HomeMy WebLinkAboutDEER HORN BLK 2 LT 2t)eerhorn
Block 2
Lot 2
#051-042-81
\ f MUNICIPALITY OF ANCHORAGE 1
1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 2644720
' ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME/
PHONE
NEW
[� L„ 0ej&p
❑UPGRADE
MAILINGe RESS
zz, S hiPeI117
.,
LEGAL SCRIPTION
G !l 2 F 2J IV
LOCATION -
/J -,Oe/ IA-)` �A
NO. OF BEDROOM
o
DISTANCE TO:!
Well 1-1 2" �,
Absorpb 6 rea /
Dwelli✓nip'! f
PER IT � / � /
7`
iQYMgsawa
Manufacturer ___
/
No. of comp ents
J
w
Liq. Mcit in allons
IF HOMEMADE:
Inside length
Width
Liquid depth.
6 Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
.+vz
0 f
Manufacturer
Material
Liquid capacity in gallons
DISTANCE TO:
Well
6!6616
Founda n
Nearest 1 Vine /
O —
PER IT Z/ /
9J
W
♦� T
W W
No. of lines /
ength of ea h ITe
Total e In lirws
Trench width //
Distance batvw n I nes
1=4
inches
/V
Top finish dr/
Material beneath
-
R
of tile to
tile /r
Total efl t a abso ,n arga
O
inches
L{ 9L/
Length
Width
Depth
PERMIT NO.
W
t7
d F
W�
Type of crib
Crib diameter
Crib de
Total effective absorption area
W
DISTANCE TO:
Well
_
Building found tion
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE TO:
Building foundation
Sewer line
Se 'c tangy
Absorptio rea sl f
7
OTHER
I
VA
f
PIPE MATERIALS
42 v G
SOIL TEST W INrnGG
`
'B
J V
INSTALLER Exiii ki -
MARKS
176-0- r
OF••Al..4%tt
E
i ' ��'•ti9 if
...:....�.� :tis
MMA A. Sheler/
.
D!r
T. C
HE
L'TH
& ti
ATE
a
_
,,
wi
T:
N
APPROVED 0• DATE 106X - LEGAL
SRL ALASKA Z"•577
tI. D 297
�PG
72-013 IRev. 31781 ---'
MUN I C I P^LL I TY OF APACHC- A G E n e °�
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION(�-4••(J�
825 L STREET, ANCHORAGE, AK 99501
264-4720
O N —SIT E 'S EWE R P E R M I T
PERMIT NO: 840914
DATE ISSUED: 10/29/84
APPLICANT: C/O S & S ENG'G LIFESTYLE IND.
ADDRESS: SRB 196X
EAGLE RIVER, AK 99577
2ONTACT PHONE: 694-2979
_EGAL DESCRIP: SUBDIVISION:
DEERHORN
LOT: 2
BLOCK: 2
SECTION: 4
TOWNSHIP: 15N
RANGE: 1W
_OT SIZE: 28770 (SQ.FT.
OR ACRES)
hAX BEDROOMS: 3
-isted below are the options
available to you
in designing
your septic
system. Choose the option that
best fits your
site.
TRENCH
113 )C)
LKJ _ DRA I N
DEPTH TO PIPE BOTTOM (FT.)
4.0
5.5
3.0 **
SRAVEL DEPTH (FT.)
3.0
0.5
3.0 �.
TOTAL DEPTH (FT.)
7.0
6.0
6.0 "
3RAVEL WIDTH (FT.)
2.5
17.0
5.0
3RAVEL LENGTH (FT.)
71.0
34.0
53.0
3RAVEL VOLUME (CU.YDS.)
23.1
21.5
34.4
TANK SIZE (GALS)
1,000.0 **
1,000.0 **
1,000.0 *
SOIL RATING (SQ.FT./BR)
142
125
150
DEPTH TO PIPE BOTTOM <
3.5 FT. REQUIRES INSULATION
*+� DEPTH TO PIPE BOTTOM <
4.0 FT. MAY REQUIRE
A LIFT STATION
** TANK MUST HAVE AT LEAST
- - - - - - - - - - - - - -
TWO COMPARTMENTS
- - - - - - - - -
- - - - - -
- - - - - - - - - - -
certify that:
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid for a maximum of 3 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
JILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORT: MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED n �FS
il� /S'lDATE: ����--APPLICANT: C/o 3�ENdG�S_G LIFESTY �-- -
ISSUED BY ( - DATE:
SOILS LOG
_ MUNICIPALITY OF ANCHORAGE
`� v1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 2644720
- SOILS LOGPERCOLATION TEST
PERFORMED FOR L/ FES 7-4---47-4---4 C ,J -O DATE PERFORMED: z' 1 Dn tr
:eN S/d
e� noc OITC P1 AN
11 }� WAS GROUND WATER NO
ENCOUNTERED?
12 I
IF YES, AT WHAT
I DEPTH?
13
14-
4
Date
Gross
Time
Al.
Depth to
Water
` 2 43 Z DC«
LEGAL
DESCRIPTION:
EPTM
ESTI
0I/�l!/7L
16-
6
2-
17-
17-
...... « s' »
bebert A. 31-Aw a
33-
4
4-<
<
�� AD=ES51v�
19
6-
c
7-
7
8-
9
9
10
G !�
:eN S/d
e� noc OITC P1 AN
11 }� WAS GROUND WATER NO
ENCOUNTERED?
12 I
IF YES, AT WHAT
I DEPTH?
13
14-
4
Date
Gross
Time
Al.
Depth to
Water
Net
Drop
or
16-
6
04
17-
17-
...... « s' »
bebert A. 31-Aw a
c.
�� AD=ES51v�
19
L
0
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
04
20
PERCOLATION RATE Z (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
L'C Li'�Li�i/ 7
PERFORMEDBY: niaX,.: -— CERTIFIED DATE / 0
72.008 (6/79)
Municipality of Anchorage
i. Development Services Department
Building Safety Division
Onsite Water and Wastewater Program
4700 Bragaw Street__
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
8,c4�.r l✓e%cJ
COSA # Q!9 1 �
Expiration Date: 1(2— 3O -D a
Complete legal
Location (site address) 2 1973 Dppr Park Dr6vP Chualak AK 99567
Current Property owner(s) Andrea & MeEten gangemann-1rihnso Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: - q
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
Day phone
Day phone
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 On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional
civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required 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 COSAs upon request to homeowners. Certificates of On -Site
Systems 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 seal affixed
certified by
d hereto das of the validationOn-Site eshown Approval I verify that fnvetgtbaeon poceduresoutlinedIn the Certificatof Systems Guidlnes o
this application, shows that the on-site water supply and/or wastewater disposal system Islam) safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify
that based on the information obtained from the Municipality of Anchorage files and from my investigation
and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all
applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Ar T rca n8in ring�lS�lrvsyvl�, Inc_ Phone_868-37g9
Address 20441 PTARMIGAN 8l VD , FAf'1 F RIVER, AK ggS77
Engineer's Printed Name KENNETH M DtIFF IS Date. 10/ 5/07
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations.
The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from
the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the
year and the water usage of the family being served by the system. The operational life of all well and
septic systems are subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a 1� OF qt>>1�
system will function satisfactory for current or future •4P(F. ••,...• .QS I
occupants or can ArcTerra guarantee that no unseenAW C-2 •••• •'••. V/-
encroachments, deficiencies or discrepancies exist. i� : _ _ �•._'9 1,
5. DSD SIGNATURE
_,L Approved for _ Z_ bedrooms.
Disapproved.
Conditional approval for bedrooms with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
1111111111
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: ---� �� t/7J��
Y ✓ Original Certificate Date:- U —_07
(R•v 1/p� /
Municipality of Anchorage ; -
• Development Services Department
Building Safety Division `
On -Site Water 8 Wastewater Program :
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519.6650
www.muni.org/onsite
(907) 3434904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description' Deer Hom Block rot 9 Parcel ID: 051-042-81-
A.
51-042-81A. WELL DATA
Well type PUBLIC If A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (Y/NJ_ Wires properly protected (Y/N) —
Total depth _ft. Cased to _ft. Casing height (above ground)—in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production 9�p•m. 9.p -m.
WATER SAMPLE RESULTS:
Coliform _colonies/100mL Nitrate ___ng/L Other bacteria _oolonies/100 mL
Arsenic: _mgll Date of sample Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/MaterialygpjtC _teems Date installed 11-10-84 Tank size _1000 gal.
Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (YM) bDate of pumping 10/23/07 Pumper ! Rs
C. ABSORPTION FIELD DATA
Date installed 11/10/84 Soil rating (g.p.d./fe or fefbdrm) 150 System type shallow Trench
Length _53– ft. Width rL ft. Gravel below pipe _Lft. Total depth _fit ft.
Eff. absorption 'area 450 ftp Monitoring tube Y Depression over field hi
Date of adequacy test 10/24/07 Results (Pass/Fail) PASS For 3_ bedrooms
Fluid depth in absorption field before test IL In. Water added-fiffl._gal. New depth 12.jn.
Elapsed Time:_4Q_ min. Final fluid depth) 2 in. Absorption rate >= aan+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date-----
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' level at—in. 'Pump off" level at—in. High water alarm level at—in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: PUBLIC WATER
Septic tankilift station on lot NA
Absorption field on lot _NA
Public sewer main NA
Sewer /septic service line NA
Animal containment areas NA
On adjacent lots _ NA
On adjacent lots _ NA
Public sewer manhole/cleanout _NA
Holding tank _NA
Manure/animal excrete storage areas NA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field _5'+
Water main 10'+ Water service line 10 1 + Surface water 10 0' +
Wells on adjacent lots '+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation .J 01+ Water main 101+
Water Service line 10'+ Surface water 10 0 1 + Driveway, parkirg/vehicie storage 10 1 +
Curtain drain •50'+ Wells on adjacent lots 2 0 0 '+
F. COMMENTS
*None Known
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and �!it a ,•':�
review of Municipal records that the above systems are in „„ ••»» ,
conformance with MOA COSA guidelines in effect on this
date. • • NNS
Engineer's Printed Name. KENNETH M. D FF tc �j roti•, aE 7,•' ti
Date.] 0/25/07 FESS
1o�P�
COSA Fee Waiver Fee $ _
Date of Payment 0 % Date of Payment
Receipt Number loi �8 y Receipt Number
(Rev. I IM)
Municipality of Anchorage O
06.
• -� Development Services Department
Building Safety Division ��
Onsite Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, Ak 99519-6650
www.ci.snchorage.ak.us
(907) 34J-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-042-81 HAA#
Expiration Dale: R - %- (, 3
1. GENERAL INFORMATION
Complete legal description Lot 2; Block 2; Deerhorn Subdivision
Location (site address ordireclions) 21973 Deer Park Dr.
Current Propertyowner(s) Tim Dean Dayphone 564-1856
Mailing address PO .Box 671 gDR r.hnoi ak , AK 40567
Lending agency Day phone
Mailing address
Real EstateAgen( Carolyn r:roin— Dayphone rgL_L7no
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup. T-/ 7/o z
2. NUMBER OF BEDROOMS: �3_
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
0
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
[
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 5 by an Independent professional civil
engineer registered in the Slate of Alaska. Certificates of Health Authority Approval are required 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 less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificrates 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 of
bedrooms and type of structure Indicated herein. I furtlier verify that based on the information obtained from the
Municipality of Anchorage files and from my Investigation and inspection• the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm S & S Engineering Phone 694-2979
Address17034 N. Eagle River Loop Ste. 204 Eagle River, AK 99577
Engineer's Printed Name Robert C. Cowan Dale 7/31/v 2-
ec_ OF Air
Ap i RCBERT C. COWAh
5. DSD SIGNATURE �j'"f\� CE -8801
Approved for 3 bedrooms. ,�1���'cpo`- _ •.....
� FCiE,;tu•" "
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
By:
(A" umm
\kk�\%Yf OF qHc�,�:
Jam: ON-SITE • 0�c�=
WATCRAND ; m=
WASTEWATER :
PROGRAM
���/I/111111111 t1�1
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: S — % " o .
Municipality of Anchorage
• Development Services Department
Building Safety Division
On-Ske Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.d.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORIT/Y� APPROVAL CHECKLIST N
Legal Description: LOT Z 5LOGIG 7, /r /' Ll �/D Parcel ID: DSI —(�r2 R
/
A. WELL DATA
WellPu3c.r�-
type _ K A, B, or C provide PWSIO # _ Well Log (Y/N)
Date completed _, Sanitary s (YIN) _ Wires properly protected )
Total depth ft. Cas ft. Casing height (a round) In.
FROM WE LOG AT INSPECTIO
I' Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULT .
Coliform colonies/ 00 ml. Nitrate ' mg.A. Othe-bacteria colonies/100 ml.
Date of sample: 'Collected by:
/
B. SEPTIC/HO G TANK DATA
Tank Type/Material l!rm-Ire, Date Installed
Tank size r vw gal. Number of Compartments _Z,: / Cleanouts (Y/N) Y'
Foundation cleanout (YM) 7 Depression over tank (Y/N) N High water alarm (Y/N)
date of pumping ttI (4n/ �Pumper
C. ABSORPTION FI A
Date installed Q I I Sou rating (g.p.d.W ft2/bdr System type <. [ 0&r4C I -f
Length S?J ft. Width 5 ft. Gravel below pipe _ /ft.
Total depth nElf. absorption area Monitorin be `% Depression over field 'v
Date of adequacy test T' �9 Results (Pass/Fail) i For _„ bedrooms
Fluid depth in absorption field before test Q In. Water addedStD gal. New depth in.
Elapsed Time: 0 min. Final fluid depth _Z_ in. Absorption rate >= 4�O g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) fl -I If yes, give date
9
D. LIFT STATION
Date installed/t/ %� Size In gallons
"Pump on" level at in. "Pump otr level at _ in.
Datum Cycles tested
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm b circuit requirements?
pu6u 4,
SEPARATION DISTANCES FROM WELL O OT 70:
Septic to MUt station on lot On adjacpnt I
Absorption field on lot On adjacent I
Public sewer main Public sewer manholeiclean
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTICMPW%NG TANK ON LOT TO:
/ t �
Building foundation S >f Property line _�-(' Absorption field S r'
Water main �� r 4' Water service line n r Surface water
Wells on adjacent lots N /A• /10c) r'+"
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ( 0 14' Building foundation 1� Water main
Water Service line ( t7 14- Surface water (� f �' Driveway, parkinglvehide storage 14"
&
JL/ / r
Curtain drain %�/E, " Wells on adjacent lots f ,�_
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines
B
gJuidelines infect on this date.
Engineer's Printed Name /L A It/LT COC. l
Date
'HAA Fee $
Date of Payment
Receipt Number
(Rev. 12100)
Waiver Fee E
Date of Payment .
Receipt Number
0
ROl�tApM/AN �@
�CE 881 1
USE ZONE
APPROVED
Iy �'!sl�/vr1dL�K
NIto
Ili mar,'; shril he flow: as shimm on this
Jai plan. Ah:prn:rd Pham and sprci(i-
Miam shall nrl he char;rel, modified
•r altered edthom first obtaining a valid
'h ange order.
r-1
e
L
1j v
ry
Cy
,
.` `,• rte<;ra:• ,
47
4.
j 4c(K
� tef
zc: :
0 20.2 F.cavz
44.0
N
Proposed .�
Cara -Se- -
7
T
II '
` ` t
{ ......... Wit,
iii Emit.. > �TB.Etay. ED•-ir. j1
+ 1 ��1UlY o4 tnDIVISION
"� AO'�t � 1<1UILDING SAPI:T71
\N
V
1AAY 2 r 1991
ne�d.nv y1 -.C- 3 64 o I(-(-
Ar -BUILT
.1 lyreby certify that 1 have survged the following descril�•r
prrpertj•IAen.; _
AtV Anchorage Recording Pleeincl• Alaska. and Iha: the Impr.•te
If \ , mentt situated thereon are within the propany lines and J., r,.
I a oeedap or encroach on lht: property lying adibcent lhrn•t.r. IIP..
rV • + rtti Improvements on property lying adpcenl thereto rr cn.a; r
\ cm the premL•es in question and that there are no toad„at,
transmission lines qr other vhible casements on said pmp(n,
emvpl as Indicated hrreon.
Dated at Ga le Ri 0t
A.iFa,>+'S3v:ii_'-1iY'tfy9•T`tf;`•`e":.: pct
t9 :'
SCALE ROBERT C. IOI IX�OX '
Registered Land Sur4vm No
Rua i4ti;o. Eagle Riv&. Al,:.l.6
Mune (' t171 694•2:4.1
r 1 MUNICIPALITY OF ANCHORAGE " ., - -
SV
• 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.# _OS/ -042-8( HAA #_I4Acfl-04.32
1.- GENERAL INFORMATION
Complete legal description Lot 2; BCock 2; Dee)L' H6an Subdivi4 ion
Location (site address or directions) Deer Pan.k Vitive
Chu .i.a-k, AK
Property owner Tim Dean Day phone Iwl 271-2351
Mailing address P•O.'Box 671908 Chucliak, AK 99567 (h) 688-1030
Lending agency Day phone
Mailing address
Agent - Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well ' - `- X" _ . ..._
- Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
-- -- - Ing to the legality and status of system.
'.'.y,
4. '.TYPE OF WASTEWATER DISPOSAL
r.l`':•": -{-_- .
Individual on-site XXX
Holding tank .
Community on-site'
_ Public sewer
xu ': a
NOTE: If community wastewater system, provide written
confirmation from State ADEC :..
attesting to the legality and status of system.
- 72-M(R..neq /mn MOA E21
5. STATEMENT ,OF INSPECTION .BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity 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 furtherverifythat 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 o hi 'nspection.
Name of Firm Phone
17034 Eagle Rlwr R
Address
Engineer's signature ems' ° Z
zrt
a •'d
••' .d
�4''dJrE55�4�� -
6. DHHS SIGNATURE
Approved for" --bedrooms.
Disapproved. _ -- -
Conditional approval for J , bedrooms, with the following stipulations*
Additional Comments
Date
t
e
.The Municipality of_P chorage 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
lonal eAglheer registered In the State of Alaska. The DHHS does this as a co6 rt*to purchaiers of homes,
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
ond
cuct inspections or analyze data before a'certificate is:issued The'Municlpaiity of Anchorage Is not
responsible for errors or omissions in the professional engineers wo&i tet ., C� r i•_ ,: f , ' 4 ,
• rummimim) Owk MOAgt
ry ,
t
® Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L r2 13u Z Dce- a- a�c.l '' r, Parcel I.D.
A. Well Data
Well type A If A, B, or C. attach ADEC letter. ADEC water system number
Log present (YIN) Date completed Driller
Total depth Cased to Casing height
Sanitary seat (YIN) Wires property protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump levell
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
g.p.m. 9 -
p.m -
Septic/holding tank on lot � -;On adjacent lots
Absorption field on lot Zoo 14- ; On adjacent lots _
Public sewer main Public sewer manhole/cleanout
Sewer service line Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
�
,�
z
T
C
rn
w
C1
��
�
0
v�
Date installed 11-10-94 Tank size 1000 Compartments 2-
CleanoutsON) Foundation cleanout 6m 2� Depression/(Y® ,l
High water alarm (Y/� r-( Alarm tested (YM) ',J/,
Date of pumping 8 -27 - Pumper 7_,e. G�csreoc
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK TO:
Well(s) on lot 206 ' + On adjacent lots 14/4 -Foundation ZS
To property line /o ry Absorption field /o Water main/service line 10 i4
Surface water/drainage /do / ,�-
72-MrAMIFnxu CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) 'Pump on' level at 'Pump otr Level at
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N)
LIFT STATION TO:
adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed IX -%o- SI- Soil rating (GPD/Ft2) 1 ShI'�t_ System type
Length S3 ' Width S Gravel thickness 3 Total depth L '
r-�
Total absorp4on area �}Sa Cleanout present ON) _Depression over field (Y1
Date of adequacy test 6-2 7-5,� Resufts&�a1) 4. s for 3 Bedrooms
Water level In absorption field before test O After test
�l
Peroxide treatment (past 12 months) (Y® ,,JC- AJ,../.J n yes, give date r1��
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
Zao r y
On adjacent lots "1`A Property line
o '
To building foundation t r
To existing or abandoned system on lot
'� A
r
'1/'
/o r t
On adjacent lots
3 o
Cutbank Water malvservice line
Surface water
loo I f
Driveway, parking/vehicle storage area 6 0
'd
Curtain drain
E. ENGINEERS CERTIFICATION
I certify that I have checked, verified, or
µ. S d S ENGINEERING
^
�I attire
Engineer's !Yarm River, Alaska
Date r/2'
HAA Fee $ 7Cl
Date of Payment n - 9
/ U y
Receipt Number Sj E:)
n-oze t"t.8&* eW9 37
MOA and HAA guidelines in
Waiver Fee $
Date of Payment
Receipt Number
t � d �te.�iihis in;
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 4� � _ 6 Jg Ll�
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date June 27, 1988
t. GENERAL INFORMATION
(a) Legal Description (include lot block, subdivision, section, township, range)
beer Horn Subdivision Lot 2 Block 2 T15N,R1W, Sec.4
Location (address or directions)
Daer Ho= street. Chugiak Alaska
(b) Applicant Name H.U.D. /Lou Cambell Telephone: Home to Business 563-3333
Applicant Address Associated Brokers 640 W. 36th Avenue, Suite #1, Anchorage, Ala
99503-5807
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer 13 ; Other ® (explain);
(d) Lending Institution n/a Telephone
Address
(e) Real Estate Company and Agent n/a
Address
Telephone
(f) Mail the HAA to the following address:
.. pick i3p by FnginPPr
2. TYPE OF RESIDENCE
Single -Family U Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well ❑ Communityla Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ® Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
S. ENGINEERING FIRM PROVIDING �SPECTIONS, TESTS, FILE SEARCH, DA'^ ND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Facile River Engineering Services Telephone 694-5195
Address P O Box 773294 Eagle River Alaska 99577
Date June 27 1988
�Q"E OF A -"%j
c ,,......... qs It
c2
..:ter ..................:... a -
S3 I
ro
Louis A. Butes Q
,• CE -6796
r�
Lp �pRnccetlONp'�
6. DHEP APPROVAL _y
Approved for 174&—a� 3) bedrooms by r' r Date
Approved x Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) Issues Health Authority
Approval certificates based solely upon the representations given In paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
Institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is Issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025(11/84)
WAR410pALiTy OF NICIPALITY OF ANCHORAGE (MO
DEPT. OF HEALTH & HEALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTAL PROTECTION CHECKLIST - FEBRUARY 1984
JUN 2 7 %8 284-4720
Legal Description: L&t-2 elAe,2 Z*e-'' y ^�
RECEIVED �,'. r/s N oe,w Se c .7!
A. WELL DATA
Well Classification Llors A If A, B, C. D.E.C. Approved (YIN) _Y_
Well Log Present (YIN) Date Completed Yield _
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit (YIN)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Sanitary Seal on Casing (YIN) -
- Depression Around Wellhead (YIN)
On Adjoining Lots —
On Adjoining Lots
_ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
^ax °r.2/3°0
Date Installed �O�irti Size AW -0 6'4 No. of Compartments .Z
Standpipes (YIN) Z Air -tight Caps (YIN) i Foundation Cleanout (YIN)
Depression over Tank (YIN) N Date Last Pumped 6.p S' -Xie
c w..w ....f
Pumping/Maintenance Contract on File (YIN) ~/�' ; for ZA
Holding Tank High -Water Alarm (YIN) N�` Temporary Holding Tank Permit (YIN) 'vim
Separation Distances from Septic/Holding Tank:
To Water -Supply Well +0200 To Building Foundation -2s z
To Property Line f16 4 To Disposal Field —/2 0
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course /00
Comments
Page 1 of 2
72-026111184)
C. ABSORPTION FIELD DATA �•
Soils Rating in Absorption Strata SSD 0—Type of System Design 14/lo4 17026 1„ .
Date Installed 6*1-q Length of Field 5 3 r
i
Width of Field s Depth of Field X15-
Gravel
.SGravel Bed Thickness 31
Square Feet of Absorption Area yse Standpipes Present (Y/N) Y
Depression over Field (Y/N) ov Date of Last Adequacy Test 6/AY/Ar
Results of Last Adequacy Test -str'p%ayb_p 46r_4j%., ^Ar moan, 4/ :lit 4ejeorG
Separation Distance from Absorption Field:
To Water -Supply Well __te2y0 r To Property Line
To Buildin Foundation _ S/S
9 11 To Existing or Abandoned System on
Lot '�f� ; On Adjoining Lots
0.34"
To Water Main/Service Line f ' To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area s ro '
Comments
D. LIFT STATION
nl�
Date Installed
Size in Gallons
"Pump On" Level at —
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
_ 'Pump Off' Level at
•• Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the dale of this inspection
Signed
Date 6 ZA 7APY
Company Eaele
Rim Engimsdqg e_pA._
MOA No. 'ST :.26.t
Receipt No.
P. 0. Box 171'"
Eagle 9977w�OF
ya,)
q{ SAX
(-, —,2
F— d�
t14.
,3
Date of Payment
....•••.4,n
Amount:S
/�0'UO
vcJ��0:0 r° Pneer� �l
0I5r ao 93�
Page 2 of 2
MUNICIPALITY OF ANCHORAGE r'
EWIRONMENTAL SERVICES DIVISION
It►N 271988
72-026'"'84' RECEIVED
Louis A. Putera
CE -6736
SHE or U&SM
DEPT. OF ENVIRONMENTAL CONSERVATION
At4CHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET. SUITE 1334
oNCHORAAE. ALASKA 99503
To Whom It May Concern:
STEVE CO WPER, GOVERNOR
DATE: 6—Z3—QS
PWSID #: __ 71—ts ------
563—A775
According to the records on file in this office. the
041-- N0:^"Water System is in compliance uith the
'=tato of Alaska Drinking Water Regulations.
Sincerely.
Ronal . Klein
Environmental Field Officer
c'SK: sa
` MUNICIPALITY OF'ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Desoption (include
Location (address or directions)
subdivision,
range)
(b) Applicant Namer zgddQ Telephone: HomeBusiness
Applicant Address
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mtanhe HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family Y1 Multi -Family ❑ Other
` . Number of Bedrooms
U?
i
3. WATER SUPPLY u
t 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.
i
I
1..
4. SEWAGE DISPOSAL
Onsite.. Public ❑ Community ❑ Holding Tank ❑
Note: If community well system• must have written confirmation from the State Department of Environmental Conservation
' attesting to the legality and status.
( Page 1 of 2 72-025(11/84)
�. ENGINEERING FIRM PROVIDIN INSPECTIONS, TESTS, FILE SEARCH, DA A AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of thiSjlealth -
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone
S 6 S Engineering
Address SRB 196X /
Date Ear11e ofver Alaska 02VZ__/ ? g 6
oF Al.-ah
JOW
It
4 f • •%
r
• M /
••� A. Shaw •� W /
J' :•• - No. 14.57-E .•vSi -
6. DHEP APPROVAL C3
Approved fo bedrooms by �'� Date
Approved � Disapprove Conditio
Terms of Condition I Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an Independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
Institutions In order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineers work.
Page 2 of 2
72.025 (11/84)
MUNICIPALITY OF ANCHORAGE (MO
HEALTH AUTHORITY APPROVAL (HAA)
MUNICIPALITY OF ANr4..C�H�ECKLIST - FEBRUARY 1984
DEPT. CF HEALTH ^ � 264-4720
EWIRONdENTAL pR0TECTI04 Legal Description:
A. WELL DATA
Well Classification
JAN 81980
REC IVSD
If A. B, C, D.E.C. Approved VY N)
Well Log Present (Y/N) Date Completed Yield
Total Depth
Static Water Level
Cased to Dot o1 Grouting
(� Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N)
Separation Distances from Well: )
To Septic/Jiaiding Tank on Lot On Adjoining Lots
I
To Nearest Edge of Absorption Field on Lot 2-4212 A' ; On Adjoining Lots _
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Water Sample Test Results
Comments r• \#� S It? • -V* ? \'S C>C> f
B. SEPTIC/Hfdtl7=TANK DATA
; Date
Date Installed 11-10-e Size I z5h-2t7 No. of Compartments �Z-
Standpipes (9/N) Air -tight Caps VDN) Foundation Cleanou� t�j
Depression over Tank (Y/19N Date Last Pumped
Pumping/Maintenance Contract on File (Y/NA —;for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) A
Separation Distances from Septic/Mehitng-Tank:
I t
To Water -Supply Well To Building Foundation
To Property Line o I4- To Disposal Field ( a
To Water Main/Service Line t I � t To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
t
Soils Rating in Absorption Strata I !SE2 `�f''FSR, Type of System Design T=*- Fi Ci
Date Installed \ \Q SL{-
i Length of Field S3
n �
Width of Field Depth of Field b
Gravel Bed Thickness 0
Square Feet of Absorption Area �'�� Standpipes PresenON)
Depression over Field (Y/� rDa
Results of Last Adequacy Test - IRS.
of Last Adequacy Test Osf�
Separation Distance from Absorption Field:
To Water -Supply Well ?" r> To Property Line al d
n . I
To Building Foundation
Lot
; On Adjoining Lots
I
To Existing or Abandoned System on
IX
To Water Main/Service Line Its A To�utbank (if present) �
To Stream/Pond/Lake/or Major Drainage Course a A
I
To Driveway, Parking Area, or Vehicle Storage Area - G� ' -
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.
S In,
5 E^yinwri 4.
Signed Date
x
Companly*916 RWMy��571_ MOA No. - > - W 3
Receipt No.
Date of Payment
Amount: $ —
Page 2 of 2
72-026 (11,84)
. .. VE OU 8L8% 8![L SWFFOEID, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION Tikphcn. (9071
AddnR:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET. SUITE 303 274-2533
ANCHORAGE, ALASKA 99501
DATE: % 1 A r( PC
PWS I.D.#, 1300(
To Whom it May Concern:
According to records on file in this office the A r./S
S//J Water System is in compliance with the State Drinking
Mater Regulations
Sincerely.
n MUNICIPALITY OF ANCHORAGE n
DIVISION OF ENVIROM ENTAL HEAL1rn
DEPARTMENT OF HEALTH AND ENVIROM ENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date 2.
(a) Legal Description (include lot, block, subdivision, section, township, range)
G Z A Z. /)2e6" fiv �Y►
Location (address or directions)
(b) Applicants Name %• J.1. 11 e" * _0_Ch2iVTelephone - Home Business
Applicants Address fin.
(c) Applicant is (check one) Lending Institution ; Ower/builder ;
Buyer [=1 ; Other Q (explain);
(d) Lending Institution /Ll O /J E Telephone
Ads s
(e) Real Estate Co. b Agent /L,"V A_J/_
Address
Telephone
(f) � the HAA to the following address:
r c S: vzpc Atn :1
hrl. vorF�J�
2. Type of Residence -----------
Single-Family Mi Multi -Family Other (describe)
Number of Bedrooms
3. Water Supply
Individual Well = Community = Publicm
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite Public Community Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
W
n
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein.. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm Telephone
Address nRi3 11 9c,", ..
Date
M
6. DHEP Approval
J."j & Shofar
Approved for 3 bedrooms B�� . ate c5
Approved Disapproved y Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. EMPLOYEES OF DREP 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 21 . 7-19-84
- 1 C.:'T. C.
'MMCIPALM OF ANCLDRAGE (MOA)
HFALXH ALMHORITY APPRMAL ( HAA) JAN 7 1985
CHE«.IST - FEBRLLARY 1984 x tC-�� l�I1,\}i E D
A. FELL DAM Legal Description: I^O 6�_`
Well Classification If A, B, or C,,D.E.C. ApprovedJVN)
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At '
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Wells
To Septic/Holding Tank on Lot %O 1 On Adjoining Lots
To Nearest Edge of Absorption Field on Lot i On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer
Cleancut/Manhole To Nearest Sewer Service Lire on Lot
Water Sample Collected By i Date
Water Sample Hest Results
Convents
B. SEPTIO140ESIM& TANK DATA
Date Installed ll- /o-,64 Size /btb,:� No. of Caepartments Z
Standpipes Zf?2) Air -tight Capse!67'N) Foundation Cleanout (AN)
Depression over Tank (YIM Date Last Pumped AJ &.J
Pumping/Maintenance Contract on File (Y )� t for
Holding Tank High -Water Alarm (Y )A- Temporary Holding Tank Permit (Y/N) -,VIA
Separation Distances from Septic/8o1d&g Tank:
To Water -Supply F311 2ZOQ4 PlIAL 1L To Building Foundation ZS
To Property Line /O 14- To Disposal Field 161
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course AVA
Comments
Receipt 4 3 0l 0-11 SC
Date Paid: 1 -w -;y
Amount: 5 ���
(Page 1 of 21
2-15-84
Soils Rating in Absorption Strata Sb Type of System Design J�A;Z.allVff2A
Date .Installed Length of Field S�
Width of Field /eQ Depth of Field
Gravel Bed 'thickness 34o
Square Fleet of Absorption Area Standpipes Present IMN)
Depression over Field (YM Da of Last Adequacy Zest 10&--)
Results of Last Adequacy Zest "'i4
Separation Distance fran Absorption Field:
To Water -Supply toll Zoe /0. "04.) To Property Line /V /f
To Building F ndation _9w To Existing cr Abandoned System cn
Lot R f On Adjoining Lots /f
To Water Main/Servios Line To Cutbank(i£ sent) -4" A
To Stream/Pond/Lake/cr Majcr Lrainage Course 'R
To Driveway, Parking Area, cr Vehicle Stcrage Area t
Ccum+ents
D. LIFT STATION
Date Installed
Size in Gallons
"Ramp On" Level at
High Water Alarm Level at _
Tested for
Electrical
Dimensions
Manhole/Access (YM)
"Ramp Off" Level at
vent (YM)
Cycles during Adequacy Zest. Meets MSA
At
ccwmants / v
*' Check Permitted Bedroom Rating Against Hh& Request *'
I certify that I have checked, verified, or aonf==d.to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed 8 8 F 02 Date Date /— S�B� �%. OF .p..
. at
Ccmpanl' AUISK4 a: T! MOA No. Li:• .`y�0
c ,vLE
iii. GCi gid e
KB1/d5/s •�.
[Page 2 of 21
%be" A. Sbd"r
Na 1457-5
2-15-84
i (-1
BILL SHEFFIELD, GOVERNOR
DEPT. OOFFENVIRONMENTAL COONSERRi'ATION Telephone: 19071
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE_
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
DATE: . ^1 lqa5
PWS
To Whom it May Concern:
274-2533
According to records on file in this office the I W CU xy-10 WMA"
1L Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
C • 01b
I