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HomeMy WebLinkAboutHENKINS BLK 1 LT 12Henkins Block Lot 12 #0§1-292-30  Municipality of Anchorage :1..~ Development Services Department ': Building Safety Division '~ ~ On-Site Water and Wastewater program, 4700 S. Bragaw St. P.O. Box 196650 Ancflorage. AK 99519-6650 Page of www.cLanchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SW020028 PID Number: 051-292-30 m,~: Wastewater System: [] New [] Upgrade Don Momblow 16022 Division st. Chuaiak. AK. ABSORPTION FIELD 6cj6-0148 2 IfflDee~Ttehch ~a$1~llowTrench DBed rlMoufld LEGAL DESCRIPTION 0.6 ~,.~..~ 5- 6 I 12 Henklns 3.0 r, 2.5 0-1 Al- r~ 4', ~,. Well: [] New [] Upgrade c,,,~,~,: ~ .~,~-: 5 rt. I pa Private rt, F~, 350 ~' r~ D3034 & F810 F, CCC Const. 61612002 SEPARATION DISTANCES [] septic f-I Holding [] S.T.E.P. D Other:. ~ Septic Absorption Uff Holding PubllcJPrtvate Iv~l~u~: C~,,.~. Tank Field Statto~ Tank S~,~ U,,o'Anchora,qe Tank 1000 w., 10W+ i100'+ NA NA 25'+ Steel s~w.,. 100'+ 00'+ NA NA ~ / LIFT STATION ~. 5'+ 10'+ NA NA/~ s~': c., F~n~lle~ 51+ 10'+ NA NA ~,~,. ~: ~.~,o, ~.,.: c~.. NA *50'+ NA NA ~"~"°~ ~"'"~'"~"~ "~': BENCH MARK *none knowrl I~ 4~.~ ~/.ll~J t ~-~'~/~4 ¥~' Bottom of sldin,cJ .~.~ ~.~, ,~..Z~,¢,~ 100 Eng~er~mp ~'~.." &Z:".-'"f' Inspections performed by: KND Enoineerin_. Dates: 1" ~ ~- ~'~ ~ /'~t' Development Services Department Appro~~ ~~~~?~~' Reviewed and approved by: /~,~'~ / ~/.~. P~.¥'- Date: ~ "~.z//'o~.. -~[?~ROFE$$~_.~'....,.· AS-BUILT SYSTEM DETAILS/SITE PLAN Pernit S~/02002B HENKINS SUBD, BLOCK 1, LOT 12 PID#051-292-30 iST i~GtXIST~ ~ . TH.KND01-1 ~ - -- I A-C: 9.0' . ~ B-E= 13.0' ~ ~moo 6A~ ~ ~ - ~ A-F=74.8' . ~S~PTIC ~ ~ ~ / i ~ TANK ~ ~ S~V~R ROCK , ,i ~~ ~¢ ~~ ,¢ ~ 160~ DIVISION ST. (907) 696-8148 ~ SEWARD m~: s,~ ~c~ KUO 20441 PTARMIGAN BLVD. '~~v~ *~: I°'~: 6/18/02 EAGLE RIVER, AK 99577-8736 ~ ~' ~sstO~ ~ ~ ~: ~ NW0755 · ....** .....-.. -.... - · - .... -.....-.-....- ·. - ....-.-.....-...- v...-.. -....... .................... mi SEPTIC ~ ~ TANK ~ ~ SEVER ROCK OOT-0t-87 k~ 09:44 RE/~X OF E~L£ RIVER FAX NO. 9078~0214 ?010 P. 02/02 MUNICIPALI~ OF ANCHORAGE Development Services Deparbnent On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (gO7) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Feb 25, 2002 Expiration Date: Feb 25, 2003 Permit Number: SW020028 ~Legal Description: HENKINS BLK 1 LT 12 ~ Design Engineer:. 0070 KND Engineering Owner Name: Donald & Timeri Mor~blow OwnerAddrass: 16022 DIVISION STREET CHUGIAK, AK 99567-6935 Parcel ID: 051-292-30 Site Address: 016022 DIVISION ST Lot Size: 20038 SQ. FT. Total Bedrooms: 2 Permit Bedrooms: 2 This permit is for the construction of:. [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Pdvate Well [] Water Storage All construction must 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: ~ Date: ~./Z.. ~/,/~ '"L...- IssuedBy:~ ~ Date: ~ ~--~~~- Municipality o.f Anchorage · Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O, Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWEPJWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-292-30 Pen'nit Number SWt92 O0 Z t~ Property owner(s) Donald & Tlmerl Momblow Mailing address (1) 16022 Divlslon Street, Chuglak, AK 99567 Mailing address (2) Legal description (Lot, Block & Sub'd.) Lot 12. Block 1, Henklns S/D Legal description (Section, Township & Range) Lot Size 20,000 Acre~ Day phone 696.0148 ~pC~e Number of Bedrooms 2 TI-IlS APPLICATION IS FOR: Sewer Only [] Well Only Sewer and Well [] Water Storage Sewer Upgrade [] 3'HIS PROPERTY CONTAINS: Hot Tub [] Jacuzzi Swimming Pool [] Water Softening Unit Therapy Pool [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: ~.~D ENGINEERING 20441 PTARMIGAN BLVD. EAGLE RIVER, AK 99577-8736 (907)696-61 II/FAX (907)696-8111 February l2, 2002 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Conditional HAA / Septic Upgrade - Henkins Block 1, Lot 12 Gentlemen: The owner has requested we proceed forward to obtain a septic permit to upgrade and replace the existing septic system and a conditional He.alth Authority Approval on the subject lot. On February 5, 2002 we performed a septic adequacy and well flow test. Subsequently, the septic system has been identified as in failure. Since wintertime conditions exist, we are therefore requesting a conditional HAA. Per the available soils data (1.2 GPD w/no GW), we have designed the proposed 5' wide shallow trench system using an application rate of 0.8 GPD. The existing septic tank will be abandoned in place and in accordance with municipal standards. Once feasible and before seasonal high gro.und water this spring, testholes will be performed for the proposed system, and design adjustments made if necessary. The general slope of this lot is from east to west at a grade of approximately 4 - 8%. There are no public or private wells within 200' of our proposed system location except as noted. Based on wintertime observations, there is no surface water within 100' of the proposed system and there are no known curtain drains within 50'. There are no apparent code violations or eminent health hazards created or prolonged by granting the conditional approval. We do not expect there to be any adverse effect as a result of granting the conditional approval or on adjacent lots by the development of the proposed septic system upgrade. If you have any questions, please contact me at 696- 6111/FAX 696-8111. Respectfully submitted, ~IqD Engineering Attachments: HAA On-Site Well and Sewer Application Wa. stewater Absorption System Details/Site Plan Existing Soils Log/Percolation Test WELL & k/ASTEk/ATER DISPOSAL SYSTEM DETAILS/SITE PLAN HENKIN$ SUBD, BLOCK 1, LOT 12 / '~q 6 ' ~ 15 ~, , 4 ~ -. / [ ..................... .K ~ '--. / 7 , 14 ~ t /,.. ........... ....~ I tt I [ ~ ~ 5 ~-.. ~. , ~ '-.. ':/ Rnnd ,, ' DESIGN DETAILS ~ BDRM X 150 GPO : 300 GPO 300 GPO/.8 GPO PER SO. FT. (0.00 MIN/IN.): 350 SO. FT ¢350/5'¢W>) X ,64(RF) (2.5' GRAVEL> =48.0 FT. TRENCH USE I TRENCH - 48 (L) X 5' (W) X 2.5' (D) To~ol dep*h oF sys~en Is 5.5' Fron original Or,de. Totol depth oF grovel below distribution pipe is ~.5' . m ~v*,¢ ~c~s ~,..~. ~ ~ NOTES= m SCPllC SYSTC~ WITHIN ~ ~ 1. USE 1000 GALLON SEPTIC TANK AND INSULATE IF ( 4' OF COVER. ~CD ~ (XCCPT ~S mTC~ ~. INSULATE TRENCHES WITH ~* HD BURIAL FOAM. 3. CONTRACTOR VILL [NSU~ NINIHUN ~Z SL~P~ INTO SEPTIC TANK. 4. ADDITIONAL rILL WILL ~E ADDED OVeR SYST~H TO ACHIEV~ MIN. 3' 5. CONTRACTOR VILL ENSURE ALL SEPARATIONS TO ADJACENT ~ ~ PREPARE9 FBR, T ~ , CHUGIAK, AK. 99567 ~.......~ ............................... - ....... ~ (9o7~ _ mCkO B~S ~ ~ ENGINEERING ~ SEWARD ~A~ ~G s,~ ~ ~uO ~0441 PTARMIGAN BLVD. · ~'; 5~WAR~ ~: 2/11/02 EAG~ RIVER, AK 99577-B736 ~ ~sstO o~ ~: ~ NW0755 ' ' ...... ~:02005.OWC ~': 02005 (OOT)Bg6-6111/FAX (907)698-8111 WASTEWATER DISPDSAL SYSTEM DETAILS HENKINS SUBD, BLOCK 1, LOT 12 EXIST TI] ~ PRB~S~m~KND02-1 ' ~ ....... : ...... ; .................. ~ ........ ~ (907) 696-BI4B PAGE " r,~o ,~s ~" ~ ENGINEERING ~ ~ SEWARD '~"...~..5¢~ ,,~ ~ KUO 2044i PTARMIGAN BLVD. ~~~ ~ ~, ~ .wo~55 II ":"-'"'"'":'"'"'"'"':'"':"' '"'"'"'"'"'"'"":"'""""'"'"" ................. .... ~:02005.DWG ~: 02005 I (907)698-6111[FAX (907)696-8111 20441 PTARIVilGAN BLVD. EAGLE RIVER, AK 99S77-87a6 SOILS PERCOLATION TEST Performed for:. Don Momblow Date Performed:~~'~: Project: Henkins BI, LI2 TEST HOLE # 92-1 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14--- 15- 16- 17- 18- Depth Org - brown/black overburden- Frost - 1.5' GW - gray sandy gravel ML- silt w/sand GP/SP- firm density, brown sandy gravel, damp, w/cobbles to 8" & ML lenses B.O.II. SEE ATTACHED SITE PLAN FOR HOLE LOCATION IWas Ground water encountered? NO What depth? N/A Depth to water after monitoring? Date? Reading Date Gross Net Depth to Net Time Time Water Drop 1 2/22/02 1:00 6" 2 1:10 10 rain dry 6" 3 * I:11 6" 4 1:21 10 rain dry 6" 5 * 1:22 6' 6 1'.32 10 rain 2/16" 5 14/16" 7 * 1:33 6" 8 1:43 10 min 3/16" 5 13/16" 9 * 1:44 6" 10 1:54 10 min 4/16" 5 12/16" 11 * 1:55 6" 12 2:05 10 min 3/16" 5 13/16" · Water Added 19- [ Percolation Rate 1.72 (mM/in) Perc Hole Diameter IlOLE PRESOAKED I 20- PRIOR TO TEST Test Run Between ~ feet and 4 feet I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in effect on this date. '  MUNICIPALITY OF ANCHORAGE r ~ 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 ~:~HT~.~ ~ [] NEW MAILING A~RESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS m(b ~ Manufactu ~~ ~ Uateri~l~~ No. o~partments ~ Liq. cap23~n~lons IF HOMEMADE: Inside length- WiOt~ ' Liqui2Oepth ~ M DISTANC~ Well Dwelling PERMITNO. ~ DiSTAnCE,O: Wall~/3~ ~ FounOati~/~ ~ ~aarestlotHn~ ~ ~m~ m No. of li~ ken'th °f ea~in~a Total length of li~ Trench ~idtl ~ ~os Distanco between lineseffectivo~ absg~tj~ ~a ~ ~ ~ Top of til~to finish grade ~ Material beneath ~i'~e ~l,~a Total Length Width Depth PERMIT NO. ~ ~ell ~ Buildi ~earest ~t H~ ~ Class Depth Driller Distance to lot line P~BMIT g ~ ~mra~c[ ,o: s~ui~ *oundatio~ Se~er li~o Septic ta~/~ OTHER PIPE MATER I~S ~ I NSTA L LE~ ' REMARKS ~ ~ LEGAL A~ DATE HEFI!_TH F~i'.,ID .ENViRO,NMENTF)L~_e:?3TECT..1;OH D E pi::i F.:'T'M E N T ~:!F ::~.:?.5 ' "STF:EE:T., fqi'-,i(:::,LIO.~:?.RGE., F!i<.- :: 'EEL THE LENGTH [.',iMENSION ZS THE LENG"FH (iN FEET::, OF THE 'FRENCH OR [:,RRZNFIELD. THE DEPTH OF' R TF:EHCH OR F'I'T' iS THE E:,tSTFtNCiE E;ETNEEN TFiE ::~;!..i?.F!:~I::E OF THE GROUND RND THE BOTTOM OF THE E::.:X::¢~VFIT:!:OI"4 ,tin FEET). THE GRFiVEL. [:,EPTH :ES 'T'HE MINIMUM [:,EPTH OF Gi. RR',/EL E:ET'P-~EEN THE OI.J"FF'F!LL PIPE RND THE BOTT'OM OF '1"HE EXCf:!'v'FIT:O!",i (IH FEET>. ,:.iF.i':.':;F.I;_.L.T.N:G OF' F!?',F¢ S'¢STI.'"ZM-.,~.TTN"" ....... r'r F]:NRL. INSF'iEt:::'T'"qi'i..., F!i",E:' .,,Au':'- -, ,-<... ,,,,..¢:" _.F:'¢ '. ......... ~H..:, C,.EF'P;RTMEN'r 141 L.L E:E 'J:; II:_:LTDE:T TO PF:]: SECIjT ! ON M ! I'.,i I ?'..IL.tH £:, ! S'f'RNCE E:E]"NEEh,I F! i.,.iEL. L 1::i?.,![:, F!I'..!V ON-'-:; I TE .':..:,IE.-'-,.iI::IGE D :r. SPOSF:IL. S'~.':::;,'TE:r,'! :1: S iO0 FREE]. FOR R PR!VFITE HELL OF:: 150 TO ;~E!O F'EET FROM R r:'LIBL, iC I.,.iELL DEPENDING LIPON THE TYPE Ct,::." PUE',LIC .t,.!EL.L.. MINIMUI',I DISTF!I',iCE FROr'! F! F'RtVF:iTE i.4ELL. TO Fi PRIVFiTE SEFiEF: L!,NE l:':'; 25 FEET F:!t'.~[:, TO R OOi',IMUI'-,!IT'¢ '_'-;Ei.4ER L..!r.,!E !::-:; 75 FEET. OTFIER REQU t' F.:EMENT'b': MI:!'.:' RF'F'L?. SPEC ! F .1.' CFFF R"v'F't l L. FIBLE TO ! N'.:_';URE PROF'EF;i: :I: NS'T'RL. LF:IT I 0N. .:T F:!;::I.;?T' ........... 'r F"r' TF!FiT .......... .4::, ::;lET .,-4'. ..T .R~"~.,, !::'RM ! i.... Z,r~iR !.'.! i TH 'T'HE ,~'; r.::','-,,~....,:.._,t'i";:'[;" ~z'i,~ ,-.,-, ,,._. ,,"*':;', .... F'F'if;? f-J~._L..,:; i'-"'-, I ,:: .......... C r"~t,lP'??:- FI.NJ:' IdFLj.. S ¢""' FOF,::TH F2,'¢ THE h'.i. hi i C '_f PF'4L :[ T'-,' OF ¢::i '. ': F ': ~' ::1 ':iE ..... :, ~ .r:,, ::.r I t' I'.,I F :::" I b.iZL. L Ii'.,!'.'T:;TF:!LJ_ T~..x:. ,, "~i:; ~ IjNDERS]'F:ih,iD'"'~Hri!" ...... THE'; ON-SiTE SE!4EP. SYSTEM hIFi'T' RES .T. [:'E'N(;:E T ':; ~.]:Ei"I ] .:'EL.F;D TC i .NE:L.!jL3E: '" ::..: .1: (:i J'.,! E [:, · ................................................... T F THE 5 6 7__ 9__ 10 __ 11__ 12 O & E EN(_,'NEERING & DEVELG, 'MENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 CO, ~.ssell Oyster 694~2774 Performed for: Legal Description: ~-~-)~'~ /~- SOIL LOG Name:... //~g, /~J~-'7 //~, c_ c~- Mailing Address: ~:?~ ~ ~ 7 ~ Earl 688-2280 Tel. N0:Z?/''//- ZqJ Depth (feet) Soil Characteristics PLOT PLAN 13__ 14__ 15__ 16__ Ground Water Encountered: Yes__ No Proposed Installation: Seepage Pit Comments: t*'"'~- If yes, what depth. Drain Field ~ PERC. TEST ' ~ ~r Date.~ ,A./z.=_ .~., /z"/ DOC CO. dba S IL, L! V_gI WATER W LLfi P.O. 80)< ~72, CHUGIAK, ALASKA~DB67 a TELEPHONEG88-27B9 OWNER OF LAND ADDRESS , ."t " LEGAL DESCR1PTI "; : :,:;,: ' : DEPTH OF WELL DATE - Started Ended PERMIT NUMBER STATIC LEVEL OF WATER FT. : ' I)RAW I)OWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From " Ft. to---" _Ft. From. ~_Ft. to ,.' Ft .... Fromm. Ft. to~ :~ Ft From_ Ft. to Ft._ From--',' ' _Ft. to ' Ft. From ,, · Ft. to ," ~' Ft.. From . , Ft. to / Ft From Ft. to Ft From Ft. to.___Ft From Ft. to.__.Ft From Ft. to Ft. From__Ft. to Ft. From__ Ft. to Ft, From Ft. to Ft. From Ft. to.__ Ft. From Ft. to Ft. From_ Ft. to From _.__Irt. to____ Ft. '. From Ft, to : ' ~',' From Ft. to__ Ft. From Ft. to.___Ft From .... Et. to ..... Et_ From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to_ Ft. From Ft. to ___ Ft From Ft. to____Ft. Frmn. Ft. to_____Ft. From___Ft. to Ft. From__.Ft. to--Ft. From Ft. to Ft. From Ft. to_ Ft. From Ft. to__Ft. MISCL. INFORMATION: ~di IL]I INI ]E EZ: % If,'::;:" ~¢:~ IL..... ~.~ -~"' '"'!i¢' I[]~ F" i¢:'.~ Il'df El: _~'--!1 lED F::~: i~:z~. ES lEE DEPARTMENT OF HEALTH RND ENViRONMENTAl- F:'ROTECTION E125 I_ STREET, ANCiqCJRAGE, AK 995C'i 26.q.-- 47 ~%:, PERM]:T NO~ D -...ri .... AF'PL I CAN]' A D Z)R E: S .S: []ONTACT F'H[]NE: L..E:GAL DESCR I F': L.E!T S :i: ~.1 ...... I c.,:~PtiFy that,", HARRY I ..... HILI_S F:'. C),, BOX '7'70377 EEAGI_E RIVER~ Al< 694-2474 99577 1, :[ am f'amJ, li. ar with -Lhe requirements £Em on.~-sit, e s(awers and wells as se:t for'hh by t. hE~ Municipality of Anchorage (MOA) arid the Stat. e c:)f Alaska,, '"¢ :[ ~,,~i].]. ins'Latl the ~:,):=L~.:fi, in ac:cordanc:e ~f.'~.t"~ a].I MOA codes and r'eEju].at, iorH~ and J.r'i comp!.iance ~,~it.h t. he des:i, gn cr'iter'ia c:){' th:i.s per'm:i.t. 3. I wi].l adhe~-e t.o a].]. l"t[]A and ,.,t..aLe (::)¢ A:.¢.~.sl<a requ:brements fc)r i:.he set. back (:JJ.f>'E¢¢.l"l[::~:~fJ Fl"C)ffl any ex:i. st:i. ng well, ~,,¢astewaiLer d'[~posal systen~ or pLh,].ic ~E,(.D(*~(~.tr'ag(~ E;VEFEEh~) 01'] this c)r any adjac:erd:, c)r' near'by ICH:.. ... - ...- ~ ..... ............................................................................................................ ~F:'PI....ICANT= HARRY t,.. MILI_S ISSUED BY " ~ " .......... .... Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Parcel I.D. 051-292-30 1, CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Expira,o" )ate: 5:/2 F.,/OZ ' GENERAL INFORMATION Complete legal des~ption Henklns Block 1, Lot 12 Location (site address c~: directions) '16022 Division Street, Chuqiak,'AK 99567 Current Property owner(s)ponald & Tlmeri Momblow Day phone 696-0148 Mailing address Lending agency (same as above) Day phone Mailing address Real Estate Agent Mike Claramitaro - ReMax Eagle River Day phone 694-4200 Mailing Address 16600 Centerfield Drive, Suite 201, Eagle River, AK 99577 : ~ Unless otherwise requested, HAA will be held by DSD for pickup.. '.. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 2 TYPE OF WASTEWATER DIsPosAL: [] Individual On-site [] [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent :professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are re~ired for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners.. Certificates .of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER · ' '. · As certified by my 'seal -affixed .hereto ..and as of. the validation date shown-below, .I,verify~that my investigation based on procedures outlined in the Health Authority 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 bf bedrooms and type of structure indicated herein. I further verif~ 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 (are) in complia*nce with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of install.~tion.' Name of Firm KND ENGINEERING Address 20441 Ptarmlgan Blvd., Eaqte Ri',:e[', AK 99577 Engineer's Printed Name Ken'n;th'Mi Duffus 5.- DSD SIGNATURE Approved for Disapproved. Phon~.(907) 696-611 t bedrooms. D~te 02/12/2002' --XX Conditional approval for p_ bedrooms, with the following stipulations: Money in +.he ,~_mo,-nt of !.5 +. !'m%-l:he~hkjk-b!d of o~minimum-of-cJ~r-ee~-bi~ls from approved contractors shall be put in escrow to construct a new wastewater.di~posal.syst.em pursuant to permit number 5WO,2q028.a.ttached. Money in escrow shall not be released until this office has given fin~! appr~oval. Additional Comments Attachments: HAA Checklist Septic System Ad. visory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report (R~. o I,o2} Municipality of Anchorage Development Services Department Building Safety Division On-Sfle Water & Wastewater Program 4700 South Bmgaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ct.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: H~nklns Block t. Lot t2 A. WELL DATA Well type nflvate If A, B, or C provide PWSID #__ Date completed t01t3/84 Sanitary seal (Y/N)L Total depU~ 81ft. Cased to FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 9 colonies/100 mi. Amenic: O. O02U mgJI. B. SEPTIC/HOLDING TANK DATA 1~/13/84 ~ ft. 25 g.p.m Nitrate 2,04 mgJI. Date of sample: 02J05R2 Parcel ID: {151.292.30 We, Log (Y/N) y Wires pmpedy protected (Y/N) y Gasing height (above ground) t2"+ AT INSPEGTION ~ fi. 6.8+ g.p.m. Other bacteria ~1 colonies/100 mi. Collected by: KJJE.Fr. IZ~II[[~II~ Tank Type/Material ~tHI Date installed 6/18/82 Tank size 1000 gal. Number of CompartmentS ~ Cleanouts FoundaUon deanout (Y/N) y_Depression over tank (Y/N) NHlgh water alarm Date of pumping 51t6/01 Pumper JRt C. ABSORPTION FIELD DATA Date installed ~/8/82 Soil rating (g.p,d./ft~ or ~/bdrm) ~L Length 3~ ft. Width ~ fl. Gravel below pipe .J._ fl. Total depth .~L ft. Eft. absorption ama 278ftz Monitoring tuba Y Deprassinn over field N Date of adequacy test .~ Results (Pass/Fall) Fall For L bedrooms System type Tren;h Fluid depth in absorption field before test 24 in. Elapsed Time: min. Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) Water addedO gal. New depth In. In. Abaorption rate >= g.p.d. If yes, give date LIFT STATION Date installed NA 'Pump on' level at __ in. Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot lQ0'+ Public sewer main 7~'+ Sewer/septic service line 25'+ Manhole/Access (Y/N) __ in. High water alarm level at Meets alarm & circuit requirements? Size In gallons 'Pump off' level at Cycles tested On adjacent lots t00'* On adjacent lots 1Q~'+ Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~'+ Property line ~'+ Absorption field ~'+ Water main I{}'+ Water sen~ice line 1[1'+ SurPace water t~g'+ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line lQ'+ Water Service line Cudaln drain ~Q'+ COMMENTS lQ'+ G. ENGINEER'S CERTIFICATION Building foundation IQ'+ Sun<ace water t00'+ Wells on adjacent lots Water main 1~1'+ Driveway, paddng/vehtcle storage ~'+ in. I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Kenneth M. Duffus Date 02112/2002 HAA Fee $375.00 Date Pa ent Receipt Number Waiver Fee $ Data of Payment Receipt Number 'FEB-12-OZ 06:09PU FROkt-CT&E ENVIRONIi~NTAL SRV 9075615301 T-299 P.02/03 F-774 .~.. CT&E Environmental S~rvices Inc. CT&lC RefJt 1020690001 Client Name KND Engineering Project Name/# llenlims L12; BI Client Sample lO tlenkins LI2; BI Matrix ~king Water Ordered Dy PWSID 0 Sample Remarks: PQL Uniks M~hod Client PO# Printed Dote/Time 02/12/2002 17:45 Collected Date/Time 02/05/2002 13:45 l).eceived Date/Time 02/05/2002 15:00 Technlcol Director · Stephen C, [de Released B~ ~ Allowable Prep Analysis Limits D~e Dare Init Anenic 0.00200 U 0.002O0 mg/L EPA 200.9 (<0.05) 02/12/02 JMP l~i~rate-N 0~.00 mg/L EPA 300.0 (<10) 02/05/02 JDT Total Coli£orm 0 COI/100mL SMIg 9222B (<1) 02/O5102 rAP Parcel LD. GENERAL INFORMATION Municipality of Anchorage Development Services Department · Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 w,~wv.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR a SINGLE FAMILY DWELLING · Expiration Date: c") Complete leg~l.desc, riptloln Henklns Rlock 1: Lot 12 ,Locat on ('stte address or directions~ 16t}~ Division Street: ChuglaL AK 99567 - ~.Curren[Pr0perty.own~r.(s}[Donald & Timeri Momblow Day above) · . Mailing address .' ':~' (same Lending a,gency- tf' Mailing address Day phone Real Estate Agent Day p h o n e.,_69._4~42DO~ Mailing Address 16600 Centerflelcl Drive: 99~77 Unless otherwise requested, HAA will be held by DSD for pickup. Mike Claramltaro - ReMa~ Eagle River Suite 201 Eagle River: 2. NUMBER OF BEDROOMS: 2 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage C~mmunity Class Public Water System Well TYPE OF WASTE'WATER DISPOSAL: [] Individual On-site [] [] IndMdual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for lhe transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Heaith Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C ~eil and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer s work. 4 S. TATEMENT OF INSPECTION' BY ENGi.NEER= ' ' U on proceoures ouuineo in the Health Authority Approval Guidelines for this application, shows th'at the dh-site water supply and/or'wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of slructure indicated herein. I further vedfy 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 KND ENGINEERING Phone ~ Address, 20441 Ptarrnig~n Riva.: F~gle Engineer s Printed Name Kenneth M. Duffus D. ate ~ '..-~ -t. s.. ................................ ........ / Approved for ~ bedrooms ~....~.[.~ ' · ~ ~p ~ ~ Condi~onal approval for bedrooms, with the following stipulations: Addi~onal Comments Attachments: HM Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer s Report Other Odginal Certificate Date: Municipality of Anchorage Development Services Department Building Safety Olvl~J0n On-Site Water & Wastewater Program ,4700 South 8ragaw SL - P.O. Bo~ 19~650 Anchorage, AK 99519-6650 www.ci.anchorage.ak-u$ (907) 343-7g04 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Desorlpfion; A. WELL DATA Well type.,IZd.~ Date complete~ Sanitary seal (Y/N) Y Total depth 81 ft. Cased to I~1 ' ft. : FROM WI~LL LOG Henklns Subd. Block 1. Lot 12 If A, B, or C provide PWSID # Date of test Static water level It. Well production 2 6 WATER SAMPLE REsuLTS: Coliform 0--colonies/100 mi. Amenlci ~ mgJI. B. SEPTIC/HOLDING TANK eATA Nitrate ...~g.ll; Date of ~ample: 2/~/02 Parcel ID:~ wen Log (Y/N) Y Wlres properb/protected (Y/N) Y Casing height (above ground) 1 2 · + AT INSPECTION 6.8+ g.p.m. - Otherbeoferla 0 colonies/100 mi. Water added gal. New depth in. in. Absorption rate >= g,p,d. If yes. give data Fluid depth in absorption field before test in. Elapsed Time:_ min. Final fluid depth Any rejuvenation treatment (past 12 mo.) (YiN & type) Tank Type/Matedal.~E]l;L~.r.g~ Date installed Tank,side 100~. l, :, Number of Compartments 2, Cleanoute (Y/N) Y '~: ? "' ~.~./~,.) Y.~_.~Depresslon over tank (Y/N).l.~gHIgh water alarm (Y/N) F~J~da~o. d~_~but C. AEI$0 .RPTION FIELD D .ATA~ Data-,~0st~lte~.-.~ll rating (g.p.d./~ or ~Fodrm) 0.8 Total depth 5.5 lt. Eft. absorption area 350T~ Monitoring tube Y Depression over field N Date of adequacy test Results (Pass/Fall) For bedrooms System type ~ Gravel below pipe D. LIFT STATION Date Installed Size in gallons. Pump on level at in. Pump off level at. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldllft ataUon on lot 100'.1. Absorption field on lot Public sewer main 75'.1. Sewer/septic sewfce line 25'.1. Water Sewice line 1 Curtain drain F. COMMENTS Manhole/Access (Y/NL, in. High water elarm level at Ueets alarm & ~,~ult requirements? On adjacent lots 1 0 0 ' .1. On adjacent lota I 00'.1. Public sewer manhole/cleanout ~ 0 0 ' + Holding tank 1 0 0 ' + SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line ~ ' + Ab~orpUon field 5 ' + Watermaln 10'+ Wateraervloellne 10'.1. Surface water 100'.1. Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation I 0 ' + 8url'ace water '1 0 0 ' .1. Wells on adjacent lots 1 0 0 ' .1. in. Water main 1 0 ' + DriVeway, parldno/veNcle ~orage ~ 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 HAA guidelines In .effect on this date. Engineer a Pdnted Name Kenneth M. Duffus HAA Fee $ Date of Payment _ Receipt Number (Rev. 12/m) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE f'~ANL/'~' iTT~ DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Ser.vices oF ANCHORAGE On-Site Services Section E ~. SERVICES DIVISION P,O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 AUG 2 5 1997 CERTIFICATE OF HEALTH AUTHORITY RECEIVED APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # O 5' ! - ,,~ ~1.3. - ~50 -'"' HAA #.:~ i".~¢'~Ot-~ t~.;230A'(~- 1. GENERAL INFORMATION : : ' , , .:.': Complete legal description T. 12: B 1; Henkins Locatipn'(si{e,address or directions) · ~,'t ..... ' ..... -.':.' :6'p ~' :" ' "seo'{2t Schafer .Er ebty owner Mailing address P.O?Box 772052 '? ~nding agency Mailing address ? Agent 16022 Division St. Eaqle River¢ AK Day phone 696-5Z29 Eagle,River, AK 99577 Day phone 267-5540 Day phone' Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: "~ TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that ~ny' 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. S & S ENGINEERING Name of Firm 17c34 Er.g!= R!¥er Lo~p R~,~ No. 204 Phone (~ ~ [/ -- ')- ';'/ 7 ~ Eagle River, Alaska~957~7 Engineer's signature ' Date ~/;-~'/~/? DHHS SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. 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. 72~25 (Rev. 1/91) Back MOA ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage AU(; 2. 5 1997 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R ~ C [ ] V ~ D 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist ~ ~F~IK[rJ5 ParcelI.D.: 0 ~"1 "~1..~ *-~0 A. WELL DATA Well type Log present(~N) Total depth I Sanitary seal (~1) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~;~ / / Casing height (above ground) I~~' + Wires properly protected ON) ~/¢',% Date of test Static water level Well production FROM WELL LOG AT INSPECTION ~5 g.p.m. 5,;~ -h g.p.m. WATER SAMPLE RESULTS: Coliform 0 Date of sample: f~/i c~ B. SEPTIC/HOLDING TANK DATA Nitrate ¢~, O~ Other bacteria Collected by: ~( Date installed ~,/l¢i~- Tank size Foundation ~leanout-~U)_. ¢1¢,~ Depression Date of. P'~'mPing' '~/2~¢'~ ;i~.. Pumper ~¢,,~,.5 Number of Compartments ~ Cleanouts (~'~N)~__ High water alarm (Y(~) ~ C. ABSORPTION FIELD DATA ~ ' Dateinstalled / Soil rating (g.p.d./ft2 or ft2/bdrm) ~ ~ £ System type ~: . . '.. Length .~ ~ Widt~ // -~ / Gravel thickness below pipe ~ ~ Total depth Effective absorption area .. _~..-~ ~"+~- Monitoring Tube present (~N)_~Cz~_ Depression over field (Y(~) Date of adequacy test ¢;~/o~1 /~' Results~,~ail) /¢~P"/'-%% For "~'~--,~ bedrooms ~.¢ Immediately after~.E¢¢ gal. water added (in.): ~,'¢', Fluid depth in absorption field before test (in.); " Fluid depth ;Z.~" (ins) Minutes later: '~ Absorption rate = +'~-~O g.p.d. Peroxide treatment (past 12 months) (Y~ 72-026 (Rev. 3/96)* If yes, give date D. LI v~~ Date installed ~ Size in gallons Manhole/Access(Y/N) ~ __~ High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line "Pump off" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~/~ Property line ~ '~- Absorption field Water main/service line iO¢+ Surface water/drainage I oo~+ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain Building foundation Water main/service line IOCE Driveway, parking/vehicle storage area IO,4` Wells on adjacent lots ~C)D~ ~r' ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal recor~a~;a~ ~..¢~ms are in conformance wit Q H~A gu~elines in effect on this date. HAA Fee $ ~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* AUG-21-199? 21:17 CT~E ESI ANCWORA~E .d~t~/m~ C T&EEnvironmentalService~lnc. CT&E lief.// Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 974851001 S & S Engineering Lot 12 Blk 1 Henkins Lot 12 Blk 1 Henlci~s Dnnkiag Water Client PO# P~inted Date/Time 08/21/97 16:25 Collected Date/Time 08/19/97 17:15 Received Date/Time 08/20/97 11:10 Technical Director: Stephen C. Ede Releasecl BY ~~t.~, ~ Total Coliform Results Units Z.O9 0,00 0.100 mg/L coL/lOOmL Allowable Prep Anatys~s Method Limits Date Date Inlt SM18 4500-NO3F 10 max' ~18 9222§ 08/19/97 JBL 08/20/97 T~W TOTAL P. 01 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) LOT 12; BLOCK I; HENKINS SUBDIVISION Location (address or directions) 16022 Division Street EaRle River Telephone:(home) Yuma, Arizona 85364 Telephone (b) Property owner Gaqlon D. & Ed.~th Mx~es Mailing Address 2233 West 19th Street (c) Lending Institution ;. Mailing Address Business (d) Real Estate Company and'Agent ~.~;+..g. ~,,.,~+..,~,, ,~¢-+,,,. -r ..... Address 1~a~v~ Eagl~ River Road, Eagl~ o;,..~,...~, Ak. 9 .... Telephone 694-4994 (e) Mail the HAA to the following address: (or check here I~,)~f hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 EaCe River Loop Road Eagle River, Alaska ~9577 2. TYPE OF RESIDENCE Single-Family,~ Number of bedrooms 3. WATER SUPPLY Individual Well .[~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site I~× 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. 72-025 (Rev. 7/88) Page 1 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 ihe 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 $ ~. g ENGINEERING Telephone 17034 Eagle River Loop Road No. 204 Add ress I=n~le River, Alaska 99577 Date 6. DHHSAPpROvAE ' Approved for_ Approved __ ~ _ bedrooms by ._. Disapproved Terms of Conditional Approval Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval 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. 72-025 {Rev. 7/88) Back Page 2 of 2 A. WELL DATA Well Log Present (Y/N) ¢ Date Completed Total Depth UN i~M,, ~ I,OIPA:~I~,~,~F_A N C H O RAG E (MOA) CHECKLIST - FEBRUARY 1984 i 'i~ 0 343-4744 Legal Description: ,/~o'¢~ I~..~ Depth of~Grouting ~ Pump Set At Static Water Level (..o .~ ' If A, B, C, D.E.C. Approved (Y/N) ' Yield Casing Height Above Ground I.~ ' '~ Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTA~NCES FROM WELL: To Septic/Holding Tank on Lot ( ~O · '~ To Nearest Edge of Absorption Field on Lot / ~ '~' Sanitary Seal on Casing (Y/N), Depression Around Wellhead (Y/N) Y To Nearest Public Sewer Line N)/~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ,.~ ~'/Jr' Water Sample Collected by ~ -~ ._.~ ~j~.~.c.¢' ~ ~1~ ;Date ; On Adjoining Lots ! 00' '~ ; On Adjoining Lots / OO' ~ Comments B. SEPTIC/HOLDING TANK DATA Date Installed t_~/I ~/_F,,Z Size Standpipes (Y/N) F ¢ (900~/rl No. of Compartments Air-tight Caps (Y/N) / Foundation Cleanout (Y/N) · Depression over Tank (Y/N) /k) Date Last Pumped ~,, ~'~,¢/)¢ Pumping/Maintenance Contact on File (Y/N) A]/~ ;for ;~ ' /1~ Temporary Holding Tank Permit (Y/N) HOlding Tank High-Water Alarm (Y/N) sEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water,-Supply Well / ~ ~ / -~ -T-o~Property Line ~ O ' f ,To Water Main/Service Line ! 0' ~ To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation. ~ To Disposal Field ~ lO0"[ _ . c.c s'?ool 72-026 (Rev. 7/88) Front page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absor,ption Strata Date Installed (.O/l~/ ~¢2. Width of Field .%-- / Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test S5 Z///~ f';~' Type of System Design Length of Field Depth of Field ! Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ! .~ ~ To Property Line ~ ~ ~ To Building Foundation ! 0 ~ To Existing or Abandoned System on Lot /~)/~ ;On Adjoining Lots -~© r' ~ To Water Main/Service Line ,/O To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course / ¢?© /7c To Driveway, Parking Area, or Vehicle Storage Area ~ cD ~ -/~ Comments D. LIFT STATION Date Installed 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 Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **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 S & S £NGINEBR!NG 17034 Eagle Ri','~:r Loop Road No. 204 Company Receipt No. ~ Date of Payment Amount'. 72-026 (Rev. 7/88) 8ack Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Orde~ # 16388 Date Report Printed: SEP 6 89 @ 10:09 Client Sample ID:LI2 B1 HENKINS S/D PWSID :UA Collected SEP 4 89 @ hrs. Received SEP 5 89 @ 09:00 Me. Preserved with :AS REQUIRED Client Name : S ~ S ENGR Client Acct: SNSENGP PiOi~ NONE RECEIVED Req $ Ordered By : Analysis Completed :$EP 5 89 Send Reports to: Laboratory Sup~y~ozs_:STEPHEN C,_EDE 1)S & S ENGR Released By : x~'~-~'~ ~ 2) Special Instruct: Chemlab Ref $: 7329 Lab Smpl ID: 3 Matrix: WATER Allowable Pa~ametex Tested Result/Units Method Limits NITRATE-N 2.0 m9/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY RDJ. 1 Teete Performed ' See Special Inetructions Above UA=Unavailable ND= None Detected ** See Sample Remarks Above NA= Not Analyzed LT~Less Than, GT=Greater Than