HomeMy WebLinkAboutBIRCH HILLS TERRACE #2 BLK 3 LT 6Bl"r c hl'o I I
Terrace #2
Block 3
_o- 6
#050-141-45
Legal DescriptionTeea � i Property Owner Name & Address:
1PG� 14 j. /4 1��l�Cc�Ge.. ✓'ifP7S Widp—S
oto
z 3 ci�ig(e Ave CZ
Pump Installation Date: & / 13-- 113
Pump Intake Depth Below Top of Well Casing: I C) feet
Pump Manufacturer's Name: K2'A JClCice -�"
Pump Model: Slow
Pump Size � 2- hp
Pitless Adapter Burial Depth: /O feet
Pitless Adapter Manufacturer's Name:
1 Pitless Adapter Installer:
Well Disinfected Upon Completion? [/Yes ❑ No
Method of Disinfection: Ghlcv-we IqE�/1e�5
Comments: e
Pump Installer Name:
;horag- Pump & Well Sen
330 best 76th a Avenue
Anchorage, Alaska 99598
Phone: 907-243-0740
Fax: 9`=7 -?4 -0742
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Development Services Department
Building Safety Division
On -Site Wa,�r ;& Was*,ewater Program
r,
4700 Gregaw Street
P.O. 20>: 196650 CDC
Mark Begrch
Andhornae, .Ad 99519-6650 s,
.:mayor:
.
19071343-7904
"Pump Installation Log
Well Drilling Permit Number:
SW Date of Issue:
Parcel Identification Number:
Legal DescriptionTeea � i Property Owner Name & Address:
1PG� 14 j. /4 1��l�Cc�Ge.. ✓'ifP7S Widp—S
oto
z 3 ci�ig(e Ave CZ
Pump Installation Date: & / 13-- 113
Pump Intake Depth Below Top of Well Casing: I C) feet
Pump Manufacturer's Name: K2'A JClCice -�"
Pump Model: Slow
Pump Size � 2- hp
Pitless Adapter Burial Depth: /O feet
Pitless Adapter Manufacturer's Name:
1 Pitless Adapter Installer:
Well Disinfected Upon Completion? [/Yes ❑ No
Method of Disinfection: Ghlcv-we IqE�/1e�5
Comments: e
Pump Installer Name:
;horag- Pump & Well Sen
330 best 76th a Avenue
Anchorage, Alaska 99598
Phone: 907-243-0740
Fax: 9`=7 -?4 -0742
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page 1 of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: S ti l "o 4f 8 7 PID Number: 05o - 14 t - Lf.5
Name
FlitL_ oJE2500 Wastewater System: ❑New )Upgrade
Address Cn3cj TCDRow DRILVI - EACCe R. ABSORPTION FIELD
Phone No of Bedrooms Deep Trench O Shallow Trench O Bed O Mound O Other
Me37AeaE"' 351-af551 �ovR � '�
LEGAL DESCRIPTION Soil Rating Total Depth fro lF}aie
Or16 GPDISQ Ft (�'- ' ��1U7``''/
Lot Block Subdivision. 4 Depth to pipe bottom from Original grade Gravel depth beneattypipe
3 diRcHFfru_ Ter?rt-aDD z- S14-8 Ft Ft
Townshio r Range Section: Fill added above original grade: Gravel length:
14 Ili 1 7-W 1 51":... 0 +O 3 Ft (0S� Ft
WELL: SY15T. ❑ New ❑ Upgrade Gravel width: Number OflinesOilunc^Der eHilines
FI 1 Ft
Classification (Private. A.B.C) Total Depth. Cased To Total absorption area: Pipe material.
Ft Ft to 4c) SO Ft 3o34
Driller. Date Drilled' Static Water Level Installer Date installed.
Ft ArOtOeRSot,) Sens r -29-30-3I, z°or
Yield.Pump Set at. Casing He.ght Above Ground
Ft Ft
TANK
GPM I I
SEPARATION DISTANCES %septic 0Holding 0S.T.E.P.
To Septic ADWIPhan UII Holding PubloUPrivale Manufacturer: ,,aa ,1NCapacity in gallons:
From Tana Field Station Tank Se.,Lmsts Apictfop-plefe IAK. 12.Sta
k • ' Material. Number of Compartments'
Well {100 *too' pO�+�O STeEL Z
SurfacWater e +roo' +100, _ - — \ LIFT STATION
Lot+ O O • - - h Size rn gallons' IM. rer:
Line � ! /30 /
• 1 "Pump On" level at. I "Pyw�bfi- leve wgn water alarm at:
Foundation 11 s + too
— —
Curtain +Too + I o c. Pump Mak M6tlel I Electrical Inspections performed by: \
Drain
Remarks: PJEw SYSTEM. ol-t) 5ySTe-0-N BENCH MARK
Location and Description:
TIZOeOR.L.y A6r PS;fc>uED. TOP SAfj. 3etAt, ^ WATER weLC.
EXI5r weLt_.
Assumed Elevation:
too o c.
°FA
a; C�
P
G .' a'�91`
Inspections performed by: ff H• wlc.SoN Dates:lst S -21-o1'
¢aw.awrrNwM• u.n wa.e•
2nd S-30-0( ' '�t WM17321 t/r%
3e,4 (a -4 -OI ��&tie Lrnal7,Mill i
Department of Health and Human Services approval d �•,e,,.ie..,.•'�,`':
Reviewed and approved by: � �W�-v /
Date: T/%-1' J �s�a.•.'+�.
72.013 (Rev 9191) MOA 25
Permit No. _� w 00 `i TI
Page Z- of `{
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 *Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: L (- 1�3 c(2r-E{ H (L -L PID No.: oro — (4 i- 45"
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Permit No. 5LO o00 L(77
Page 3 of L(
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Desc iption: L(- 133 I Rc N µ t c.t, PID No.: D S° — f q 1- 4S�
72-019 A (ICOM
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I hereby certifylbat a survey of Lot_A
Subdivision was made on /JQyt_�i,�0 and
that the Improvements 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 Indicated hereon. It Is the
responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision
plat. Under no circumstances should any data hereon be used for
construction or for establishing boundary or fence lines.
Dated at Anchorage, Alaska, this 7 day of
re�dD�
CONSTRUCTING ENGINEERS*MC�
9601 Buddy Warner Dr.
Anchorage, Alaska
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Permit Number: SW000487
5T'
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Nov 22, 2000
Expiration Date: Nov 22, 2001
Parcel ID: 050-141-45
Legal Description: BIRCH HILLS TERRACE #2 BLK 3 LT 6
Design Engineer: 0011 Constructing Engineers, Inc. Site Address: 017639 TEDROW DR
Owner Name: Phil Iverson Lot Size: 49174 SQ. FT.
Owner Address: 17639 Tedrow Dr. Total Bedrooms: 4 Permit Bedrooms: 4
Eagle River , AK 99577 -
This permit is for the construction of:
F Disposal Field [✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 (24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received BOX A�ff'�Gtfveys0
Issued By: 5act4y j 1 4 — I
Date: !%Z%7.e)a
Date: //-22-00
HANK WILSON
CIVIL ENGINEER
LAND SURVEYOR
CONSTRUCTING ENGINEERS
L (. B 3 B 12 c. 1.4 H I %-t, Ta f t lit. 64 c. E A 00 *1 2-
5crTsc. vPca¢.I!-pe'.
9601 BUDDY WERNER DRIVE
ANCHORAGE. ALASKA 99516
PHONE/FAX (907) 346-2000
11-11-00
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Im �'sa
L r e• apt ��
a v Municipality of Anchorage L
qj
DEPARTMENT OF HEALTH & HUMAN SERVICES / - aan
825 "L" Street, Anchorage, Alaska 99502-0650 �!>%><%e
SOILS LOG - PERCOLATION TEST
7f1 ��'t
PERFORMED FOR: ?141G MVG R:,o►J DATE PERFORMED: "OV 1I ?"o I ) 00
LEGAL DESCRIPTION: Lt. 133 TP IRC.4t41LL- Township, Range, Section: T 1 y nJ Rtw 512,
DEPTH TE(L(LtIrGC 149D dZ SLOPE SITE PLAN
(FEET) 0-1 0I:tgRWIC.5
1- ,tom
I -Z. SILT A 50 N
2-
3- -
3- PIT
4- 2- Zo Lj'P- di VA N lo'1t� _ So. _—
5 -
Pt r ALFA PIA S11
6-
7-
EtCISf..+s e.
8-
9-
10-
WAS GROUND WATER
0
ENCOUNTERED?
11-
S
IF YES, AT WHAT
^
L
/1
12-
DEPTH?
P
E
PIT AR"eAt
13 -
Dept b Water After
Monitoring? 'Qu Date:
11-tl-Oo
14
Reading Date
Gross
Net
Depth to
Net
Time
Time
Water
Drop
15-
11-V-00
Pae roaaKe"D
16-
/o ..e
/o+e
y4z
Vz'
Yo-.
/0 -A
/owl
7 w
ytt!{
20- PERCOLATION RATE 20 (mmutesnnch) PERC HOLE DIAMETER Gar
TEST RUN BETWEEN /0 FT AND /P"'r
FT
COMMENTS a%EEO 7*12EavG14. 'TOP e9RApwe- 6' 16.4.- //E 7-o 47XtSi
G-,•uq - 3oiro.H (1t214vEc. To BE w i3.G-
PERFORMED BY: 14.14. WILSON 1 14.14. W tLS0 A% CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 11 -it -00
72-008 (Rev. 4185)
GRF'" R ANCHORAGE AREA BO'''IGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
�f INSPECTION REPORT ON-SITE SEWAGE QDISPOSAL SYSTEM
NAME r4�''i T rtp" MAILING ADDRESS I?�( G(G 't"`t�cwv ,ee f�PH�O/NjE 333-�kJWO
LOCATION /Ifd r&W U✓t Pt LEGAL DESCRIPTION Z � ""`- 3 "�"��'+(1A t= tt'4(Q
SEPTIC TANK: ULd l.PyY%q
DISTANCE SfktA� SfC« Sfe>•� NUMBER OF
FROM WELL MANUFACTURER MATERIAL COMPARTMENTS_
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH I IQUID CAPACITY /000 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER 61- OR WIDTH )�/, LENGTH �Qt, DEPTH (Ct
LINING MATERIAL (' CRIB SIZE: DIAMETER DEPTH DISTANCE FROM: WELL
r 0 TOTAL EFFECTIVE
BUILDING FOUNDATION IL NEAREST LOT LINE 2L . ABSORPTION AREA (WALL AREA) 3]z SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE
CONSTRUCTION
DEPTH
DISTANCE FROM:
BUILDING
NEAREST NEAREST
SEPTIC
SEEPAGE
FOUNDATION
LOT LINE , SEWER LINE
, TANK
, SYSTEM
CESSPOOL
OTHER SOURCES
APPROVED
DISAPPROVED REMARKS
DISTANCES:
i ^ '' �^*k 73
DIAGRAM OF SYSTEM
Y
INSTALLED BY:
n
Gl�c�er
I--I��—
c %ccvafiNa
/ T,
PIPE MATERIAL:
(sem Iho�..
i
LOT SLOPE:
REMARKS:
DATE 0t/�'3�!`�%S APPROVE��o
G.A.A. B.
Form No. EQ -031
_ /GREATER ANCHORAGE'AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
3330 "C" STREET ANCHORAGE, ALASKA 99509
'TELEPHONE 270-4561
SEWAGE DISPOSAL SYSTEM -,APPLICATION AND PERMIT
NAME OF APPLICANTGin'/ (MAILING ADDRESS ly� ~ �hvPHONE 337 -Y'f
INSTALLATION LOCATION Col 6 /)C/r /.T In C_ AJ NN_ 4' ;&-&A_AAc D'
LEGAL DESCRIPTION A%!'R c Oq`k Fn"" 7L'OR6w P.Zi.li /n FR..++ 1✓Es j f'A•/'E2;Y 41NF
INSTALLATION OF: SEPTIC TANK / Q'1tb GA L SEEPAGE PIT rf 4EQCFC DRAIN FIELD OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED S /NLL IT PA • 01. '/ 3 !SI C is M Al
FINANCED THROUGH TO BE INSTALLED BY C- L N C /CA rz x L"
SOIL TEST RESULTS NOTE, THIS PERMIT 15 NOT VALID WITHOUT SOIL TEST
.y
COMPLETION DATE ANTICIPATED Se PT 2g '- ..O
FINAL INSPECTION: 26 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE /000 TYPE -• ^" 0 "N'& SEEPAGE AREA SIZE � TYPE 4rw/
MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM
FOUNDATION TO SEPTIC TANK
S'
y 1
FOUNDATION TO SEEPAGE PIT io DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANK
TO NEAREST LOT LINE.
SEEPAGE PIT 0 DRAIN FIELD
WELL TO SEPTIC TANK
0 O
DRAIN FIELD
SEEPAGE PIT /" ,
ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD
SEPTIC TANK. /010 SEEPAGE PIT Vy DRAIN FIELD
TO RIVER. LAKE. STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
E�CAVATION S FEET INTO UNDISTURBED SOIL.
11NCH DIAMETER CA<T IRON eIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO
REGARDING
^IIINNSTALLATION
� 1, 1,
.A.A.D.
OR
fD DESIGNER
1 CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS INhACCORDANCE WITH SAID CODE.
DATE ! 2 / APPLICANT'S SIGNATURE ��^�
FORM NO. 9"18
RF/ssv6
Municipality of Anchorage 0 -
Development Services Department :.-w
i Building Safety Division
On Site Water S Wastewater Program
4700 South Bragaw St
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.usw�
(907) 343-79D4
CERTIFICATE OF HEALTH AUTHORITY APPROVAL I 1
FOR A SINGLE FAMILY DWELLING
Parcell.D. 050-141-45 HAA# HA O/o / 0 (.
1. GENERAL INFORMATION Expiration Date: //'iZ'A - 01
Complete legal description BIRCH HILLS TERRACE #2, LOT 6, BLOCK 3
Location (site address or directions) 17639 TEDROW DRIVE
Current Property owner(s) PHIL IVERSON Day phone CONTACT AGENT
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
CONTACT AGENT
Day phone
DYNAMIC PROPERTIES — MARGARET GOCHE' payphone 261-7612
3111 C STREET, ANCH., AK. 99503
Unless otherw/se requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
N
Individual On-site
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 State 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.) 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.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $225.00 at, or prior
to closing for the engineering sendces provided.
4. STATEMENT OF INSPECTION BY.ENGINEER
As certified by my seal affixed hereto and as of the varrdstion date sham below, I verify that my
investigation, based on procedures outlined In the Health AuthorltyApproval Guidelines for this application,
shows that the -on-site wafer supply and/or wastewater disposal system Is(are) safe, functional and adequate
for the number of bedrooms and" 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 ls(are) In compliance with all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of Installation.
Name of Finn ALASKA WATER do WASTEWATER CONSULTANTS, INC.
Address 6901 DEBAR ROAD, SURE 2B • ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A GARNESS, P.E.
Engineer's Comments:
In conducting VVs evaluation, AMM, Ina attempted to provide a thorough,
conscientious engineering analysts of the system M accordance with ADEC and MOA
DSD Guidelines a 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 readily identifiable features. The operational No of all waifs and
septic systems depend on the local sobs condition, groundwater krvels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the contort of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do theyguarantee that
there are no hidden defects or encroachments. AK%V, Inc. can therefore not provide
any warranty or future estimate of howlong the system will confine to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Is for
Me sole benefit of the owner fisted above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal dght whatsoever.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
(wo. 1zao)
bedrooms, with the fllowing
Phone 337-6179
Date817-1/al
Manitenance Agreements
Supplemental Engineer's Reort
Other
OF
Jr: • • ON-SITE G�
WATER AND ; m
WASTEWATER
PROGRAM '
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Original Certificate Date: g - ;? q' O I
Municipality of Anchorage
• "
Development Services
Department
Bumrq saw DIVl6tam
i On"Slbs Water 3 Wastr~ PMW*m
47W South Btagew SL
I P.O. Banc 198650 Anchorage, AK 995196650
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HEALTH AUTHORITY APPROVAL CHECKLIST
a Legal Dmjcripsom BIRCH HILLS TERRACE /2, LOT 6. BLOCK 3 Parcel to: 050-141-45
s
A. WELL DATA
I Wen type PRIVATE If A. S. or C Provid8 PWSID# N/A
I
Wen Lop (YIN) NO
I Date completed N/A Sanitary seal (Y/N)YES
WIM property protactad (YM) YES
' Total depth 119'+ fL Cased to 40'+ R
Casing height (above ground) 120+ In.
FROM WELL LOO
AT INSPECTION
Date ofted N/A
3/19/01
I Stalk; water level N/A ft.
114' It.
Well production N/A g.p.m.
1.2 +/- g,p,m,
WATER SAMPLE RESULTS:
Conform 0 coloniea/100 ml. Nitrate 5.33 mgA.
Other bacteria 3 coonles/100 mil.
a Date of temple: 3/15/01 Collected by:
AWWC, INC.
S. SEP ICIHOLDING TANK DATA
Tank TypelMaterial STEEL
Date Installed 5/29-6/4/01
Tank $I= 1250 gaL Number of Compartments 2
i
Cieanorts (Y/N) YES
I Foundation desmon (Y/N) YES Depression over tank (Y/N) NO
High water alarm (Y/1) N/A
i
g Data of pumping NEW Pumper
C. ABSORPTION FIELD DATA
Data Installed 5/29-6/4/01 Son rating .p.d t firm) 0_6
System type DEEP TRENCH
Length 65 IL Width 3 R Gravel below pipe B ft.
Total depth 16 + - fL Eff. absorption area 1040 fe Monitoring tube YES Depression over field-MO—
eld NODate
Dateof adequacy lest NEW Reser (PasdFam
PASS For 4 bedrooms
Fluld depth In absorption field before teat _ In. Water added _gal. New depth _In.
Elapsed Time: _ min. Fine! Auld depth _ In.
Absorption rate :on g.pd.
Any rejuvenation treatment (peat 12 mo.) (Y/N 6 type)
K yes, give date
i
D. UFT STATION
Date Installed Size In gallons Manhole/Arrpm- (YIN)
'Pump on' level at--Jn. 'Pump 011 "I at ---in. High water alarm level at In.
Datum Icycles testers Meets slamr & dreuti requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic term station on lot 100'+ On adjacent lots 100'+
Absorption Held on lot 100'+ On adjacent kft 100'+
Public sewer main N/A Public sewer menhololdeanart N/A
Sewer /septic service tine 25'+ Holding tank N/A
SEPARATION DISTANCES FROM SEPTICAiOLDING TANK ON LOT TO:
Building foundation 5'+ Property Ilne 50+ Absorption Reid 5'+
Water main N/A Water service Me 10'+ Surface water 100'+
Wells On adjacent kris 1 oo'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property Me 10' Building foundation 10'+ Water main N/A
Water service Kne 1o'+ Surface water 100'+ Driveway, parMnghmhlde storage 50'+
t'urtWn drain NONE KNOWN Wells on adjacent lots—! —OOL+
F. COMMENTS
0. ENGINEER'S CERTIFICATION
r cov* that I have deterfned Uumvh flefd Inspections and
review ofh1unkW rowds that the above systems we In
conformance with MOA HAA gufdeffnes In effect on Bras date.
Engineer's Printed Name
Date 9/7-1/1),
HAA Fee $
Date of Payment
Receipt Number
Mm.17l00)
JEFFREY A GARNESS
Waiver Fee $
Data of Payment
Receipt Number
Y
CE` 7953
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program -
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-141-45 HAA# 14,A9 O / O O
1. GENERAL INFORMATION Expiration Date: G —
Complete legal description BIRCH HILLS TERRACE #2, LOT 6, BLOCK 3
Location (site address or directions) 17639 TEDROW DRIVE
Current Property owner(s) PHIL IVERSON Day phone CONTACT AGENT
Mailing address CONTACT AGENT
Lending agency
Mailing address
Day phone
Real Estate Agent DYNAMIC PROPERTIES — MARGARET GOCHE' Day phone
Mailing address 3111 C STREET, ANCH., AK. 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
261-7612
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual On-site
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 State 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.) 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.
Note: Alaska Water and Wastewater Consultants, inc. shall be paid $800.00 at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat 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 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 Slate codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC.
Address 6901 DEBARR ROAD, SUITE 28 a ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AMVC, inc. attempted to provide a thorough,
conscientious engineering anaysis of the system in accordance with ADEC and MCA
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 readily identifiable features. The operational life of all 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. AWWC, inc. 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 partyls not authorized, nor will It confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for __V_ bedrooms, with the Glowing
Phone 337-6179
Date 3/27/01
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O�0 C -7953 FFG
4n�^. ..... '•eogo
\SY OFAI
ON-SITE
WATER AND m=
WASTEWATER
)•, PROGRAM
c. N
Money shall be placed in escrow in the amount of 1.5 times the highest of three bids f0rxc nstructibi�gJ
the proposed wastewater system in accordance with 11IOA permit number SIN'000487. i1*'drjf c lfti t�`
shall not be released until this office has given final approval to this system. All wort: must MimilhI
no later than June 15, 2001.
Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It
Is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate
concentration is 5.33 mail. EPA maximum concentration is 10.0 mg/l. more information on nitrates is
available from the On -Site Services Program, at 343-7904.
Attachments:
HAA Checklist Manitenance Agreements
Septic System Advisory Supplemental Engineers Reort
Well Flow Advisory Other 1V, tYrr. f -c- A A vl r o &7
By: iv�� 7iT� • Original Certificate Date: -2� ' 2 $' 0
(Rev. 12/00))
� Municipality of Anchorage
A. WELL DATA
Development Services Department
Well type PRIVATE It A, B. or C provide PWSIDN N/A
JJ Building Saar own
' • '
0"lis water & Wastewater Program
Total depth 119'+ R Cased to 40'+ R
4700 South Bragaw St
FROM WELL LOG
P.O. Baa 1966.0 Androrsge, AK 99511}8650
Data of test N/A
wwwxLanchonW.sk us
(907) 393-711%
Statlo water level N/A R
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: BIRCH HILLS TERRACE 1112, LOT 6, BLOCK 3 Parcel ID: 050-141-45
A. WELL DATA
Well type PRIVATE It A, B. or C provide PWSIDN N/A
Well Log (Y/N) NO
Date completed N/A Sanitary seal (YIN) YES
Wires property protected (YIN) YES
Total depth 119'+ R Cased to 40'+ R
Casing height (Shove ground) 12'+ in.
FROM WELL LOG
AT INSPECTION
Data of test N/A
3/19/01
Statlo water level N/A R
114' ft.
Well production N/A g,p,m,
1.2 +/— g,p,m,
WATER SAMPLE RESULTS:
Colifcrm 0 colonieW100 ml. Nitrate 5.33 mgA.
Other bacteria 3 colonies/100 ml.
Date of sample: 3/15/01 Collected by.,
AWWC, INC.
B. SEPTICIHOLDING TANK DATA THE SEPTIC TANK WILL BE
UPGRADED IN THE SPRING OF 2001
Tank Type/Materhd STEEL
Data installed 10/23/73
Tank size 1000 gal. Number of Compartments 2
Cleanouls (YIN) YES
Foundation cleanout (Y/N) NO Depression over tank (YIN) NO
High water alarm (YIN) N/A
Date of pumping N/A Pumper
N/A
C. ABSORPTION RELD DATA THE SEPTIC DRAINFIELD WILL
BE UPGRADED IN THE SPRING OF 2001
Data installed 10/23/73 80 rating .p.d ffftmt) ?
System type LOG CRIB
Length 19, R Width 12' fL Gravel below pipe 6' it
Total depth 11.6• fL Eff, absorption area372 R` Monitoring tube YES Depression over told NO
Data of adequacy test 10/2000 Results (Pass/Fam
FAIL For 2 bedrooms
Fluid depth in absorption field before test _ in. Water added _gal. New depth _In.
Elapsed Time: _ min. Final fluid depth _ In.
Absorption rate >- g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN &type)
N yes, give date —
SEPTIC SYSTEM IS SURCHARGEP UPGRADE PERMIT# SW000487
a
i D. LIFT STATION
Date installed Size In gallons Manholaftmas (Y/N)
"Pump on" level at--Jn. "Pump off "I at fin. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requlrements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: ' � 4ED Ge— V-6� �
Septic tankAHt station on lot 76.5 On adjacent lots 100'+
Absorption field on lot 100.5 %K On adjacent kala 100'+
Public sewer main N/A Public sewer manhole/cleanout N/A
Sewer /septic service One 25'+ Holding tank N/A
I SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property One 5'+ Absorption field 5'+
Water main 10'+ Water service One 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property One 10'+ Building foundation 10'+ Water main 10'+
i
Water service line 10'+ Surface water 100'+ Driveway. parldngMehlcle storage 50'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
l
1
0. ENGINEER'S CERTIFICATION
I cer* that t have determined through field LwpecOons and
review of Munhypat records that the above systems are In
conformance wish MOA HAA guidelines in effect on Kris date.
Engineers PMjed Dame
Date
JEFFREY A. GARNESS
HAA Fee $ 30 O • CXR
Data of Payment 3 — a6-01
Receipt Number R9,500
Mm. 120M
Waiver Fee $
Date of Payment
Receipt Number
03-20-01 17:13 FROM -CTE ENVIRONMENTAL 5615301 T-699 P.02/03 F-465
CUE Environmental Services Inc.
Cr&EReLN
1011330001
Client Name
AIC Water & Wastewater Consultants Inc.
Project Nomem
Birch Hills Terrace #2
Client Sample ID
Lot 6 Bik 3 / Outside Hose Bib
Matrix
Drinking Water
Ordered By
PWSID
0
Sample Remarks
Paonmler Rendu
Waters Department
Nitrate -N 5.33
Microbiology Laboratory
Total Coliform 3 OB, No Coli
Client PON
Printed Datalrime
03/20/2001 11:35
Collected Date/rime
03/15/2001 14:50
Received Dste/rlme
03/16/2001 13:40
Technical Director
Steppes C. Ede
Released By y7%• ��
PQL Units Method
0.500 mg/l. EPA 300.0
coI/I00mL SM189222B
Allowable Prep Analysis
Limits Date Dam lnit
10 max 03/16/01 SCL
03/16/01 SKW