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Home My WebLink AboutDAWN VILLAGE BLK 2 LT 9 SUBSURFACE EXPLORATION Shift Report of Operations PEDERSON CONSTRUCTION, INC. Da~u Subdivision, Lot # 9, Block 2 Domestic Well, 6" WESTERN STATES ASSOCIATES 22W 4. CONT~ACT NO. HOL[ NO, TO TII~IE DISTP, IBUTION HOUI~,S Herb Johnson RIG HOURS CASING' LOG NO. 7 10 11 12 13 16 11' 0" '0 ' 11 ??'l~ 83'0" 87'~" 90'9" 93' SOILS LOG. DEPTHS Pump tested at 12 gallon per minute. I"IATERIAL$ AND P, EI"IARKS Tight sand and gravel. No water. Tight sand and clay imbedded with gravel and rocks. No water. ~ater bearing gravel. DRILLER Water level 21 feet from surface. INSPECTOR. PERH ! T I~"ILJN I C I ;"].L I TY OF' DEPRRTHENT OF HEALTH AND ENVIRONHENTRL r'ROTECTION ~516 E. TUDOR RD., ANCHORAGE, AK. ~507 WELl PERr'I ( 77020 ) APPLICANT LOCATION LEGAL ~ETERSON CONSTRUCTION TESHCAR ST L9 B2 DRi.IN VILLRGE SRR 80X i718X LOT SIZE ~44-86~8 10000 SQUARE FEET HINIHLIH DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWRGE DISPOSRL SYSTEH IS ~00 FEET FOR fl PRIVATE WELL OR 200 FEET FOR R PUBLIC WELL. WELL LOGS RRE REQUIRED AND HUST BE RETURNED TO THE DEPRRTI~ENT WITHIN ~0 DAYS OF THE WELL COMPLETION. SPECIFICRTIONS AND CONSTRUCTION DIRGRRHS ARE AVAILABLE TO INSURE PROPER INSTRLLATION. PERI"1 I T ',,,'RI_ I D FOP. OI'-~E '-r'EFIR FROI-1 I _cJ--c:UE I CERTIFY THAT ~L: I RH FRHILIRR WITH THE REOUIREHENTS FOR ON-SITE SEHERS AND HELLS RS SET FORTH BY THE HUNICIPRLITY OF flNCHORRGE. 2: I HILL INSTALL THE SYSTEH IN flCCORDRNCE WITH THE CODES. RPPLZCnHT PE'~SON,; CONSTRUCT IbN MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-061-47 Legal description DAWN VILLAGE BLK 2 LT 9 Site address 6631 TESHLAR DR Anchorage AK Current property owner(s) ADLER Expiration Date: r 3 Zo2 -5- X The On -site system(s) is/are approved for 2 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 5/3/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE o Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 014-061-47 Complete legal description DAWN VILLAGE BLOCK 2, LOT 9 Location (site address) 6631 TESHLAR DRIVE, ANCHORAGE, AK 99507 Current property owner(s) AMY ELIZABETH ADLER Day phone 2. ON -SITE SYSTEMS SIZED FOR 2 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ® Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit r Waiver request for: IN � LL- � � UAL e L S l �= (L— /VI4 1 ni Distance: ZlU Expedited review requested: ❑ By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ 2.,S0 Waiver Fee $ /_115- Date of Payment COSA # 05 C 2 c.l 10!2 1 Date of Payment Waiver # COSA Application.doc COSA Checklist WELL ONLY.docx COSA Checklist Legal Description: DAWN VILLAGE BLOCK 2, LOT 9 Parcel ID: 014-061-47 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 1977 Total depth 93 ft Cased to 93 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 4/3/2024 Static water level at beginning of test 6 ft. Well production at time of test 5.9 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 0.687 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 4/3/2024 Comments __________________________________________________________________________________ B. TANK DATA – PUBLIC SEWER Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA - PUBLIC SEWER Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist WELL ONLY.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No NA ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No NA ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if N **40+ ft Community Sewer Manhole/Cleanout > 100’ Yes if No *50+ ft Private Sewer/Septic Line > 25’ Yes if No * ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS *WELL MET REQUIRED SEPARATIONS AT TIME OF INSTALLATION. ALSO, ATTACHED AWWU DOCS. **MOA WAIVER REQUESTED WITH THIS COSA SUBMITTAL. G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 05/02/2024 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 05/02/24 �CAnc S : Municipality of Anchorage �u} P.O. Box 196650 e 4700 Elmore Road Anchorage. Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV241017 COSA#:OSC241091 Permit#: P I D#: 014-061-47 Legal Description: DAWN VILLAGE BLK 2 LT 9 Engineer: First Water Consulting Your request for a waiver of the required 50 feet horizontal separation from the public sewer trunk to the private well has been approved. The approved separation distance is 40.0 feet. This waiver approval applies to the existing public sewer trunk only. Any future upgrade to the on -site wastewater disposal system will require all separation distances be met or another approval from this department. Waiver is Granted: X Waiver is not Granted: / Date: c3 � 2 y Approved by: Name of Reviewer .............................................................................. 1 **** VARIANCE/WAIVER REVIEW **** 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / FirstWaterAK@gmail.com May 2, 2024 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: DAWN VILLAGE BLOCK 2, LOT 9 – WELL TO SEWER MAIN Per the attached as-built survey by Shane A. Holt dated April 3, 2024, documents provided by AWWU and Municipality of Anchorage (MOA) On-Site record documents – we have generated a drawing of the water and wastewater / sewer systems serving this property. Separation requirements at time of sewer line install and well drilling was 50’ between the public sewer line & manhole (MH) to the private well. The closest existing MH was over 64’ to the referenced private well. Based on this information, we are therefore requesting a retroactive waiver of 40’ to the existing sewer mainline between the referenced well be granted at this time. Granting of this waiver is justified in the fact that the wellhead is physically located up gradient of the sewer line with no potential surface effluent interaction possible or reaching the wellhead. The recently submitted CAN water samples show no bacteria and nitrates were analyzed at 0.687 mg/L that indicates the subject encroachment has not adversely impacted the water quality for approximately 50+ years. The sewer line was constructed with 8” ductile iron pipe with joints encased in asbestos concrete to assure against possible leakage and per AWWU as-built & site survey is 43’+ from the well. The existing property has received several MOA approvals over these several decades. The MOA has issued other similar waivers in this subdivision such as #WR960057. To reiterate and per record documents, it appears the subject sewer mainline is watertight constructed, MOA has issued previous approvals, inspection reports, COSAs/HAAs along with MOA issued waivers and that numerous well logs show that the aquifer is protected via geological confining soil layers. There have been no known issues or influence over the past several decades from these encroachments. Granting of this waiver will not impact any of the neighboring properties. Please contact us if you have any questions. Respectfully, Curtis Huffman, P.E. Attachments: Well-Sewer Drawing FIRST WATER CONSULTING DAWN VILLAGE BLOCK 2, LOT 9 PRIVATE WELL TO PUBLIC SEWER WOOD FENCE ti 0 N 89 5720" W 91.86 10' UTILITY EASEMENT WOOD FENCE WELL \�F TESHLA R DRIVE DECK C/o SINGLE FA MIL Y HOUSE THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. EASEMENTS OF RECORD OR OTHER RIGHTS OF WAY, OR ANY ENTITY NOT ON THE RECORD PLAT ARE NOT SHOWN HEREON, UNLESS NOTED. NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. ANY PAVING SHOWN HEREON MAYBE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. ONLY VISIBLE IMPROVEMENTS ARE SHOWN HEREON CHAIN LINK FENCE WOOD FENCE �Q•�� OF A c'9, 49 TH// O N SHANE A. HOLT �� a Q4LS-6914 .... a o fessions\ boo ASBUILTSURVEY I" = 20` NO CORNERS SET THIS DATE 1 HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT9BLOCK2 DAWNVILLAGESUB. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 3 RD DAY OF APRIL 2024 HOLT LAND SLIRPEYING 9309 GROVER DRIVE ANCHORAGEAK 99507 223-8615 16022 236-20 ion < o z Q q m 4> IIIft1I21 s Hill 1111111 ti tiff I z N �$ Y� 0 J Z qi) N QHill U — N U a 8 y R P{ q4111111111111111114f "s it 11111111 lid 111111111M - Mi Mil 1111111111 All ]F, J TI 11111111111 111.11111 111,111 W o 11111 Hill _ hN zo 3Atl Yr¢i wvoi w111 W „� d as #f 0 i V to N 11 rh m Y +J % a CO 3 m .°" (Q� _ q — r IIIIIIIIIIIIIIINI s'cN' d IIIIIIIIIHNIIIIIIIIIWD �6oF E p F o�E33 It A 1111-31 111 1 11119 i QV a 11 11111111111111 111� I "IR1111119 1[ Ii A; IIIIIIHIIIIHIIIIII 4Y-,-i-a '•^ov' - J 9 €_ r N Mir .R'os<Z ti # f 1r TAX CODE Nod. Dim MUNICIPALITY { .fir ems* �"'+ x4� y 4:`- .� r e!' ` yt,t y+ -► r # '+• VNEEP"Mmummolo (9) P ANCHORAGE SEWER r - _ GRID No. UTILITY } PROPERTY= 6631 Name ddress G�1�� C f-ecz-4eF cct_No Plat No. Subd_ G*i L- � Lot Black Residential �� Commeriai 0 Industrial 0 Na. of units AE: oeael?! _j CON N DT S&E JPA J min Tap on Property Permit Flo_ Size Type Drawing No Size Main I Type Depth at Connect Insulation 0 Cleanus Type Connect en �� f Inspector 45= �,ADate �� omment � ■ ASSESSMENTSa L.l_ D. No. Private Dev. No. Su d. Agreement No. Severer Agreement 0 N. RTE. ED Roll No. DYE TEST: Positive Cl Negative Live N _ S.A. Date Page Igo-& M.H. No. Billing Cycle Tested Comments I I lv I L4ua Vli 10JIU03 to U 14 -1 MC L4 -Lis 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. # (~ ~-I - ~2)t~ \- ~-~"~ 1. GENERAL INFORMATION Complete legal description Lot 9; Block 2; Dawn Village Subdivision Location (site address or directions) 6631 Teshlar Circle Property owner Mailing address Lending agency Mailing address Mauser and Hankins Day phone C/O Charlene McLean/2001 Realty 2600 Denali Street ~400 Anchoraqe, AK 99503 Day phone e Agent Charlene McLean/2001 REALTY Address 2600 Denali Street ~400 Da~"p-~ne 276-2001 Anchoraqe ~ AK 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY:. Individual well XXX Community well Public water NOTE: If community wel! system, provide written confirmation from State ADEC attest- ing to the legality and status of system. If community wastewater system, provide written confirmation from State ADEC ' attesting to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: 7~-02§ {Rev. 1/91) Front MOAI21 o 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 inves.t~ation 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. ~$ & S ENGINEERING Nameof Firm J_?0?4Ea leRiv , ..._ Phone Address . Engineer's signatu~ ~ DHHS SIGNATURE .~ . Approved for '~=~- ~'~) bedrooms. Disapproved. Conditional approval for 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. 72-02~ev. 1/91) B~ck MeAl21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /.~7' A. Well Data Well type Log present~N) /~U,~'~ 7_. /~r~,./,,J {/((J./~(,E' Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed Iq~ ~ Driller Total depth f.~ ~ Sanitary seal~_~N)'~'~---~ Cased to g.p.m. ~'..~ ~' Casing height E~' Wires properly protected (~) AT INSPECTION g.p.m.~ ~ ~ > FROM WELL LOG Date of test Static water level Well flow Pump ~even ~ SEPARATION DISTANCES FROM WELL TO: Septi~olding tank on lot Absorption field on lot ~o~ Public sewer main 5~ / Sewer se~ice line ~/+ ; On adjacent lots ,,Uo,,,~£ ~,,r.~3'~'-,',J./ ; On adjacent lots Public sewer manhole/cleanout ~-:::,d,., ~' ' Petroleum tank WATER SAMPLE RESULTS: Coliform ~///OO ~ , Date of sample: C> Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Tank size Compartments (Y/N) Foundation cleanout (Y/N) D~ Cleanouts High water alarm (Y/N) ~ ~ Alarm tested~)fJN~~ ~;'{~':~ F.;~:~!:- :, :. .', SEPARATION DISTANCES FROM TO Well(s) on lot n adjacent lots Foundation To property line_.~...--/ Absorption field Water main/service line r/drainage 72-(326 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION ,/L/c,~ F/?-~'%C'''T'J'T~' ' ";' Date installed Manufacturer ~ / Size in gallons Manhole/Ac._cess ~ Vent (Y/N) 'Pump on' level at ~ 'Pump off' Level at High water alarm level ,.-"'"'"""'""~ Cycles tested Meets MOA electrical ~o~~ SEPAR~NCE FROM LIFT STATION TO: ~ot On adjacent lots ,Surface water D. ABSORPTION FIELD DATA/t.J~,,x./~_~. f°/'~$E-/,.J~' ~ Date installed ', Soil rating (GPD/FF) System~type _ width Gravel thickness Total~ _ Length Total absorptio? a~'ea Cleanout present (Y/N) Depr.~,~ion over field (Y/N) Date of adequaCY test Results (pass/fail) J for. Bedrooms Water level in absorption field before test fter test Peroxide treatment (past 12 months) (Y/N) j ,If yes, give date SEPARATION DISTANCE FROM ABSORP~ Well on lot__ ~ ~~jacent lots ~ Property line To building foundation f To existing or abandoned system on lot On adjacent lots / Cutbank Water main/service line Surface wa~ter .'"~. Driveway, parking/vehicle storage area E, ENGINEER'S CERTIFICATION I cer~fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect oQ.th ~ .date'S, this inspection. Date / ~ ./~.f~ ? ~ '~::.,... _, .-~ t~,' H~ Fee $ / 70. ~ Waiver F~ $ Date of Payment ~--~ Date of Paint R~eipt Number 2~ 7~-~ ~ ~D ¢ ~ Receipt Numar 72-Q26 (3/93)° Back Parcel I.D. # 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 HAA # ~:~o~ ~ ~ 1. GENERAL INFORMATION Complete legal description Daw~ Villaqe Lot 9 Block 2 Location (site address or directions) 6641 Teschl,3~, 7Lnchoracje Property owner Mailing address Lending agency _N/A Mailing address ::i]-.c rick/~_h~/J'/'~.,~q~ Day phone N/A c/o Vista Realty, 621 W. Dimond Blvd., Anchorage, AK 99515 Agent William de Schweinitz Address ~,91 w. n~rn~n~ Rlv~-. An~horRg~: AK 99515 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well X Community well Public water Day phone Day phone 344-9603 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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, 72-025 {Rev. 1/91) Front MOA 1~21 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 regula~r~..~ ~v~f~eB~G~,r[l~bdsa~,~Et~is inspection. Name of Firm EAGLE RIVER, AK 99577 phOne P. O. ~OX 7732~4 Address 694-5195 Engineer's signature Date ~"///?,/ DHHS SIGNATURE Approved for /;~'~77 bedrooms. Disapproved, Conditional approval for 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. 72-025(Rev. 1/91) ~ck MOA#21 Legal Description: A. WELL DATA We,i tyPe. ff'+-.~/~ Log present (Y/N) ,~' Total depth ~'.? · Sanitary seal (Y/N) Municipality of Anchorage Department of Health & Human Services ~"¥""" ..... HEALTH AUTHORITY APPROVAL CHECKLIST ~-N,~r^L sr-~ ;:~_,..; ~;,,~,cl : ' RECEIVED If A, B, or O, attach ADEC letter. ADEC water system number Wires pr'0perly protected (Y/N) Date of test Static water level Well flow /.2 ~'~/.., Pump level FROM WELL LOG AT INSPECTION / ~; ~ :, ~/.~o/~ r · ~" ~ .z '" g.p.m. ~- ~ ..g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank On lot "~' ~ Absorption field on lot ~"'""~- Public sewer main ' ~'"'~ / Public sewer service line ~' / ; On adjacent lots ~'""-"~'- ; On adjacent lots ' ~"/'~° ' Public sewer manhole/cleanout ~'~ ,e~ r, Petroleum tank /~'"'"~ WATER SAMPLE RESULTS: Coliform Date of sample: '(-./z/'~ ~,/'~ / Nitrate )')~ ~'~~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping .~' Tank size Compartments Foundation cleanout (Y/N) Depression(~/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ~Vell(s) on lot To property line Surface water/drainage 72-026 (Rev. 3/91) Front MOA 21 On adjacent lots Absorption field ' ' Foundation ~ Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed .Size in gal!ohs Vent (Y/N) H gh water a arm level "Pump on" level at Meets MOA'electrical 'cOdes (Y/N) '" ' ' S FROM LIFTST''IAT O'-N '' SEPARATION DISTANC TO: 10ts Well on lot On adjacent ABSORPTION FIELD - Date installed Length Width Manufacturer 'Manhole/Access (Y/N) "Pump off" level at Cycles tested Soil rating Gravel thickness Surface water - System type · · Total depth Total absorption area "- Depression over field (Y/N) .... Results (pass/fail) Cleanouts present (Y/N) Date of adequacy.test for Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: If yes, give date bedrooms Well on lot "- On adjacent lots Property line To building foun. dati0n To existing or abandoned system on lot On adjacent lots ~Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guideli'ne-s in effect orztb¢date of this inspection. Signature Engineer's Name ~ ,~~'.~ . 5o~.~ ..... ,..:.~_ Date · Waiver Fee: $ Date of Payment / /' ,'" '"'X Date of Payment R,~ceiptNumber. ,,~-~-~--7 C-~ ~ ~) Receipt Number 72~26 (Rev, 3'91) Back MOA 21 ~ A i' '" ng ' F, ag! River R ineering Services 11940 Business Blvd, Suite ~205 P.O. Box 773294 /e~=~;er- Eagle River, Ak. 99577 694-5195 Fax 694-3297 Date: Meter Well GPM Tir~e Reading Level ~:~'~",.I,. l l, r /~o ~ ~ " 7,~ Meter Well GpM Time Reading Level · ** MUNICIPALITY OF ANCHORAGE t DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete MI part~ on page 1. focomplet~ mqu~ will not be proce~Md. Please allow ten (10) clayl for proce~ting, 1. PROPERTYOWNER ~ PHONE M~ILING ADDRESS PROPerTY RESIDENT (if different from above) PHONE 2, BUYER ~ ~ ~ '~HONE MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE I MAILING ADCR~ 4. REALTOR/AGENT I PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION TYPE OF RESIDENCE [~r~ SINGLE FAMILY D MULTIPLE FAMILY 7. WATER ~UPPLY ~" ]' INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE OISPOSAL SYSTEM [] INDIVIDUAL/ON~ITE** PUBLIC UTILITY NUMBER OF BEDROOMS [] One [] Four [] Other r-I Two [] Five ,~ Throe [] Six * ATTACH WELL LOG. A well log is required for all wells drilled since June 1976. For wells drilled prior to that date, give well depth (attach !og if available.) , **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 724)10(3/78) , / THIS SIDE FOR OFFICIAL USE ONL~ / - -.., DATE RECEIVED INSPECTION APPOINTMENTS ~'~Px~ ~-~.~ TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS I--i SINGLE FAMILY [] ONE [~ THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [~ COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED •PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL ~,. DISTANCESwELL TO: Septic/H°lding Tank IAbs°rpti°n Area ISewer Line INearest L°t Line Absorption Area to nearest Lei: Line B. COMMENTS [~] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev. 3/78)