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Home My WebLink AboutDEER PARK BLK 3 LT 8 Municipality of Anchorage Page [ 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: ~:~(~-~C1'~-'-'~O~:~ I PIDNumber: .".~me~--1~¢''1~ ~ C~ ~'~ Wastewater System: D New ~pgrade ~o, ~ ~~ ~t ~l ABSORPTION FIELD Phone: I NO. ~edrooms: ~eep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from original gra~e: LEGAL DESCRIPTION S°ilRating: ~.~PDlSq Fl Lot: ~ Block: ~ ~d~ Depth lo pipe bottom from origi~a~e:. Ft G¢aveldepth beneath pipe ~¢Ft WELL: D New D Upgrade Gravel width: ~ / Number of lines: 1Distance ~twe~ lin~: Yietd: GPM Pump Set at: Ft. Casmg Height Above Ground:Ft. ' TANK SEPARATION DISTANCES ~'se~,,c ~~.¢ ~'~ s.~ TO Sephc Ab~rphon Lift Holding ~ub~ic/PrivateManufacturer: Capacity in ga~s: Surface Water [~+ I~ ~ ~ ~ LIFT STATION U~e ~G I( ~ ~ ~ · Foundation ~' ~' ~ ~ ~ "Pump °n"~Pump °fi" level at: I High water atarm at: Cu~ain Drain ~ ~ ~ ~ ~l ~ ~ Pu~& Model Electrical Inspections pe~ormed by: Remarks: ~~ I ~u~~ BENCH MARK Assumed Elevation: S & S ENGINEERING , ~; Inspections performed by: ~~+.,~~s: 1st ~[~, '-'~ -'"-~' Department of He Human Services approval , "~:~"~":'~-'~..,.,~..,. ... Reviewed and approved by: ~~,~ ~ Date: ~-2~-~ '":"="'"""" 72-013 (Rev. 9/91) MOA 25 P~r~it No. ,S~t~nnn ~ Page 2 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: PID No.: co~. CO1 ~ I ~_~ / [ ........... ~rELL 4 BDRM HOUSE DRIVE :I)2 //95,0 ~' 84.5' ~,--"78.§' NO WATER FOUND COZl ~5.~' I rtz' I co314t' I[to' I co4 I ~s.~' I t73.5'1 EX/ST. 1250 GAL SEPTIC TANK I~ELL RADIUS ' ' S SEAl. 72-013 A {Rev. 9/91J MOA 25 ROBERT SHAFER. P.E. ROGER SHAFER. P.E. May 10, 1993 CIVIL ENGINEERS (9O7) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER IA~IN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES J~ID REPORTS WELL INSPECTION & FLOW TEST Municipality of Anchorage Department of Health and Human Services Attention: Robby Robinson P.O.Box 196650 Anchorage, Alaska 99519-6650 RECEIVED MAY 1 1 1993 Municipalib/of Anchorage REFERENCE: Lot 8 Block 3 Deer Park S\D Dept. Health & Human Services Dear Robby, The work required on the conditional Health Authority Approval dated 1-4-93 has been completed. Attached is the on-site inspection report of the upgraded system. Please issue a final Health Authority Approval. rt A. Shafer, P.E. SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SrrE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RIVER, ALASKA 99577 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930001 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:REID GARTH & GAYLE OWNER ADDRESS:P.O. BOX 2603 KENAI, AK 99611 DATE ISSUED: 1/05/93 EXPIRATION DATE: 1/05/94 PARCEL ID:05104246 LEGAL DESCRIPTION: DEER PARK BLK 3 LT 8 LOT SIZE: 40000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM 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 (iSAACS0). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DURING THE INSTALLATION OF THE NEW DRAINFIELD, THE EXISTING SEPTIC MUST BE RELOCATED OUTSIDE OF THE 100 FT. PROTECTIVE RECEIVED BY: ~ec~ber 25, 199'~ ROBERT SHAFER. P.E. ROGER SHAFER. P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Mu~paIlty of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERFZCES 825 L S~e~ P.O. Bo~ 196650 An~or~g~, A~ 99519-6650 REFERENCE: Lot 8; Block 3; Deer Park referenced property.. On November $0, 1992 the ~/6t~ng l~ehfi~ld wa6 t~6t~d.. The ab6orptlon e. apcte, lty wet6 found to be. inadequate to obt. aln ct He. ztlth A~thority ApprouaL A 6oZl6 t~t wa~ performed ~nd th~ aXtached ~ite p~n/d~ign dev~oped.. We do not antlclpate any adver6e effects on the neighboring proper,fle.6 by the lnsta~on of the propo6e, d upgrade. If yo- have any q~e6tlon,s, or require adtLtio~ lnforma~on for your review, p~e.z~6e cont~c,,t ~6. ROGER J.. SHAFE~, P.E. RJS/tv 17034 EAGLE RIVER LOOP. SUITE 204, EAGLE RIVER. ALASKA 99577 I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alasl~a 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: LEGAL DESCRIPTION: L--~) *~'"~ "~:;;~'~/~;z'C,'~°wnship, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED?~ s L IF YES, AT WHAT O DEPTH? p E Depth 10 Water A..~.qu.~,?.l Monitoring? ~-~,'"¥~ ~( Date: SITE PLAN 3 4 5 6 7 8 10 11 13- 14- ~8 19 2O Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ (m,nutes~inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~:~ FT COMMENTS PERFORMED BY; S & S ENGINEERING i ~ CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River loop RoAd No. tO4 I \'~-..-' ~-.,F-~ -~ ~ ACCORDANCE WITI~d~t~i~J~'L~,Fr~A~[~I~I[,L~I~.,~I~ GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE 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 NAME PHONE Chad Erickson 688-2700I I--IUPGRADE MAILING ADDRESS SE2 Box 1424, Chugiak. Alaska 99567 LEGALDESCRIPTION ':Lot 8Blk 3 Deer Park Estates Peters Creek~ Alaska LOCATION NHN - Deer Park Drive~ in named subdivision I Well ~ Absorption area DISTANCE TO: q3' I 1OR" Menufacturer Liq. capacity in gallons IF HOMEMADE: Inside length Well Dwelling DISTANCE TO; Manufacturer Well Foundation DISTANCE TO: ]-08 m ~[,'), NO. of lines Length ofo~ch line Total length of lines Top of tile to finish grade Material beneath tile Length Width Deptt~ Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Driller DISTANCE TO: Building undation Material Steel IWidth - -- NO. OFBEDROOMS 4 PERMIT NO. R10926 No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons inches inches Nearest lot line Trench width PERMIT NO. R!oq?6 Distance between lines ] line Total effective absorption area 6O(1 so. ft. PERMIT NO; Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. :lc tank ~tion area{s) OTHER PIPE MATERIALS Plastic ASTM 3034 SOILTESTRATING [50 sq, ft./bdrm INSTALLER Tim & Chad Erickson (owner) REMARKS Request waiver of 100' separation between well and septic tank. Topo- graphy is such that contamination of well from septic system is very unlikely. Septic is located 93' from well. InsPected by John R. Chambers~/~/~ Donald E. BF~g~s-- ~'~""-/'~ '~ AK CE 4882 12/14/81 72-013 (Rev. 3/78) LEGAL Lot 8, Blk 3 Deer Park Estates Peters Creekt Alaska PERMIT NO. I-.1LI I'-.I T C I"'""R L I T%-' C~F RI'-.I~:I/"'.~RR GF DEPRRTMENT ._,r' HERLTH RND ENVIRONMENTRL pROTECTION 825 "L" STREET, RNCHORRGE, RK. 99501 264-4720 < 810926 ) RPPLICRNT LOCRTION LEGRL ERICKSON?CHRMBERS PETERS CREEK LE: B~ DEER PRRK EST 4_~21 IRENE DR LOT SIZE 44000 SQURRE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MRXIMUM NUMBER OF BEDROOMS = 4 SOIL RRTING THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH=._. o LEI'-.IGT H = 75 G R R'-.-' EL DEPTH= 4- THE LENGTH DIMENSION IS THE LENGTH <IN FEET> OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE E×CRVRTION (IN FEET>. THERE IS NO SET HIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE HINIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION <IN FEET>. REL-~. LI I RED SEF'T I C PERMIT RPPLICRNT HRS THE RESPONSIBILIT~r' TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF RNY HELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE HELL HILL SERVE, TI.40 ( ~:..-:., T [.ISPFmDT I O[4--~. RRE RE_rILl I RED BACKFILLING OF RNY SYSTEM HITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT HILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETHEEN Fi HELL RND ANY ON-SITE SEHRGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE HELL OR 150 TO 200 FEET FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HELL. MINIMUM DISTRNCE FROM R PRIVRTE HELL TO R PRIVRTE SEHER LINE IS 25 FEET 8ND TO R COMMUNITY SEHER LINE IS ~5 FEET. OTHER REQUIREMENTS MRY RPPLY. SF'ECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PERt.11 T E>(P I F.'ES DECErdE:ER _?-~t_.. -1 9e.-1 I CERTIFY THRT l:,I RM FRMILIRR HITH THE REQUIREMENTS FOR ON-SITE SEHERS RND HELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I HILL INSTRLL THE SYSTEM IN RCCORDRNCE HITH THE CODES. -?.: I UNDEF,'STRND THRT THE ON-SITE SEHER SYSTEM r'IRY REQUIRE ENLRRGEMENT IF THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST I-I SOILS LOG PERCOLATION TEST PERFORMED FOR:~ DATE PERFORMED:~ SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? .~1~ ~'? ~F IF YES, AT WHAT ,z~ P/Z-~ pEPSIn 1 2 3 4 5 6 7 8 9- 10- 11 12 13 14 15 16 17 18 19 20 .,Vo t O P E Gross Net Depth to Net Reading Date Time Time Water Drop I 8.~.~I ~:~ - ~" - PERCOLATION RATE ~ (minutes/inch) ~FT AND ~' ~ FT TEST RUN BETWEEN - ~ COMMENTS ~ PERFORMED BY= RTl I ~Z~o~'~ DAT : 72-008 (6/79) ... 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~'1~-~,- k-~(z3 HAA# GENERAL INFORMATION Complete legal desCription Lot 8; Location (site address or directions) Property owner Mailing address Day phone ~83-5188 285-5977 Lending agency NATIONAL BANK OF ALASKA Day phone Mailing address. Agent Ca~ol~/n G~u~¢n~ - RE/,~,X of EAGLE RZI/ER . Day phone Address '76600 C¢~te~ZeJM O~/.u~ Su.~ 201~ E~z,q£~ I~.% Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well. Public water NOTE: 694-4200 A~a6ka 99577 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/~1) Front MOA 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 ......... ,~,,,,~- -----, Address· Eagle i~iver, Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Mqnicipality 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}. Back MOAIt21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:~'~'r'~ ~;;~-I/-''5 ~;)E-~¢..~. ~-~l~arcel I.D. A. WELL DATA Well type ~"P(~t ,J Log present ~_.~N) Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cl o [c~-~5~ Driller X.~,~-~.., Cased to \ c~ ~5 ~ Casing height Wires properly protected (~/N) y Date of test Static water level Well flow Pump level .{ AT INSPECTION ecl -o~ FROM WELL LOG Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank I~ O SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Other bacteria $ & S ENGINEERING 17034 Eagle River Loop Ro~d No. 204 Eagle River, Aleaka 99577 Compartments Cleanouts~/N) High water alarm (Y/I~ Date of pumping Foundation cleanout(~)'N) "-/ Depression (y~)~ i .-, :':t :'. ' ;' '; Alar~ested(Y/N) ~'~ ~-~7-~3 Pumper, :3'"J~, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ o'z.- To property line \ o Surface water/drainage On adjacent lots Absorption field ~ c~-'- x 4-- Foundation 7..~ % lo ~'¥' * Watermain/serviceline_ ~.o ~'~' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level SE~ISTANCE FROM LIF'~_' sTA..TIoN TO: Well on lot ' ' On adjacentlois D. ABSORPTION FIELD DATA Date installed ;: /_~_ ~. c). c~.~ Soil rating Manhole/Access (y/N) "Pump on" level at: . ...'i, .~ .;~at ,,--'-"~~'~Cycles tested Surface water L~'hgth : ' I.~.~.p, Width ~"z'~ T.-~t ~al absorptioln area \.~ D(~pression ove~ field (Y~ Resulted(pasS/fail) ~'/'": C~'e~'/~r~- ,Syster~ type Gravel thickness" ~E> ~ ,Total depth Cleanouts present ~Y'N) ~/ Date of adequacy test for Peroxide treatment (past ,2 months)(Y/~ d SEPARATION DISTANCE FROM ABSORPTION FIELD TO: If yes, give date Wellonlot X~.~' Surface water Curtain drain To building fo, und, ation On adjacent lots "~'t ~ On adjacent lots ~c~,~ X-- Pr pertyline ~- _.,o ~, ~ To existing or abandoned system on lot Cutbank "[1~ Water main/service line Driveway, parking/vehicle storage ar;a ~,~ E. ENG'IN EER'S :CERTIFIC~,T'IO~I~0[! bedrooms I certify that I have checked, vexed to afl MOA and HAA guidelines in effect on the gate of this inspection. HAA Fee $ Waiver Fee: $ Date of Payment Receipt Number Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 8; Block 3; Deer Park Subdivision Location (site address or directions) 9~ D~,' Park Property owner Mailing address ~arth and Gall Reid Day phone P.O. Box 2603, Kenai, Alaska 99611 283-5188 hm 283-5977 wk Lending agency NATIONAL BANK OF ALASKA Day phone Mailing address Agent Carolyn Griener - RE/MAX OF EAGLE RIVER Address ._16600 Centerfield Drive, Suite 201, Eagle River, Alaska Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: Day phone 694-4200 99577 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 IRev. 1/91) Front MOA 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 ~ ~. s E,~IGINEERING 17034 Eagle River Loop Road No. 204 Address -_.~;!? ~!-~,. ~_1.,(~., 99577 Engineer's signature Phone Date \,~..-"~ 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. '~, Conditional approval for '¢'" bedrooms, with the 'following stipulations: Additional Comments Date J 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. , Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~ '~=~". ~ Parcel I.D. A, WELL DATA Well type~"~ ~'11~ If A, B, or C, attach ADEC letter. ADEC... water system number I '"'-'-' : " Logpresent~ig'N) ? , Date comp eted .~ ~(::~- I~..[ Drier \/~l~t-~t~',/'.~-~/l~' Totaldepth ~ ~ Cased to FROM WELL LOG Sanitary Date of test Static water level. Well fl0w Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ~ ~1 Casing height Wires properly protected ~;/~1) AT .,SPECTIO. g.p.m. ; On adjacent lots :' ; On adjacent lots · Public sewer manhoie/cleanout. 'Petr01eum tank WATER SAMPLE RESULTS: '~ ~---~'¢-" "l--'/~'~"~V'~' '"'~'~ ' ~ '~~ Coliform ~ Nitrate ;~. Other bacteria Date 0f sample:" ' ~' ~ ~ ..... ' Collected by: ~ ~ ~~. . ~,., ; , :, · . ' . . ~ato In~tallod [~ ~[~ ~ I Tank ~ize ~ Compa~m~nts High water 81arm {WR} ~larm te~ted {W~) ' Date of PumPing~.''' ~ ~ ~ Pumper ~'~ 8EPARATIO~ DISTANOfiS ~ROM SEPIIC/HOLDING TANK TO: On adiaeent Iot~ [ ~ Foundation To property line \ ~==.t..~.. Absorption field t_~.~ ........Water ~in]ser~ic'e line surf)ce water/drainage \ ~ {'''3r'' .... 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE ' C. LIFT STATION . ;* Date installed · · ' ' Size in gallons .. Vent (Y/N) High water alarm level Manufa(~turer~ '~ Manhole/Access (Y/N) "Pump on" level at ,pump off" level at Cycles tested Meets MOA'electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot Do ABSORPTION FIELD DATA Date installed =: -~ Length ;/' Wid TotaLabsorption area De~ssion,over field (Y~ ~ ReSults Peroxide treatm;~ (past 12 months)(Y~ On adjacent lots ' ' Surface W~te'r ~,, Soil rating ~ System type ~ Gravelthickness ' ,d~ Totaldepth Cleanouts present:~;~N) Date of adequacy test for ; if ye~,'give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Weiionlot \ ~ On adjacent l0ts ~ ~1~ Propertyline To building foundation ~_~__.. . To ex/isting or abandoned system on lot ,.., .. , ~ ..~ "~,_.. ~/,, . . . .. Onadjacentlots · - ,'?-.~ ~ ' Cutbank /'r",' , Watermain,/serviceline ' '. '1~ · ~ .... '/i " ~ . ' ' : -'" Surface water: ~, ~ "~ .... Driveway, parking/vehicle storage area bedrooms ...._ .... ~ : · -'~¢::,~..Y~;r' ~ '~:~v-r..~c,..~.~y ENGINEER'S CERTIFICATION ' ~ ~ ~' I certify that I ha ve checked, verified, or conformed to a, II .MOA, and HAA guidelines .in e. ffect on the date ~t~is in~. ~ection. ... $ & s ENGINEERING 17034 Eagle River Lo~p Road No, 204 Signature Engineer's Name HAAFee$ '~ 70,'~____~..~. Date of Payment Receipt Number , I Waiver Fe~: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 JAM ;)5 '93 i1:49 ~BA MORTGP~ LOA~ PRODUCTIC~ P.i 1-.5-93 Hunictpallt¥ of Anchorage Dapt o~ Envlrocmental Control Ac=enclon: ]~bble Robinson Loc 8, Block 3 Deer Park Estates Subd, accordtnS cb the o£ftclal plat i 79-7 Ratd/C~or & Havner Dear Mr. Robinson, Upon closing of a loan on this purchase transaction, National ~ank of Alaska will escrow funds co up~rade tb~ sepclc sys=em on she cap~toned p~oper=y. Vice President Alaska's Mo~t Cono~nlent ~k CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562-2343 AIO. LI$I$ t~.I$[][,TS ~oz I~VOIC~- ! 60528 Ch~leb lid.! 92.64t5 Sable ~ I Matrix: FAX: (907) 561-5301 Client Seaple ID : L$ IS DEli Pill S/D Client Name :8 & S I~GI#E~[I~ P~ID : UI Cliont Jcct :S~$E~CP Collected : 11/18/92 ! 17:00 h~s. IPO! : Received" : 11/19/92 { 15:30 h~s. Req! : Preserved with : Ordered ly :~. $1~IIR POI :NOk~ RECII~D Analysts Coapleted : 11/20/92 Se~d heports to: Laboratory Supervisor : $TIP[II~ C. IDI 1)3 & S I~I~I[ING Released Il :~.~/~ . 2) ParaMter Results U~ts Metho~ Allowable [t~ts ~H~-N ~C0.10) ~]1 ~PI 153.2/300.0 10 Twits Performed ' See Special Imtructton~ Above UA-Unavailable None Detected "Bee Sample ReMrks Above Not Analyzed ET-Less Than, GT-$reater Than ~,~SGS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) r' APPLI(" NT FILLS OUT UPPER ONLY ~roperty Owner ~',t~'~ ~. c~ /~".'/.re ~ ~ ~ ~ ~' ' , Phone Address /~.~ ~ /~ ~ Zip Code Len~ina Institution /~ ~ /. ~--~ ~/ /~ ~' Phone Address ~.~ ~ ~. '~ Zip C~e Realty CO. & A~nt Phone Address Zip ~e Type of Resl~nce ~ Single FamllV ~ Multiple Family No. of Bedroom. ~ Other Water S~pply . ~ Individual A~ACH ~LL LOG. A w~l Is for all wells drl~ed since June 1975. log required ~ Comm~ily For wells ~llled prior to that date, give well depth (attach log If available). ~ Public Utility Sewer Disposal ~ ~, When Connected to Public Utility: · , ~, Holdi~Ta~ ~ NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Dale Date Date Date Inspector Inspector Inspector Inspec~r Field Note~: ~f ( ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size Time Time 'ne Date Date Date Inspector Inspector Inspector Comments Date Sewer InstelledT~,~ Permit No. Septic Tank Size } ~- --~"1 Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank y,.~.,,,_., APPLICANT FILLS OUT LOWER HALF ONLY Buyer Lending Institution /~'/~,~'~, ~f~,,~.,~'/ ~ Phone Realty Co. & Agent Phone Address / ly~of Residence ~Slngle Family ~ Multiple Family No. of ~rooms. D Other Water Supply ~ Individual A~ACH WELL L~. A well I~ Is requlr~ for all wells drlll~ since June ~ ~mmunlty 1975. For wells drlll~ prior to that date, give well depth (attach log If ~ Public Utility available.) Sew~ Disposal ~ Individual Year Individual InstallS: ~ Public Utility When C~n~t~ to Public Utility: ~ Holding Tank NOT~ THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PRocE~ING CAN BE INITIATED.