HomeMy WebLinkAboutDEER HORN BLK 2 LT 5r Horn
Block 2
Lot 5
#051-042-84
,.~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE ~ ~NEW
LEGAL DESCRIPTION
, J Well ~ ~ ~Ab~orpt~on area ~/ D~lling PERMIT ~O.
DISTANCE
TO:
~ ~ ~ Top of tile to finish grade Material be~ath tile Total eff~ti~ absorption area
m Building f~ndation ~ Sewer line Septic tank Abso piton · ea
~ DISTANCE TO: PT. OF HE~
OTHER
PIPE MATERIALS '~11~
REMARKS ~ ~ ~ '
3 {Rev. 3/78)
MUN I C I PAL I TY OF ANCHORAOE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK ~501
2&4-4720
ON--S I TE SEI~JER PERM I T
PERMIT NO:
DATE ISSUED:
840&28
07/26/84
APPLICANT: LIFESTYLE IND.
ADDRESS: % S&S ENGINEERING
EAGLE RIVER, AK ~577
CONTACT PHONE: 6~4-2~7~
LEGAL DESORIP: SUBDIVISION: DEERHORN
SECTION: 4 TOWNSHIP:
LOT SIZE: 85480 (GQ.FT. OR ACRES)
MAX BEDROOMS: 5
LOT: 5
15N RANGE: 1W
BLbCK:
Listed below ape'the options available to you in designing your,septi~
· system.· Choose the option that best fits your site.
I~ED
DEPTH TO PIPE BOTTOM (FT.) ~ 5.0 **
GRAVEL DEPTH (FT.) 0.5
TOTAL DEPTH (FT.) 5.5
GRAVEL WIDTH (FT.) 17.0
GRAVEL LENGTH (FT.) 54.0
GRAVEL VOLUME (GU.YDS.) 21.4
TANK SIZE (GALS) 1~000.0 **
SOIL RATING (SQ.FT./BR) 125
'** DEPTH TO PIPE BOTTOM < 5.5 FT. REQUIRES INSULATION
** DEPTH TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE A LIFT STATION
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I cepti~y that:
1. I 'am ~amiliap with the ~equipements
2.
5.
4m
on-site.seweps and wells as set
fopth by the Municipality of Anchopage (MOA) and the State o[ Alaska.
I will install the system in accordance with all MOA codes and regulations~
and in compliance with the design cpitepia of this pepmit.
I will adhepe to all.MOA and State o~ Alaska ~equipements fop the set back
distances ~rom any existing.well, wastewatep disposal system op public
sewepage system on this or an~ adjacent op neapby lot.
I understand that this permit is valid fop a maximum of 5 bedpooms and
any enlargement will pequipe an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELEGT~T ~ PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVE ~ITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
'ELECTRICAL WO~F~ MUG .~xI~B~E BY A LICENSED ELECTRICIAN. ~
SIGNED. ~_~ ~x~i~ .--~-~ ....... DATE:~_~__~_.~~__~_~__'/
APPL I CA~T~L~I FES~ '~_ _ ~_~~_
ISSUED BY _~____~ __~ ..... DATE: ....
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
LEGAL DESCRIPTION:
1
2
3-
4-
5-
6-
7-
8-
9
10
11
12
13
14.
15.
16-
17-
18-
19-
20-
COMMENTS
SLOPE SITI LAN
J
\
W^SOROVNDWATER
ENCOUNTERED? . pO
/' E
IF YES. AT WHAT
DEPTH?
Reading Date Time Time Water Drop
'PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inchl
FT
72-008 (6/79)
· '& ENGINEERS, INC.
4'"""'TI25 OLD SEWARD H'WY.
ANCHORAGE, ALASKA 99503
549 -6561
SOILS LO(.; PEI1COLATION 1'ES I
11
1S-
f6-
20-
...ou.,o.
TEST RUN OETWEEN . FT
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM ~
APPROVAL TO CONSTRUCT
Ptans for the construction of T~ ~- ~. ~
public water system located
, Alaska, submitted in accordance with 18 AAC 80.100
p ,, -'
,o -~ f~'~(-have been reviewed and are
approved.
conditionally approved~e/e attached conditions).
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no. Approved by Date
or clescrl~lve reference)
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public,
APPROVAL TO OPERATE
The construction of the b~',~- !t F~'¢~ ~ ! f'~ f, V.~-~ P ~1 ,m~"l public
water system was completed on .-~ O,.-.~ ~ i ri ,:'", ~ i (date). The system is hereby
granted interim approval to operate for 90 days following the completion date.
As-built plans submitted during the interim approval period, or an inspection by the Department has
conf. irmed the system was constructed according to the approved plans. The system is hereby granted
finbl approval to operate.
.,, _-- .,~-~.,f ~ t
~,,~..).,. , £ /., . .-~__ (" ;,' it)
BY TITLE " (~ATE
Municipality of Anchorage
Development Servtces Del:}artment
Building Safety Division
On-Site Water and Wastewaler Program
4?00 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.tJ s
(907) 34:~-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O~
1. GENERAL' INFOiS, I[,/IATION
Complelelegald. escripti~n L5; B2; Deer l-Iorn Subdivision
Localiot~ (site add~es~ or directions) 22050 Deer Horn Circle, Chugiak,
HAA# P Zq ' 03_o '57,
Expiration Date: ~-'-- ~ - O ~
AK 99567
Current Property owner(s)C h a r 1 e s B e 11 Day phone 688- 3146
'Maili..gaddress 22050 Deer Horn Circle, Chugiak, AK 99567
Lending ~gency Day phone
(Hm)
Mailing address
Real Estnte Agent
Dick Brown
Dayphone 694-2388
Mailing Address
Unless elherwise requested, HAA will be held by DSO f. or pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Indivichml Water Storage
Conm.~nity Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding lank []
Community On-site
Public Sewer []
The Municipality o[ Anchorage Developmenl Services Department (DSD) Issues Cerlificates of Health Authority
,approval (H,~A~,) based only upon the representallons given In paragraph 5 by an Independent professional civil
engineer regiotered in the Stale of Alaska. Cedificates of Health Authority Approval are required for the transfer of
lille (except belween spouses) for propedies served by a singte family on-site wastewater disposal and/or water
s.pply syslem. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for propedies served by a privale or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificales may be reissued for a period gl up to one year with
valid water samples.) Certific~les are valid [or one year for propedies served by Class A or B wells or a public
water syslem. The Municipalily of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As cerlified by my seal al'fixed hereto and as oJ' the valldatlon dale shown below. I veri~y lhal my Investigalton,
based on procedures outlined in Ihe Health Authorily Approval Guidelines for this application, shows Ihal lhe
on-site water supply and/or waslewater disposal system Is(are) sale, funclional and adequate for the number of
bedrooms and typo of structure Indicaled herein. I furlher [,erify Iha{ based on lhe Informalton oblained from the
Municipality of Anchorage files and from my Invesltgatlon and inspection, the on-site water supply and/or
wastewaler disposal system is(are) In compliance With all applicabl~ Municipal and Slate codes, ordinances,
and regulations in effect at the time o1' inslallafion.
NameofFirm S&S EngineerinR
Address 17034 North Eagle
Phone 694-2979
River Loop, Ste. 204, E.agle River, AK
Date ~-~'--2002
. ..'&.??
bedrooms, wilh lhe following slipul~lions:
Engineer's Pdnted Name Robert C. Cowan, P.E.
5. DSD SIGNATURE
L./ Approved for '~ bedrooms.
Disapproved.
Conditional approval for
Addilional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Cedificale Date:
Mnnlcipality of Anchorage
Development Services Department
Building Safety Division
On-SIta Water & Wastawater Program
4700 South Bregaw St.
P.O. Box 196650 Anchemga, AK 99519-6650
vnvw.ci.anchorage.ak.~s
(S07) ~3-7~04
Legal Description:
A. WELL DATA
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel ID:
Well type ~ ~ If A, B, or C p~/Jv~=WSID #
Data completed S~,,~eal (Y/N)
Total depth ft.~,~,ased lo __ft.
· ~ WELL LO0
Data of test
Static water ~ ~ ~' fl.
Well prod~on ~ .~ g,p.m.
Well Log (Y/N)
W'~es property pmtacted (Y/N)
Casing height (above ground)
AT INSPECTION
Other bacteria
g.p.m.
colonies/100 mi.
Date of sample:
B. SEPTI~G TANK DATA
Tank Type/Matadal,. ~
Tank siz® ~ gal." Number of Comparth~ents ~ Cleanouts (Y/N) ~
(Y/N)'.. ,_~ Depression over tank (Y/N) /'~ High water alarm (Y/N)
Foundation
ctaanout
Data installed ~
C. ABSORPTION ~LD DATA
Length 4 t ' ft. Width I ~-/ ft. Grave, below pipe D, (~'"""' ff.
Total depth ~ ft. Eft. ebs.orption area ~__.~ Monitoring tube y
Fluid depth in absorption field before test ~ In. Watar edded ~'~'~al.
Elapsed Time: J ~'~min. Final fluid depth C) in.
Any rejuvenation treatment (past 12 mo.) (Y/N &
Depression over field./~t
For ~ bedrooms
New depth ~_- in.
AbsorpUon rata >= ~ g.p.d.
tyPe)~l~c' ~.__~.~%~_ Ifyes, givedata '"---'
D. LIFT STATION ~
Date installed ,, e 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 tanld~Jf~.statien on lot ~//.~r
Absorption field on lot /~/ /'~'
Public sewer main //~/ ~//l'
/,,~m~T/septic sewlce line
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?,
Public sewer manhole/cteanout ' ..
Holding tank
Absorption field ~ ~' /'/"'
I t
: / 0 ~ Smface water / 0 ~ ~'-
SEPARATION DISTANCES FROM SEPTI~G TANK ON LOT TO:
Building foundation ~ ~'~ . Propelly line. ~' ~L.
Water main '.--/- '-~) ~1/'- Water service line
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line [ O I.+. ~- Water main ~'-
Building foundation i .~ I , ~ ~"-O~ !
I O O % Driveway, parking/vehicle storage. ~ ! ~
I
Water Service line ~'~) .4-- Surface water
Curtain drain ~t/~WeIls on adjacent lots t..~/-'-
F. COMMENTS
ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal rec4:~/s that the above systems are in
conformance with MOA I-IAA guidelines in effect on this date.
Engineer's Printed Name
Date
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
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. # 0~-f -oq~. -~'y~/ ,'. HAA#
: ,_ '... ~ .' :;
1. , GENERAL INFORMATION ... *.: ...._
Complete legal description Lot 5: Blo"-k 2: Deer Horn Subdivision
Location (site address or directions)
22050 Deer'Horn Circle
Chuoiak, AK
.l~r~tyowner ' ,~-~6ara t~urkha~c
· .Mailing address- :~2050 Deer Horn Circ].e
ng age6cy
Mailing address ' '
Day phone 688-O195
Chuqtak, AK 99567
Day phone
Agent:- Liz Kerbo~/ Tarqet Realty
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 '~
TYPE OF WATER SUPPLY:
Individual well
Community well xxx
Public water
NOTE:
Day phone 694-2388
If community well system, provide written confirmation from State ADEC attest-'
lng to the legality and status of system.
TYPE ~F WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
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 S & $ ENGINEERING
I/U,~ ~.agie ~;wr i.~p
"Address Eagle River, Al~aska.
Engineer's signature
Phone
Date
Se
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.
Legal Description:
Municipality o nchorage .~va~O~U~A~Sav~ff'~
DEPARTMENT OF HEALTH & HUMAN SERVICES" I~
Environmental Services Division I{0V 0 6 ~1
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
RECEIVED
Health Authority Approval Checklist
A. IATA
Well
B, or C, attach ADEC letter. ADEC water system number
Log present
Date completed
Total depth Cased to
Casing height (above ground)
Saniten/seal (Y/N)
Wires properly protected (Y/N)
FROM AT INSPECTION
Date of test
Static water level
Well production g.p.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Dateinatalled ~)~C{~,~' Tank$ize_.~l[2~,~!__NumberofCompaxthlents ~'~ Cleanouts~)/N)~
Foundation cleanout (~N) b~_5 Depressto. (Y~) J~O High water elam1 (Y~
Date of Pumping. ' &, [ 5, ["~ pumper
c. ABSORPTION FIELD DATA ·
Date .. lad Syatemtype
Length ~ / Width ~ ~. I Gravel thickness below pipe · ~ / Total depth {" /
Effective absorption area ~'~[ ~ Monitoring Tube present,N) I~ Depression over field
Date of adaquacy teat Fo. bed=..
(,n.): ~.~1
Fluid depth in ~. orl~.on field before test (in.): ~ Immediately after?/// gal. water added ' "
Fluid depth ~ (ins) Minutes later:. (~) Absorption rate = '~.~d') ~ g.p.d.
Peroxide treatmem (past 12 months) (Y/N) ~ If yes, give date
72-026 (Rev.,3/96)*
D. UFT STATION
Date installed ~.~ Size in
gallons
Manhole/Acce~ (Y/N) __ ~.~on" level at* _ __ "Pump off" level at*
High water alarm level at*._ __ ~__
SEPARATION DISTANCES FROM W-'-LL C:~ ,.OT TO:
Septic/holding tank on lot
Absorption field on lot
On adjacent lots
On adjacem lots
~eanout
Public sewer main
Sewer IsepflC ~;~"/ Uft station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~ /
t
Property line
Absorption field
Water main/service line ~ ~ ~ Surface'water/dralnage
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
Building foundation ( ~ '4 Water main/service line ~ D ' '~'
Driveway, parking/vehicle storage ama ~ /
Wells on adjacent lots ..... ,,'
F. ENGINEER'S CERTIFICATION
I certify Ihat I have determined thru field inspecgons and review of Muni~pal ~6~te~ are
in confo~ wf~ IVJOA HA, A guidelines in effect on this date.
Date 7
HAAFee $ ~OO,OO
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)'
Parcel I.D. # I~'J O~4Z- ~
1. GENERAL INFORMATION
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES.
Division of Environmental Sen~tces
on-site Services Section ,,
P,O, Box 196650 Anchorage,'Alaska 99519-6650
. 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Complete legal description
Location (site address or directions) Z. 7-O~'O
e
e
Property owner ~o~.,,.I 4- b~8.1~l-~ ~Z..H~L.crr'H
Mailing address
Day phone
Lending agency.
Mailing address
Agent
Day phone
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: '"-J--~'~_ r&-
TYPE OF WATER SUPPLY:
NOTE:
Individual well
Community well y,, )t,. y~.
Public water .... . .- .
If community well system, provide written confirmation from State.A_DEC attest-. '. r~
lng to the legality and status of system. '-: .-'~ -"-. :.~"
· ...-. ;...... ~.:'
TYPE OF WASTEWATER DISPOSAL: -:"
~ X."X ' '.
Individual on-site ".::
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed he~'eto 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.
.ameofFirm 4/'~h~--~O~'1 ~L-'~JCI~J&'"G"J~/,~& Phone
Address PO. goy. zWO'/'/$ AIZ..
Engineer's signature ' ~ ~ Date
Se
DHHS SIGNATURE
/ -
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
'rhe Municipality of Anchorage Department of Health and Human Servic, es (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
end 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 omlsslons In the professional engineer's work.
Municipality of Anchorage ---' ,~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /--or'~'~ /~'co~ 7-I be't-~Z./-J~n.~ Parcel I.D.
o 5'1 o
A, Well Data
Well type ~ A
Leg present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
.Cased to Casing height
Wires properly protected (Y/N)
ZI~OD I
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewe~ main
Sewer servic~ line
WATER SAMPLE RESULTS:
~ ~O0~
g.p.m.
Coliform,
Date of sample:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Nitrate Other bacteda
Collected by:
AT INSPECTION l
' g.p.m. ~ ~ c~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed c~/~,/~ Tank size /j D~)0 ~--.~/-.5. Compartments --'"~'"~ 0
.¥
Cleanouts (Y/N) Foundation cleanout (Y/N) ,~r Depression (Y/N)
High water alarm (Y/N) A//t~ Alarm tested (y/N)
Date 0f PUmping I/L~-/~ ~' Pumpe,r ~'P. ~J 1 I"A I~.)/ ,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surtace water/drainage
On adjacent lots
Absorption field
>1oo~
Foundation
Water main/service line
CONTINUED ON BACK PAGE
" ' Manufacture;
Manhole/Access (Y/N) "'
Vem(Y/N~" '" ~' "' 'l~nl~~------~:"~ ' ' 'H~arm level ~'"---~'"---~ _Cycles leste~Ump °fr Level a~t
M;ets MOA elect' ricat ccdes (Y/N) ~"
~ANCE FROM LIFT STATION TO: _
Well on lot On adjacent lots Surface water
D. ABSORPTION fiELD DATA
Date Imtalled ~/~/'~ q'
Length..~ 1 m W'~h
Total abso~ti0n area ~, q'7 5 F
Date of adecluacy test' ///Z.7/C)~"
'. Water lev~ l.n'at~o~ion field ~lom test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) I~.~"
I'71 .Gravel thick, ness
.Clear, om present (Y/N)
Results (pass/fa~)
· , ~' ~_~Total depth "~- ~ ~
Depression over lieid (Y/N) J'~
' for
Ntertest
*If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot
To building foundation Z.~)
On adjacent lots '~ SO '~ Cutbank (. /'1~~7 ~ Water main/service line '7 ..~Dm
' ' · '- - · '" ~ ' ~ ,"'~:'-' ~_..I
~/00 ~ ' Driveway parking/vehicle storage area
Sudace water
Curtain drain
Bedrooms
E. ENGINEER'S CERTIFICATION
I cer~fy that I have checked, verified, or conformed to a~l MOA and HAA guidelines in effectp~d..~te of ~is inspec~on.
· ' , ! ' ~'<,'~.*' ~,~. '..~,r'~ ,
., , ..'T.7
Date ~ e~ y'<: ... ,.... ,~,,~,
HAAFee$' :'~D~-~
Date of.ayment - 7- ?5--
- Waiver Fee $ "'
Date of Payment
Receipt Number.
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Sen~lces
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 5: Block 2: Deer Horn subdivision
tocation(addressordirections)
Deer Ro~n Ciccle (RRN)
(b) Property owner AHFC ~75296
Telephone: (home)
Business
Mailing Address
(c) Lending Institution National Bank of Anchorage Telephone
Mailing Address Attention.' Suzanne
(d) Real Estate Company and Agent Jack Wh~_te CO./L_vnda ~anner
Address 10928 Eagle R~ver Roan, Eagle River, Alumina 99577
Telephone 694-5500
·
(e) Mail the HAA to the following address: (or check here if hold for pick up.)
List contact person and day phone number below:
$.-&-~-ENGENEERING
17034 Eagle River Loop Road No. 204
E a_q~.e r~Jtla ska~ 9577
2. TYPE OF RESIDENCE
Single-Family JD Number of bedrooms
3. WATER SUPPLY
Individual Well CI
Community~ Publicn P.W.S. 'rD. ~ 213001
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 []( Public r-I Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
Page I of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe.
functional end adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the inlormation 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 $ & $ ENGINEERING Telephone d'~ ~;~'~"~'- Z4.:~,,~ ~
17034 Eagle River Loop Road No. 204
Address Eagle River, Alaska 99577
Date
6. DHHS APPROVAL
Approved for -~
Approved ' ~
bedroomsby ,4~-~~. ~
Disapproved
Conditional
Date
Terms of Conditional Approval
The Municipality ol 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. Em ployees of DH HS do not conduct inspections
or analyze data before a certificate is issued. The M u nicipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72~25 (flay. 7/88) Beck
Page 2 of 2
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth~ Cased to
Static Water Level
Casing Height Above GrouNd
Electrical Wiring in Conduit (Y/N)
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
,' 343-4744 ~ '. ' ..
Legal Description~: ' ~ ~
,MUNtCtPALII'Y OF ANCHO~AGL
[,,,IVl~.O N FAENT AL
OCT 2 4 1988
C_ VED
Date Completed
Depth Of Grouting
IfA, B, C, D.E.C. Approved~)~
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot '~..~,.c::,
To Nearest Edge of Abs..orPtion Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ?. [-~,~, t'[~, JI~ "~.--~,"~e:~::>
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed '~'-' ~" ~/' Size
Standpipes ~TN)
Depression over Tank (Y/~
[ ~ No. of Compartments
Air-tight Caps,/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
Foundation Cleanout (5~'N)'-/
_Date Last Pumped ' lC> -2/
Temporary Holding Tank Permit (Y/N)
To Water-'Supply Well ~/.4-
TO ProPer~y LiNe '. / ~ /~"
TO Water Main/Service Line /C:) I~
TO Stream, Po'n~l, Lake or Major Drainage Course
Comments
· · .· . . ~ .... ;l;a;;
To Building Foundation' ' ' ..~T'j . ..
To Disposal Field ~ I
Page I of 2
C. ABSORPTION FIELD DATA * '
Soils Rating in Absorption Strata
Date Installed ~c:~.. ~, _.
Width of Field I '7
Square Feet of Absortion Area
De, pression,over Field (Y/~
Results of Lest Adequacy .Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation.]/.
Lot
To Water Main/Service Line ~' c, If_.
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Date of Last.~,,dequacy Test
TyPe of System Design
Length of Field ,::~./
Depth of Field "~ '/2.,
' Gravel Bed Thickness O ,~"'
· ~ '~ "~ Statndpipes Presentd~N) y
To Property Line /{~ I~,...
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if~resent) '
Date Installed
Dimensions
High W ta er Alarm Level et ~
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
"Pump Off" Le~,el at. ' ' ' '
Vent (Y/N)
~ ~ycles during Adequacy Test.
,
'*Check Permitted Bedroom Rating Against HA~, Request'* ~
I certify that l have checked, verified, or conformed to all MOA and HAA guidelines In effec.~
Date of Payment ,'~;:z~/O'--x~/ ~ Waiver Fee: $
Amount: $ ,'/,~' ~ Date of Payment
7~-o~ (R.,. 7~),.c~ ~age 2 of 2
DEPT. OF EN%'~RONMENTAL CONSERVATION/
STEVE COWPER, GOVERNOR
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
563-6775
DATE: 10-21-88
PWSID: 215001
To Whom It May Concern:
According to the records on file in this office, the CI~GIAK UTI-
LITIES/NORTHW00DS Water System is in compliance with the ,
State of Alaska. Drinking Water Regulations.
MPL:pkk
Sincerely,
Michael P. Lewis, PE
Environmental Engineer
, HUNICIPALITY OF ANCHORAGE
'~ DIVISION OF ENVIRONHENTAL HEALTH
DEPARTMENT OF HEALTH AND ERVIRONH~NTAL PROTECTION
APPLICATION FOR ~ZALTH AUTHORITY APPROVAL CERTIFICATE
..General Information Application Date
1.
. I /
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
NameZ// 'FS /L C- Telephone - Home Business
(b)
Applicants
Applicants Address
(c)
(d)
Applicant is (check one) Lending Institution
Buyer ~ ; Other ~ (explain);
Lending Institution
Address
0~mer/builder._~.;
Telephone
(e) Real Estate Co. & A~ent
Address
Telephone
(f) Hail the IlAA to the following address:
2. Type of Residence
Single-Family~
Number of Bedrooms
3. ~ater Supply
Individual ~ell~
Hulti-Famlly ~--~
Community F--~
Other ~describe)
Public?
Note: If community vel1 system, must have ~ritten confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
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 I of 2]
5. ~n~ineerin~ Firm Frovidin~ Inspectionst Tests~ File Search~ Data and Infor~ation
As certified by my seal affixed hereto and as of the validation date sho~n below, I
verify that my investigation of this Health Authority Approval aho~s that the on-site
water supply and/or ~astewater 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 Hunictpality of Anchorage files and from my
investigation and inspection, the on-site uater supply and/or uastewater disposal
system is in compliance with all Hunicipal and State codes, ordinances, and re§ula-
tions in effect on the date of this inspection.
Name of Firm
Address
Date
DHEP Approval
Approved for ,,___~
Approved
Terms of Conditional Approval
CABYION
Tlfl~ ltI~ICIPALITY OF ~CHORAGE DEPARTEENT OF HEALTE ~ND E~IRO~
(DHEP) lSS~S ~LTH ~HORI~ ~PROV~ ~RTIFICATES BAS~ SO~LY U~N T~ ~PRESE~-
ATIONS GIVEN IN PA~ ~ ABOVE BY ~ I~PE~E~ PROFES~IO~L ENGI~ER ~GISTE~
,IN ~ S~ OF ~S~. ~ ~EP ~ES ~IS ~ A ~TESY TO P~C~SERS ~ HOaES ~ND
T~IR ~lgC INSII~IO~ IN ORDER TO SATISFY CER~IN ~DE~ ~D STATE
~S. ~PLOYEES OF ~IEP ~ NOT COh~UCT INSPECTIONS OR ~ALYZE ~TA BEFORE A
CERTIFICA~ ~ ISS~D. ~ H~ICIPALI~ OF &~CHO~ IS NOT ~SPONSIB~ FOR ~ORS
0R O~Ii~IO~ I~ ~ ~0FESSIO~L ENGI~ER~S ~0RK.
· ;-' (DHEP SEAL)
[Page 2 o~'21
7-19-84
Well Classification
MUNICIPALITY O~ ~NCHORAGE (FDA)
HEALTH AU/I~RITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description: _~.~"~'Z P~-~/'/(96~'~
If A, B, (x C, D.E.C. Approved(Y/N)
Yield
Depth of Grouting
Date Completed
Well LoG Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiri~z~ in Conduit (Y/N)
Separation Distances f~cm Wall:
To Septic/HoldinG Tank on Lot Z~[~)
Pump Set At
Sanitary Seal on Casing (Y/N)
Dapression Around Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot~)O ~ ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on LOt
; Date
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected By
Water Sample Test Bssults
SEPTIC/HOLDING TA~( I~TA
Date M si. No. , ar.nts
Sta~i~s~' ' ~ Ai~ti~t ~) F~t ~ Clea~t~Y~
~essi~ TaD~ (~ ~te ~st ~d ~ ~ ~ V
Holdi~ Ta~ Hig~te~ Mare (Y.) ~/~ ~ra~ ~ldi~ Tank
Separation Distances f~cm Septic/If'-l~-Tank:
To Water-Supply Wall
To Property Line
To Water Main/Service Line
co =se
!
To B~ilding Foundation ~
To Disposal Field F
To Stream, Pond, Lake, c~ Major Drainage
[Page 1 of 2]
Receipt # ~
Date Paid: -_~_~
Amount: ~ ~/-_-~. O~
2-15-84
C. ABSORPTION FIELD ~ATA
Soils Ratirg in Absorption. Stzata
Date Installed W
Width of Field / ~ ~
Square Feet of Absc~ptio~_Area
Deunession over Field ~Y~
Results of East Adequacy Test
Type of System Design
Length of Field ~/'
Depm of Field '
Dete of East Adsquacy Test
Separation Distance frcm Absorption Field:
To Water-SuPPly W~'li ~) 7L To P~oparty Line
To ~ildi~ F~n~ti~ ' ~/ f To Existi~ ~ ~nd~d
~t'~ ~/~ ' ; ~ ~joini~ ~ /~
To ~r ~i~vi~ Lir~ ~O To ~t~(if ~e~nt)
To ~i~y, Pgrki~ ~, ~ Vehicle St~a~ ~ea ~o
D. LIFT STATION
Date Ir~talled
Size in Gallons
"Pu~p On" ~vel at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimsnsions
/gP~Off" Level at
Vent (Y/N)
Pumpi~.g Cycles during Adequacy Test.
** Check Bsrmitted Bedroom Rating AGainst HAA Bequest
I ~ertify that~'~ve checked, verified, c~ confo~,,~d to all MOA HAA Guidelines in effect
on the date ;~ ,~/~;s~. _-~-"''~ - ~,~
[Pa~ 2 of 21 : '
2-15-84