HomeMy WebLinkAboutEAGLE RIVER HEIGHTS BLK 2 LT 36
,~,-....~ GRE/~.R ANCHORAGE AREA BOR""3H
Department of 'Environmental Quality
3330 C Street
Anchorage, Alaska 99503.
INS_PECTION REPORT O~.,EW,.OE=~_,$_ _~"2rS~_..'L SYS .~
(-~"~'/~g~,-~ MAILING ADDRESS PO ~,~OY
LOCAT,ON J'Y? ~/1' ~';"~ /"~'~LEG^L DESCR,PT,ON,~" Z' "¢ ~, ,~Z',<"C"Z. .~'X/" ,e'":,'Z' //~"S'"~.
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER
INSIDE WIDTH
MATERIAL
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY
GALLONS
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISH GRADE
FOUNDATION
DISTANCE BETWEEN LINES
NEAREST LOT LINE
TOTAL LENGTH
OF LINES
TRENCH WIDTH IN. TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE .
DEPTH OF FILTER
MATERIAL BENEATH TILE
IN. ABOVE TILE IN.
WELL:
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCT,ON .5' 7"f~.'Z),~Z 0 .
LOT LINE
OTHER SOURCES
NEAREST
SEWER LINE
DEPTH
SEPTIC ~//j~ SEEPAGE
TANK fVl", SYSTEM
DISAPPROVED
REMARKS
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL'
LOT SLOPE:
REMARKS:
DIAGRAM OF SYSTEM
Form EQ-032
Gre~.'R ANCHORAge AREA
DEPARTMENT OF ENVIRONMENTAL QUALITY
*'~'~-z'-~'-~'~-~L--*~='."---T.~.~: ~ APPLICATION AND PERMIT
PHONE
OTHER
TO'''"'T'LL, D., )
FINAL
DEPARTMENT
24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
IRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION,
FOUNDATION TO SEl~rlC TANK
DRAIN FIELD
DRAIN FIELD
EEPAGE PIT
SO CONSIDER AREA WELLS.
SEEPAGE PIT
\
\
CONFO~DING INSTALLATION.
TYPE
DIAGRAM OF SYSTEM
NO. ~-~ND THAT THE ASOVE
Pt,4AI
MUNICIPALITY OF ANCHORAGE
Development Services Department ;' Phone: 907-343-7904
On-Site Water& Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 050-282-21 Expiration Date: -1-i q -/ 7
1. GENERAL INFORMATION
Complete legal description Eagle River Heights B2 L36
Location (site address) 10120 Chandalar
Current property owner(s) Collette Bentz Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
n Single Family(w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well Private Septic ❑
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee$ 6f,/U Waiver Fee $
Date of Payment (15119 Date of Payment
Receipt Number (')56 7-Y6 Receipt Number
COSA# Q�CIg/r)9q 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.
In conducting an adequacy test, I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the
time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems
depend on the local soil condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by
the system.These conditions are outside the control of the evaluator of this system.All systems eventually fail and satisfactory test results
do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments.Therefore
we cannot provide any warranty for future performance,nor can we estimate remaining life of the system.The content of this report is for the
sole benefit of the owner listed above.
Name of Firm Pannone Engineering Services Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E. Date / q®je7,5--
*:4611. i` :*
6. DSD SIGNATURE ••••..., `a
,K System#1 Approved for .3 bedrooms ' —*even.i - -T nope
..
System#2 Approved for bedroomsCE 8149 "
Disapproved , ...
�'
Conditional approval for bedrooms, with the following stipulations:
ol((((((((((q
0\IY OF
Q
z� UN-SITE '77;
_ WATER AND '''
o WASTEWATER Z
PROGRAM rot
- //‘
,�)))))sERV�II\\\�.
By: L---------- ( � Original Certificate Date: ( --/c(---1 c7
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 X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: Eagle River Heights B2 L36 Parcel ID: 050-282-21
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) Well production at time of test 4.21 gpm
Date drilled '1"1975 Water storage tank volume gallons
Total depth +83 ft Well disinfected for coliform test? ❑Yes 0 No
Cased to +40 ft ❑■ Coliform bacteria is Negative
Sanitary seal is functioning correctly Nitrate 8.06 mg/L ❑ Nitrate less than MRL(ND)
0 Wires are properly protected Arsenic ND ug/L Ej Arsenic less than MRL(ND)
Casing height(above ground) +12 in. Collected by PES
Date of flow test for COSA 3128,2019 Date of Sample 3,28.,2019
Static water level at beginning of test 75.9 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) years ❑ Required maintenance completed
Tank type/material Age of lift station years
Measured operating fluid level in septic tank Lift station material
❑ Standpipes/foundation cleanout per record drawing . Comments:
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested(date installed) Adequacy test date
❑ALL standpipes present per record drawing Results ❑Pass For bedrooms
Total measured depth from grade ft(max) Fluid depth prior to test in
Measured depth to pipe invert from grade ft(min) Water added gal
❑ N/A—pressurized field
New depth in
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective Elapsed time min
LICode-requiredsoil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
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' Community Sewer Manhole/Cleanout> 100'
✓❑Yes if No ft ❑ Yes if No ft
Neighboring Tank> 100' p Yes if No ft Private Sewer/Septic Line>25' ❑Yes if No ft
Absorption Field on Lot> 100' ❑✓ Yes if No ft Holding Tank> 100' 0 Yes if No ft
Neighboring Absorption Fields> 100' Animal Containment>50' 0 Yes if No ft
❑✓ Yes if No ft
Manure/Animal Excreta Storage> 100'
Community Sewer Main> 75' ❑✓ Yes if No ft Q 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 Surface Water> 100' ❑Yes if No ft
Property Line>5' ❑ Yes if No ft Wells on Adjacent Lots:
Absorption Field >5' ❑Yes if No ft Private Wells> 100' ❑ Yes if No ft
Water Main> 10' El Yes if No ft Community Wells>200' ❑ Yes if No ft
Water Service Line > 10' ❑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 If absorption field is under driveway comment below
Property Line> 10' ❑ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' ❑ Yes if No ft Private Wells> 100' ❑ Yes if No ft
Water Service Line> 10' ❑ Yes if No ft Community Wells>200' 0 Yes if No ft
Surface Water> 100' ❑ Yes if No ft
F. ENGINEER'S COMMENTS
.e,,.aa'ker,0A
G. ENGINEER'S CERTIFICATION ��''f• OF A(...4�k ¢
I certify that I have determined through field inspections and review co.�
of Municipal records that the above systems are in conformance with d*. TI I dr 0
MOA COSA guidelines in effect on this date. � UPJ _.Ilk I��
r4 ; r
‘‘ ' '1.e0.7:39 ,-.....'.....
.ri'L'J �� r 41
INt\\�:-o
COSA Checklist yellow sheet
MUNICIPALITY OF ANCHORAGE
0-Th
DEVELOPMENT SERVICES DEPARTMENT • ;.717 I 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Nitrate Advisory
Certificate of On-Site Systems Approval # OSC191099
Subdivision: Eagle River Heights B2 L36
A water sample revealed a nitrate concentration of 8.06 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.O.Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids,and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse-osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Mailing Address: P.0. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
P �
. WATER WELLS
Drilling• Piling• Pumps Date:4-10-19
P.O. Box 670269 Chugiak, AK 99567
P: (907) 688-2759 F: (907) 688-2259
Pannone Engineering
Job Address:
10120 Chandalar
Eagle River,AK 99516
Well Camera Report
Static Level 72'
Ran camera to 107',casing appears to be continuous and perforation/breach free.
Thank you,
Cole Sullivan
4
�u� ..�u_._._.--•.----_.___. N 89 56'12"W 131.97
I ( ope "
-4
1
f, Asp:+J,,•CA aXR,.iOLAt arRIN.!
•
I
1
;�__.............—_._._. i 37.0
�ll
` I �.
4.
r2 r?, (( ,.\
OI 1 1 I I
{ L QC
,NI4 o
i �P��o1. Com ro I Q
o1
I
I i �tsQP�` i :;: Q
2! r ... 2 i
i J-
I Ii
V
;:•
I 1
i
ma-e7 ane9
N8956'72"W 131.97
0000ppp% .
ooP��• .�F q•q�S 40
,L �4 ..•�000o NOTE
o*:. 49 TH ^ NO EASEMENTS APPEAR ON TMSLOT
/�j�� /j� aVTHE RECORD PLAT
4 , Alt ' " .Q AS BUILT SURVEY 1"=20'
OQO s SHANE A.HOLT .. �sO,
00 LS-69 4 •• - y;e:
AO CORNEAS SAT THIS DALE
n". -. cad I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
O `OJessional �pQo OF THE FOLLOWING DESCRIBED PROPERTY
��pp�O�Qo IO 3E BLOCK 2,EAGLE RIVER HEIGHTS SUB
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS: AND IS EXIST OTHER THAN NOTED.
HOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELTIIES. DATED AT ANCHORAGE,ALASKA THIS 18TH DAY OF
CASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT • ARE NOT SHOWN A!'RCH , 2019
HEREON ( UNLESS INDICATED)
NOTE, FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMIIE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
HOLT LAND SURVEYING
9309 GROVER DRIVE
ANCHORAGE P.K 99507
14169,FB 195-36,196-16 907.3455513
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. # . (-~ ~"O- ~_~ ~ 7_-
1. GENERAL INFORMATION
Complete legal description
Location (site address or d'rectfons) . I c~ / ~Z, ~
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
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
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.
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
ress
Engineeff~ signature
Phone
Date
Se
DHHS SIGNATURE
Approved for~,'~~--~-'6~'
Disapproved.
~ Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
There are &~lL~aL~ p[esenc. X[ is sugges[~d [hac p~[lud£c [es[xng be per[ormed
to:~dsu~e the wells continued suitability. Current nitrate concentration is
6.23 mg/1. EPA maximum concentration is 10 mg/1. More information on nitrates is
available from the On-Site Services Pro,ram. DHHS. 343-4744.
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
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Dascription
A, WELL DATA
Well type .Pr J ~,; 7~
Log present (Y/N)
Total depth '/'-
san~a~y seai (Y/N)
Health Authority Approval Checklist
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ /~
Cased to 4- 4.f,~:~ · Casing height (above ground) '~'~'
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Date of sample: /gT-- / -- ~, ~
SEPTIC/HOLDING TANK DATA ./'[~/4~
Tank size
Wires property protected (y/N)
AT INSPECTION
g.p.m. (~'. ~.
Foundafior
Date of
C. ABSORPTION FIELD DATA
Date Installed Soil
Length Width
Effective absorption area
Date of adequac
Fluid ~ test (in.);
Fluid ~ (ins) Minutes later:
(past 12 monms) (y/N)
(Rev, wi)s)'
g.p.m.
Nitrate ~ Other bacteria
Collected by: F~.,~/¢ ~.'/..~,. ~Z'/,~.~/
Number of Compartments __
Depression (Y/N)
(Y/N)
(Y/N)
Results (Pass/Fail)
Immediately after
Absorption rate =
If yes, give date
System type
Total depth,
field (Y/N) __
(in.):.
bedrooms
O. UFTSTA O,
Date installed ~
Manhole/Access (Y/N) ~el at* *Pump oft level at'
High water alarm level at'~._ ~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ~ ~7-.<'' ·
Sewer/septic sswice line
On adjacent lots
On adjacent lets
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Properly line ~
W-:te;mai~/drainage Wells on adjacent lots
SEFA~TiON DISTANCE FROM ABSORPTION FIELD ON LOT TO: /J//J
Property line Building foundation ~
Surface water .,~-~'~--~:~~, ~n~hicle storage area
Cu~n_.~l~-~'~~ Wells on adjacent lots
I certify met I have determined thru field inspections and re*.v~.w of Municipal reco~lM~LN~aa are
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev.
CT&£
Ordered
CUe,n!
Pt,'iar~l Date~ime .T0/0S,~8 16:32
Collet'~ed ,Da~e~'Z'imelO/O1/gg 10:40
Re~'ieed D~e/T'une 10~1J98 14:..~O
TecbakM D~reclm':. S~ep~ C. Ede
#;Crate,il ,~.~I O.lOil I~G/t, EPA 300.0 10 ~ I0105l~8 10/O$1~t, CCp
To,at c~tlfom 0 ¢otll0O~. S~I,a ~22a '~O/01/gS ~
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.# ~35~-?R?-71 HAA# ~O~.~
1, GENERAL INFORMATION
Complete legal description
E~,qle R~ver Heights ~ot 36, Block 2
Location (site address or directions)
10120 Chandalar, Eagle River
Property owner Robert & Anita Wells
Mailing address 6617 Pive,--~3c~] ~c~d. WalkeTtown. NC
Lending agency City Mortgage/Rita
Day phone. 694-9125 msg
27051
Day phone. 263-0783
Mailing address P.O. ~o}: 92810, Anchorage, /~ 99509-2810
Agent n~ T~n~ ~e~,//~ndy n~ndhl~m
Address !l':!! ~ ~-~ u,~, E~!e ~,,~'- ~w
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
x
Day phone 694-9125
99577
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
x
If community wastewater SYstem, provide written confirmation from State ADEC
attesting to the legality and status of system.
If community well system, provide written confirmation from.State ADEC attest-
ing 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 Eagle River Engineerin9 Services
Phone 694-5195
Address P.o. Box 773294. Eaale River. AK ~77
Engineer's signature
Date
Se
DHHS SIGNATURE
Approved for ..~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Commen~ Note: The well for this property meets existing
State and Municipal Codes. There are nitrates present. It is
con~inue~suitabilit~ Nitrate concentration is 6.13 mg/1. EPA
ma~.._mum ccnc=ntrztidn'!c !0.0.
...
~'~ ~,./ Z-~,~. Date /
By: . /
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
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825~." Street, Room 502 · Anc.~omge, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
WELl. DATA
Parcel I.D.:
B+
Well q, lg
Log prescm (Y/N)
Sanita~,. seal (Y/N)
If A. B. or C, attach ADEC leiter. ADEC water .system number
Date completed
Cas~ te ~ ,~'"
Dam of test
Static water level /
/
Well production
WATER SAMPLE RESULTS:
CoiEorm ~
Wires pmperb' protected (Y/N) y~-~ g'1'1
AT INSP~ON
Date orsampte: ./d//~ ~;/? ,'~V''
SEi~-IC/HOLDING TANK DATA
Da~ i~-teUcd
Foundation cleaaout (Y/N)
Date~Pumper
Ta~ size . ~m~/~aml~ats __ Clemmuts (Y/N)
..~ression (y/N) High wate~ aJarm (Y/N)
C. ABSORPTION ~ DATA
Date iasudled Soil ratiag (g.p.d./fi'~ or f~/bdnn)
Effective abso~tion area ~ prat(Y/N) Dep]~sion over field (Y/N)
Date ofn~__,~22~mcv test / Results (Pa,ss/FRii) For bedrooms
Fluid depth in abso~om tesl (in.); Immed~trt.~' a-f~f ~. Water ridded (in.):
Fluid ~ (ins.) Minutes later: Absorplion rate =
~ g.p.d.
Peroxide treatment (pa~ 1 2 months) (Y/N)
ffyes, give date
:SEPARATION DISTANCES FROM WELL ON LOT TO:
;Septic/holding lank on lot
~dosorptiou field on lot
Pubbc sewer main
Sewer/aeptieservice liue
/x/ /,~ : on adjacent lots
Public sewer manhoie/cleanom
Lift station
SEPARATION DISTANCES FROM SEFTIOHOLDINO TANK ON LOT TO: ~///q
Building foundation Pmpc~.' line ~eld
Water ~ ~aa~~~~ Wells on adjacem lots
SEPARATION DISTANCE FROM ABSORPTION Fl~-r~ ON LOT TO: /~//~1
Buildm8 foundation
Surface water
Wells on a~jacent lots
line
in conformance with MOA I'L4,4 guidelines in effect on this date, t~ "9 :' ~ 'e._'¥ ~e
_ V..~- ~-~ , :
~1 ~:".. ' .." ~.~'"
Waiver Fcc $
Dalo of Payment
Receipt Numbcr
I~oeD,~i
IO/03/gS · ~Jt3$ hE's.
lLtrmc4o~ .... ~%3 · ug/L ~I'A 3S$.2 10.' %0/al/SS CMX
3330 "C" Street, Anchorage, Alaska
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
99503 274-4561
Date Received
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Approval'requested
Mailing Address: ~q[')l
Property ~ner:
Mailing Address:
Legal Description:
Location:
Type of facility to be tnspected~,,~J~
Well Data:
A. Type I,-~,~
C. Construction
No. of bedrooms C'~ ~ ~
B. Depth I~'
D. Bacterial Analysis
Sewage Disposal System:
A. Installed B. Installe~
C. Septic Tank: 1. Size 2. Manufacturer
Seepage Pit: 1. Absorption Area
2. Material
E. Disposal Field: Total length of. lines
8. Distances:
A. Well to: Septic tank , Abso~ptlon area , Sewer Lines ,
Nearest lot line
Other contamination
B. Foundation to septic tank
, Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street, Anchorage, Alaska 99503 -- 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA
2. Property Owner: JAHES~ John & Virginia K
Mailing Address:
3. Name of Buyer:
Mailing Address:
XXX FHA
P, O. Box 733 Eagle Rtver 99577
CONV XX
Robert L & Anetta Wells
SRA Box 216B Eaele River-Alaska
Day Phone
688-2430 or 688-2141
Day Phone 694-9337
4. Name of Lending Institution:
Maiming Address: 3g01 Seward Htehwav Anch.Ak.99503
5. Name of Realtor or Agent: ~0n0
Mailing Address: --
Al ko ~attonal Bank University Center Branch
Phone 279-4585
Phone --
6. Legal Description: Lot 36, Block 2, Eagle River Heights Subd.
Location: See attached map
7. Type of Facility to be inspected:
8. Water Supply
Type of Supply:
o
Single family
Public Utility
No. Bdrms. 3
Individual XX Wel 1
If Individual, number of dwellings presently served l.
If Individual, depth of well 110'
Sewage Disposal System
Type of System: Public Utility XX
Individual (on-site)
If Individual, date of installation
EQ-037 (I/74)
Page 2 of two pages - Re~' ~,~ for Approval of Individual .c~'~~.. & Water Facilities
Legal DeScription F~F~F ~r ~[~_ ~ ~rq~LO ~ ~-I~_,L~Y~& ~/;:~
Coelnents
Approved
_m~Disapproved Oate/~y~-~
Approval ~Valid for one year from date signed
Greater Anchorage Ar&a Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)
x,
PRELII~INARY : ·
I hereby ceriify that I have surveyed tb~d following:
described pr o p e ~y '~.~ p _ ~./..~:~.~ '
Anchorage Recording Precinct, Alaska, and that the pro-
posed improvements, as planned thereon by the builder.
will be within tho property lines and will not overlap
or encroach on tho property lying adjacent thereto, that
no improvements on projperty lying adjacent thereto
no roadways, transmission 'lines or other visible es. se-
merits on said property except as indicated hereon. '.'
Dated at Eagle River, Alaska
thls_,2-~ r_~, Say of ~"/~-y '"' Ii) ~'.,
SC~E:r Registered Land Surveycr No. 8SO-LS
1': ~" BOX 455. Eagle River, Alaska ' ~ ~'",
~Phone 694-g~43 ' , : . :
'','i: ":"' ' ~' :":'."'"'-_. :'~