HomeMy WebLinkAboutTONJESS ESTATES BLK 3 LT 7(nOnm nn ?C?&141V)
4110Sx- 21a- Oa
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TO 6541211
FROM Northern Rehab
Rua 06.1992 10:37AM
HCOI 6761
DAILY DRILLING LOG
S & S DRiLL!NG
Panner, Arica 95645 (907) 746-0606
OWNER OF LAND.PRO.I .__ _t�S�ON...._.. _....._
ADDRESSLO.E_...tits...3.. TQ.inSuE:._.....__....
WELL -SiTE_,�:._C9RAi;[,._ Q �T.,__..__....._.._...._
DACE -STARTED..,:. _ 97 --
DATE - ENDED
2.DATE-ENDED Z' 1` : .... ...._............._
KIND OF FORMATION:
FROM -5R- ....
FROM=......
FROMI _
._...FT.TO '‘-
. _FT.
_.__.FT. TO- . B
.FT.
.... _FT. TO 24.0.
r
DEPTHOF WELL- ........__.__...__�___..._._..______.._..__-____.
STATIC LEVEL OF WATER FT_._.__.._...__.
DR.Iw DOWN FT. .._..__....._.........._.___.__.�.____..._....__.__._..._
(:ALS. ?Eft W ...t
KIMDOFC1SING4'............._4AS+.N._T_e.....3.L.` ......................
Fgcm LOQ TO T1 -K. ba-rou
F-rmawk e.e Sim l "I ci K�ts /tO.m_......_......_....FT. TO...__.___......JT.
F'T.`isfK?t.s. d ..-ants. L .kRt''N�vlj.._
Fr. cP.P„0 /Ram _....__..._.._....FT.TO- .FT...
tC;A%1Z i- +�
_Fr.3�9.CCIC 4 u
..__'..._ __..`��rROM.._.._..__.._._..Fr.ro.......___._..__FT._
FT. TO ............. _...FT.
FROM.. FT. TO -FT .. ..............
FROM.._....___.... _... FT. TO .. ___._.FT._ _ _..__.._ _......._
FROM..._.......___....fH. TO.. -TT
FROM....._......._...__FT. TO....__.........._ST.............._...........
FROMFT. 10......._...__.._. IT._._...___ .............
FROM ....... _..»...._..... FT. TO FT.
FROM ....... _...._..___FT.TO FT.
FROM..__. ..... ....-.FT. TO.._..._._.._...._FT.
MISCL INFORMATION:
FROM IT. TO. .FT...
FROM_ __FT. T0.._.._._.._.....Ft...
FROM FT. TO..___....._; _...FT._
FRO.M.._... _....
FROM.._.._..........__.IT. TO. .FT...
FROM....__ FT. TO FT...
FROM........_..............FT. TO...._.__......__ FT...
FROM........___......_.FT. TO......._....._.„FT...
DRILLER'S NAMs gr_ � QS+� -
•
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920262
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:JACOBSEN CAROL
OWNER ADDRESS:BOX 876624
WASILLA, AK 99687
PARCEL ID:05183202
LEGAL DESCRIPTION: TONJESS ESTATES BLK 3 LT 7+
LOT SIZE: 45311 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1 •
DATE ISSUED: 9/02/92
EXPIRATION DATE: 9/02/93
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISION•
RECEIVED BY:�/_�/'(,'K6/ �/L_
ISSUED--LBY:
//!/.S "/yin/
/tiefrrnite.7 a//
.s0-1
Goe_// 04/40' fl
#4)%
DATE: 0'/4?
DATE :C/fl'e___
��L w/)4 CT
•
r..
Lf. F;
• •
.
NAME
MAILI
LE
l , MUNICIPALITY OF ANCHORAGE
h
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
P 6
fipn��7Tl Mira"
13 DS? .ee/Jn sn'e /91XC E� Pts -79
DEE$C/{tIPTION�
TS37nx e 5 2 �.SN v�;
air
LOL\Lli ^'g$ ' I VI fub- �L6^ ' 10) f ,w)M O. OF BEDROOMS...3
WeI�O �� I Absq�pt� area/ �L Dwelli PEITfj{O.! L/ e
ManufactureLL 707 (,
H2E NEW
L.' B� OUPGRADE
DISTANCE TO:
re/
No. of compartments gE,
Liq.yep�7cyty�t(ygylIons
IF HOMEMADE: Width Liquid depth
(/ (/ V
DISTANCE TO Well
Manufacturer
Inside length
Dwelling
Material
Wall Poun byn Nearest y1 t line
DISTANCE TO: //7 it. /f• /O .rG
No. of lines / Lengov each Met Total IeaalD,of I/natL Trenc ayidttr�
GG'C�� L. G Cl inches
Top of tile to finis grade 1 Ma�yial »neath/il/e �� �+ /7 r
Z. r/2, —Z/2 Sic /Z Inches
Length O�
Type of crib
DISTANCE TO:
Width pth
Crib diameter / {aib depth
Well / Building foundation
` j u0 -G e Fflt, t
Building to dation
DISTANCE TO:
PIPE MATERIALS
OTHER
SOIL TEST RATINV C
INSTALLER
ELKS
/00 /2
4(aHu- l_UO.rT
'l7 xri
Sewer line
APPROVED; a " Spn 119La1r;0
Lemtr Ft1VEa, PLASM 4..i'
1)11, C04.27J,
_..7J
72-013 (Rev. 3/78)
DA
k
/7
A
PERMIT NO.
Liquid capacity in gallons
yll
Distance j�%twy7. nes
Totaly?�ve ab ion area
PERMIT NO.O
V1/29
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorption weals)
i- {- ZZ 1 FS`{Y'T
10 1
t0
CO
Far °s`'
/logs>
RETURN T0:
•
Division of Geological and , .pnyslcel Surreys (DGGS)
3001 Porcupine Orly. (Telephone: 277'6615)
Anchorage. Alaska 39501
WATER Will REt0R0
or1111eg co.wny Was Foss Drillinr
LOCATION OF WELL ! Please complete either la, Ib, or It.
la. borough Subdivision Lot block Ib. Fraction Section No. Township Range Mar id Ian
`,'3 Anche Tonjess 7 3 / / / tits w I
lc. Distance end Direction From Road intersections 3. OWNER Of WELL: Jesse : Prince
U.S.G.S. Local No.
DrlllInq Penile No,
A.D.I. No.
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
• 'Address: 2412 West 29th Ave.
Anch.p'Ak. 99503
Street Address and Area of Well Location
2. WELL LOG -..: /• feet talo b. WELL DEPTH: (co.pI.ted) Surface Elwatlon Date of
Surface 'j tj3
1 Materiel£Iib`/
Type Topbona. 162 ft.
r Till: Kray and hard, with 0 73 S. "gable tool Dot ry 0 Dos
1 large boulders.❑4"`ed ❑bred .0 Other:
❑ Au r
1 'Till:- brown and hard. "i3 53 _
i Sand & Gravel: -light brown. 83 b5 .0. USE: ®Do..stic ❑Public Supply ❑Industry
• 1 'with.. water; .2 gpm. . ❑lrriD.tlon Plethora* ❑Cor-arcial
Bedrock: light grey and hard. 85 b9 ❑Tat Man ❑oehen
Bedrock: blue and hard. 59 91
Bedrock: light grey and hard. 91 13b 7. CASING: ❑Threaedred paraded •
3odrock: blue—greon and hard. 13b 1b2 61e. to 8t ft. Depth Weight 19 hell t.
In. to ft. Depth
0. FINISH OF WELL: Open hole
Type •- 04rter:
Slot/Mash Site: Length:
Set between ft. and
Fittingsi
9. STATIC WATER LEVEL: - ib - rt,
0Abov. Nlw land surface -.
Type of.Measureeent: Band'line
ID. POMPING LEVEL below land surface
+160 .'h' after. hrs, .pusping." q.p...
• ''•ft after' • hrs.. pumping M: •. :Lia•
11. NELL'READ COMPLETION: ":r;;' ❑ In Approved flt? t t' '.
❑pl flea Ad 18 ` - IncMs above geed. e
I2. GROUTING; ; ;.'Well Grouted` . ;.®Vs • Olio„...;");,0,-;•
, v ' +h.:
`”• i natural ::
Mater•141a in Carnet ❑Other'
.13. PUMP[ (If available) M/'- . •.:.• e. K:.;..,t,.. I:•,..:•.:
Length of Drop Pip. ft: cep.clty -'••'''_r -• g.0a
Typo:,., 0 Subears Ible ❑R.tlpnating11
❑2at,> C La
:R. REMARRSt i s:•amt:..
'ft.
IS. WATER KU. CONTRACTOR'S CERTIFICATION:.:]
4.: .. a *..
�y ` TNis well Mas drilled WMerey Jurlsdlctlon old this report Is'tree to the bast of myw,
�knledge and bolls....
34.44:-.11,..
''E 'IFoaa; Dr1111nP .: .' > I;
" -. Real Business Nees Contract license Number
le'; Addnes: SR 'Box 7580 Churrtak lnnkn 9'4567
'��:'. flyn.da '_--ec ' ( f
Author and n L. Ire
Det.:
s mot 0,1,1Wt Copy•Dl$trlbutlon: WHITE - State 0005, PINK - Driller, CANARY - Customer
-DEPARTMENT-OF-HERLTH'AND 'ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501'�
/'
r1 264-4720 7
Ct•d—S I TE SEE 44ER S: 44ELL F'ERr'1 I T
PERMIT•t10:
DATE ISSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP
LOT SIZZE:
' MAX BEDROOMS:
•
840018
02/22/84
MATT ADAMS
S&S. ENGINEERING
EAGLE RIVER, AK 99577
2276-7644
-7
SUEDIVISION:.TONJESS LOT:.
SECTION: 2 TOWNSHIP: 15N RANGE: 1W
(SO. FT. OR ACRES)
3
3
BLOCK:'
LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE.
DEPTH TO PIPE BOTTOM (FT.)
GRAVEL DEPTH (FT.),
TOTAL DEPTH (FT.)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
GRAVEL VOLUME (CU. YDS. )
TANK SIZE (GALS) -
SOIL RATING (5Q. FT. /BR)
TRENCH .
4. 0
6. 0
10. 0
2. 5
22. 0
13. 2
1, 000. 0
85
**
** TANK P1UST HAVE AT LEAST TWO COMPARTMENTS
E:EL�
4. 0
0. 5
4. 5
14. 0
28. 0
14: 5
1, 000. 0
85 85
**
14. GRNItil
4. 0
3. 5
7.5
5. 0
28. 0
20. 7
1, 000. 0 **
I 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 FROt9 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 I5 INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND C3) THE
ELECTRICAL WORK MUST BE DONE BY RR LICENSED%%�ELECTRICIAN.
•.‘2_62,/a0_4444___
2_ 2/x0_444 ----- DATE: _..e/4.7:4?:21.
SIGNED
APPLICANT: -MATT vu ANS
ISSUED BY a.i nnI-� )/I ._ _ : CL / DATE:
'376 q'iMUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
��/�f'/� SOILS/,LOG-y/�PERCOLATION TEST
PERFORMED FOR: �/ / / IQ W `�6 %f" S"
TLEGAL DESCRIPTION: 47 .8i �j c.c.s
SLOPE
1
k
Ei Orr/7i efriz
5- Ub
6- V�
V
/0y
9- Co
isi
10 - i
WAS GROUND WATER /00 S
11_, G ENCOUNTERED? L
E
12 - s ���_1li P
�,o s E
C 111' IF VES, AT WHAT
o �4 OF Ks, ii DEPTH? tC
I onV
G ' 0 �':: lj1 - Gross Net Depth to Net
14 - / j„ Reading Data Time
15- Time Water Drop
l
•
�. ..
�• o- i'
!OHM A. Shafer 4
�'. No. 1457-5 1 �1
S. fr af�
17 - `�,\ �lEzee*'�
ic SOILS LOG
DATE PERFORMED:
O PERCOLATION
TEST
2—/SVT
SITE PLAN
18-
19-
20 -
COMMENTS
PERFORMED BY:
72.008 (609)
PERCOLATION RATE
TEST RUN BETWEEN FT�FT
,J/
(minutes/inch)
ittt SREliff�YAIU:
PH. 69,;-2979
CERTIFIED
�i�j DATE,2 N -614/
MUNICIPALITY OF ANCHORAGE : r r ..
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 ..
'UIYALIIY UY ANUnUko vn
NMENTAL SERVICES DIVISION
NOV 10 1997
RECEIVED
Parcel1.D. N orf - 5'3 - o Z •..:HAA 11 lAcNo ni,
1. GENERAL INFORMATION
Complete legal description Lot 7: Block 3: Tonjess Estates
Location (site address or directions)
rt:
,i.:
,• Prdperty owner f Kathie Potter
Mailing address •••• P.O. Box 671892
i, ;L•eriding agency M:
*Mailing address '
Agent _.Rolf Milton/ Partners Real Estate
21624 Tony Circle
Chugiak, AK
Day phone
Chugiak, AK 99567
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 N
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
Day phone
`Day phone
688-6766
694-4995
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system:
4. TYPE OF WASTEWATER DISPOSAL:
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. `' °'
• 724251n.'.IMO front MOA KI
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 -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.
of Firm Phone 6 �N }aj
17034 Eagle River Loop Road No. 204
Address Eagle River, AI ka 99577
(
Engineer's signature e/skZs Date if /164'7
$ 3 ENGINEERING
Name
ecPNOF gCsti
n9 �• as
1.,.a
CE -8801i{.( -
DHHS SIGNATURE I et ».. '.: �C ..;•
�/ 1t1�FROkssv5,1 �+;.
_p_ Approved for bedrooms. x,•
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
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 eriors or omissions in the professional engineer's work... ,
72-025 (Rev. 1/91) eck MOA n1
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES MUNUrAUU 03-
Environmental
rEnvironmental Services Division LNVIRONMENTALSER
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-47fy 1 p 1991
Lot
Authority Approval Checklist
RECEIVED
Legal Description: Lz I - R1_MK 3' 1 » Tt SS sr Parcel I.D.: O S/ — 3 A —o 2
A. WELL DATA
Well type W%vATt If A, B, or C, attach ADEC letter. ADEC water system number
Log present3l) t.1r,5 Date completed .0/19/92
Total depth cJ(ob"r Cased to PS3'411 Casing height (above ground)
1a"t
Sanitary seal ICON) teri Wires properly protected Y�/ J) tr-
FROM WELL LOG AT INSPECTION d
Date of test a." iq-91 (I f I719*
Static water level SD / 910/
Well production t g.p.m. . &Z
WATER SAMPLE RESULTS:
Coliform (7 Nitrate a , 91 Other bacteria en
Date of sample: ff 'f f 9 `t a Collected by: ale S 6%/64.-
B.
L,.-B. SEPTIC/HOLDING TANK DATA
Date installed '.3i 11 I d4 Tank size loco
* g.p.m.
Number of Compartments _ CleanoutsYj4) r3
Foundation cleanout (DN) 4 Depression (Ye / i b High water alarm (Y1 Alb4
A
Date of Pumping 11(6 le -} Pumper 0PS
C. ABSORPTION FIELD DATA • •
$S' ns/IR (P44 Pins)
Date installed 1 I i (iii' f'` Soil rating (g.p.d./ftt or ft2/bdrm) (no c42/0 System type 1VE401
Length as• Width 4-D Gravel thiclvress below pipe % Total depth ID
Effective absorption area rl%4 •H Monitoring Tube present(ltl) trs
Depression over field (Ye) 00
Date of adequacy test it In Results s 'Fail) PPSc. For r .4 Z i;L bedrooms
Fluid depth in absorption field before test (in.); 4-11 Immediately after 500 gal. water added (in.): d% !r
Fluid depth 4 n (ins) Minutes later: rD Absorption rate =t g.p.d.
Peroxide treatment (past 12 months) (Y/N) gerJk tt'ow,J If yes, give date
72-026 (Rev. 3/96)•
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump • " = =I at "Pump off" level at*
High water alarm level at* 'Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot Will I -
Absorption field on lot 100 4
Public sewer main
Sewer /septic service line
On adjacent Tots
On adjacent Tots
-451+ Public sewer manhole/cleanout tool+
+ Lift station 16.2
'4
OLDING TANI< ON LOT TO:
f:IW µrru6 r* 'C 040.4 4444r6 A l,K1a PANunTNI&. P1441.
SEPARATION DISTANCES FRO
* No nave t c
Foundation * I ,o
Property line
5' ; Absorption field 514
Water main/service line 101+ Surface water/drainage cot 4' Wells on adjacent Tots Imp;
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line lo' + Building foundation Water main/service line 10
Surface water IoOIt
Driveway, parking/vehicle storage area fol +
Curtain drain dput: KNoaoN Wells on adjacent lots 100 It
F. ENGINEER'S CERTIFICATION
11.
I certify that I have determined thm field inspections and review of Municipal records jsr9�j ns am
In conformance w�itthh M�(OA%HAA gui lines in effect on this date. s 0Signature -���U�'/[�-ii:41::
Engineer's Name .R 044 CLT
Date it 1, a /9 7
HAA Fee $ 3 oo .coo Waiver Fee $
Date of Payment 11— U1D-5) Date of Payment
Receipt Number v 3 D.8 s ) gip 14 Receipt Number
72-026 (Rev. 3/96)'
A \ lORSRT.C. COWAN
`g• CE -8801
:araaz.•►��
rp"'ll/12/1997 07:4. 7U40]•11411 b AND}j G!'ItalPttK11`N
NW -11-199.7 21.1e2GT8E ESI 17r:CFtaaal,t
AIL C'T1BE Environmental Swims Inc.
_v.
CUE M4
Client Name
Project Name//
Client Sample ID
Matrix
Ordered By
MUD
Sample Reins a:
Perimeter
Nitrete•N
Total Cell/corm
976845001
S do S Engineering
1.7.83 Toilets Est
1;.7.83 Toajeu En
Drinking Water
0
aeeults
POl Unite
rN,t 171
1'
Client PON
Printed Dateffime 11111/9718:49 •
Collected Dateflime 11/04/97 12:00
Received Date/Tis; 11/05/97 08:30
Techakel Director: Stephen C. Ede
Released By Are ,,,d Q , D / /_ nn
Method
2.82 0.100 emit IPA 300.0
0.00 C01/10001 3418 92220
Alleveble Prep Analyst;
Limits Date Date !nit
10 mix 11/05/97 CCP
11/05!97 TKa
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. # -9-‘3-D•n„Q
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
HAA# k\tC\cla/I5.1
Lot 7; Block 3; Tonje66 Eb.tate6 Subdiv.i.6.Lon
21624 Tony C.Lacte
Property owner Canoe Jacob6en Day phone 688-5465 gun
Mailing address P.O..Snx 8766?4 (Vasi.P.ta. Ata6ka 99687-6624
Lending agency Day phone
Mailing address
Agent Vi»gtnia Knhsiotd Ito/May n6 Fagfo. Rivt& Day phone 694-4200
Address 16600 Centoh6lold Daae Suite 201 Eagle Rtvek. Ak. 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
XX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL.:
Individual on-site
Holding tank
Community on-site
Public sewer
XX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Pa. 1N1) From 40A 721
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is sate, 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 tiles 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
Address
Engineer's signature
5 & StNOIN!fRINO
17034 Eagle River Loop Rosd No, U13
Eagie River, Alaska 993//,
6. DHHS SIGNATURE
XApproved for bedrooms.
Disapproved.
Conditional approval for
By:
Additional Comments
Phone
Date 1jedeka'Z-`(2
.,aF A�t
�a
rit
Or CO r �! � �• win
sr/1,1491H% dd
oJ.. •
• o;; •
t
ef
ROG R4. HAFER S W
�c• No. 15 s-_
441.P4i0.
FESS\;141:4►:
bedrooms, with the following stipulations:
CAUTION 1
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.
72425 (Rev. IN1) Bock uW n1
Tom Fink,
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
August 28, 1992
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Lot 7 Block 3 Tonjess Estates Subdivision
Health Authority Approval Disapproval
PID 4051-832-02, HA920527
The Health Authority Approval request (HA920527) attached
hereto has been denied. The existing well drilled by
S & S Drilling was obviously drilled in February, 1992 without
a permit issued by this office. This is the second such
offense this year by S & S Drilling, and another citation will
be issued by this office. There is no provision in the
Municipal Regulations for issuing a retroactive permit.
Therefore the subject well will not be recognized and approved
as a legally permitted well for the purpose of approving the
Health Authority Certificate. When the existing unpermitted
well has been properly abandoned and redrilled under a permit
issued by this office, the referenced Health Authority request
(HA920527) will be re-evaluated for approval. The fee for
a individual well permit is $75.00, however, there will be no
additional fee for the re-evaluation of the Health Authority
Certificate.
If there are any further questions, please call our office
at 343-4744.
Since
Robert W. Robinson
Civil Engineer
On-site Services
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
• On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 89519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel 1.D. # fie l - S - f
1. GENERAL INFORMATION
Complete legal description
HAA # Rq r.•5'l
Lot 7; Block 3; Tonjess Estates Subdivision
Location (site address or directions) 21624 Tony Circle
Property owner Carol Jacobsen Day phone 688-5465 hm
Mailing address
P.O. Box 876624, Wasilla, Alaska 99687-6624 561-3162 wk
Lending agency Day phone
Mailing address
Agent Virginia Kohfield - RE/MAX OF EAGLE RIVER Day phone 694-4200
1660,0•Centerfj.eldprigj,.$iiite•201, Eagle 'River, Alaska 99577••
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
xxx
,• 1.
NOTE: if community well system, provide written confirmation from State ADEC attest-
-. ing to the legality and status of system.
_.. •.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
-t..
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 plot 1191) Front MOA 121
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 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 5 8 5 ENGINEERING Phone
17034 Eagle River Loop Road No.204
Address E•gle Diver, a)it " 09577
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved. M// d///ea/ •z/9/Sge 1.S1p44;71)0CA01,71
Conditional approval for bedrooms, with the following stipulations:
-
.r
Date e-7\ -1%
----
,c.a.-win,
OF.ACP%
�.
r is •ti9oit
,�
em. J. HAFER ?
vi bi-p :• f o. 8 15 'C��.+
1 'F •• •••ag
��.
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (R«. 191) Bock MOA .2t
a'
df
ut
a
X
"r' (ss-ni Q-r,at\ MT'ys%r�
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: \---CT 1 V- 3 T' t-5 Parcel I.D.
WELL DATA . .
Well type Pe-% P'C'E• If A, B, or C, attach ADEC letter.
Log present ON) Y
Total depth Z Le. 0
Sanitary seal 0N)
i1.
ADEC water system number ' ' ' �� A
Date completed Z'- q2 Driller '� S PRA LA -t -IA
`k eta
Cased to 4D Casing height 12
Wires properly protected ('N)
FROM WELL LOG
Date of test
Z \`1 :92
Static water level gpt
Well flow g.p.m.
ti
Pump level
SEPARATION DISTANCES FROM WELL TO: i,
Septic/holding tank on lot )o`er ; On adjacent lots oc%
Absorption field on lot \ oo 4-; On adjacent lots \ OO
Public sewer main /* Public sewer manhole/cleanout j
Sewer service line `' Petroleum tank 14a ' }
AT INSPECTION
• MUNICIPALITY OF ANCHORAGE
B - 4 -4114-NIRONMENTALSERVICES DIVISION
eco
AU3 2 1 1992.
esvA
3fl�` ktCEIVED
WATER SAMPLE RESULTS:
pOV•
Coliform d lJl)...L• Nitrate
Date of sample: 5 1.4 Az- / A - 2.-
B. SEPTIC/HOLDING TANK DATA
Date Installed ��-94 Tank size 1000 Compartments 2-
Cleanoutsed/N1 y " ` Foundation cleanout ON) 'j "Depression (Y6 ►1
High water alarm (YA4 ^' Alarm tested (Y/N) I .
Collected by:
Other bacteria hie "IE
Sit S ENGINEERING
17034 Eagle !Mir Loop Rood No. 204
Eagle River, Alaska 99577
Date of pumping: 6 -lar -q?. Pumper Cie4SGpcet�
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: .
Weil(s)onlot \6D 1+•On adjacent lots toe';- Foundation tar
To property line ' toesar-
"Absorption field "_yp''"" "Watermain/serviceline t 014
Surface water/drainage 1 bot
72-026 (Rev. 7/91) Front
CONTINUED ON BACK PAGE'
C. LIFT STATION �;
Date installed ' - - r'"'•" Manufacturer ' "
i .:>.. ... .. Cr.
1"1/1,. ;. ._ 1
Manhole/Access (Y/N)
"Pump on" level at " r< " / ` -P mp off" level at
Size In gallons
--Vent (Y/N)
High water alarm level
f/
Meets MOA'electricat codes
SEPARATI1• • STANCE FROM LIFT STATION TO:
"(, 1
on lot
D. ABSORPTION FIELD DATA
. 11-9 `( Soil rating e%i3� System type -11R-b.=LFi
Length ZZtWidth T4'
Gravel thickness 1>t
Total absorptigp area 1t'`(' 4 Cleanouts present &I)
<.),. I- _.
Depression over field (Y�jV /"' Date of adequacy test
--IA e .t x'33
Results �� ail) P�� for �
If yes; give date d/a,i T
r Eat''Si) M PEP -I -tar 1 .._.- -t
SEPARATION pISTANCE FROM ABSORPTION FIELD TO:
Well on lot 1potk On adjacent lots Lab t + Propertyline 1e,
To building foundation • es.
`a To existing or abandoned system on lot i
On adjacent lots 3° Cutbank a1a Water main/service line 1Dx+
lovsk'
Surface water s+-
Driveway, parking/vehicle storage area
-Curtain drain �.
i".11): J2413111 2 3 Z
—tar rill t•v.,y p..,, t...:r'-1- a.raft -
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this Inspection.
\1\\; _ f
��Eof44alio
_
in $ & $ ENGINEERING P lr . r tcro •••M•• � •.~s.....
Signature 17034 Eagle River Loo Road No.204if 0
Eagle River, Alaska 995/1 , _ .r* 1491U ,`'; Nit e
Engineer's Name �, 6 ..•w•••...• wi .•...0 . 5
Date » \ — .,Ts; ROG R SHAPER j4W�
C'i; ,. T ",: ��J:, No. 2'11.15A
5 ':: �Fr ,':
.t• 0.6.4. 4i
1 ) '' 1 ,.fe - 1 .• � _
T I
On adjacent Tots
Cycles tested
Surface water -
{
Date installed 3
i4
Peroxide treatment (past 12 months) (Y& .lak.lC 4a1J4
Total depth 161
Y
d -14-9L
bedrooms
j —01
HAA Fee $ 70
Date of Payment B' )'/' 92-•
Receipt Number 2 7 7.0 I / s%S>
7226 (f1«. 3191) Dock MDA 21
•, n C' 13/4e4pihnitkrtter
Waiver Fee: $
Date of Payment
Receipt Number
1
i
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 8 STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561.5301
1NALISIS RESULTS fax INVOICE 156795
Chmlab Ref., 92.4036 Semple 1 3 Matrix: WATER
Client Sample ID : 17 E3 TONIESS EST
PMSID : UA
Collected : AUG 6 92 4 12:40 hr,.
Received : 100 7 92 1 16:00 his.
Preserved vlth : 13 REQUIRED
Client Mame :S & 3 ENGINEERING
Client loot :SNSENCP
EPOS 1
Rpt:
Ordered ly :R. SHAPER
Analyst, Completed : l0G 10 92 Sand Reports to:
Laboratory Supervisor • STEPHEN C. IDE 1)3 & 3 ENGINEERING
Released Ey : /2 .�L.�� 2)
P01 :HONE RECEIVED
Parameter
Results Unit, Method Allovable Limits
NITRATE -N
Sample ROUTINE SAMPLE COLLECTED IT: 11E.
Remarks:
2.4 mq/1 EPA 353.2 10
1 Test, Performed
ID- None Detected
M►• Mot Analyzed
• Sea Special Instructions Above
• ' Sae Sample Remark, Above
LT•Lese Than, C1 -Greater Than
Ilk -Unavailable
42$% SGS Member of the SGS Group (Societe Generale de Surveillance)
l,oT -1 t't.,L'5 11, s--..r-rt es -r.
a•14.c12
nesse,------N.4.\•• . RD_. -f.a`P.A.
10•.1•6' sot - -
td•.5- lociI..._.�' - 9.5
to.Sa \15. 115 4.1.
‘ t •.D'i Vrrp% ts0 ` AtT -n RU-tp
.,* as -cls . 41 Cana .
TMs - 1s.6S14.a.
1-1 -
<- 11.21 Kt
it l GtiP.k�.
1.4 -es" P R -e ?
441. S „H. '" limas ueeak 1r MCI -6J
(rIA
-r.-
0-.24 mi s
51'25- 46---- 4-46..n, 0 ja-G,h6A-T .
'-1 ..
S SS ENGI\3tiRING
17034 Eagle River Loop Road No.20 }
_ Eagle River,' Alaska 99577 '—
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND UJVIRCNMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
Application Date 3 Z7—c-941
(include lot, black, subdivisimenctjcn, township, range)
1. General Infcrmaticn
(a) Legal s i, i
ion (address
i0/rss
(b) Applicants Name
TON]es-J. sz ris to
or directions)
�/�fs-r s'//o ��,//-51:
/ 77 /&c'a/l�f Tblephcnef� " NYC/
Applicants Address •
(c) Applicant is (check cne) Lending Institution L ; Owner/builderj571;
Buyer fj ; Other j (explain);
(d) Lending Institution
Address
(e) Peal Estate Co. & Agent
Address
Telephone
2. Type of Residence
Single-Familf
Number of Bedrocns
3. water Supply
Ai o,-11-
Multi -Family J
S •
Other (describe)
Telephore
Individual tii, Community Public
Note: If can:unity well system, must have written confirmaticn frau the State
Department of Environmental Conservation attesting to the legality and status.
Is the well adequate fcr the number of bedrooms specified in this
4. Sewage Disposal
Onsite,, Public Camunity n Holding Tank Cr
Is the wastewater disposal systema adequate far the number cf bedrooms ((Y,
[Page 1 of 2)
2-15-84
5.
•
Engineering Firm Providing Inspections, Tests, Data and Information
I certify that I ,ve %.eeked, verified, or conformed n all M]A NAA Guidelines in
effect on the •• • A3 inspection.
SSigne,.igne•'
�
Name
-1 Firm
-8 Q 0 r 1Q141GGAldn
,'. SRO 196X
Address ra.:ALE RIVCR. ALASYA "L.?.
Signed by
Date
(ENGINEER SEAL)
6.0*2 Approval
Approved for. bedrooms By
Approve Disapproved 1
Terns of Conditional Approval
Date //2,7Telephone
et
.. O 1
tsit
111
'�...3
1, A),
s ...n L a.r., ^ rt
��. .1...14474 t .r
S 41C? 4.;
1 CYT rl �C/l
Conditional int
Date
The Municipality of Anchorage Department of Health and Environmental Protection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval indicates that, as of the validation date
shown above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func
tional for the number of bedrooms and type of structure indicated.
•
(MEP SEAL)
7. Mail the HAA to the following address:
c r9 7 7 iJJ es 5- rs
3 lC 7
G3M13D3I
MUNICIPALITY CF ANCHORAGE (MCRA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA
Well Classificati <-5"/CWe11 Log Present (AQ--
Total Depth / Z / Cased to
Static Water Level %R 1
Casing Height'Above Ground
Electrical Wiring in Conduit
Separation Distances from Wall:
To Septic/AC3tttm Tank on Lot / 0 r I • t on Adjoining Lots CIOs' (%
To Nearest Edge of Absorption Field on Lot 7/7 / ; Cn Adjoining Lots 200
To Nearest Public Sewer Line /0 / le- To Nearest Public Sewer ///
Cleanout/Manhole "/4 To Nearest Sewer Service L on Lot ^ n
Water Sanple Collected Sy s''rs E dfrit ij e/%YI Date //7...y ll"
5Cl
Water Sanple Test Results r. r 4 c "./i
Convents
If A, B,crC,
Date Completed
87/
Pump Set At
1/
MYDEb d
samosa wiNgvitosinte
Ha° .iM
tDD. .C. GAppr d /N) .�
/ ��/p 3 Yield WA,
pth of Grouting /
W
Sanitary Seal on Casing
Depression Around Wellhead ('d
B. SEPTIC/HOLDING TANK DATA
Date Instal -d 3^/7-61-74 Size /0(90 No. cf Compartments 2
Standpipesm : Air -tight Caps ( Foundation Cleanout
Depression over Tank (Xr J Date Last Pumped AJP £-i
Pumping/Maintenance Contract cn File (Y/140 ; fon //,,
Holding Tank High -Water AlarmV0I
(Y%N/7 - Temporary Holding Tank Permit (Y/W0/4
Separation Distances frau Septic/Holding Tank:
To Water -Supply %ell /O /4 To Building Foundation e
To Property Line AO 72= To Disposal Field Z 0 i
To Water Main/Service Line ', To Stream, Pond, Lake, or Major Drainage
Course
Cements
(Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /09 Type of System Design *da
Date
PI%c-
Date Installed 73-1/-191--C Length of Field 22 I
Width of Field 4 dr Depth of Field /D
avel Bed Thickness ,A72 1(
Square Feet of Abscrption ea ?Oa Standpipes Present
Depression aver Field (.0)) Date of Last Adequacy Test N( Cc)
Results of Last Adequacy Test /(1/ /
Separation Distance frau Absorption Field:
To Water -Supply Wall /17 " To Property Line ...93 i
To Building Foundation .5, r To Existing or Abandoned System ai
Lot
; On Adjoining Lots /e20 7/_
To Cutbank(if present) • Ai hCh
Course Ai in
Storage Area 570 ye �/
/ )w 5ce /til
To Water Main/Service Line `..57' f -
To stream/Pond/Lake% Major Drainage
To Driveway, Parkarig Area, or Vehicle
Laments e) 41C/ screfc C,c
/E'QC✓
D. LIFT STATION
Date Installed Dimensions
Sim in Gallons o /Access (Y/N)
"Pump On" Level at " Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles daring Adequacy Test.
Electrical Codes(Y/N)
Ccu ants
**
Check Fermi
I certify
on the
Signe
Cavpa W r�
d Bedroaa Rating Against HAA Request
cke verified, or conformed to all MOA HAA Guidelines in effect
cn.
�,
Date 3-7--7--1
MOA No.
•
Meets MaA.
e. a.. L.JGI �eenu�a
i,p;• SRF.ISCX
RBl /d5/s 1 "1-E RNEr7. ALAs vA "5" i •Y. 654 7
(Page 2 of 2]
T¢
2-15-84
1
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