ~,lat'y .C;humwR¥ ~ VI .~t:R
Address
(f)
Telephone
Mail the HAA to the following address:
P'l ckup hy ,~ppl 4 t-nnf.
TYPE OF RESIDENCE
Single-Family [] Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well[] Community[] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmati(~n from the State Department of Environmental Conservation
attesting to the legality and. status. -....
12.025 {11164)
Page 1 of 2
· 5.
ENGINEERING FIRM PROVIDII.. INSPECTIONS, TESTS, FILE SEARCH, D~,. A AND INFORMATION
As certified by my seal affixed hereto and as of Ihe validation date shown below, I verify that my investigation of this Healtl;
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 lurther verify that based on the information obtained
from the Municipality of Anchorage files and Irom 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 EAGLE-RIVER-ENGINEERING SERVtCE-(~ Telephone
Address EAP, LE RIVER, AK 99577
....,/, /,.~. P.O. BOX 773294
Date
1~94-5195
DHEP APPROVAL
Ap'~roved for 7'~'~-~'~,) bedrooms by
Approved ~' Disapproved
Terms of Conditional Approval
~'?~-'~-'~ 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 of 2
72-025 (11/84]
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field 3,~/''
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
To Water Main/Service Line ~/~ /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field "~ ~ /
Depth of Field /'"~ ·
Gravel Bed Thickness <~ ·
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /o"
To Existing or Abandoned System on
; On Adjoining Lots '~ .3'~ ·
To Cutbank (if present)
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 **
HAA guidelines in effect on the date of this inspection.
I certify that I have checked, verified, or conformed to all MOA and
Signed ~ Date
MOA No.
Company
Receipt NO.
Date of Payment q-/-C~'~
Amount: $
Eagle River E~oineeflng S~rvices
P. O. Box 7732~4.
Eagle River, AK 99577
694-5195
Page 2 of 2
WELL DATA
Well Classification ,/~/~' / ~',~ ~' -~*
Well Log Present (Y/N) ,Y
Total Depth /0.5- · Cased to
Static Water Level
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
To Nearest Public Sewer Line "75-/
Cleanout/Manhole ~-"¢~ ·
Water Sample Collected by
Water Sample Test Results
Comments
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal D, escription: . ~¢~ ~ ~'
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /~-"-~- -~- Yiel~,E' ~-,"~', ~',-,.,--
Depth of Grouting ~-~'~
Pump Set At ~ ='~"'-
Sanitary Seal on Casing (Y/N) )/
Depression Around Wellhead (Y/N)
DEPT. OF HEALTH &
ENVI~N. MENTAL PROTECTION
RECEIVED_
; On Adioining Lots ~'/~
/~ 7' · ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
~-~& ."~'~ ~*"'~";'""~'"'~'~ ;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed //////E,( Size /.~..~ c./. No. of Compartments ~
Standpipes (Y/N) ./v Air-tight Caps (Y/N) ,~ Foundalion Cleanout (Y/N) ~
Depression over Tank (Y/N) ~ Date Last Pumped ,,~'c'¢~' ~.~-.~.~.,..~.
Pumping/Maintenance Contract on File (Y/N) '4'/,~'/ ; for -
Holding Tank High-Water Alarm (Y/N) ""~'~./.-~ Temporary Holding Tank Permit (Y/N) ~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /,y,,o ·
To Property Line ,.,~o ·
To Water Main/Service Line '~/~ /
Course ~*~/.m
To Building Foundation -5-/
To Disposal Field 5- /
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)