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HomeMy WebLinkAboutDEER HORN BLK 2 LT 6Deer Horn Block 2 Lot 6 #051-042-85 r I MUNICIPALITY OF ANCHORAGE 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 PHO�N/E L FE S' tJ—Zg% ❑UPGRADE MAILING ADDEOr � SftS LEGAL DESCRIPTION Lc�T L� G./G 7_� LOCATION Ste• ri1' S� 2/w NO. OF BEDROOMS DISTANCE TO: WA�6L Absorption eea s Dwelling I PERMIT N§ OS� Manufacturer Material No. of eompartmentsLiq F�0� =on gallons IF HOMEMADE: Inside leoptlt__ Width Liquid depth DISTAANCEETO: Well ! Dwelling PERMIT NO. Manufacturer Material Liquid capacity qin gallons DISTANCE TO: Foundat76 I Nearest lo)�yn�a PERMIT Nq(/ � s� = Z No. of lines/ Length of a r Total leng of ryes Trench wid)p Distance between lines A. %L W D inches H Top of tile to finish grade Material beneath lila �f 3160 Total alfeyiyq qb rnuan area �%�' inches >% Length Width PERMIT NO. W rpepth (Ii- Type of crib Crib diameter Crib depth Total effective absorption area W L DISTANCE TO: Well Building foundation Nearest lot line JClass Depth Driller Distance to lot line PERMIT NO. J W 3 DISTANCE TO: $wilding foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER r 1, REMARKS \ F Ls :x ` tis' er J 9 r ••0 r R1 • i r"51•`bort A. JAe1.r • No. 1437-E ti Z � �VP�OFE! StOt`P�"N� APPHOVED v R E ERIN U DATE c-. �...r �7 72-0131Rev. 3/781 MU" I C I PAL I TV OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 O N— S I T E S E W E R F"E R M I T PERMIT NO: 840581 DATE ISSUED: 07/16/84 APPLICANT: C/O S & S ENG'G. LIFESTYLE IND. ADDRESS: SRH 196X EAGLE RIVER,AY. 99577 CONTACT PHONE: 694-2979 LEGAL DESCRIP: SUBDIVISION: DEERHORN - LOT: 6. SECTION: 4 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 28500 (SQ.FT. OR ACRES) MAX BEDROOMS: 4 BLOCK: 2 Listed below are the options available to you in designing your septic system. Choose the option that best fits your site. ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certify that: 1. I am familiar with the rQquirements 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 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS TRENCH SED W . I7RA I N DEPTH TO PIPE BOTTOM (FT.) 4.0 5.5 4.0 , GRAVEL DEPTH (FT.1 3.0 0.5 3.0 TOTAL DEPTH (FT.) 7.0 6.0 7.0 GRAVEL WIDTH (FT.) 2.5 19.0 5.0 GRAVEL LENGTH (FT.) 74.0 .0 35.0 52.0 GRAVEL VOLUME (CU.YDS.) 23.9 24.6 33.7 TANK SIZE (GALS) 1,250.0 ** 1,250.0 * 1,250.0 ** SOIL RATING (SQ.FT./BR) 110 . 110 110 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certify that: 1. I am familiar with the rQquirements 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 4 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 ELECTRMPERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APP ITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WO_ MUF.7DONE BY A LICENSED ELECTRICIAN. SIGNED APPLICANT: ISSUED BY DATE: S & S ENG'G. LIFESTYLE IND. vDATE: ------------------------------------ PERFORMED FOR:_ LEGAL 1 - 2- 3- 4- 5, -3•4•5, 6 7 8 9 10 it 12 13 14 15 16 17 18 19 20 COMMENTS (� MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST / C iS �`'/ e e� ( DATE PERFORMED: S/L7y- / Ov y 4<1jcJ �CoLgete /�/B 2. S A. anlc..~ r .moire V i•w r ; �� S r. PERFORMED BY: fi 1^ Y;4LE 1 72-006 (6/79) SLOPE WAS GROUND WATER /)� ENCOUNTERED? /s• IF YES, AT WHAT DEPTH? « SOILS LOG 8g0.5�'I ❑ PERCOLATION TEST SITE PLAN Reading Date Gross Time Net Time Depth to Water Net Drop AA E DEPT. OF F 1'%CNORAGE 'EA ru PROrECTION ICA,? PERCOLATION RATE V[�lminutes/inch) TEST RUN BETWEEN FT AND -1 FT CERTIFIED taw �1"I e CONSTRUCTION AND OPERATION CERTIFICATE JjJ--' ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT Plans for the construction of n E=E L^ -H 0 P'— IJ ,s / 0 tTN dF--oz— 12— , ..I . . 2—,../_.. 1 . r. r vs.411111 public water system located in �f"t P.+rS `r P `r' 1` , Alaska, submitted in accordance with 18 AAC 80.100 by %�1 e i c i% Ola ( e Pw 'AI e til 1 d, , S 4 114 t, Ir _-M-have been reviewed and are K approved. ❑ conditionally approved (see attached conditions). V - r Ly'g3 J-481ITLE DATE 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. or oeteripliw reference) Approved by Date The "APPROVAL TO OPERATE" section must be completed before any water is made available to the public. APPROVAL TO OPERATE I The construction of the P.t^ 1f ov yl .'C� / n re )r,Tt= 71n public water system was completed on S_�) y s�j (date). The system is hereby granted interim approval to operate for 90 days following the completion date. TITLE DATE As -built plans submitted during the interim approval period, or an inspection by the Department has con armed the system was constructed according to the approved plans. The system is hereby granted finM approval to operate. 41, �� TITLE • '� Municipality of Anchorage p On -Site Water and Wastewater Program �$ (907)343-7904 Certificate of On -Site Systems Approval Parcel I.D. 051-042-85 Expiration Date: 1. GENERAL INFORMATION Complete legal description Deer Horn Block 2 Lot 6 Location (site address) 22030 Deer Park Cir, Chugiak, Ak 99567 Current Property owner(s) Angela & Michael P Graham Day phone Mailing address 22030 Deer Park Cir. Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU)T ❑ Duplex ®1►F i, ❑ Multiple Dwellings (Single Family and/or Duplex) MAR i 1 2014 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual F1 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System El Public Sewer ❑ WaiverNariance request Received by: '' 1--777, ' COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 11A(0• 1. / Date of Payment jai / IL Receipt Number 615a15(i COSA# 4&4.1(j<Ug3 Date Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services LLC Phone (907)272-8218 Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven R Pannone Date 4� 6. DSD SIGNATURE _JL� System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved R: 4V to W x • : �leveri it, •�aririorie : •' CE -8149 1 Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: 3--27—/4 The M ni, aliq of,� chorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f c If more than 1 septic system is on the lot: COSA Checklist # -L_of + Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Deer Horn Block 2 Lot 6 A. WELL DATA Well type A Date completed Total depth ft. Date of test Static water level Well production If A, B, or C provide PWSID # 213001 Sanitary seal (YIN) _ Cased to ft. FROM WELL LOG WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate Arsenic ug/L Date of sample: B. SEPTIC/HOLDING TANK DATA Parcel to: 051-042-85 Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) in. AT INSPECTION Collected by: ft. Tank Type/Material Septic/Steel Date installed 7/31/1984 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 8/23/2013 Pumper JRs Pumping C. ABSORPTION FIELD DATA Date installed 7/31/1984 Soil rating (g.p.d./ftz or ft2/bdrm) 110 sf/br System type Deep Trench Length 74 ft. Width 2.5 ft. Gravel below pipe 3 ft. Total depth 7 ft. Eff. absorption area 444 ft, Monitoring tube Y Depression over field N Date of adequacy test 3/11/2014 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 26 in. Water added 627 gal. New depth 30 in. Elapsed Time: 220 min. Final fluid depth 26 in. Absorption rate , 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed — "Pump on" level at Datum Size in gallons — in. "Pump off' level at Cycles tested - E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot — Public sewer main in. Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer /septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots>D6 2n0 4 ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ � Curtain drain 50+ Wells on adjacent lots Ig �T F. COMMENTS * AS BUILT ON FILE G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven R. Pannone Date CLOS 2C) COSA brown sheet 10-10-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage 110+ Municipality of Anchorage • 'tel Development Services Department Building Safety Division On -Site Water 8 Wastewater Program 4700 Bragaw Street / P.O. Box 196650 Anchorage, AK 99519.6650 U �' www.muni.org/onsite (907)343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-0y2-4;5 COSA# ()—a 607 2- 1. GENERAL INFORMATION Expiration Date: 3 -.2-5-JO Complete legal description DEER HORNS D• BLOCK 2 LOT 6 ark Location (site address) 22030 DEER IRCLE * CHUGIAK, AK * 99567 Current Property owner(s) LOUISE SANTANGELO Day phone 688-2314 pG, k Mailing address 22030 DEER HQRH:jlRCLE • CHUGIAK. AK • 99567 Lending agency Mailing address Real Estate Agent Mailing address Day phone GREG MOORE W/ PRUDENTIAL VISTA Day phone 16635 CENTERFIELD DR • EAGLE RIVER, AK * 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ❑. Individual Water Storage ❑ Community Class A Well 0 Public Water System ❑ 689-6464 TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 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 samples. (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 Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage riles 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 GARNESS ENGINEERING GROUP, Ltd. I Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date b Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readilyldentifiablo features. The operational life ofall wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. S. DSD SIGNATURE (/ Approved for _4 bedrooms. Disapproved. Conditional approval for bedrooms, with the Illowing Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory ,' / Other By: G&/ (Rev 11105) ,0 llUuu,1,,, �N�0 P �,�AY OF • ON-SITE WATER AND • rn WASTEWATER �• • PROGRAM Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program " 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.munl.org/onsite (907)343-7904 CERTIFICATE OF ON—SITE SYSTEMS APPROVAL CHECKLIST Legal Description: DEER HORN S/D: BLOCK 2, LOT 6 Parcel ID:0,5�1— 011.2'165_ A. WELL DATA Well type A Date completed Total depth ft. Date of test Static water level Well production WATER SAMPLE RE! COMMUNITY WELL If A, B, or C provide PWSID# 213001 Well Log (Y/N) _ Sanitary seal (Y/N)_ Wires properly protect�ro(u Y/N Cased to ft. Casing height (ab nd) in. FROM WELL LOG Coliform _� colonies/100 ml. ug./L. B. SEPTIC/HOLDING TANK DATA ATI ft. g.p.m. Nitrate —mg./L. Other bacteria colonies/100 ml. Date of sample: Collected by: Tank Type/Material SEPTIC/STEEL Date installed 7/31/1984 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 3/10/2009 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA tBELOW EXISTING GRnDE Date installed 7/31/1984 Soil rating (g.p.d./ft'o t/bd 110 System type TRENCH Length 74 ft. Width 2.5 ft. Gravel below pipe 3 ft. Total depth *_ft. Eft. absorption area 444 ft' Monitoring tube YES Depression over field NO Date of adequacy test 3/16/209 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test25 in. Water added 1030 gal. New depth 30 in. Elapsed Time: 10 min. Final fluid depth35 in. Absorption rate >= 600+ g,p,d, Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date D. LIFT STATION Date installed Size In gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service On adjacent On adjacent lots Holding tank COMMUNITY WELL manhole/cleanout areas Manure/animal excrete storage areas 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'+ Surface water 100'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 200'+ 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 COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. CARNESS Date .7/Igb C9 COSA Fee S L1 efo Waiver Fee $ Date of Payment! e q Date of Payment Receipt Number y� 0 Receipt Number (Rev. pros) tl i 0r•-�� W 0 Lo zu w� d p E LO r CL :.�a��8aalx's2�aa6.SMI. 0 -- .................................. ..... .:...k/._.__......._..,. — — BeHGI 0 9• ............. o ..... - �... w vb o 0 .8r .... ........................... .....^ ll� 3.as e \ is � P P 1 p OEM o N r� LLI i �. td z ®®0®P]©@3©0 CL 9<��3 5 fart Wi A coVJ t t ^ ' P � 1 N ,,A 1 0 . u l�Cr M1 G cn O L f V/ co i i 23125 23224 ptiAr1� m � g „ Xo i 1 roti � g 1 1 pyo 4 Yo 6/ n rr 11.ee Ill �? . :............__..____..__.... _.... _...__-__..___ ._ .__..�r'pol B8 R1 t 1 i 1 t • �. r I, e i�•I 1 t2r I d �y L Z o i. yt 1' • j AS -BUILT I hereby certify13I have surveyed the following desc ribed pery: g, r- c -;-- r— 4,F n Sbnd AJ Anchorage Recording Precinct, Alaska• and that the imp e- inents situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indkated hereon. Dated at Eagle River, Alaska this ILM day of AJ2 h- to i ROBERT C. JOHNSON SCALE: Registered Land Surveyor No. N&LS r 3 01 Box 77-0456, Eagle River, Alaska 99577 Phone (907) 694-2543 7" 'a % w. r A AS -BUILT I hereby certify13I have surveyed the following desc ribed pery: g, r- c -;-- r— 4,F n Sbnd AJ Anchorage Recording Precinct, Alaska• and that the imp e- inents situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indkated hereon. Dated at Eagle River, Alaska this ILM day of AJ2 h- to i ROBERT C. JOHNSON SCALE: Registered Land Surveyor No. N&LS r 3 01 Box 77-0456, Eagle River, Alaska 99577 Phone (907) 694-2543 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. -General Information Application Date 13 R y (a) Legal Descrie;io�n, (include lot, block, subdivision, section, township, range) Location (address or directions) 5 Lr/S Aj (b) Applicants /v U Business Applicants Address (c) Applicant is (check one) Lending Institution ; Owner/builder ; Buyer [:::I ; Other E:] (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. S Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single—Family Multi—Family Other (describe) Number of Bedrooms 6 3. Water Supply �vb�TNw�nl c'c�ssl� Individual Well 1= CommunityPublic 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 Ez;l 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] 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 Addr G 6. DHEP Approval (v.,?= IIIVE�L ALAS:.1 t:417 (ENGINEER SEAL lY L LYl) it Approved for T"— bedrooms B�7+ Approved Disapproved Condit Terms Terms of Conditional Approval CAUTION Telephone of & t S ! e .. �? •• Q it 4i ...... r Z �.b•A A. yp•y.r 1 _ THE 14MICIPALITY 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 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 n %QINICIPALITy OF ANCHORGE A _ '•• DEPT' OF HEALTH g MUNICIPALITY OF ANCHORAGE ( MOA)1RO ENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) SEP 1 tiimi CHECKLIST - FEBRUARY 1984 F 1 A. WELL DATA Legal Description: f,ef�O�G/v Well Classification 14 If A, B, or Cr D.E.C. Approved(Y/N) Well Log Present (Y/N) Date CrnQleted Yield Total Depth Cased to 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 Well: To Septic/Holding Tank on Lot ZD On Adjoining Lots To Nearest Edge of Absorption Field on Lot 20 s'-/-, On Adjoining Lots To Nearest Public Sewer Lire To Nearest Public Sewer Cleahout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected By Date Water Sample Test Results Depth of Grouting B. SEPTIC/HOLDING TANK DATA Date Depression over Tank Size Z 0 No. of Ccnpartments 2 - tight Caps (Y Foundation Cleanout (Y Date Last Pumped /V e [.c/ Pumpirg/Maintenanee Contract on File Holding Tank High -Water Alarm (Y )A L; for N :Z TLemporary Holding Tank Permit (Y ) A% roo C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata _'//a -141>1 Type of System Design Date Installed Z 5/ Length of Field % Width of Field 30 �� Depth of Field Gravel Bed Thickness (� �• Square Feet of Absorption ea S% Standpipes Present (Y Depression over Field ( Date of Last Adequacy lest Ne &.) Results of Last Adequacy lest ICJ P C.L/ Separation Distance from Absorption Field: To Water -Supply Well 9,0 a f- To Property Line ltd To Building Foundation 2 A I To Existing or Abandoned System on Lot W I /A- On Adjoining Lots !Zr) vC To Water Main/Service Line 3 O f— To Cutbank(i�sent) A-- To Stream/Pond/Lake/or major Drainage Course /-L To Driveway, Parking Area, or Vehicle Storage Area Lo f Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (YM) "Pump On" Level at Off" Level at High Water Alarm Ievel at Tested for Electrical Codes(Y/N) Cements Vert (Y/N) Pumping Cycles during Adequacy lest. Mets MOA ** Check Permitted Bedroan Rating Against HAA Request ** I certify that decked, verified, or conformed to all MOA SHAA Guidelines in effect on the date th coon. --. Signed Date ►1C�..• ....A;'4 ti►) Conpany o. MOA N.dl. KB1/d5/s f»•aE [Page 2 of 21 7-A VISM 1 74 M6wl A. lIM1w W Na 14574. L, rWOFESS10 !+ 11-15-44