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SKYHILLS PH 1 BLK 3 LT 3
kyhl'*11s #1 Block 3 Lot 3 #011-262-39 Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 U Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: S W oCt? 2 fq PID Number: _ ©i < 2 & 2 Name —oy e Wastewater System: VNew ❑ Upgrade Address: ABSORPTION FIELD Phone:No. of Bedrooms: �--_ & _S.f di kDeep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION n Soil Rating: �Z GPD/Sq. FL Total Depth from original grade: /-2-2— Z � Z Lot: i7 Lot: Block: (I'S'ubdivision: 3 6k,YL41 Dept tto pipe bottom from original grade: Si Gravel depth beneath pipe LLS J' Ft. -R` Ft. Township: Range: of on Fill added above original grade: -- U Gravel length: 6 Ft. Ft. o�������®�� WELL: ❑ New ❑ Upgra Gravel width: Numberotlines: Distance between lines: 1 Ft. FL Classification (Private, A,B,C): epth: Cased To: Total absorption area: Pipe material: Ft. Pt SQ. Ft. �'v�L /303 _ Driller: Lt G Date Drilled: Static Water Level: Installer: Date installed: Yield: Pump Set at: Casing Height Above Ground: TANK Ft. 1=1. SEPARATION DISTANCES 'Septic ❑Holding ❑&T.E.P. TO Septic Absorption Lift Holding Public/Private Manufacturer: `caro Capacity in gallons: /s From Tank field Station Tank Sewer Lines AA)C�- IL on Well �--. �_ �.. Material: Number of Compartments: Watere 1 -r -(- —^ -- — LIFT STATION Lot Line Foundation �� I 'z� 1 _ Size in gallons: Manufacturer: —I _ "Pump on" level at: "Pump o a//�� High water alarm at: Curtain.f.. /C,,--r��? Pump Ma el Electrical Inspections performed by: Drain Remarks: BENCH MARK -------- -- -- Location and Description: — Assumed Elevation: y,t( �` r3��,�YM.•1fl.f,•r� I.J•Y � i�kJrTT •'v �r� Inspections performed by: Dates: 1st _/ 2nd_/p/22/P9_ •A Steven R� Pannone E - 8149`. , Department of Health and Human Services approvallF,r,`2laz2, tifs. W. 10-,25 q� Reviewed and approved by: 22L± Date: Date: -- 72-013 (Rev. 9/91) MOA 25 PERMIT NO, SWSW990024 AS -BUILT P.I.D. NO, 011-262-39 WASTEWATER A13SDRPTIIDN SYSTEM LOT 3 BLOCK 3 SKYHILLS S/D SWING -TIES CO A B FC 18.2 TI 8.2 33.4 T2 11.9 34.4 DC 15.0 35.6 NEW WATER SERVICE Cl 21.4 393 RESERVE MT 19.5 21.3 SITEiv LINE. C2 3B.9 17.3 NEW PRIMARY 234' TM 82 ........... .. _ DRAIN FIELD, -212' r ON ;-iCE y ,46,5 LFx6,9' EFF r P`' ';TH PI _�--� C2 ; MT ` , C1 I 3Y,., TM 81 NOTE, 1 CIN FILE FC- 1) SUBD. IS SERVED BY AWWU, THERE Wh1HHSARE NO WELLS WITHIN 200 FEET CSF r o ,NEW THE PROPOSED INSTALLATION. 1(4 BR d HOUSE F_a rri � � I rrl I I 1 ®^ PROPOSED 1500 g SEPTIC TANK ?IO Ci\Work\3-3SKYH.DWG DESIGN, ��•4�E OF SAI♦.♦(p♦♦ SOIL 5LSR/BE➢R'DOM, GPD/SF 1.2 BEDROOM uu'�po'••• • ' '�•.+7�♦♦ 625 SF REQUIRED Ar �•° �O DEEP TRENCH, 7' EFFECTIVE A ° 49TM 11-12' TOTAL DEPTH, 45 LF EACH .....e............ .......................A.... 2-3' WIDE, 630 SF TOTAL -. �••••;••te ••• �•••K•� PREPARED FOR PANNONE ENG. SVC ♦) .Steven R.•Pannone�• ■ 5 - �� : ■ Jahn HagMeler P. ❑, BOX 102954 ♦ •. No. CE 8149 •� O John Ha Meler Co, ♦0♦.2P�622 .••'tum HC 52 Box 8765 ANCHORAGE, ALASKA 99510 ♦ u Anchorage, AK 99503 272-8218 Phone & Fax ♦♦♦�.-ESSs�rAu (907) 248-6789 DATE1 10-2?_ 99NitsAS—BUIC.T SCALE, 1,= PERMIT NSI SWSW990024 AS --BUILT DETAILS P.I.D. NSI 011-262-39 WASTEWATER A13SORPTIIDN SYSTEM LOT 3 BLOCK 3 SKYHILLS S/D � If7 N C6 v N (U N 1(IONV3' 3RL ' m d ' v I (L si d s !I w w U_ R U n s. d R 3Hn1 N01INOW ,� W N a K t U W L_ R Z�, .,.` a 7 J I W. Zd Z R V H w l I' WI N N W 3 ¢ � J h H m / �� N ; ON LL N ¢K L7 L d o .' m �a o N w CL N.J-. W U o A La CL l d -___ a- _� ¢ Z o N V I I 1(10NV310 .0 ' z 1now3-13 N w U W 1n0Nv313 in oa a;; A a7 Ll a o Ci\Work\3-3SKYH.DWG 1n0Nv3'10 D, -WJ� -- wz a � , �-z CQ Arn.. OF ♦//__�P.•... " YS to z a 5 v:.•• •• �'•.•�O N I1tl0Nn0! 9TH °;'? 0e .......... io .................//�� PREPARED FORI PANNONE ENG, SVC, ,Steven R. Punnone��/ ' John Hn reeler !� X %. No. CE 8149 lir John Haameler Co. P. O, BOX 102954 QIo ...••''4 �•� HC 52 Box 8765 ANCHORAGE, ALASKA 9951.0 �♦�,11 � `�.��r (907) 248-6789AK 99503 DTD 10?2 99 HONE & FAX --- NOT TO SCALE] AS -BUILT Municipality of Anchorage t DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: ''-TVWNGV,A �i,o4i11ly tF I — Cb DATE PER LEGAL DESCRIPTION: [41 LLS Township, Range, Section: DEPTH SLOPE (FEET) 1 S� 2 3 �P 4 5 6 7 8 9 bP 10 11 12 13- 14- 15- 16- 17 314151617 18- 19 �D YI ' 1G StLZ`S �r7b/2L'� Ct,Q�r� AJ tot - ✓V 0— S L 0 E Dale: _ SITE PLAN Reading Date Gross Time WAS GROUNDWATER Depth to Water ENCOUNTERED? G'L"N— Oval; IF YES, AT WHAT DEPTH? Depth to Water Alter Monitoring? _ ✓V 0— S L 0 E Dale: _ SITE PLAN Reading Date Gross Time Net Time Depth to Water Net Drop 20 PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND --FT COMMENTS V «�t L' QOC:� * U0A (/j'L_nJ`G'—P CyC YZIA N. PERFORMED BY: & Q ' `1 AAJ1uq II w I ___ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /0 ",-2 (/,P I — 72-008 (Rev. 4/85) q MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Mar 05, 1999 Expiration Date: Mar 04, 2000 Permit Number: SW990024 Parcel ID: 011-262-39 Legal Description: SKYHILLS PH 1 13LK 3 LT 3 Design Engineer: 0062 Pannone Engineering Services Site Address: Owner Name: John Hagmeier Lot Size: 40457 SQ. FT. Owner Address: 2204 Cleveland Avenue, Suite 204 Total Bedrooms: 5 Permit Bedrooms: 5 Anchorage , AK 99517 - This permit is for the construction of: ❑✓ Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage 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 ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: A6u,US,_ �(�f A�S`S!._J�_---- Date: - "Z7 99Issued By: - ��1�?/I///%/� i V" Date: MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 �.? It ("., v v ,q , n'1. Z i - N 00/v ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Mar 05, 1999 Expiration Date: Mar 04, 2000 Permit Number: SW990024 Parcel ID: 011-262-39 Legal Description: SKYHILLS PH 1 BLK 3 LT 3 Design Engineer: 0062 Pannone Engineering Services Site Address: Owner Name: John Hagmeier Lot Size: 40457 SQ. FT. Owner Address: 2204 Cleveland Avenue, Suite 204 Total Bedrooms: fd � Permit Bedrooms: Anchorage , AK 99517- 9C� This permit is for the construction of: I] Disposal Field [] Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage 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 ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: J3.��I Issued By: ��� /�"'�" Date: Steven K. Pannone, P. Ls. Consulting Engineer (907)272-8218 February 27, 1999 Municipality of Anchorage Dept. of Health & Human Services Ori -Site Services Section P. O. Box 196650 Anchorage, Alaska 99519 Subject Lot 3, Block 3 Sky Hills Subdivision, Septic System Permit Gentlemen: P.O. Box 142025 Anchorage, Alaska, 99514 (907)277.-8218 Fax My firm was contacted to design and install a new septic system for the referenced lot. We conducted it field investigation to locate existing wells and septic system before designing the proposed system. A single test hole was excavated on August 11, 1998 for the system design, which is on file with your department. No ground water was encountered. No bedrock was encountered in the test hole. The lot is approximately 0.9 acres in size. Lot s 3 slopes to the southeast at a rate of approximately 6-11 percent. The north eastern portion of the lot is flatter (approximately 2-5%). The proposed installation will be located on the western portion of the lot. Double clean -outs will he installed after the tank and diverter valve. The proposed location is grealer than 100 feet away, from any wells. This lot is served by AWWU water service. The proposed system will he greater than 10 feet front the water service lines. The proposed installation will not affect the future development of the surrounding or existing lots. See the attached design. Please contact me at 2 /2-8218 or 227-3522 if you have any questions about the proposed installation. Sincerely, Steven R. Pannone, P.E. Altaclunents: C:\WORK\3-3Sky1IiIIS (JOl.cepd PERMIT NO, SW D 17S TG N P.I.D. NOi WASTEWATER ABSORPTION SYSTEM LOT 3 BLOCK 3 SKYHILLS S/D NOTE, 1) SUBD, IS SERVED BY AWWU, THERE ARE NO WELLS WITHIN 200 FEET OF THE PROPOSED INSTALLATION. PROPOSED WATER SERVICE LINE. MAINTAIN 10' SEPARATION 234' FROM DRAIN FIELD, 1....212' ... .... ............... .................. _._._.......... ........................._.... __............ ..... _._.__..._........._..._._..._.._..__-PROPOSED PRIMARY I i DRAIN FIELD, 45 LFx7' EFF � t i l I RESET VE TH 81 TE { 224' ON FILE W/DHHS 11'i..... n W-- .28• V DRIVEWAY w..... N - PRDPOS D r o 5 \B R HE E twj �m 228' ( I M I i f f PROPOSED 1500g J �,2 SEPTIC TANK 210 0\Work\3-3SKYH.DWG DESIGN, -- PERC RATE- 2 MIN/INCH OF 0♦ SOIL RATINGi Li' GPD/SF Age (�G............. ♦j♦ 125 SF/BEDROOM, 5 BEDROOM -ee��P ••' ♦. 625 SF REQUIRED DEEP TRENCH, 7' EFFECTIVE 49TH s}♦♦ 11-12' TOTAL DEPTH, 45 LF EACH a . °; E•,• ................................. 2-3' WIDE, 630 SF TOTAL p♦ .�1". 1 ° PREPARED FOR PANNONE ENG. SVC - ;Steven R. Pannone- % John Hn roeler r g P. ❑. :BOX 102954 ♦ "•. 'CE 8149 •;' AW John Hagmeler Co, s♦�,4oz �.. � ANCHORAGE, ALASKA 99510 ♦ �,: � ZZc>4ctevEcauoAvls ♦ �\p�e Anchorage, AK 99503 sem, ezoy 272-8218 Phone & Fax ♦♦♦♦ ':pee (907) 248-6789 DATE, 2-27-99 1 DESIGN — --- -- ' _E, 1 40'—j -- PERMIT NO, SW DESIGN DETAILS P.I.D. NO, WASTEWATER ABSORPTION SYSTEM LOT 3 BLOCK 3 SKYHILLS S/D .. V' In n 00 I I I I I m I� CI\Work\3-3SKYH.DWG MON 3Hn1 N0IINOW 1noN' ln0NV3"13 1nONV3l0 al]03l0 1f10NV3'13 1nONV3l3 NauvaNn03 REPARED FOR, John Hagneler John Hagneler Co. u^ -Z ZoU cCevE4AA3b qVff- Anchorage, AK 99503 so(�E aoa (907) 248-6789 uw z ~w o � I wi z o� w o' u w w 2! z tl Jf-q� �a o 2ViJJ a .z.HQo zp Z'z Aa z Z.iO�ND PANNONE ENG. SVC. P, ❑. BOX 102954 ANCHORAGE, ALASKA 99510 272-8218 PHONE & FAX 1TE1 2-27-99 DESIGN [IT TO SCALE Municipality of Anchorage . DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "T" Street. Anchorage. Alaska 99502.0650 SOILS LOG •— PERCOLATION TEST PERFORMED FOR' L H Construction LT 3 BLK 3, Sky Hills Subdivision LEGAL DESCRIPTION: i1 G 13 14 1 15 is n 19 20 COMMENTS �l (ENGINEER'S SEAL) DATE PERFORMED: e, "I '--g WAS GROUND WATER ENCOUNTERED? SITE PLAN IF YES. AT WHAT L DEPTH' —t O E UA La WzW .Vier I T Maaitanngt , Oak 7_.. 1 I__7__—_ 177111 a G..__r_. e I 20' T a Eusameat..• � I II I N I, IpO y 1 � 40.457 s4 -Et, — ._1___1_L—J_� I i 243 2 �J IF YES. AT WHAT L DEPTH' —t O E UA La WzW .Vier I T Maaitanngt , Oak 7_.. 1 I__7__—_ 177111 a G..__r_. e I Gross Net Depth to Time Time Water I 303: L)5 � �8• 3: 13 25; 14::3 — ._1___1_L—J_� �J ReaBin9 Dam fir". 98 Gross Net Depth to Time Time Water I 303: L)5 � �8• 3: 13 25; 14::3 Nes OroD d PERCOLATION RATE L_.__ Iminule �ACa , PERC HOLE DIAMETER �.. TEST RUN BETWFEN�� FT ANr�s/__FT Pere ca -,it '.gas cresoakec PERFORMED BY. ._ CERTIFY 5'HAT THIS TEST WAS PERFORMED IN Michael Anderscn ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EF°E=T UN THIS DA-= DL— Steven R. Pannone, P. E'. P.O. Box 102954 Consulting Engineer Anchorage, Alaska, 99510 (907) 272-8218 --_(907)272-8218 I ax October 17, 19nn Nlunicipality of Anchorage Dept. of Health & Human Services OIl-.cilte SCCVICCS SCC1i1l1 P. O. Box 196650 Anchorage, I;laska 99519 Subject: Lot 3, Block 3 Slay Hills S/d Septic System Permit SW990024 Modifications Ladles and lleaticincn: Your department issued Permit Number S W990024 for the above referenced property on March 5, 1999. This permit was to construct a deep trench in the vacinety of Test Hole 81 in Sky Hills Subdivision. The builder would like to relocate the system to the north. The new location is in the vaciuity of'fest I Tole 82. The percolation rate of the sarin in that test hole was 0.5 minutes per inch. I propose installing the same size system as was designed for test hole 81. Additional sods will aced to be verified to a depth of 18 feet, to establish no bedrock or water is within 6 feet of the bottom of this system. The contractor is planning to install this system on Monday October 18, 1999. 1 request approval to modify this system as discribed above and on the revised site plan. Please contact me at 227-3522 if you have any questions about the proposed installation. Sincerely, Steven R. Pannono, P.E. Attachments: 3laven R. Vennma Cl. - 0149 s� rROF�'SStO''Ll`y C AW012KVI.If"I'I'IiIZS\33SKYI [ILLS 002.1)OC PERMIT NO SW DESIGN P.I.D. NO, WASTEWATER ABSORPTION SYSTEM LOT 3 BLOCK 3 SKYHILLS S/D C,\Work\3-3SKYH,DWG DESIGN, PERC RATE, 2 MIN/INCH SOIL RATING, 1.2 GPD/SF 125 SF/BEDROOM, 5 BEDROOM 625 SF REQUIRED DEEP TRENCH, 7' EFFECTIVE 11-12' TOTAL DEPTH, 45 LF EACH 2-3' WIDE, 630 SF TOTAL W PREPARED FOR PANNONE ENG. SVC John Hagneler P. O. BOX 102954 John Hagmeler Co. ANCHORAGE, ALASKA 9951.0 HC 52 Box 8765 272-8218 Phone & Fax Anchorage, AIC l<99503 (907) 248-6789 DATEi 2-27-99�-DESIGN PROPOSED WATER SERVICE INE. MAINTAIN 10' SEPARATION FROM DRAIN FIELD, 234, TH 82 PROPOSED PRIMARY ON FILE DRAIN FIELD, 45 LFx7' EFF ESERVEi .....................1.... :.: .. W.7..DHH.S......._........._.............................................................._............................................................................. SITE r ' i� k k ll.l - r� c �e W r, W. I l TH 81 -..,. ON FILE W/DHf TS NOTE, w ! PROPOSED 1) SURD, IS SERVED BY AW' ('% r o C:J ' 5 BR H11 SE ARE NO WELLS WITHIN 200 INSTALLATIO THE PROPOSED fit ..._.J - fq f 3 MI , IX j PROPOSED 15009 I X21, SEPTIC TANK C,\Work\3-3SKYH,DWG DESIGN, PERC RATE, 2 MIN/INCH SOIL RATING, 1.2 GPD/SF 125 SF/BEDROOM, 5 BEDROOM 625 SF REQUIRED DEEP TRENCH, 7' EFFECTIVE 11-12' TOTAL DEPTH, 45 LF EACH 2-3' WIDE, 630 SF TOTAL W PREPARED FOR PANNONE ENG. SVC John Hagneler P. O. BOX 102954 John Hagmeler Co. ANCHORAGE, ALASKA 9951.0 HC 52 Box 8765 272-8218 Phone & Fax Anchorage, AIC l<99503 (907) 248-6789 DATEi 2-27-99�-DESIGN PERMIT ND SW DESIGN DETAILS PLD, NO WASTEWATER ABSORPTION SYSTEM LOT 3 BLOCK 3 SKYHILLS S/:D 1nONV3l3 v , a I a L�, a I a � `a LL. c 5 taiY `I L.. Y I w d a W v 0 x. U. A K n Z L.a 3Hn1 NUENow ^. ., U a + o i, I 0 L.. V R ii W.) z i7 � W la Z �S. it jl Ad w ,.. ¢ I; I LLJ U o II J Ld ¢F '^ H W Z t' r pq J Z 1naNtl313 r ne LL - NF J W No — 7 -•Ld a) v---_ y L� L J a 1- d N l7 N q ., lo- p 1nONtl313 �a o i 1nONtl3l3 o s w 1naNtl3l3 i >� Ci\Work\3-3SKYH.➢WG 1nONV313 — _ www Z.z� Zo ZNu F••i6 ZAr ^El>„> ���P. z oyN> 1naNV313 AV NauvaNnaA i rf 49TH U• ■ •. ........................d.....• ■...... ........ ..�-- A _ U�/�"'� ' s PREPARED FOR, ;Steven R. Pannone ■ PANNONE ENG, SVC, • , •t John Ha Meler ••�%No. CE 8149 \ i� John Hal3meler Co. P, O, BOX 102954 ppp Qg�p(.•'�" HC 52 Dox 8765 ANCHORAGE, ALASKA 99510 Ip .. Anchara;3e, AK 99503 272-8218 PHONE & FAX p11 �.0 (907) 248-6789 -- �"llilk � DATE, 2-27-99 N9T T❑ SCALE I DESIGN r11UN= rvu. 1107 -5626276 ,� y ,� MuRtafpallty of Anchgrwp® . OEPARTWN7 OF HEALTH & HUMAN SERVICES 825 "L" 61rDet, Anohgrage, AIgrY¢ 99602.0660 SOILS L.00 — PERCOLATION TEST sent <� ::=9 in: isw•1 PERF0IIMEDFOri:—,_•„ � E_Cunstruct.ian DAI1: PERFORMFD. -.,, �I-9b ,HGAL 048CRiPTION:_ LT al HLA 3, Sky .Halle Subd_ivinion SLD/E 6176 PLAN -- r WAE GROUND WATER t, ENCCUNTCRSD> y 6 -� :F VER AT WHAT'— _�. P Ontk to wow me I�'ip- 17 - IbrciilbfiGp7 __•"'�'�Ovx��"I�tS .„ ...,._ ...... _..JJ., .._,. Rnotlin0 Ir 1 — r t40057 cq.1t, I,ri- I�rras I T ;,fit L.....1__ r WAE GROUND WATER t, ENCCUNTCRSD> y 6 -� :F VER AT WHAT'— _�. P Ontk to wow me I�'ip- 17 - IbrciilbfiGp7 __•"'�'�Ovx��"I�tS .„ ...,._ ...... _..JJ., .._,. Rnotlin0 Da:E Grose Time Net Deed, ra .._ Nr: Time IY®te, Drpp r 3:x ,3:4.- I,ri- I�rras o 20 Y PERCOLATION FIAT E .2�- S' Iminutevincnt PERC HOLE DIAMETER __Y IC- J Tull RUN SEYWF l tY AND —'L- FT COMMENTS »Pere �u�-,,-,o,..e.....E-r..e....n..-o.eak..oe..dT.-....,-,.-•---.�—._�...W_...-..e....._v- r, o PtRFORMED 8Y. ��..��.�--..— I xi-e��U.4 �n'�'ex; In DCIZRTIPYTHAT T'MILfE„SY WJ4MFORMED IN • •} .�-� Municipality of Anchorage On-Site Water and Wastewater Program •;v i (907) 343-7904 s t r CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 011-262-39 Expiration Date: /0— I 7^( 1. GENERAL INFORMATION Complete legal description SKYHILLS PHASE 1 BLOCK 3, LOT 3 Location (site address) 8423 SKYHILLS DRIVE,ANCHORAGE, AK 99502 Current Property owner(s) RONNIE &CAROLYN LEE Day phone Mailing address 8423 SKYHILLS DRIVE,ANCHORAGE,AK 99502 Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well - ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: , l i Date: I/'' 7—/ 9 COSA to be released to the engineer, unless othe/ssquested by the engineer. COSA Fee $ 5gles Waiver Fee $ Date of Payment /6 f, ///' Date of Payment Receipt Number 03 /33-D Receipt Number COSA# 666-I'81544 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. Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 10/19/2018 Engineer's Comments:This investigation was completed in compliance with ADEC and MOA regulations. 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 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 systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments,deficiencies or discrepancies exist. �L�`\ 1 4• TUX. : 6. DSD SIGNATURE ��� A'ti/f 1` -- System #1 Approved for "�"�'" '' °err Y pp bedrooms. , 7116 System #2 Approved for bedrooms. 1 �0 .0a - cam°i Disapproved. Conditional approval for bedrooms, with the following stipulations: ON-SITE gm WATER AN • WASTEWATER o. PROGRAM �? air SE B y WVA, /,G�ryEC.. t Original Certificate Date: iia/8 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 Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet_10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist# of_ Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: SKYHILLS PHASE 1 BLOCK 3, LOT 3 Parcel ID: 011-262-39 A. WELL DATA— PUBLIC WATER Well type If A, B, or C provide P' SID# _ Well Log (Y/N) Date completed Sanitary seal (Y )Y Wires properly protected (Y ) Total depth ft. Cased to . Casing height (above •'•und) in. FROM WELL L• AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE ESULTS: Coliform -olonies/100 mL Nitrate mg/L Arsenic: ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL _ Date installed 10/22/1999 Tank size 1500 gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N Date of pumping 10/17/2018 Pumper ONE STOP C. ABSORPTION FIELD DATA Date installed 10/22/1999 Soil rating (g�.d./ft2 or ft2/bdrm) 1.2 System type DEEP TRENCH Length 46 ft. Width 3 ft. Gravel below pipe 6.9 ft. Total depth 15.6 ft. (Measured 10/18/18) Eff. absorption area 635 ft2 Monitoring tube Y Depression over field N Date of adequacy test 10/18/2018 Results(Pass/Fail) PASS For 5 bedrooms Fluid depth in absorption field before test 0 in. Water added 1100 gal. New depth 42 in. Elapsed Time: 1320 min. Final fluid depth 0 in. Absorption rate >= 750+ g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at_in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES - PUBLIC WATER WELL ON LOT TO: Septic tank/lift station on lot_ On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 200'+ F. COMMENTS Vacant 1 year-field presoaked per code prior to testing. 49"septic tank fluid level. G. ENGINEER'S CERTIFICATION I certify that I 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. OF Aj Engineer's Printed Name KENNETH M.DUFFUS j<S!�� x'11 Date 10/19/2018 * 9TH KEflu " Alf COSA canary sheet_2-6-15.doc )1l5. <� ' F' •rti'_io"\ i `__� Municipality of Anchorage Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-262-39 1. GENERAL INFORMATION Complete legal description Skyhills Phase 1 Block 3 Lot 3 Location (site address) 6423 Skyhills Drive, Anchorage COSA# 0801oS Expiration Date: ri = 0 q Current Property owner(s) Mary & Leonard Horst Day phone Mailing address PO Box 1241 Chickaloon, AK 99674 Lending agency Day phone Mailing address Real Estate Agent Dan Wolf / Keller Williams Realty Day phone 865.6512 Mailing Address 101 W. Benson Blvd., Anchorage, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑Q TYPE OF WASTEWATER DISPOSAL: Individual On-site ✓❑ Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Onsite Systems 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 COSAs upon request to homeowners. Certificates of Onsite Systems 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 sample results. (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 Certificate of Onsite 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. Name of Firm Watkins Engineering, Inc. Phone (907) 949-1851 Address 2520 Laird Cldce Anchorage, AK 99516 Engineer's Printed Name Cindy W. Ellis Date 4/24/08 6. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Gt/, Original Certificate Date: 4 _a -7 C)g (Rw.. 7Ift) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsfte (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SKy Hills Block 3 Lot 3 Parcel ID: 011-262-39 A. WELL DATA Well type _ If A, B, or C provide PWSID # — Date completed — Sanitary seal (Y/N) _ Total depth ft. Cased to ft. FROM WELL LOG Date of test Static water level ft. Well production 9.p -m, WATER SAMPLE RESULTS:, Coliform colonies/100 mL Nitrate' mg/L Arsenic: mg/I Date of sample: B. SEPTIC/HOLDING TANK DATA Tank Type/Matedal Steel Septic Tank Tank size 1500 gal. Number of Compartments 2 Well Log (Y/N) Wires properly protected (YM) Casing height (above ground) in. AT INSPECTION 4-17-08 ' Other bacteria colonies/100 mL Collected by: Date Installed 10-22-1999 Cieanouts (Y/N) Yes Foundation cleanout (YIN) Yes ' Depression over tank (Y/N) No ' High water alarm (Y/N) N/A Date of pumping 4-17-08' Pumper A+ Home Services C. ABSORPTION FIELD DATA, Date installed 10-22-99 Soil rating (9.p.d.tft2 or ft2/bdrn)1.2 System type Deep Trench Length 46 ft. 9 Width 3 ft. Gravel below pipe 6.9 ft. Total depth 15.3 ft.Eff. absorption area 635 . fe Monitoring tube Yes Depression over field No Date of adequacy test 4-17-08 Results (Pass/Fail) Pass For 5 bedrooms Fluid depth in absorption field before test 63 L in. Water added 1431 gal. New depth 62' in. Elapsed Time: 0 min. Final fluid depth 62 in. Absorption rate >= 750 g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) If yes, give date D. LIFT STATION Date installed NA 'Pump on' level at_ in. Size in gallons 'Pump ofr level at _ in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot NA Absorption field on tot Public sewer main Sewer /septic service tine Manhole/Access (Y/N) High water alarm level at Meets alar 8 circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Animal containment areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 5' Property line38_ Absorption field T Water main 100'+ Water service line 42' Surface water 100'+ Wells on adjacent lots 200+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 27' Building foundation 12' Water main 60'+ Water Service line 31' Surface water 100'+ Driveway. parking/vehide storage 14' in. Curtain drain NIA Wells on adjacent lots 2008+ F. COMMENTS: Lot and adjacent lots are served by city water. Water introduced directly Into trench C/O. 'Water level in field dropped during test. �- - G. ENGINEER'S CERTIFICATION I certify that I 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. Engineer's Printed Name Cindy W. Ellis / Watkins Engineering, Inc. Date 4/24108 COSA Fee $ 4 '� U Waiver Fee $ Date of Payment L-1 — z Y — O Receipt Number C r/' ' o 7 D -- (Rev. 11/05) Date of Payment Receipt Number 49111 idy W. Ellis CE. fo5n Municipality of Anchorage .. t��• Development Services Department Building Safety Division On -Site Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING d Parcel I.D. 011-262-39 HAA# fh C Zy &C3 1. GENERAL INFORMATION Expiration Date: lL &/CZ, Complete legal description SKYHILLS S/D PHASE ill: LOT 3, BLOCK 3: Individual Water Storage ❑ Individual Holding tank Location (site address or directions) 8423 SKYHILLS DRIVE Current Property owner(s) ELAINE TEST Day phone 243-3886 Mailing address 8423 SKYHILLS DRIVE Lending agency Mailing address Real Estate Agent Mailing address Day phone PEGGY GONZALEZ w/ DYNAMIC PROPERTIES 3111 "C" ST. ANCHORAGE, AK. 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 5 Day phone 242-3825 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. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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 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. Address 6901 DEBARR ROAD, SUITE 2B . ANCHORAGE, AK 99504 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 8 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 or party is not authorized, nor will it confer any legal right whatsoever. 5. DSDSIGNATURE V/ Approved for bedrooms. Phone 337-6179 Date t t2•(o ', Disapproved. Conditional approval for bedrooms, with the flowing stipulationl��ttt��iYfOFq r' ON-SITE Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other By: Original Certificate Date: �Z ' (R". 17N1 O U Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SKYHILLS S/D PHASE #1; LOT 3, BLOCK 3; Parcel ID: 011-262-39 A. WELL DATA •• PuOuc WATER Well type **N/A If A. B, or C provide PWSID# N/A Well Log (Y/N) N A Date completed — Sanitary seal (Y/N)= Wires properly protecte ) — Total depth — ft. Cased to — ft. g heove ground) — in. Ca�NSPECTION FROM WELL LOG Date of test — — Static water level — — ft, Well production — g.p.m. — g.p.m. WATER SAMPLE RE S: Collform colonies/100 ml. Nitrate — mg./L. Other bacteria — colonies/100 ml. epic: — mg./L. Date of sample: — Collected by: — S. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC / STEEL Date installed 10/22/99 Tank size 1500 gat. Number of Compartments E Cleanouts (YIN) YES Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A Date of pumping 5/02 Pumper DENALI SEWER &' DRAIN C. ABSORPTION FIELD DATA Date installed 10/22/99 Soil rating 02D3or ft'/bdrm) 1_2 System type DEEP TRENCH Length 46 ft. Width 3 ft. Gravel below pipe 6.9 ft, Total depth 12.2 ft. Eff. absorption area 634.8 ft' Monitoring tube YES Depression over field NO Date of adequacy test 11/22/02 Results (Pass/Fail) PASS For 5 bedrooms Fluid depth in absorption field before test48 in. Water added 772 gal. New depth 53 in. Elapsed Time: 30 min. Final fluid depth 49.5 in. Absorption rate >= 750+ g,p,d. Any rejuvenation treatment (past 12 mo.) (Y/N & 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 Absorption field on lot Public sewer main service line On adjacent adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 50+ Water service line Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Buildingfoundation 10'+ Water main 10'+, Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 200'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 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. Engineer's Pnn ed N me JEFFREY A. CARNESS Date tJ 7 HAA Fee $ Date of Payment - 2- -Oz Receipt Number 2-9tV& (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number Nov 14 02 12:50p X 1 0 N Elaine H. Test AMI 3l{A0.00 H 'AMM 'mAl _ 1 - 907.243.3006 k vQ SMIHAXS yO V II p.2 MUNICIPALITY 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. ## 0 11- Z b7 —3cT HAA it _E=d(WG`1 n )SL 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner ZA_0 AMAq. aV:: L erg. _— Day phone Mailing address `� z° 14 CLu&j6=1 kAJZ�sc�i_� /0V Lending agency ---- -- Day phone Mailing address --_ Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF 13EDROOMS: j 3. TYPE OF WATER SUPPLY: Individual well Community well ,t _ 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 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 f urther 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 cz Nc+. GV C-- Phone Address (J'•n c24.SL( 6 �N cEl Ale- °S,�,S-/0 Engineer's signature Date �o 1z2�4 Q 6. DHHS SIGNATURE Approved for El VE bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments M 4t1TIC Date 2°-2-5" 99 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 orderto 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) Back MOA N21 ti Municipality of Anchorage I DEPARTMENT OF HEALTH &HUMAN SERVICES C*D Environmental Services Division OCT 25 199J 825 L Street, Room 502 •Anchorage, Alaska 99501(00i40EIf�ty4t744icnorage slept. Health & I-luman Services Health Authority Approval Checklist Legal Description: _ `3 r 23 V_ IC 0 r LL- _ Parcel I.D.:__—26-Z A. WELL DATA lY' d1 rad �Y �AwwV Well type _ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) _ — Date completed Total depth Cased to _ Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) Date of test Static water level Well production FROM WELL LOG WATER SAMPLE RESULTS: Coliform Date of sample: D. SEPTIC/HOLDING TANK DATA Nitrate AT INSPECTION g.p.m. -- g.p.m. Collected by: Other bacteria Date installed /o /za�g9 Tank size Number of Compartments _? Cleanouts (Y/N)�' Foundation cleanout (Y/N) Y Depression (Y/N) High water alarm (Y/N) Date of Pumping. !0122.191 —Pumper C. ADSORPTION FIELD DATA Date installed 1012214 4 —Soil ratin<((g.p.d,/ft2 r ft2/bdrm) ,Z —System type r Length /-/6 JWidth _ 3 _ Gravel thickness below pipe ` —Total depth 12, 2 Effective absorption areaMonitoring�'� Monitoring Tube present (Y/N)`C Depression over field (Y/N) -� _ Date of adequacy test �U L•�_-w Results (Pass/Fail) VSA S For _ -5� bedroo Fluid depth in absorption field before test (in.); — _ Immediately after=- gal. water added (in.): Fluid depth -=__ (ins) Minutes later: — _ Absorption rate := _g.p.d. Peroxide treatment (past 12 months) (Y/N) LA-� C7) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm E. SEPARATION DISTANCES Size on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: � � Lic �-OA L- Septic/holding tank on lot Absorption field on lot Public sewer main service line On adjacent lots adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: t Foundation J Property line ybe Absorption Water main/service line SO ` Surface water/drainage /CL) t Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: � Property line z Building foundation /31 Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain / doT Wells on adjacent lots /,!:,d F. ENGINEER'S CERTIFICATION / certify that / have determined thru field inspections and review of Municipal records in conformance with MOA HAA guidelines in effect on this date. Signaturel� Engineer's Name/S`r �N,J ,PJB Ajc),o pr3. Date /d G 22 14 `�• HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 30f ZOt r ' /9�a-1�49 .�G/VLZ ,.••••E�, A !'aoressio`i��`�