HomeMy WebLinkAboutMOUNTAIN PARK ESTATES BLK 13 LT 7PERHIT NO.
[:'EF'K~RTH?IT ~ HEK~LTH RNC, EI'-,IV I R. ONMEt"!TRL f'"~iOTECT I 0N
~..Z5 ". ~ STREET.. RNCHORFIGE,
264-472A
( B207t0 )
RPPLICFINT
LOCFiT I ON
LEGFtL
PFtUL I"ICOUILLIN
L?E',~ MT PRF.:I< ESTRTES
LOT SIZE
264-4401
999999 SOURRE FEET
TYPE OF SOIL RBSORPTION SYSTEI,I IS: TRENCH
MR,.,IMUM NLIHE:ER OF BEDROOMS = 4
SOIL RRTING
THE REQ. UIRE[:, SIZE OF THE SOIL RBSORPTION SYSTEM IS:
DEPTH= 2 ~-Z'~ LEr4ISTH= '"'~=: 4 ~3 R I-/'..-' E L DEPTH= 6
THE LEHGTH DIHENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR F'IT IS THE DISTFtNCE BETHEEN THE SURFRCE OF THE
GROUND RN[> THE BOTTOM OF THE EXCRVFITION (IN FEET).
THERE IS HO SET HI[>TH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUH DEPTH OF GRRVEL BETHEEN THE OUTFFILL PIPE
RND THE BOTTOH OF THE EXCR\,'FITION (IN FEET).
F~:~l_--~..l_l I F-."FC-, SEPT T I~ TR[-4~( S [ ZE= -1 25~_"~'1 1.3FtLLOr-~S
PERMIT RPF'LICRNT HRS THE RESPONSIE:ILIT¥ TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RNY HELLS RDJRCEHT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE HELL HILL SER\,'E.
TI.,]C~ ,-:z'; .-', I I'-,ISPEI~:T 1' C~t'-,IS RF:E F:FC..!I_I I RED
E:FtCKFILLING OF RNY SYSTEM HITHOUT FINFIL INSPECTION FIND RPPROVRL 8~ THIS
DEPFtRTMENT HILL BE SUBJECT TO PRASECUTION.
HINIMUr,1 [>ISTRHCE BETHEEN R HELL RN[:, RNY ON-SITE SEHRGE DISPOSRL SYSTEM IS
100 FEET FOR R PRIVRTE HELL OR ~50 TO 200 FEET FROM R PUBLIC NELL DEPENDING
UPON THE TYPE OF PUBLIC HELL.
MINIMUH DISTRNCE FROM R PRIVRTE HELL TO R PRIVRTE SEHER LINE IS 25 FEET RND
TO R COHr. IUNITY SEI4ER LINE IS 75 FEET.
OTHER REQUIREMENTS r,lR¥ RPPL'¢. EF'ECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVR!LRBLE TO INSURE PROPER INSTRLLRTION.
F'FRI'.I I T E.'--.' P I RES DECEI'dE:EF..: '~:-,1 . 2_L.-~. E:2
I CERTIFY THFIT
· ~: I RM FFIMILIFIR HITH THE REQUIREMENTS FOR ON-SITE SEHERS RND HELLS RS SET
FORTH E,'Y THE MUNICIPRLITY OF RNCHORRGE.
2: I HILL INSTRLL THE SYSTEM IN RCCORDFtNCE HITH THE CODES.
_"Z: I UNDERSTRND THF~T THE ON-SITE SEHER SYSTEM MR¥ REQUIRE ENLRRGErdENT IF THE
RESI£,ENCE IS, P. cBEP~;E~ELE[~.TO INCLUDE MORE THRN"'4' BEDRCIOr,IS.
......
FIF'PLi~C:I~I'.IT-~ PRUL MCQUILLII".I
V4. 0
.~,.~' GRE~,.ER ANCHORAGE AREA BOR~J. GH
Department of Environmental Ouality
3330 C Street
Anchorage, Alaska 99503
INSPE. CljlON REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK.:
DISTANCE NUMBER OF
FROM WELL /~//)~"7'--MANUFACTURER ~--'"~ MATERIAL ._~T~---~-~_/
COMPARTMENTS
INSIDE LENGTH ~" INSIDE WIDTH ~'- LIQUID DEPTH ~ . LIQUID CAPACITY~(-~GALLONS.
DISTANCE FROM WELL/J/~ ~ .FOUNDATION ~/
NUMBER OF LINES / DISTANCE BETWEEN LINES
ABSORPTION AREA ~'~O ,~'/ SQ. FT.
DEPTH: TOP OF TILE TO FINISH GRADE ~
TOTAL LENGTH
NEAREST LOT LINE~ / OF LINES ~1~
DEPTH OF FILTER
MATERIAL BENEATH TILE '7'"~--' IN. ABOVE TILE '~ IN.
WELL: ,1/\ ~.r
TYPE __'~J_]~.Z~- CONSTRUCTION ~' ~'~-~ DEPTH 5 _ DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC / SEEPAGE
FOUNDATION ~ LOT LINE ~, SEWER LINE. ~ TANK /~ , SYSTEM //~ /
CESSPOOL .-------------'; OTHER SOURCES
APPROVED ~ DISAPPROVED
SEWER LINE DEPTH:
PIPE MATERIAL:
S,OPE:
REMARKS:
Form
,,.o.,_.,,,,'
DIAGRAM OF SYSTEM
�,W�
� � �.
�Il41�'i7 i71L=� Qu
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 167 feet,
DRILLED AT THE RATE OF $17.00 PER FOOT.
PROPERTY OWNER Mr. Jim Joke
LOCATION OF WELL SITE Lt.- -j Blk. (?.3 Sub: Mt. �k
DRILLER Bernie Claus of Rampart Drilling Works
4.
.WELL LOG:
0----621 Sandy clay: 15% gravel
• Y
62---140' Clay. Several cobbles 104 sandy gravel
140--1651 Sandy gravel. Wet. traces of water but no production.
165--167' Sandy silty water producing 5GFH. Cased to 167 feet to shut off the silt. "..
�Y
_ Good water bearing gravel at 167 to 168 feet. 17 foot head stand. Pump should be
installed two feet off cased bottom of 167 feet. Top of casing measurement: Pump
intake three feet off bottom;
Cost of Drilling: $2839.00
. Well Seal: $22.50
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF $2861.5o
THANK YOU VERY MUCH.
BER CLAUS OF RAMPART DRILLING WORKS
DATE may 26th.76
SERVICE CHARGE 0 F IV1% PER MONTH WILL BE ASSESSED ONPADUE A OUNTS.
. DEPRRT['IENT OF HEALTH AND ENVIRONMENTAL PROTECTION
276-2221
L4ELL Rf4B, ON--S I TE SEI*IER P~RM I T
PERMIT NO. (76066)
~OycE 8t~II_OER~ SRfl BOX ~77B 24,18882
LOCATION ALPINE & CRESTVIEN
LEGAL L7 Bi~ MT PK EST
LOT SIZE 26688 SQFT
TYPE OF SOIL ABSORPTION SYSTEM... TRENCH
NUMBER OF BEDROOMS 4 SOIL RRTING, SQFT/BR_I¢O~__. ~ ~
':~MINIMUM DEPTH OF 6Rfl~,,'EL BETHEEN THE OUTFflLL PIPE fiND THE EXCAVATION BOTTOM
THERE IS NO SET HIDTH FOR TRENCHES. FOR DRRINFIELDS, THE HIDTH IS ~FT.
THE DEPTH OF TRENCH OR PIT IS THE DISTANCE BETHEEN THE GROUND SURFACE AND THE
BOTTOM OF THE EXCAVATION.
THE LENGTH DIMENSION IS THE LENGTH OF EACH SIDE FOR R SEEPAGE PIT OR THE
LENGTH OF THE TRENCH, OR DRRINFIELD.
THE REC!UIRED SEPTIC T8NK SIZE IS i25~ GALLONS
BACKFILLING OF ANY S~STEft HITHOUT FINAL INSPECTION BY THIS DEPARTMENT HILL
BE SUBJECT TO PROSECUTION.
lilNIIiUM DISTANCE FROM HELL TO tiNY SEPTIC TANK/PACKAGE PLANT OR SOIL ABSORPTION
SYSTEI4 IS iBB FT FOR R PRIVflTEHELL AND 20~. FT FOR R PUBLIC HELL.
HELL LOGS ['lUST BE RETURNED TO THE DEPARTMENT HITHIN ~8 DAY~ OF THE HELL
COMPLET I ON.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS fiRE AVAILABLE TO INSURE PROPER
I NSTRLLRT I ON.
I CERTIFY THAT I RM FAMILIAR HITH THE RE~.UIREItENTS FOR ON-SITE SEHERS AND HELLS
AS SETFORTH BY THE MUNICIPALITY OF ANCHORAGE AND HILL INSTALL IN ACCORDANCE
HITH THE CODE.
..... ....
N
CRESTVIEW DR.
Log Represents
Location of Test Hole
Lot 7 Block 13
Mountain Park Estates
T.H.1
·
Consultants Inc.
V~ ,.c.a,,e, r,me4.Ks ALASKA
3-5--76 !TM 1" = 3' I~ S,
T.H.1 ·
'" 0.0'
ORGANICS (PT) 0.5'
ORGANIC SILT W/SOME SA}~D (ML)
1.0'
SANDY SILT W/SOME GRAVEL
(Mi,) ')
,3.5' ..
SILTY SAND W/SOME
GRAVEL (SM)
SANDY SILT W/TRACE
GRAVEL
9o0~
1-1-0'
SILTY SAND W/
so'~ ¢~vzr.- (SM)
No Water Table
]9.0' T.D.
JUNEAU
Joyce Construction Co.
Log of Test Hole
Anchorage, Alaska
E P LRtJS
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. 017-391-55
1. GENERAL INFORMATION
Expiration Date: d — I — zoZy
Complete legal description MOUNTAIN PARK ESTATES BLOCK 13 LOT 7
Location (site address) 13101 ALPINE DRIVE, ANCHORAGE, AK 99516
Current property owner(s) MATTHEW & JENNIFER COAR Day phone
Mailing address
Real estate agent
13101 ALPINE DRIVE ANCHORAGE, AK 99516 ;
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5-56 Waiver Fee $ '
Date of Payment i b�q�'� ( O! Date of Payment
Receipt Number (��1151co Receipt Number
COSA # 050CIL 1U_-( 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4661 NATRONA AVENUE, ANCHORAGE, AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON, PE Date 10/7/2019
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 * "C* 9 TR it
well and septic system. Therefore, any 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 FWf5 and Anderson Construction & Engineering.xctuft X. AKifOx`
l X'1+1 Ct 9040
DSD SIGNATURE ! 10/7/19d.r•'
./
System #1 Approved for bedrooms �`
System #2 Approved for bedrooms
Disapproved
��t�uccrrrrr
Conditional approval for bedrooms, with the following s�#li{i i:OF
�� �' moi•
WA SITE �y
VVVA D m
� S��W.4
ROGf?
AM
p
BOriginal Certificate Date:
The Municipality of Anchorage 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 X
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: MOUNTAIN PARK ESTATES BLOCK 13 LOT 7 Parcel ID: 017-391-55
If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 5/26/1976
Total depth 167 ft
Cased to 167 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 9/26/2019
Static water level at beginning of test 148 ft.
Well production at time of test 4.8 gpm
Comments
B. TANK DATA — 5/26/2009 - 1250 GAL
Age of tanks) 10 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 49"
® Standpipes/foundation cleanout per record drawing !
Date of pumping 9/26/2019
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® Nc
® Coliform bacteria is Negative
Nitrateq•S mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
WC 5
Collected by
Date of Sample 9/27/2019
C. LIFT STATION
® Required maintenance completed
Age of lift station 10 years
Lift station material Fiberglass
Comments: See maintenance log.
D. ABSORPTION FIELD DATA — 77'L x 2.5'W x 10'ED — 0.45 GPD/SF = 1540 SF
Which system tested (date installed) 5/26/2009
® ALL standpipes present per record drawing
Total measured depth from grade 14.5-15.25 ft (max)
Measured depth to pipe invert from grade ft (min)
® N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Adequacy test date 9/26/2019
Results M Pass For 4 bedrooms
Fluid depth prior to test 0 / 0 in
Water added 600 gal
New depth 11 / 13 in
Elapsed time 1080 min
® Code -required soil cover over field Final fluid depth 0 / 0 in
❑ System presoaked Absorption rate 600 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced gallons WE
Comments/Deficiencies:
COSA Checklist copy 3.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes
if No ft
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
® Yes if No ft
Property Line > 5'
® Yes
if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes
if No ft
Private Wells > 100' ®Yes if No _
Water Main > 10'
® Yes
if No ft
Community Wells > 200' ® Yes if No _
Water Service Line > 10'
® Yes
if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No * 6
ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No _ ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
"2009 lot -line waiver.
G. ENGINEER'S CERTIFICATION
1 certify that 1 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.
COSA Checklist copy 3.docx
OF
49TH
MICHAEL N. ANDERSON:
No. CE 9469
10/10/19'. G4'
�FEssto��`ti
ft
ft
MUNICIPALITY
r�
AC
Development Services Department �_ / Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Owner
Septic Tank:
-Sludge level 0 inches
Lift station:
Lift Station/Pump Vault
Maintenance Log
Street Address _,310% A! am,
-Pumping-, required es no -Pumping completed (g no
-Pump basket cleaned yes no �tb2 •Effluent filter cleaned es o
-Control floats cleaned s no -Proper float settings confirmed @L no
-Operation satisfactory e no
Alarm System:
-Dedicated electrical alarm circuit e no -Audible and visual alarm inside dwelling es
-Alarm system operation satisfacto not satisfactoryW0+_
Manhole Riser
Ground water intrusion at riser to tank connection es no
-Ground water intrusion around pipe penetrations es o -Weep hole functional es no
-Manhole lid: Functional e no Insulated es no Properly Secured e no
Other
-All manufacturer required inspections and maintenance completedey s no
Comments:
Qualified Maintenance Provider:
Technician �A Cri, � J,, -
Company �, ur-S•
Signature
Date of maintenancelt51
Date ��
DEVELOPMENT SERVICES DEPARTMENT
On -Site water and Wastewater Section
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC191476
Subdivision: Mountain Park Estates, Block: 13, Lot: 7
.i�
A water sample revealed a nitrate concentration of 9.75 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
M�I�n Adss Box 19�65QC�orage, Alis a'5�66St} * �trww muni or ��
Mail!'�
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
'Tr-3ro:a'�'.'3`Ar amu.'
~ :.:?' ' ' MUNCPALITYOFANCHORAGE .... : ~.:.' ;'_~:':':':'T'. ,- .;' ;
. ... ~,~JJ~'~_ ,I .~:' DEPARTMENT OF HEALTH & HUMAN SERVICES
';:. ;~ ............... . ..-.. :*. ...... : - ..,.. .
_- .~ ;5.~;:..,- .*%~i*' ,, '., ' , .... . ,I ~ .:', ..:..,:.~ .
;~'/~:~;~' ~ P.O. Box'l~0 Anchorage, Alaska - 9951~0 .... ;' '-'~? :t-::~-;' 'tt~ ;;: ~ .....
;<'" ~ =" ~';" :: "APPROVAL FOR A SINGLE FAMILY DWELLING "'*' ':'
...... : .... : _T.ff.;:: .............. . .... .:: ::": ....... ;.';.~
........ ..:>..~'.~_::. v ..~ .... ~'~'r--'.'r'" '. 'Z:.:':i ' ~ ........... ..:J
1. GENERAL INFORMATION
· - .-'ComPlete,legal description
. 7~.~;~ :..~' ~ ~.~'~..~'~.
Day phone
Day phone
-~ ..~ ........ Agent. ,~*~ ~e ~ ". Da one;..
...................................... Communi~ well ...........................................................
':~ ~ :;';':':-';~5"?:~:~0~i~:~%~~i ~tem, provide w~i~n confi~ion from'st~e ~D~C~-
. ,~ r -z NOTE: -" If commum~;~stewater system, prowde wn~en confirmation from State ADEC :~,-~ :~: :.':~.
' ".': :' : ' _i '.::' :':: · :' 'a~estin~to the legali~ and status of s~tem. '" ....... :":' "~ ..........
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 verifythat 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.
NameofFirm '=~o-ev1' <:~'~,jr~'.._[~.J~.~_ Phone
Address ~fl.e.~ tjZ/I~"'/-G pt ~-6 ~
Engineer's signature' '~"~ ~ Date
- Approved for ..... f bedrooms.
- .'..':~'.-~*'.~: ...... D sapproved.*: ..... '* :'-~:~ .;* ~, ..... .. - - .... ' '~'~ - ~*' ........ '**':
-- -~_..:;::-_-.--_-:~.Z= - Cond~bonal approval :for~ ..... bedrooms, w~th the following st~pulahons:-:~::~.~.~
' *"-' '"" "* -*;* ~;~;i~ Additional Comments ~ ........ '=~' ............ ' ................ '-" ' ............ ' ~'*
......... : ...... *. ,=,~ . ,... ........ ~Z'C;.. ,.'.: . :.
Muh'~cgpal,ty;, of An.ch.orage Depa,'b,,ent of Health and Human Serv,ces (DHHS) Issues Health
e
Authonty
: ' ":',,~,pprOval (~rtificate~:'~,~l only' .bPOn'the representations givenin paragraph 5 *above by'an IndePendent
professional eng ,n, eer registered in the State of Alaska. The DHHS does th~s as a courtesyto purchasers of homes
and their lending inst~tubons 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 p.rofe~s...i0nal eng!n .ear's wor~.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICER
.. Environmental Services Division RE CE I V E D
825 L Street, Room 502 · Anchorage. Alaska g9501· (907) 343.4744
SEP 2 8 1995
_ Munic,palib, o! Anchorage
Health Authority Approval Checklist Dept. Health &Human Services
A. WELL, DATA
Well ~ '-~
Log pmsem (Y/N)
Total depth
ff A, B, or C, attach ADEC lette~. ADEC water system amaber ~'~/Ar
Date completed
FROM WELL LOG
Wires properly protected (Y/N) X
AT iNSPECTION
Date of test
Static w~ level /~-O
Well production ' _~
Nitrate
WATER SAMPLE RESULTS:
Coiiform ~/ ;q
Date of sample: i2-
Be
SI[FI'lC/HOLDING TAN~ DATA
Date installed ] ? 7 ~' Tank size ]~. ~g) Number of Compemncnts p~ Cleanouls (Y/N)__/y___
Depression (Y/N)
Foundation cleanout (Y/N)
Date installed
Length 7t_~ t Width a(2 I Gravel thickness below pipe ~ I Total depth
F-ffeCtiW abso~)Qoa
P~ ~cnt
Do
Date i,smlled
Manhole)Access (Y/N)
Size in gallons
"Pump on" I~vei at*
"Pump ofT' level at*
High water alarm level at*
Cycle~ tested
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding lank on lot ~ [ 0'0 /
I
AbsorptiOn field on lot ~ if ~
Public sewer main (q/Ac
Sewer/septic service line ~ 10'e.)
: On adjacent lots
: On adjacent lots
Public sewer manhole./clednou!
Lift ~fion
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation .~ Propert~ line ~ / 12) Absorption field
Water main/service line )o9.=~ Suffaccwater/dminage I'~/{Z) Wells on adjaeent lots
SEPARATION DISTANCE FROM ABSORPTION FII~-LD ON LOT TO:
Building foundation
Smface water
Curtain drain
Water mnin/scn4ee line ~ ~
Driveway, parking/vehicle storage ama ~ '-~ O
Wells on adjacent lots > / ,.'.'.~O riu~ny line [ 13
Fo
I certify that I have deterrmned thru field mspect~ons and revtew ofMumctpal recor~tbat4ttd ~b~e .svat~ns ar~e.
tn conformance wtth ,~lOd HAA gmdehnes tn effect on thfs date. / r~' c2, :" *', - ',,..-~"
HAA Fcc $ Waiver Fee $
Date of Payment
Date of Payment
R~pt Number
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Tobben Spurklarid P.E.
hLAA b. OT "~ BM
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received September 28, 1976
Time of Inspection 1=30 p.m.
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
9-28-76
Buchholz
1. Approval requested by:
e
Be
Mailing Address:
Property Owner:
Mailing Address:
Joyce Builders
Star Route A Box 3778
Phone:
Phone:
344-8883
Legal Description: Lot 7 Block 13 Mountain Park Estates
Location: Alpine on Crestview
Type of facility to be inspected
Well Data: Individual
Sewage Disposal System: On-site system
Sinqle Family
No. of bedrooms
, Sewer Lines
B. Depth 185'
D. Bacterial Analysis
A. Installed 1976 B. Installer
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
C. Absorption area to nearest lot line
, Absorption area
Other contamination
, Absorption area
EQ-034 (1/74)
Page 1 of two pages
.Pag~ 2 of two pages . R~e,~"~st for Approva'l of Individual .'"~er & Water Facilities
Legal Description Lot 7 Block 13 Mountain Park Estates
Conments
Approved
· Approva~lid for one year from date signed
Greater Anchorage A~a Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO , VA
2. Proper~Owner:-~-'~\?,, ~t \~
MailingAddress'~ ',~-~;)-I~'~' I~ .~7 7 ~
3. Name of Buyer:
Mailing Address:
4. Name of Lending Institution: ~ , ~. , ,
o
:FHA~CONV
Day Phone:..-~q q- 0C~oD<;~ ~
Day Phone:
Mailing Address:
Name of Realtor or Agent:
Phone:
Mailing Address: Phone:,
Legal Description: ~._~_~_ r-/ ~'-b~. \--~ ~'~, ~)O~'~C_
Location: r lp, ,
e
Type of Facility to be Inspected:
Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System:
Public Utility
If Individual, date of installation (/~ -- / ~:~ 7~-~
No. Bdrms. ~
Individual
Individual (on-site) t'//
72-003(3/76}
