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HomeMy WebLinkAboutHULSE #2 LT 1Hulse #2 Lot 1 #050-521-78 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231170 PID Number: 050-521-78 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Patricia Natale A ORPTION FIELD Existing 01] De Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 25301 Cates Ave Other Phone Number of Bedrooms Soil RatingTotal depth from original grade 3 D/S F Ft. LEGAL DESCRIPTION Depth to pipe invert from original de Gravel depth beneath pipe Ft. Subdivision Block Lot Hulse 92 1 Fill added above original grade Gr el length Ft. Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dist a between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between ches From Tank Field Tank Line Ft2 Well 1001+ TANK FZ1 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 1001+ Greer 1000Gal. Material Number of compartments Lot Line 57+ NA Plastic 2 Foundation 101+ L ATION Manufacturer Capacity RemarksGal. Septic line insulated between tank and field. Tank barricaded from driveway access. Alarm location Electric ailed by Installer PIPE MATERIAL House to tank Tank to D3034 drainfield D3034 Hylan Excavation Drainfield CO/MT D3034 Inspector Arcterra Consulting BENCH MARK (Assumed elevation) 100 ft Inspection 5t dates: 7/12/23 2nd 7/12/23 Location and description 3b 7/13/23 411 Garage slab ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp � ' h 41111 Conditional Approval: Date •�•�M�4"`'"�,�a. •♦1 � firt= 491H !�V �'�•,s fYMMY�YWY��YYYiWY�YYMAfdHiY� Yria �retaYYswY�rwrau�iYr�Yrtetuw M KENNETH M `b.UFFUSf Septic System �a) Aff +♦j►`��c``n'''• CE Approved Date �iis� V Nt . his approval does not include well permit requireents. MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit n`cnt S c U � O Depai,tIllent Permit Number: OSP231170 Effective Date: Work Type: SepticTank Upgrade Expiration Date: Tax Code Number: 05052178000 Site Legal Address: HULSE #2 LT 1 G:0262 Site Mailing Address: 25301 CATES AVE, Eagle River Owner: NATALE PATRICIA Lot Size in Sq Ft: Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: This permit is for the construction of: 6/29/2023 6/28/2024 116741 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By:��� Issued By: �) Date: Date: (0 2 3 3 MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section Parcel I.D. 050-521-78 ANCHORAGE ON-SITE SEPTIC/WELL PERMIT APPLICATION Property owner(s) Natale Patrica Day phone Mailing address 13190 Calle De Las Rosas, San Diego, CA 92129 Site address 25301 Cates Ave. Eagle River, AK Legal description (Sub'd., Block & Lot) Hulse #2 Lot 1 Legal description (Township, Range & Section) Lot Size 116,741 Sq. Ft APPLICATION IS FOR: (® all that apply) Absorption Field ❑ Septic Tank ❑R Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 APPLICATION IS AN Initial ❑ Upgrade ❑X Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Phone: 907-343-7904 Fax: 907-343-7997 TYPE OF DWELLING: Single Family (SF) ❑X (w/wo AD U) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Dea Duffus (Signature of property owner or authorized agent) Permit/Rush Fees: rr2 2, Waiver Fees: _ Date of Payment: / Z,o 2 3 Date of Payment: Receipt Number: C% Lf I S 0 G) Receipt Number: Permit No. ® S P 2 3 f7 -p Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc A TRCERR A A TRCERR A C O NSULT I N G ,I N C . 49TH.. . 2 !� -Ryan G. Johnson - No , 192159 ,•��0� �lf�'' • 7/18/2023, • � � 1 `ll �OFESSI)NA���� TRACT 1 PLAT #2001-120 UNSUBDIVIDED BLM LAND LEGEND O FND. 5/8" REBAR O FND. 1/2" REBAR ( ) RECORD DATA PER PLAT #76-29 ® 4" SEPTIC RISER (D WELL —E— OVERHEAD UTILITIES fp POWER POLE 0' 80' 160' SCALE: I"= 80 FEET O O O O r�o N 00 LOT 13 / PLAT #81-223 / I / I (s I 3223, I � I 3� I °o °J �(10' UTILITY ESMT) I LOT 12 PLAT #81-223 I� \ I � ` LOT I \� 1� PLAT #76-29 I I � � -100' WELL � RADIUS I � , I 2f D STORY CANTILEVER— �FCK yo �-122.3' S TAN 59 I ° � 59,4' � m 10, ASPLS MORTGAGE LOCATION SURVEY NOTES: NO TITLE REPORT WAS PERFORMED FOR THIS SURVEY, EASEMENTS SHOWN PER THE RECORD PLAT. THERE MAY BE ADDITIONAL EASEMENTS NOT SHOWN HEREON. THIS MORTGAGE LOCATION SURVEY HAS BEEN PREPARED IN ACCORDANCE WITH ASPLS MORTGAGE LOCATION SURVEY STANDARDS. IT IS A REPRESENTATION OF THE CONDITIONS THAT WERE FOUND AT THE TIME OF THE SURVEY. THIS SURVEY DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. THE INFORMATION CONTAINED IN THIS DRAWING SHALL NOT BE USED TO ESTABLISH ANY FENCE, STRUCTURE, OR OTHER IMPROVEMENTS. UNLESS GROSS NEGLIGENCE IS DISCOVERED, THE LIABILITY EXTENT OF THE PREPARER SHALL BE LIMITED TO THE AMOUNT OF FEES COLLECTED FOR SERVICES IN PREPARATION OF THIS PRODUCT. w 11-11 00 ;t 00 (A=55.43'03") (TANGENT=26.43 ) FRENCH, 5pp�p �6 P (LENGTH=48.62') DRAIN (50') ; I I P�� �t� GS,, Gp�,G' LOT 4 �pp1 I PLAT #76-29 LOT 3 PLAT #70-340 I _--- AS -BUILT OF: LOT I HULSE SUBDIVISION, 2ND ADDN. PLAT 976-29 ADDRESS: 25301 CATES AVE, EAGLE RIVER, AK 99577 LOCATED IN: ANCHORAGE RECORDING DISTRICT TIMBERLINE SURVEYING AND MAPPING DRAWN BY: R.G.J. 17035 BARONOFF AVE FILE NO.: 23.13 EAGLE RIVER, AK 99577 SCALE: I"= 80 FEET 907-242-5320 DATE: 7/18/2023 ry-an@timberlinealaska.com SHEET: 1 of 1 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231170, Curtis Townsend, 06/29/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231170, Curtis Townsend, 06/29/23 r 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 HONE EW �gv UPGRADE M4: �(i {3 - MAI LIN GESS 7 _. 037 � /C�( LEGA�CRIPTION 8 I , "V �'�� • IrV^\ LOCATIO / NO. OF BEDROQMS t Cf/f We Absorption ares Dwelling �jt PERM Uy DISTANCE TO: KJ Materi No. Ez wF ManufactureG T� c partments ti Liq.a�� ac t in gallons IF.HOMEMADE; Inside length Width Liquid depth C DISTANCE TO: Well Dwelling PERMIT NO. O? Q Manufacturer Material Liquid capacity in gallons = h G Well Foundation J Nearest lot Iine.2o/, PERMIT NOt'� .0 / GJ AcJ w= DISTANCE TO: ( pG ¢. 2 Z w No. of lines - Lengtlq e�1ch lie pl Total I tH o� lines Trench�ritlxh J (p inchas Distance be w e lines _ F- Fes... Top of tile to finish grade Material beneath the Total effect ve absor ion area inches Length Width Depth PERMIT NO. Lu C7 a F- Type of crib Crib diameter Crib depth Total effective absorption area - Lu W co Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. J w �+ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER r P:16, OJ L. PIPE MAT ALS SOIL TEST RATING J 5 V INSTALLER G REMARKS Oe-11 n at J `(� LVis cC-t(JK O P APPRO D - DATE L GAL DEPARTMENT Oi HEALTH .AND ENVIRONMENTAL PR TECTION dSLcllA0Ljs o 825 'L e STREET, ANCHORAGE, AK. 99501 264-4720 WE1�1._ F:1N1 } 101t4 --45ITEE 55Mt4MM F"*§7=i;ZM { PERMIT NO. t 790331n1�taUCe. �U1S. a7 -?,3. APPLICANT MIKE VHER PO BOSS 537 EAGLE RIVER LOCATION MI 6'EAGLE RVR VALLEY LEGAL L1 HULSE S/D 2ND ADD. LOT SIZE 7.7972 SQUARE FEET TYPE OF 'SOIL ABSORSTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS 3 SOIL RATING (SQ� FT?8R)=' 145 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: es, , I>Etom"-r 1-t iL;z t_i—=NChi-r C3 FR vt-L.,. r>EP'TM� � THE LENGTH DIMENSION IS THE LENGTH <IN'FEET) `OF THE TRENCH OR DRRINFIELD. 1 I THE DEPTH OF A TRENCH OR PIT I5 THE DISTANCE BETWEEN THE SURFACE"OF THE; GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET'WIDTH FOR TRENCHES. THE .GRAVEL DEPTH IS THE MINIMUM DEPTH OFGRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION'<IN FEET). Tr F:4 #< :S 12: 9=— PERMIT RPPL'_ICANT HAS THE <RESPON IOfL.ITY TO I-NFORM THIS DEPARTMENT DURING THE,, I NSTALLAT I QR,jNSPECTI ONS OF ANY 'W LS ADJRCENT TO THIS PROPERTY ;AND THE NUMBER OF, RES IdENCES.THAT THE'WELL%tWILL SERVE. T W C;2F4F t= -- BACKFILLING OF ANY SYSTEM WITHOUTFINAL INSPECTION AND APPROVAL BY THIS . D%�#ARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN'A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM fS' 100 FEEjr FOR A PRIVATE WELLS OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.• WELL. LOGS ARE REQUIRED AND MUST BE RETURNED;TO THE DEPARTMENT WITHIN .10 DAYS OF THE WELL COMPLETION, OTHER REQUIREMENTS MAY APPQY.._SPECI;FICATIONS AND CONSTRUCTION DIAGRAM5 ARE AVAILABLE TO INSURE PROPER INSTALLATt'ON. F'Et M x T r=-xP° x mE I CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ONSITE SEWERS AND WELLS AS SET 'FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2.,I DILL INSTALL THE SYSTEM IN ACCORDANCE WITH:THE CODES. St I UNDERSTAND THAT THE ON-SITE S WER SYSTEM MAY REItUIRE'ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCL E MORE THAN E3EDROOMS. SIGNED:_ _ - ---_ _ --� -A-LICAN�' MIKE�UHER-< -- ISSUED BY'- _--- --.. V3. 2 O Ft E GEO CHNI CAL Ef DEVEL 'MENT CO. n Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russ*ll Oyster Earl Ellis 688-22eo 694-2774 SOIL 'LOG Soils Et Foundations Land Development ` D � Performed for:, Name: %, 1 Tel. NO-, IPSS ` 9OZ �9 "-7 Mailing, Address: 37� ;,4,t�-U��-.: Se Legal Description: ! Death (feet) Soil Characteristics o t,tJ 3 u - .W Fr d 1A154 8 v 9. 10 .1"M111 AJCIW 12 13 , 4h��,. 16Ground Water Encountered: Yes_ NoIf yes ' Proposed Installation: Seepage Pit Oram Field Comments: l ! ! e,.t,,...,sel l,v• t� �sS4 ( /res Z' Date:`f c! i� i..vl- �R� T �V 'Y`�^. \L 4- ` U . WE iN� 1fl'3%o' r\ 1p�50 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:SW920220 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:UHER MICHAEL L OWNER ADDRESS:PO BOX 770537 EAGLE RIVER, AK 99577 PARCEL ID:05052178 LEGAL DESCRIPTION: HULSE #2 LT 1 SEC 23 T14N R1W SM LOT SIZE: 116741 (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: 8/11/92 EXPIRATION DATE: 8/11/93 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 PROV-----� RECEIVED BY: DATE • ISSUED BY _���� ��� o . i fll I' this._ day of ©G r, ..,e.. ROBERT C. JOHNSON " . SCALE: Registered Land Surveyor No 880 -LS 1" = L4 Box 77-0456, Eagle River, Alaska 99577' Phone (907) 694-25.43 ;: i q (( l fll I' this._ day of ©G r, ..,e.. ROBERT C. JOHNSON " . SCALE: Registered Land Surveyor No 880 -LS 1" = L4 Box 77-0456, Eagle River, Alaska 99577' Phone (907) 694-25.43 ;: DAILY DRILLING LOG S & S DRILLING RECEIVED 140Y 181992 Municipality of Anchorage HC01 6761 Palmer, Alaska 99645 De n+ig07) 746 0606 Health & Human Se OWNER OF LAND .... I�!!S... U` �---------• -»- DEPTH OF WELL.. 81.E Elt ADDRESS»._.. AV — it l STATIC LEVEL OF WATER FT S S �c SCR, • iLv DRAW DOWN FT ..... !!�.A xs�W\.%............... WELL - SITE .....:.........}... _ .... DATE. STARTED c"3:. .5.. ... Z ..._...._......» ---- ........»....»..»»... nATF _ FNDED---..8:.! ��:.9Z...... ».............. _..... _..___»_.... ........... KIND OF FORMATION: GALS. PER i?04 of 4c- uNaR KIND OF CASING.Gp,.......:.......................�....... JI SO rismFo RFr, ^o.D 4 FROM ..»_..J..._ .......... FT. TO.... L.......»_»FT»Se!-R�.. P!�I?»C7a'#lud701ky FROM .... ..... ...»........ FT. FROM ..... L. ... »........ FT. TO_2d...... ....... T. I nLMI.. gr�1 FROM. Zo ............ TO...t7sS.........FT. FROM..I '�......._..FT. TOJ... ........ »FT yJATEtt„_3 S � r^ FROM.. 3.'_3 _..__FT. TO_ 5.�—....»».FT. FROM..»...._..»»..»..»FT. TO........»..»_..»_.FT._»»_........»....»...._..» FROM............ _...... _..FT. TO........... FROM ....................... FT. TO_ ...... _.....» ...... FT._.._»_»_...._..».._.»» FROM..» ....................FT. TO ............ »»....... FT.. ...... ..... a.. .............. . FROM ........ _.._».... _..FT. TO ....... ............. FT..»...»»_.......»_.._.»__ FROM....»_:...._.: ...... FT. FROM....__»...._..».».FT. TO.._»........»...:..F'T...._.......»..»».._».._».. FROM..........____»»..FT.TO ... »... » .... _....... FT ................. .....» _..» FROM........... »..». ..... FT. TO».._»......»..»...FT--------------- _..---- »_---- __ FROM...»...__»..».._..FT. TO..»»_»»_»»»»FT----- »---------- - .._.„_----- FROM......... .............FT. TO..»..»__.._.._..FT....._»......»_».._»_»»» FROM.._»_.._..__.._..FT. TO ... ....... _:......... .FT. ...... _.............. _... .... FROM... .................. »FT. TO..»..».....»..»»..FT....------ _.-------------------- FROM.. ...... » ..............FT. TO....._...»..»......FT... ......................... ».... FROM........ ............... FT. TO ............... ...... FT.».._ ---------- ----- »---- _---- FROM ................ »...... FT. TO ....................... FT................................... MISCL.INFORMATION: DRILLER'S NAME.:S-...l Gf}�5'ah.1... ........ »..»... _»»».. MV UHMPAUYY OF AHCHOR,A GE 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. 050-521-78-000 Expiration Date: 10/26/2023 Legal description HULSE #2 LT 1 Site address 25301 CATES AVE Eagle River AK 99577 Current property owner(s) NATALE PATRICIA(TOD) X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: a bedrooms, with the following stipulations: Original Certificate Date: 7/26/2023 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 Development Services Department P p Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 11 AP a` Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 050-521-78 Complete legal description Hulse #2 Lot 1 Location (site address) 25301 Cates Current property owner(s) Patricia Natale Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 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: V Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ✓❑ Plastic ❑ Concrete ❑ Fiberglass Age 0 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed © Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: N Distance: 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 $ g Waiver Fee $ Date of Payment 7/4o/z_5 COSA Date of Payment Waiver # COSA Application—June 2022 � Legal Description: Hulse #2 Lot 1 Parcel ID: 050-521-78 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 8/18/92 Total depth 184 ft Cased to 20 ft 0 Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 27 in. Date of flow test for COSA 5/11/23 Static water level at beginning of test 27 ft. Comments B. TANK DATA Measured operating fluid level in septic tank NEW Date of pumping New 7/12/23 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 9/28/79 ALL standpipes present per record drawing Total measured depth from grade 8 ft (max) Measured depth to pipe invert from grade 4 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 4' ❑ 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 Comments/Deficiencies: "Per available field measurements COSA Checklist June 2022 Well production at time of test 3.3 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑✓ No 0 Coliform bacteria is Negative Nitrate 0.513 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 0 Arsenic less than MRL (ND) Collected by Areterra Consulting Date 5/11/23 STATION ❑ Require'l ' tenance completed Age of lift station rs Lift station material Comments: Adequacy test date _ Results D Pass Fluid depth prior to test Water added 450 gal 5/11/23 0 in New fluid depth 12 in Elapsed time 20 min Final fluid depth 0 in Absorption rate 450+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 96 in Effective depth used 48x in Effective depth remaining 48x in 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' 0 Yes if No Community Sewer Manhole/Cleanout > 100' Yes if No ft 0 Yes if No ft Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' F,-/] Yes if No ft 0 Yes if No ft ft If tank or field is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft 0 Yes if No ft ❑ NIA — 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' 0 Yes if No ft Surface Water > 100' E2] Yes if No ft Tank to Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' 0 Yes if No ft Private Wells > 100'✓❑ Yes if No ft Water Main > 10' 0 Yes if No ft Community, Wells > 200' ❑./ Yes if No ft Water Service Line > 10' 0 Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS 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 Arcterra Consulting Phone (907)-696-6111 Engineer's Printed Name Kenneth Duffus Date 4*� Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. +*%7 O 444 The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The +rp. „�.w++■a. 44 now and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic or D} ;* systems are subject to these various and dynamic characteristics and are outside the control of the evaluator S■■■■■�■ of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will f f function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen �� a encroachments, deficiencies or discrepancies exist. 44� %ted,, CE 4 6 a ii COSA Checklist -June 2022 444��1♦ Municipality of Anchorage • Development Services Department Building Safety Division , r, On -Site Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING , %�G t 55 vCcL. Parcel I.D. 050-521-78 HAA# Q a O S�2 7 1. GENERAL INFORMATION Expiration Date: - 9 O 3 Complete legal description HULSE SUBDIVISION #2: LOT 1 Location (site address or directions) 25301 CATES AVENUE * EAGLE RIVER, AK Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JOE & JACKLYNN LEVITT I Day phone 223-8611 25301 CATES AVENUE * EAGLE RIVER, AK 99577 CINDY WILSON w/ REMAX OF EAGLE RIVER Day phone Day phone 16600 CENTERFIELD DRIVE * EAGLE RIVER, AK 99577 Unless otherwise requested, NAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: .3. TYPE OF WATER SUPPLY: Indivictual.Well c! ' Individual Water Storage Community Class Well Public Water System 3 694-4200 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage riles 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. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person orparty is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for —3 bedrooms. Disapproved. Phone 337-6179 Date Z 0 Conditional approval for bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Lam' Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other le r A. ss; —7953 : '`�� �pJ"?ro f es sloop° v .• •. ()N -SIT -•. WATER �"p,TEQ. PROGRAM :. By: Original Certificate Date: 1 — 19 - O (Rev. 12/01) 1 Municipality of Anchorage 4, • "� Development Services Department Building Safety Division ` On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.d.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: HULSE SUBDIVISION #2c_ LOT 1 Parcel ID: 050-521-78 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 8/18/1992 Sanitary seal (YM) YES Total depth 184 ft. Cased to 20 ft FROM WELL LOG Date of test 8/18/2002 Static water level 30 ft. Well production 3.5 g.p.m. Well Log (Y/N) YES Wires properly protected (YM) YES Casing height (above ground) 12+ in. AT INSPECTION 10/12002 45 ft. 0.9 g.p.m. WATER SAMPLE RESULTS: ` Coliform colonies/100 ml. Nitrate 0.51 mgJL. Other bacteria �— colonies/100 ml. j• 10 3/ 002 Arsenic: N/A mglL. Date of sample: 12 2003 Collected by: AKWWC, INC. P B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 9/28/1979 Tank size 1000 gal. Number of Compartments 2 Cleanouts (YM) YES Foundation cleanout (YM) YES Depression over tank (YIN) O High water alarm (Y/N) N/A Date of pumping JR'S PUMPING Pumper 9/30/2002 C. ABSORPTION FIELD DATA +MONITORING TUBE ONLY EXTENDS 3 FEET INTO GRAVEL Date installed 9/28/1979 Soh rating (g.p.d./fib t /bdrrr 145 System type DEEP TRENCH Length 29 ft. Width 3 ft. Gravel below pipe 8 ft. Total depth •i.e ft. Eff. absorption area 435 ft' Monitoring tube YES Depression over field NO Date of adequacy test 10/1/2002 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 In. Water added 450 gal. New depth 1 in. Elapsed Time: 5 min. Final fluid depth 0 In. Absorption rate >= 450+ g.p.d. Arry rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed Size in gallons "Pump on" level at in. E. SEPARATION DISTANCES High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 1000+ Public sewer manhole/deanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 1001+ Driveway, parking/vehide storage 01 Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION .0_<1 v.'•.• I certify that I have determined through field inspections and review of Municipal records that the above systems are in "' • . • • .. • .. "' .. • . •�• conformance with MOA HAA guidelines in effect on this date. t7o ...:: • ff y A. ..... ess,:.. . Engineer's Printed Na a JEFFREY A. GARNESS Q"°� C —7953 ,�•` Date /L d3r°.°0p••......•��4 �ofessW° HAA Fee $ Waiver Fee $ Date of Payment Date of Payment Receipt Number Receipt Number (Rev. 12/01) Municipality of Anchorage u Development Services Department Building Safety Division , „ a On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # 020527 Daring a recent Health Authority Approval on-site inspection and test of the potable water supply Well on Block , Lot 1 of Hulse #2 subdivision, the Well's productivity was determined to be 0.9 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.3 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. Municipality of Anchorage Development Services Department / Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. i P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE FOR A Parcel I.D. 050-521-78 1. GENERAL INFORMATION OF HEALTH AUTHORITY APPROVAL SINGLE FAMILY DWELLING HAA# gA-o a Expiration Date: Complete legal description HULSE SUBDIVISION #2; LOT 1 Location (site address or directions) 25301 CATES AVENUE • EAGLE RIVER, AK Current Property owner(s) JOE do JACKLYNN LEVITT Day phone 223-8611 Mailing address 25301 CATES AVENUE • EAGLE RIVER, AK 99577 Lending agency Day phone Mailing address Real Estate Agent CINDY WILSON w/ REMAX OF EAGLE RIVER Day phone 694-4200 Mailing address 16600 CENTERFIELD DRIVE • EAGLE RIVER, AK 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ■ Individual On-site ■ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or prior to closing for the engineering services provided. 4. 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply andlor 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. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179 Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Dateto/I1/,L Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, the in ADEC MOA 000dD�Op QF conscientious engineering analysis of system accordance with and DSD Guidelines & Regulations. The reported described the of the vow `,. • "' " results performance S�oOI system under the conditions encountered at the time of the test, and separation QDo distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may :... fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that ... OO eft a A. Garne-s. there are no hidden defects or encroachments. AKW WC, Inc. can therefore not provide ()� •, —79 any warranty or future estimate of how long the system will continue to meet the 0N8�-_ 4�0°d �Po operational requirements of the ADEC or MOA DSD. The content of this report is for Pr°feast°^°& the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE t. Approved for _; bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory M bedrooms, with the tllowing stipulations: \ `G\Q�VZYIOFgN�yo .. 3 ON-SITE WATER AND ; m WASTEWATER pPnrRAM Supplemental Engineer's Reort Other Manitenance Agreements By: i/�e Original Certificate Date: Municipality of Anchorage • "' Development Services Department Building Safety Division On-SRe water 6 Wastewater Program 4700 South Bragew St. P.O. Box 196650 Anchorage, AK 995196650 www.d.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: HULSE SUBDIVISION /2: LAT 1 A. WELL DATA Well type PRIME If A. B, or C provide PWSID# N/A Date completed 8/18/1992 Sanitary seal (YIN) YES j Total depth 184 ft. Cased to 20 ft. Parcel ID: 050-521-78 Well Log (YIN) YES Wires property protected (YM) YES Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 8/18/2002 10/1/2002 Static water level 30 ft. 45 ft. Well production 3.5 g,p,m, 0.9 g,p,m, WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate Q_n mgJL. Other bacteria colonies/100 ml. Arsenic: N/A mg./L. Date of sample: 10/3/2002 Collected by: AKWWC, INC. B. SEPTICIHOLDING TANK DATA s Tank Type/Material STEEL Tank size 1000 gal. Number of Compartments E Foundation deanout (YIN) YES Depression over tank (YM) NO 1 Date of pumping JR'S PUMPING pumper Date installed 9/28/1979 Cleanouts (YIN) YES High water alarm (YM) 9/30/2002 N/A C. ABSORPTION FIELD DATA *MONITORING TUBE ONLY EXTENDS 3 FEET INTO GRAVEL Date installed 9/26/1979 Soil rating (g.p.dJft2o<ER0145 System type DEEP TRENCH Length 29 ft. Wdfi 3 ft. Gravel below pipe 8 ft. Total depth •7.e ft. Eft. absorption area 435 fe Monitoring tube YES Depression over field NO Date of adequacy test 10/1/2002 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth In absorption field before test E In. Water added 450 gal. New depth I In. Elapsed Time: 5 min. Final fluid depth E In. Absorption rate >= 450+ g,p_d, Any rejuvenation treatment (past 12 mo.) (YM & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Acrp« (Y/N) "Pump on" level at _in. "Pump ofr IPVgI at _in. High water alarm level at in. Datum ICycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/deanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 1001+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 0' Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certNy that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printedme Date Dai. JEFFREY A GARNESS HAA Fees 15 Date of Payment 10/14/0'7- Receipt Number � h'1 G Sf-' (Rev. 12101) Waiver Fee $ Data of Payment Receipt Number \� Municipality of Anchorage 10 a � Development Services Department Building Safety Division ....,. On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # 020527 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block , Lot 1 of Hulse #2 subdivision, the well's productivity was determined to be 0.9 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.31 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. ti s 4 � wry +•� �� nswn O•h N � b !� I6 X111 Y a 4r N 10'J!•OY�I 10.1) (NOLO / b s e ioL.t eau• P 'xLt san• c 4 sua Some M 9 Mr3O`C eW.lt• M Lo• WV= F--'MdDf LOT 1 MI s TR 1 PARK 12 A h MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES M 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. # 050-521 � 78 1 HAA # 0 y1 In�l 1. GENERAL INFORMATION Complete legal description Hulse #2 Lot 1 T14N'R1W Section 23 Location (site address or directions) NHN Hulse Circle, Eagle River Property owner Mike & Cheryl Uher Day phone 694-3981 Mailing address Lending agency N/A Day phone Mailing address Agent Lori Crouse/ReMax of Eagle River Day phone 694-4200 Address 16600 Center Field Dr., Eagle`River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well X Community well Public water 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. 72-025 (Rev. 1/91) Front MOA #21 0 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 Eagle River Engineering Services Address P Engineer's signature 6. DHHS SIGNATURE 0 Approved for Disapproved. .5 bedrooms. Conditional approval for Additional Comments AK 99577 Phone 694-5195 Date bedrooms, with the following stipulations: -_ F_111191610� 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 tending 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) Rack MOA k21 Municipality of Anchorage Department of;Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �/ Z -/c,/. -e ;L rid Add--' Parcel I.D. A. WELL DATA Well type Pa2tdAiC If A, B, or C, attach ADEC letter. ADEC water system number h/lA Log present (Y/N) y Date completed R -1V _ Total depth -Cased to 0D �/3'�c�rac�C) Casing height Sanitary seal (Y/N) y - Wires properly protected (Y/N) .� FROM WELL LOG Date of test Sls Static water level 3D, Well flow 3.5" g.p.m. AT INSPECTION MUNICIPALITY OF ANCHORAGE X0/7 4 ENVIRONMENTAL SERVICES DIVISION -1 ? 1992 rLn.® Pump level u"�N"'. 15% LLIVED SEPARATION DISTANCES, FROM WELL TO: Septic/holding tank on lot �° ✓ ; On adjacent lots f°d Absorption field on lot +1104 ; On adjacent lots Public sewer main JA Public sewer manhole/cleanout /`' Sewer service line �. Petroleum tank /v°,i a G,004 �� ✓t WATER SAMPLE RESULTS: Coliform Nitrate d' r"S��- Other bacteria 9Y Date of sample: lite %9a Collected by: ',+-iene� B. SEPTIC/HOLDING TANK DATA Date installed Tank size °°D S Compartments Cleanouts (Y/N) Y Cr') Foundation cleanout (Y/N) Y Depression (Y/N) A/ High water alarm (Y/N) IV)A Alarm tested (Y/N) v 1,4 Date of pumping 71/6Ly2 -� Pumpern �s SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot UD On adjacent lots 4-1601 Foundation r To property line 7S" Absorption field _ " 05'S Water main/serviceline '"a Surface Water/draina a 1/0o 9 CONTINUED'ON BACK PAGE ' 72-026 (Rev. 7/91.) Front _.. _ _ _. - � �. , , C. LIFT STATION Date installed Size in gallons Vent(Y/N) "Pum' level at Manufacturer Manhole/Access (Y/N) High water alarm level Meets ,MOAAee rical codes (Y/N) SEPA AR TION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Surface water _ Date installed /5 71 Soil rating /'ds '616PS System type Tree �. Length -29 Width 3 Gravel thickness Total depth Total absorption area We" Cleanouts present (Y/N) Depression over field (Y/N) Date of adequacy test Results (pass/fail) /" �► SU for Peroxide treatment (past 12 months) (Y/N) �4 If yes, give date Ir SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ti,W/ On adjacent lots •2O° Property lined '3 bedrooms To building foundation / To existing or abandoned system on lot i✓/<I On adjacent lots t/ao Surface water t/od Curtain drain 110VI-4 E. ENGINEER'S CERTIFICATION Cutbank -2-0 Water main/service line Driveway, parking/vehicle storage area 4o« �t I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. /-/,� � c Date of Payment Receipt Number �a5 °COP, Signature Aw��; °c �,!`'r;Y3> Engineers Name 1dy//f �Gsrs. �ri er;a• ro.oa°°woo. Date {{fi�rr ` �/ l 1•�9 ciJ,�. .r u., V e¢o rtc. 176 �U HAA Fee $ Waiver Fee: $ Date of Payment /-/,� � c Date of Payment Receipt Number �a5 �� Receipt Number