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Home My WebLink AboutHERITAGE PARK BLK 2 LT 28H itage Pa k Block 2 Lot 28 #050- 211 - 52 ~.~,/ 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 IPHONE LOCATION DISTANCE TO: Manufacturer Liq, Well Absorlhtion area IF HOMEMADE: Well inside length Dwelling Dwelling Mater~ Wd% NO. OFBEDROOMS¢ No. of compartm~ts Liquid depth PERMIT NO. Manufacturer Material Liquid capacity in gallons PERMIT NO, DISTANCE TO: We,, No, of lines Length of each ' e i of tile to finish grade 9 ~,./L~ Width Crib diameter Well Depth F ° u n d at i 71z~;~.~ Total length of I ~L-~es/ Material beneath tile Depth Crib depth Building foundation Driller Sewer line Length Nearest I ot~ n~e Trench widt~L ~(.~ inches Type of crib DISTANCE TO: DISTANCE TO: Building foundation Distance between~/,~ Total effective abso~.~t~%a PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER PIPEMATERIALS|~ SOIL TES~ RA~I~G INSTALLER REMARKS APPROVE ~ r// ' DATE LEGAL ,, . ',' ' 8~5 "'b-'" STREET, FINE:HCF.'RGE, RK. '9'B.~::';¢J± ~__¢ '-, 264-4728 PERMIT NO. ,' 8---':E~4±:3 ', ~';~..(;-,~_~,'.,L,.:,. RPF'LICRNT DEVCON ,:.'BILL CURUTHERS 54if OLD SEN. RED HIGFINR"r' 9S~502 56i-t082 LOCRT I ON LEGRL L28 82 HERITRGE PRRK LOT SIZE 9L~':399~ SQURRE FEET TVPE OF SOIL RBSORPTION SVSTEM IS: TRENCH blRXIMUM NUMBER OF BEDROOMS = 4 SOIL RRTING (SQ FT,-"BR)= 85 THE REQUIRE[..' SIZE OF THE SOIL RBSORF'TION S~'STEM IS: [:,EF']-H= 13: LE~'-~GTH= ;;~: '-:~- L3 F-: F-1%-" E L [:,EF'T[4= 6 THE LENGTH DIMENSION IS THE LENGTH (tN FEET) OF THE TRENCH OR DRRINFIELD. THE [:,EPTH OF R TRENCH OR PIT IS THE DISTRNCE BETNEEN 'THE SURFRCE OF THE GROUND RN[:, THE BOTTOM OF THE EXCRVRTtON (IN FEET.'.'. THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL [:,EPTH IS THE MINIMUM [:,EF'TH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE E,'.-,',CRVRTION (IN FEET:..'. F.:Ei_-4Lll :I F:E[:. ~.;FF"T :i C: T RP-.~It-:-'.' '_-] :IZE= 125£"~ ,]~RLLC, P--~-- PERMIT RPPLICRNT HRS THE RESF'ONSIBILITV TO INFORM THIS [:,EPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF RNV WELLS R[)JRCE, NT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. BRCKF'ILLING OF RNY SYSTEM NITHOUT FINRL INSPECTION RN[) RPPF.:OVRL B"r' THIS [:,EPRF'.TMENT WILL E:E SUBJECT TO PROSECUTION. MINIMUM [.',ISTRNCE BETNEEN R WELL RND RNV ON-SITE SEWRGE DISPOSRL SVSTEM IS LI(~F~ FEET FOR R PRIVRTE WELL OR "15~3 TO 2RE~ FEET FROM R PUBLIC NELL DEPENDING UF'ON THE TVPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRI',,,'RTE NELL TO R PR I ',,,'RTE SEWER LINE tS 25 FEET .FIN[:, TO R COMMUNITV SEWER LINE IS '75 FEET. OTHER REQUIREMENTS MR'¢ RPPL. V. SPECiFICRTIONS RN[.', CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. -ir ]- E::-::F' ][ F.:E':; [:.EC:Et"-IE:ER 3:.±.- :-1L. 9:=::=: I CERTIFV THRT t: I RM FRI',II[_IRR WITH THE REQUIREMENT'~] FOR ON-SITE SEWERS RN[:, WELLS RS SET FORTH B'¢ THE MUNICIF'RLIT'¢ OF RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ]:: I UN[:,ERSTRN[:, THRT THE ON-SITE SEWER SYSTEM MR'¢ REQUIRE ENLRRGEMENT IF THE RF':,I[:,ENF:E I'=, ~MODELE[:, TO INE:LU[:,E MORE THRN 4 E:E[:,ROOh'lS. ..... SI GNE[): -~F'L I CRNT [:,E ,,, 9IN ¢ I L~:I_IRUT~;-- - PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 8 11 12 ~5- 17 18 20- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST ~_~IC~ SOILS LOG [] PERCOLATION TEST O ~' 10' 15' Z°~ WAS GROUND WATER I ( S L ENCOUNTERED? ~:~ O P E IF YES, AT WHAT DEPTH? SITE PLAN 5' Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (min TEST RUN BETWEEN FT AND -- FT COMMENTS PERFORMED ~Y: John R, "t~'r~DcoYlfi"~.]~ CERTIFIED BY: DATE: 72-008 (6/79) ~'-~ Lli~'-4t 1' C: I; F"-U-~L 1' T"T' ~Z~F Ft~-~C:Hr DEPRRTMENT 0, ~,HERLTH RND · ENVZ RONMENTRL ~.<0TEC:T ~ ON 82~ "L..'" ~TREET, RNC:HORRGE.. RK. PERMIT NO. ( 830277 ) RPPLICRNT DEVCON ENT. INC. 54'11 OLD SENRRD HWY. ~LLOCRT I ON EGRL LOT ';.'8 BLK '2 HERITFtGE PRR. K SUB LOT SIZE TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH MBXIMUM NUMBER OF BEDROOblS = 2 56±-±082 99999 SQURRE FEET SOIL RRTING (SQ FT?BR)= 200 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVFITION.(IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF GRFIVEL BETWEEN THE OUTFFILL PIPE FIND THE BOTTOM OF THE EXCRVFITION (IN FEET). PERMIT FIPPLICFINT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLFITION INSPECTIONS OF RNY HELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. BFtCKFILLING OF RNY SYSTEM WITHOUT FINFIL INSPECTION FIND FIPPROVRL B"r' THIS DEF'RRTMENT HILL BE SUBJECT TO PROSECUTION. idlNiMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS t00 FEET FOR R PRIVRTE WELL OR ~50 TO 200 FEET FROM FI PUBLIC.WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVFITE WELL TO FI PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY FIPPLY. SPEE:IFICRTIONS FIND CONSTRUCTION DIRGRRMS RRE' RVFIILRBLE TO INSURE PROPER INSTRLLRTION. i CERTIFY THRT d.: I BM FFIMILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND HELLS RS SET FORTH BY THE MUNICIPFILITY OF FINCHORRGE. 2: I WILL IN~,TRLI_ THE SYSTEM IN RCCORDRNCE 'WITH THE CODES. 3:: I UNDERSTRND THRT THE ON-SITE SEWER S'¢STEM MRY REQUIRE ENLRRGEMENT IF THE : MOD OANCU-'D SS_ : : ......... [:'RTE ..... - --- V4 8 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 5 6 8 12 13 14- 16 18 x,'.': ' 19 20 COMMENTS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST SLOPE WAS GROUND WATER ENCOUNTERED? TE PLAN 15' /~' IF YES, AT WHAT DEPTH? Gross Net Depth to I Net ~.%-..?~. -~ _ ..: . :: . Reading Date Time Time Water Drop PERCOLATION RATE ~ ~ (minutes/inch} PERFORMED BY: 22-008 CERTIFIED BY: ,.'~.P-- ,¢' '/~./¢¢,,¢-~-' DATE:. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and 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 Parcel I.D. 050-211-52 GENERAL INFORMATION Complete legal description Location (site address or directions) Expiration Date: Lot 28: Block 2: Heritage Park Subdivision 19405 Citation Dr. Eagle River, AK 99577 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Pam Stllmrt Day phone Day phone Larry @ Buyers Real Estate Day phone NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding tank [] Community On-site Public Sewer The Municipality of Anchorage Development Se,wices 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 St--.te of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties se,wed 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 A~proval are valid for 90 days frcm the date of issue for propert:,es se,wed by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a pedod of up to one year with valid water samples.) Certificates are valid for one year for properties se.wed by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errcrs 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 be!ow, 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 files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in ccmpliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. NameofFirm S & S Engineering Phone 694-2979 Address 17034 N. EaEle River Looo Ste. 204 Ea~le River, AK 99577 Engineer's Printed Name Robert C, Cowan Date ~./'7/c ~ bedrooms. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval for ~,~ .o~.~ c. ccw~N /.~ bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other By: (Rev. OIZC2) Original Certificate Date: Municipality of Anchorage Development ServiDes Department Building Safety Division On-Site Water & Wastewater Program. 4700 South 8ragaw SL P.O. Box lg6650 Anchorage, AK 99519-6650 www.cLanchorage.ak, us (g07) 343-7g04 HEALTH AUTHORITY APPROVAL CHECKLIST _ Legal Desc,"iption: ' ~ t Parcel ID: O~)-- ~-./I - ~',Z.. A. WELL DATA /~,~,' C Well type / IfA, B, or C provide PWSID # Date com,~fed _ . Sanitary seal (Y/N) Total de, gth .ff. Cased to / FROM WELL LOG/ Date of test Static water level · / ft. Well production / g.p.m. WATER SAMPLE RESULTS: ~ Coliform colonies/10Oj/nL Nitrate mg./L ArseniC: mg./1. / Date of sample: B. SEPTICIHO,,LDI~TANK DATA Tank Type/Material. '~p,r~ c. ~ Tank size ~ gal. Number of Compartments ~.- Foundation cleanout (Y/N) ¥' Depression over tank (Y/N) Date of pumping .~/~O'~ Pumper ,_TJ'~ IS c. ABSORPTION FIELD DATA Well Log (Y/N) Wires properly protected (Y/N) Casing height (above gro~_ / AT INSPECTI~ Ott~fer bacteria colonies/lO0 mi. / Cfll~cted by: Date installed ~ Cleanouts (Y/N) High water alarm (Y/N) "~ System type ~'"/~,t~::=~ ~__~ff Gravel below pipe (~ · ~" ft. ~7' Depression over field Water added '~gal. ._~m. Absorption rate >= Date installed ~ Soil rating (g.p.d,/ft2 ~ ~ Length '~ l- .._ fL Width "~"' ~' ft. Total depth j ~ ft. Eft. absorption area~,ft2 Monitoring tube Fluid depth in absorption~ 'field before test~::~ ! in. Elapsed Time: ~ min. Final fluid depth __ For ~ bedrooms New depth --~in. ~ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) ,,',,/ If yes, give date D. LIFT ~TATION Date installed 'Pump on" level aV in. Datum E. SEPARATION DISTANCES Size in gallons 'Pump off' level at in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/^__~cess (Y/N) High water aiarm level at Meets alarm & circuit requirements? in, Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots */ On adjacent lots / Public sewer manhole/clea?t Holding tank ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ ' '~ · Water main / ~) 4- Well~ on adjacent lots P~/~' Pmpe~'y line Water service line SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / (~ / ~ Building foundation /~/~- Water Service line ! ()t 4- Surface water /~:) t ~'- Curtain drain ~N~.~.Z~[~._ Wells on adjacent lots ~ Absorption field Surface water F. COMMENTS Water main Go 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 Printed Name Date HAA Fee $ ~"7 ,)'-. ~ Date of Paymen~ - ;z / -./ /o 3 Receipt Number 03',0~' 0~. (Rev. 12/01) / O~r- Waiver Fee $ Date of Payment Receipt Number Driveway, pa~ing/vehide storage. ~6968042 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wasteweter Program 4700 South Bragaw St. P.O. Box lg6650 Anchorage. AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D..O 5-0 - 3, I I - ...c' ~. 1. GENERAL INFORMATION .Cqmple. telegaldescdption L28 ~ m.,:~ ~:.~.. P,r~- ~!~ Location (site address~rdiJ'ections) ].9405 Citation Dr Ea~;le River Expiration Date: A~ 99~77 Current Property owner(s) Mailing address Lending agency SteDhanie Reich SAME Day phone 694-3389 Day phone Mailing address Real Estate Agent Mailing Address Unless otherwise requested. HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: 3 Kathy Geraci Re/Max od Ea,~le River Day phone 694-9125 3. 'I'YPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class ~ Well [] Public Water System [] 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of AJaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a sing!e 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 we!l and may be reissued with new water sample results less than 30 days etd. (Certificates may be reissued for a pericd 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 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. NameofFirm $ & ~ F.n~.in~,.~-i~.¢; '- Phone 694-2979 Address 17034 N. EaRle River Loo9 Ea?le River Engineer's Printed Name Robert C. Cowan P,E, Date 3',~1y $ t · ?Cml 5. DSD SIGNATURE ~ Approved for ~ . bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~' - 3 - O / 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 wv~v.ci.anchomge.ak.us (907) 343-7904 Legal Description: A. WELL DATA Well type Date completed Total depth __ Date of test HEALTH AUTHORITY APPROVAL CHECKLIST -.! If A, B, er C provide PWSID # Well Log (Y/N) Sanitary seal (Y/N) Wwes pmpedy protected (Y/N) ft. Cased to ft~//~Cesing height (above ground) in. FROM WELL LO~./" AT INSPECTION /--' fi. : : .. Static water level . Well production / g.p.m. WATER SAMPLE~LTS: " Coliform 7~.~colonies/100 mt. Nitrate Date of~ampte: Collected by:. rog./1. Other bacteria __ B. SEPTIC/HOLDINGTANK QA_TA 4/ Tank size F~:)undaU°n cleemout (Y/N) ~ Dep _re~__<,on over tank Date of pumping Pumper C.~ABSORFrlON REI-~.~O .ATA 9.p.m. coloniesJl00 mi. Date InsteJted ~._~ Clesnouts (Y/N) High water alarm (Y/N) Date of adequacy lest ~ Results (Pass/Fail) Fluid depth in absorption field before test ~a J in. Water added.~ gal. fi. Gravel below pipe ~.~" ft. Depression over field For ~bedrooms New depth ~ in. Any rejuvenatlon treatmem (pest12 mo.) (Y/N & type) ~0N't= ~JR~ Ifyes, givedate. D. UFT STATION Date installed ~//"~ Size in gallons on" level at ._~ in. "Pump off' level et 'Pump / Datum / Cycles tested In. Manhole/Acc__~_s (Y/N) High water alarm level at Meets alarm & circuit requirements? E. SEPARATION DISTANCES / SEPARATION DISTANCES FROM WELL ON LOT TO: /'~ in. Septic tank/lilt station on lot Absorption field on lot Public sewer main Sewer e~'C~~ I~e Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: On adjacent lots -/-- ' :~ole/cteanout Water service line ] O I~. Building foundation Water main Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / Water Sewice line Curtain drain ~ Wells on adjacent lots Absorption field Surface water Water main F. COMMENTS Driveway, pmking/vehicJe storage / (~ /'"if-. I cerg~y that l have determ/ned ti~mugh field inspect/on m~w of Muni~pal m~s ~at the a~ s~e~ ~n~an~ ~ MOA ~ gu~ellnes ~ eff~ on ~ d~e. ~..~....~ HAA Fee $ Date of Payment Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number ~ ,:.:~; ~. ~.'i. ~ .-, ~,~i~.* ,-:2:~,'~,ivision of Environmental Services ' ~.~ ,-..~ , ~.~:,~.~' ~, 'L.~.~-'~:- ;~. - .~,;~ ..... :~ ......... ~:¥, ,.-. ...... ~. :...--:~ - . ~. -. ~ . -~- .... ~.~._- {~- - ~.;~ ~ : -.. .... ; ..P.O. Box 1~50 Anchorage, Alaska .9951~650 ' '. ' -'~. : ' . '. ~;:~'~ '-{A~PROVAE FOR A SINGLE FAMILY DWElLiNG~'~:~-~' ":' ~?~"-;~-:'?~;;~::-~: ,, -.;L~_:v -_ ;~- .;: !..~::..GENERAL INFORMATION '~';-q'~ ~]~F?¥.-¥;~}~_'.~:;'~;~' ~ ~; - : ,:-. 'r *~ :'; .... .: ..}. - j~._:. :.'_. ~.:'~-...~.~ .;~--_~.;.;~ ~'~:'-:~d.'~,7~*~ ~X~_~"~.~';.~ '~C~{X~ .~J~*~.,~'~'F~; -~-'~r,;;:7 r':W~Y~ ~ B2:r~' :--7:r'~;':~ ' X~'~' ~" x:::?;2'?}~;~:i~?~.~&~; ,-~--':-'~.~:z-~ ~::F:~t:.~,~:L-;~--~,-~-:~-:~,~& Mai in~ addr~" ?~:~-'*.19405 .C~on .-'-.~-~Lending agency-~x'~-:~< .......... -~-- Mailing . ~. :_~ ~: ~. .~ .:ln to the/e all and status of system .............. ~- ...... ~ ~,, ...... ~ .......... ~ ~.. ~ ....... -5. STATEMENT OF INSPECTION BY ENGINEER ,~ .... ' :"-'::" ;* -i As ce rtified bY my seal :affixed her'~io and as of ~he v~'lidati~n~d~t~ 'sh~r~'beloW,-I: ~eri~ that my investigation 'of this Health AuthoriW ApproVal appl~tion shoWs thin'the.on-Site water supply ' ' and/or wastewater disposal system is ~fe,*f~hctiofial'~fid adequate for'the numbe~'0f b~rooms and ~pe of structure indicated herein. I fu Aher veri~ that bas~ on .... the information obtained from the Municipali~ of Anchorage files and from my inves~ation and ins p~tion, the on-site water d~sp~l system iS'in Compliance ~ith all Municipal and State codes, supply and/or wastewater ordnances, and reg'u,;'l~tio~s in ~ff~t 0h th~ d~teof thiS'insp%tJS'n.'''. ~'.: '.'-' r.~ -- ' I ''. ' '; .... Name'of Firm :' $ & s ENGINEERIB / ./ ' ' , .. , ,17~4EagleRive~L~pR~NO'2~/---- --'-- .: . ~-'-~- , , ~'L,,'~;' : . ..... ,.,, , . ., . ...... ~,,~ , ..: ,/.., .,,. -.. , .. , · . ; :ApPro~ai Ce~ f cates' based Only"Upon the representatiOn~ given in PAragraPh';8 ab~ve':b~:~n'independent ;;:;professi~aJ e'~gineer registere8 'n the state of AlaSka; Th~ DHHS does this as ~ 8e~y~ purchasem of hom~s and their le~d~ng institUtions in 0rder t° ~tis~ ~e~ain f~eral a,d State'r~bi~e~h~?~mP ~Y~ 0f DHHS do not Municipality of Anchorage Department of Health and Human Services HEALTH. AUTHORITY APPROVAL CHECKLIST A. Well Data Well type J/~ C)/~ Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height FROM WELL LOG Static water level Wires properly protected (Y/N) AT INSPEC~IO~~ Well flow g.p.m. Pump level1 T~:~~ SEPARATION DISTANCES FROM WELL Septic/holding tank on lot /" ; On adjacent lots Absorption field on lot Public sewer main Sewer service line WATER S~SULTS: ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: Date installed ~'~-~'5 Cleanouts({~l) ~/ High water alarm (Y/~. Date of pumping B. SEPTIC/HOLDING TANK DATA Tank size t'?~5'-~> Compartments Foundat on cleanout.('~N) ~ Depression.(Y/~) ~ Alarm tested (Y/N) --~ ~4~ -'~-- Pumper -2-~,~ To property line Sudace water/drainage 72-026 (3/93)* Front SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 'J/.,4- On adjacent lots /~4) ./~- ./~ ! ~ Absorption field ~- / ' Foundation Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pu~ High water alarm level ~ Meets MOA electrical codes (Y/N) SEP~M LIFT STATION TO: WelFon lot On adjacent lots Sudace water D. ABSORPTION FIELD DATA Date installed Length Total absorption area Date of adequacy test Width Soil rating (GPD/FF) ~ 5~/~:~-- .System type q~d~JC~ Gravel thickness ~,~ ~ Total depth /o Cleanout present~) ~ Depressbn over field (~ / Resu~s ~il) ~ for ~ Bedrooms After test ~ ,~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation l On adjacent lots Surface water Curtain drain ^~/~- On adjacent lots /o ~ ~'~ Property line /-F To existing or abandoned system on lot Cutbank "'//4~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or confo~rme~dtoa~MOA and HAA guidelines in effect On the~ Engineer's NameE,~gl¢, ~,iv~,r. Ala~Jk?~.// ' u r HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back 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. # ~3~ - "~\\- ~-~, 1, GENERAL INFORMATION Complete legal description Lot 28; Block 2; Heritage Park Subdivision Location (site address or directions) 19405 Citation Driv6 Property owner Mailing address Gordon R. ~ Denis6 N. Crawl~y Day phone 2300 N.E.. '13th St. Redmond, Washington 98055 Lending agency Mailing address Day phone Agent BUYER~a~Y~a~ ALPHA GROUP Day phone Address 3351 Ar~ B£.ud. #~01 Anoh~ag~; A£.~a 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: $ % TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water 563-3242 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 NOTE: ×X Public sewer 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 o STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies 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 & S ENGINEERING Phone 17034 Eagle River Loop Road No, 204 Address Eagle River: AIn<bn 9_q~7.T Engineer's signature Date DHHS SIGNATURE X Approved for~-~'/~"-~'~ L/'~) bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~ ~ Date 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. Em ployees of DHHS do not conduct inspections or analyze date 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 MOA #21 Legal Description: ~'~ ~-~ ~.V.-7-- ~t~..{~vc'~-'~ A. WELL DATA Well type ~ (~ '~ If A, B, or C, attach ADEC letter. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D~ ~) ~'-~ Date completed Log present(Y/N) Total depth Cased to FROM WELL LOG ADEC water sYStem nUmber Driller Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanoui g.p.n¢=~ Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. SEpTIc/HOLDING TANK DATA Date installed ~ ~'~ Tank size ~.<~'c> Compartments Cleanouts ~/N) ~ Foundation cleanout k~r/N) ~ Depression (Y,~ High water alarm (Y~.~ /'-J Alarm tested (Y/N) Date of pumping ~ ..c{'7..- ' Pumper ~"J~-, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot '7.-~ ~¥ : On adjacent lots To property line \ ~t J¢ Surface water/drainage Absorption field Foundation Water main~ervice line 72-026 (Rev. 7/91) Front : CONTINU ED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~l;ycles tested Meets MOA electr~ SEPA~TANCE FROM LIFT STATION TO: We'll on lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~ ~vel at Surface water D. ABSORPTION FIELD DATA Date installed -,/.- c¢~ Length ~ t ~ Width '~ ¢ Total absorption area ,cdCc,'~ ~ Depression over field (Y(~) J Results ~ail) ~2~¢, Soil rating ~' Gravel thickness ~.~,,~' ' Cleanouts present C/N) Date of adequacy test for~ System type Total depth Peroxide treatment (past 12 months) (Y,~ /*~,d~. lZ,,Jo ~J ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot '~'c,~ ~ 4'- ~ ~ On adjacent lots Property line To building foundation 1~~ '~ To existing or abandoned system on lot On adjacent lots f~ Cutbank Water main/service line Surface water c~ Driveway, parking/vehicle storage area Curtain drain ~'/A, bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspo~tion. .... _uub~d. 8~AFEM ~ ,~ HAA Fee $ / 7D Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number / / / / ',2,E{;,S' /,Cl O Nl :~ /