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Home My WebLink AboutCAMPBELL HEIGHTS BLK 2 LT 3A1Compbell Heights Block 2 Lot 3A1 #014-071-57 From : I::LPII'EE DRILL 907 ~45 02~2 . ~.. ..~?..ff.. · R .CEIVED ~ture of Authorized ~csp~tative IApr. 04. :1994 E~8: 06 PM POi :.: ' ".' ~ATE OF A~ ' ; ' DEPARTM~ OF ~TU~ R~OUR~ DIVISION OF WATER WELL OWNER: WATER WELL RECORD ;;i;~ · O, DE I' Os ow. ~ .:~J.::, . i:' Oepth o! hmo: '2 / Depth el ea~ing: '~' ~ tt , ,~ DEFTH TO STATIC WATER LEVEL: ,,~ '~ ft below I~ to~ of eating Date: Ocab~e~O~ . i. METHOD OF DRILL~IO: 1~' air rotary O other ut~ or wm.: I~ ~om.tic O ~.~a~Ion. O mo~,., I'1 public eupply, ri other i', WEU. INTAKE OPENING TYPE: I!' open end 0 ,~ ~;; L · I'1 perforated ~ open hole ..* , REMARKS; O,-/ PLEASE MAIL WHITE COPY OF LO{[~.I'0: DNR/DIVISlON OF WATER Date PO BOX 772116 -- . EAGLE RIVER AK 99E77-2116 ' Depthe of oper~ngs: to ft: * ".; ~ ~r~REEN TYPE: '~ Diem: : qn.': .':;~ ': $1ot/Melh SiZe: . Le~: ," · ~ -".~:; ~' G~VR PACK TYPE; . . , s :,, .} V~ ~: x... Dep~ to tOp: . ~.,.'~ '. .,.'* :~; ~ Dept. H, alth & Human ce, v".-leOMPl~O LEVEL ~D/YIELD: PUMP ~TAKE DE~H: ft Horlo~ ~ : MUNICIPALITY OF AMCHORAGE DEPARTMENT OF HEALTH AMD HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW940024 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:WIDMAR RAFAEL OWNER ADDRESS:3636 E 67TH AVE ANCHORAGE, AK DATE ISSUED: 2/09/94 EXPIRATION DATE: 2/09/95 PARCEL ID:01407157 LEGAL DESCRIPTION: CAMPBELL HEIGHTS BLK 3Al 2 LT LOT SIZE: 8830 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. 1 SPECIAL PROVISIONS: RECEIVED BY: ~~/~ DATE: Da~e 12/21/93 Grid 2035 Drawn by ~.0T 3A-2. N 30 ~5 0 30 60 SCALE l'-30' V~TICAL DATUH WAS ASSU~EO LOT 3A-$ HAS 8.830 SO. FT. OF A~EA PlOt Plan ffo=:pRE$?ZG]~: ~OMES. 340 Petrie Rd. Anchorage, Alaska 99515 (907) 349-1488 Scale 1"=30' Plot Plan Field 8ook Z hereby certify that the property de$cFLbed hereon has been surveyed Legal Description Lot 3A-ZIB1ock 2 Subdivision CAMPBELL HEIGHTS SUBDMSION OT 48 FOR: PRESTIGE HO~S 340 Per,is Rd. Anchorage, Alaska 99515 (907) 349-1488 LI~G£NO: · FOUNO 518' REBAR Date 02/20/94 GrAd 2035 Draw~ by ScaLe 1"=30 ' AS -Built Field Book #53 ' ' I~ga[.~eEcript ion Lot 3A-1 ~lock 2 Subdivision CAMPBELL HEIGHTS SD'BD M S'ION ~B? ~44 ~?~ RECEIVED FEB 1 0 1994 Munic~pah~ ol/~f~chorago Del~t. Health & Human Services Municipality, of,Anchorage Development Services Department www.ci.anchorage.ak.us ~'¢~ E ~'~/.~" · Complete legal descriptiqn ..... '.CAMPBELL HEIGHTS SUBDM~;IONi LOT- 3A-1~ B,LOCK 2 - ',,-, Location (stte address o[ directions) ............ 3636, ~E~,,' 671H ..... ANCHORAGEs., AK .... Curr.ent Propedy owner(s) ..... CR~G,.EIGHILE ....................... Day phone 261 7373 Lending agency Day phone · '.:'. " , Mailirigaddres{; - :.- Real Estate Agent PEGGY THERIAULT.w/: VISTA MORTGAGE Day phone 273-77B5 : . ~ ,,, ,,,,,.... '4241 "B" STREET * ANCHORAGE, AK 99503 ' ..... Mai,,ing ~'?'t~.'.~:"":'"'".~v'j.'-,' ~',.','~'-"' ',~ "~,. -_~--';.. ............. '~ ~,,~,-,,r~,~:,,~-P-~.:.,.,;.,.v...., ,.- ~. ,~,,;~.~ .,., ........ , .,..:-~:' ':.: ' Unless Otherwise req'u~ted, HAA v~ill bb I~'eld b~'DSD fo?~ickdD. :-":" :.. ..... ., ,' : !,'," ,"':' .' : ' 1<~ , .': ,.: ~ .,:. ,!' .: '.,.', .,"..,.:,;.. ,. . . 'z~ .~ . . , 2. NUMBER OF BEDROOMS: 4 . ........... 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well..' ' ', ',.: t :'~1~,~_": ~:':'. . . ', , Indwldual. On-slte '. ,, [] ,., . , ~, ;;.,. -.. ' .~ · Individual' ' Water ........ Storage ,.. :"" :: :"..., ~(J'(~""ia'n'~':/'''''''''":''''''':i"g , · D,"' ";'":':"'~';'"'. '"'"'"'.. ~:''?- Community Class Well [] Community On-site [] The Municipality of Anchorage Development Sen/ices Depadment (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the rep?esentations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. C~rtifi. cates of Health Authority Approval are required for the transfer of title (except between spouses) for properties sen/ed 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 d~te of issue for properties sen/ed 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 pfior . ' · t°cl°s~ngfor, theeng~neenng~ervlcesprovided,'~:~ ,.~:.' ..... ~' '. ~i~"i¥.~'i:'::'.?:':".::.;¥."" ' · :. ' 4. STATEMENTtOFINSPECT ON BY. ENG NEER.. . . .,., .... . .,.. ...... ;..:~:, ;~. ,~:; :;, .,.,....,-.-.',... _ ~;. :.~.,,"...,,'.'..~' :. '- · . ' ' for the number of bedmoms and lype 'of st~ctdm 'ingi~te~ he.in' I fu~he~ ~;~bt information obtaine~. ,from ......... ~he'Municipafit~'ofAncho~gEfiles'. .... and f~m,my investigation Englnee(8 Comments ..... : ~ :, ..... . ........ '. ,' ' .' '." '~ . , ::.::: ' :' .'. ' ' ....,. ; . * , , · conscientious engineenng enalys~s of the ~ystem in accordance w~th ADEC and MOA, .'; '~ .... distances measured to readily identifiable featdres ~;The operational life of ail wells ~nd : , ', ": '¢ · uctuate duringihe year, and the ~ter usage af'th8 ~ami/~beia~e~ed ~y the sys~em.";~~~:/: ~ ;_'~ ~':" '~'- These conditions are outside lhe'contr~l af lh~'eValu~lo~ of th~'~y~tem. Sati~facto~'l~st ' - ~~,~ ; .~J ...... '..~ ,' results do not guarantee future peffd~ana8 b~f ~8's~ste~; nO/,do thay~daraatee'th~t : '~ :~f~*A, .~ss . ..., there are no hidden defdcts or.encroachments. AKin,. Inc. ca~ therefore no¢ p~vlde,. ,'- ~~7953' :? ;', · ¢~ ," ,' ' , . . , any.wa~anty or fufure estimate of how long lhe system wtll co~l~nue lo meet the ,,- *- '..:i. ~ ~¢ , ·,: ' . . , ,the sole benefit of the ownerlisted ~bove .Anyreliance upon or,use oflhls re?o~ by an~ '. ' ,' ' otherpersonorpaHy~snotaulhonzed, nor w/lHt ~nfer any legal ~ght whatsoever. ¢"',- ~- .,',.v, ,".. Disapproved - . .... . ....... , .......... · -, ...... :, ' ':- . ..... ' ' ~ndition'al approval for- . /: . ! bGdroo~s, ~ith the ~lowi g SUp. - . ..... , , . -':. , : · '. .... . .. ,. ,.",, "'.: ;.. - · ..,.. ,-.. .,:-.,,kk~'~,~ ~, ~N~(~ - . ........ . ......... ............ . .... ........ · .... . ........ dWA TEWATER:. :.. Attachment~: ' ' ' .... · . .. . H~ Checklist , Maintenance Agreements · , ~, Septic System Advisow Supplemental EngmeeFs Reo~ Well Flow Ad~iso~ Other (Rev, 1;','01) Original Cedificate Date: Mu icipa!ity of Anchorage De e!opment[ Services Department O~lts:Water~& wastewatsrPn~ram: 41~:~ 8mgaw SE (907) HEALTH: AUTHORITY APPROVAl. CHECKLIST Legat:Oes~pt!o~ CA~PBEIJ~ I-]Ei(~I.ITS ,,S/D; LOT 5A-1, ,BLOI~K 2 ,, ,,, A. WEU. DATA Well~typa ,~,~A~,,, Il:A, Bi or. C. prcMde PWSID~ N/A Datecomple~ted, _2t:15/t 99~t., ~Sal~Itary.$ear,(Y/N),~ Date of test Statlowater level Weltproductlon Total~lepth - , 81: ,fi; Ca~edto - 81 ft. , ......23, ,.: ,[ .... ,. 40' g,p.m. W^TER eAMPt~E,RES~: Coliform 0 colonles/lOO~nl; Arsenic ~ N/A. mgm1. SEPTICIEI~DJ~G ~ANK DATA Parcel ID: ,, O1~..071-57,,, Well Log (Y/N) YES , Wires properly protected (Y/N) , YES ,, Casing height (above ground) 24.+ in. AT INSPECTION .10/19/2002 , , ,25 ,, ,. ,ff. , 6+ , g.p.m. *WELL F'LOW DONE BY ORENT P. EATON Nitrate 0;24.8: mgJl.. ~e//~o2, Other bacteria , Data~ofeample: 2.1~/o:~ , Collected by: PUBLIC SEWER 0 , colonies/100 mi. AKWWCr, iNC. ~ Tal~k SlZer, ~, ~ :::~:gal. :Number of, Compartments ~ ~, . .: ..... Pumper ..... Oate~nstalled, ~ Date:inStalled,. ~: ....... ~p~;t~ll~g.,(g p~dJ1t~3rlt,~xlrm) ,: 6ystemtype , ,, Tomlde~. :: ~, Eft: p~e~ama , fl~ Monitoring tube ~presslon ever field Da~,ofedeq~te~ ,,.-, R~ul~ For bedrooms Flu!d ~eP~ tD:pb~o.=fl~~T~. Water add~ ,,, , gal. N~ aleph. , , in. ~ena~n ~e~nt,:~a~ 1Z~o;):~& ~) ~ ........ If yes. give,date,, D. LIFT STATION Date installed Size in gallons , Ma~ 'la~1~a~~~ ~gh water alarm level at in. "Pump on" level at in. ~ ~ Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: SeptJc tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A Public sewer main 75'+ On adjacent lots 100'+ Public sewer manhole/cleanout _ 100'+ Sewer/septic service line 25'+ Holding tank N/A SEP^RAT, ON D,STANCES FROM SEPT,C~HOLO,NG T^NK O. LOT TO: p U 13 L IC S F W E IR Building foundation Water main Property line Absorption field. Water service lin ace water. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water service line Building foundation Water main Surface water way, parkingNehicle storage Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections end review of Municipal records that the above systems ere in conformance with MOA HAA guidelines in effect on this date. Engineer's Print.ed ,~e Date "Z-' /ll ~ JEFFREY A. GARNESS HAA FeeS Date of Payment Receipt Number (Rev. Waiver Fee $ Date of Payment , . . Receipt Number 9o75~5301 cl~r I~f~ 10269500O1 Claqat N~me Eaton, ~r~t · P~ No~ 3636 E S~ Ave O)st Ssmpb ~ 3636 E 67~ Ave ~ SID O To~ Colit'om~ t trniu ~ O2OO ms/L EPA300.0 col/]OOmL SMll 922213 ~rinl~ ~lmt J~l~ 9:]2 ~l~t~ Dat~l~ 10/15~ 9:40 ~ Dat~lml ' 1~15~2 13:05 T~hulcal Dir~lor Slij~I~ C, Ed* Inlt (<-1o) 10/15/02 JS* 10/IS/02 F,,AP ., Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastawater 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 --.03 q --- o'fl -- ? Expiration Date: ] - ~. ~ ~ O ~ Day phone Day phone Day phone GENERAL INFORMATION Complete I~gal description Location (alia address or directions) Current Pinpert,/owner(s) ~ {g'-~ Mailing ~tddress Lending a0wnc7 Mailing address Real Estate A~;ent Mailing Address NUMBER OF BEDROOMS:"nless°th°'W'~er°qua'ted' HAAwillboheldbyD~,fo£pick~/~.~.~ TYPE OF WATER SUPPLY: ' Individual Well Individual Water storage Community Ciasar Well Public ~'Vater Syr~tem TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank [] Community On-site [] Public Sewer The, Municipahty cf Anchorage Development Services Department (DSD) Issues Certificates of Health Authority APProval (HAA~ ~',~"~ed only upon the representations given in paragraph 4 by an independent professional c~vil en,3~neer registehA: in tho State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except bet~:~n spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. D~D alao I:~sues HAAs upon request to homeowners. Certificates of Health Authority Approval are valM for 90 da\.,,- P,-cm tho date of issue for properties served by a pdvate or Class C well and may be reissued with new water samlN~ result1 (Certificates may be reissued for a period of up to one year with valid water samples.) Ce[tlficates are \~-'id for one year for properties served by Class A or B wells or a public water system. The Muu,cipality of ,.\:,,.,..~oraOO m not responsible for errors or omissions in the professional engineer's work. 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.ek,us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. Expiration Date: GENERAL INFORMATION Complete legal description Location (site address er directions) ~,:~, ~". Current Property owner(s) ~ (C-~ ~(~'~ Day phone ~ ('~ Mailing address Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Un/ess otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ~7~ 3. TYPE 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 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 pdvate 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 ere 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 vedfy that my investigation, based on procedores 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 vedfy 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 ins{allation. Name of Firm "~/_~'I,J'T' ~. ~"~f"4:~ ! po ~". Phone - ' 7"7'7 Engineer's Pdnted Name ~:~'7,..P~ p, ~'"$~'f'~/~[ Date [0 -~"~ "" O~....- DSD SIGNATURE ~ Approved for 3 Disapproved. Conditional approval for Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: Municipality of Anchorage Development Services Department Building Safety OJvtalon On-Site Water & Wastewater Program 4700 Sot,,~ Bragaw St. P.O. Box 196650 Anchorage, AK g9519-6650 wvnv.ci.anchorage.ak, us (9O7) 343-79O4 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA We, type Date completed Total depth ~'1 FROM WELL LOG Date of test ~ -' Static water level Well production WATER 8AMPLE RESULTS: Wail Log (Y/N) Wires property protected (Y/N) Casing height (above ground) Coliform colonies/100 nd. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Foundation cteanout (Y/N) AT INSPECTION in. Ni~ate0-:2-~'mg,/L Other bacteria O colonies/100ml. Date of sample: ~._~(~Z- Collected by: ~,,~-~ I~1"~ Date installed Number of Compartments Cteanouts (Y/N) Depression over tank (Y/N) High water alarm (Y/N) Date of pumping Pumper ABSORPTION FIELD DATA Date installed Soil rating (g.p,d./ft= or ~/bdrm) Leng~ ft. ~ ft. Total depth ~ ft. Eft. al3sorption area ~ Monitoring tube Date of adequacy test Results (Pass/Fail) Fluid depth in absorption field before test in. Water added gal. Elapsed Time: min. Final fluid depth in. Any reiuvenatton treatment (past 12 mo.) (Y/N & type) System type Gravel below pipe Depression over field. For New depth A/osorptton rate >= If yes, give date in. g.p.d. Date installed Size in gallone Manhole/A _ _,~e_ss (Y/N) "Pump on' level at in. 'Pump off' level at in. High water alarm level at Datum .Cycles tested SEPARATION DISTANCES Meets alarm & circuit requirements?, SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lilt etation on lot Absor~ion field on lot ~ I Public sewer main ~' ~ la/ Sewer/septic service line '4"~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank in. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Water main Water sen. ice line Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Sewice line Curtain drain COMMENTS Bull.ding foundation Surface water Wells on adjacent lots Absorption field Surface water Water main D~, patldng~ehicie storage, 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. Date of Payment / ' J'/ Date of Payment Receipt Number ~ "~ :::1 ~ ~.. Receipt Number (Rev. 12/01) 0CT-21-02 09:16~ FRO~-CT,IE ENVIRONI~NTAL $9V ,~f~. CT&E EnvJronmen,.l Se/vic. Inc. 9075615,i01 T-,I28 P.02/O,I Fo544 L-~E Ref.~ Cleat Name P~.Jtn Name/# C1)nt Sample ID M~rlz 1026950001 F~ton, Brent 363~ E 67th Ave ~1636 E 67th Ave Drinking Water ~ SID 0 Sa~ole Remarks: " Nim~te-N 0.249 PQL All Dates/Times ire ~klaska Standard Time Printed l~t~/Time 10/21/2002 9:12 Collected Date/Time 10/15/2002 9:40 Reeelvmi Date/Time ' 10/15/2002 13:05 Technkal Director Ste/fl~lln C. Ede 0.200 mg/L EPA 300.0 (<=1o) lO/Ii/02 10/15/02 col/lOOmL SM18 9222B (<'1) Init .IS' ! KAl' ' '"';"* ~ MUNICIPALITY OF ANCHORAGE ":'"'"" ' DEPARTMENT OF HEALTH & HUMAN SERVICES. · :. ',_ · ' .... v' :'.. : Division of EnvironmentaIServices .... ' , ' · · .,. : On-Site Services Section, .... :- : . ..-' :' ,P.0. Box 196650 Anchora_ge,'Alaska. 9951~-6650 · · .. ,-=. 343-4744 OF HEALTH AUTHORITY :- - · 'APPROVAL FOR A SINGLE FAMILY DWELLING' 1. GENERALINFORM.A. TION ,. .' Location (site address or directions) Property owner ~n~.~ II '~,,'~ cr-,~r~ Dayphone Mailingadd'~ess '~_~(~,L~. J[~)C~.{~ ,~,~ ~ ~ Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: '3; TYPE OFWATER SUPPLY: Individual well Community well Public water NOTE: If community weJi Sys~e~ni'pr~vid~ W~i~ten confi~m'ation fr~m State AD'EC attest- - '~ ......... lng to the legality and status of system. - - ., 4~' "~'E OF WASTEWATER DISPOSAL: ........... -" · ' ~,'-':' IndividuaJ o'n~slte ' ' - i ~ NOTE: , If community wastewater system, provide written confirmation frown' State '~DEC attesting to the legality and status of s tern. ./ - '~ ' ' -. ~ . . , -... T2'O2~iRev. 1/91) Front MOA~21 .~, 5. STATEMENT OF INSPECTION BY ENGINEER. As Certified by'~ny seal affixed hereto ahd as of the ~alidation date shown below, I verily that m~ investigatior{ of this Hca th Author ty Approva app ~cat on shows that the on-site water supply and/or wastewater disposal system is ~afe, f~nct~onal and ~deq~te for the number of b~rooms and ~pe of structure ~ndi~ted he rein. I fu~'~'~)i~ that based on the information obtained from · _ the Municipali~ of Anchorage files a~d frpm .my ~v~stjgation and inspection, the on-site water . .' ' supply and/or wastewate~ dispoml ~ystem is in compliance ~i(h all Municipal and State Code~, ordinances, and regulations in eff~t on the date of this inspection. Address · ' · I,~ Date Engin~ffs signature Oonditional approval ,for b~r6om~ with the [ollowing ~fipulation,: -' . · - Additional Comments .. ', '-:'The Munic Pa ty of Anchorage Department of Health and HtJm~n Services (DHHS) issues Health Authority ·, · ",.',A~sp,,rova C~rtific~(e~' based only upon the representations given in 'paragraph 5 above by an independent · !,,, . ~rSfe~sionaleri6in~er'registeredlntheState0fAlaska. The'DHHSdoe~thisasacourtesyt°purchasers°fh°mes ~: i :/ ~' a~(Jltheiri6nding ihstituti°ds n order to s~tisfycertain federal andstate requirements. Emplo~ecs of DHHS do n~t, f" '" ':":: "'c~ld{Jct In{pections 0t anal~rze :data· before a 'C~rt f c~{e is issued. The Mun c pa ty of Anchorage s not , ]: .':ii:;; ~j'''! ~; '~ /:.e'sPonsible~ . . for errors or omissions, in the prQ~essional.' ":. eng, ineer's.: work., i · .' .:' .-- Municipality of AnChOrage " Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescdption: ~rr'~t-I ~'~.o~(.. ~, ParcelLD. A. Well Data Log present (Y/N) ~ Total depth ~;'! / Cased to Sanitary seal (Y/N) ~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~//~/~g Driller A ~,~/~" ' Casing height Wires propedy protected (Y/N) AT INSPECTION : : On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Well lype FROM WELL LOG Date of test Static water level Well flow ~ g.p.m. Pump level1 SEPARATION DISTANCES FROM WELL TO: Seplic/holding tank on lot Absorption field on lot ~/'~' '" Public sewer n-,~in Sewer service line ~ ~ 0 I Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ,, 1/ /vt g / I.... Otherbacteria O Collected by: ,~[. ;~[' B. SEPTIC/HOLDING TANK DATA ~1 ~ ~ ~ CU ~ Tank size Foundation cleanout (Y/N) High water alarm ~ Compartments Depression (Y/N) Alarm tested (Y/N) ~ Date of pumping' ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLD "'.. Well(s) on lot On adjacent lot~ Founcl~lo~=~ To property llne Absorption lield Water main/service~ Surtace water/drainage ' "'~'"'; ?:: :" ~ "'; "" ' ~ ~.e2~ ~. F~,~ CONTINUED ON BACK PAGE Date Installed ~'"~.~' Manufacturer Size In gallons ~_ Manhole/Ac¢:~ {Y/N) Vent (Y/N) 'Pump on' leve~ al~--~-----"'-_-_~.~, ~ ' Pump off" Level at ' High water alarm level ' C~ Meets MOA electrical codes (Y/N) , ~ . s .^RATION .ROM L,. ST^TIO .". TO:. , Well on lot On adjacent lots Sudace water Dat~ln~ ~.1 Soil rating (GPD/FF) , System type Length ~"-...~'~ Width Gravelthickness ' Total depth ~ abs°~ption. ;r~~ Cleanout present (y/N) . Depression over fieid (Y/N) · :Date of ~leclu.aW ~est ~ Results (pass,a,) ' ' for Bedrooms ' Water level ,n'~so~ion field before ,est~'~--~ ' 'Ntertest Peroxide treatme.nt (past 12 mont~) (y/N) : ~" It yes, give date SEPARATION DI~'rANCE FROM ABSORPTION FIELD~'. '., - ' Well on lot , - On adjacent lots~, ~_ProPerty line TO building loundatiOn· To existing Or abandoned s~ On adjacent lots Cutbank . Water maWservice line"-...'"~ Surface water Driveway, parking/vehicle storage area Curtain drain F- ENGINEER'S CERTIFICATION I cerUfy ~at I have checked, ve#fied, or conformed to all MOA and HAA guidelines in effect on-the date of ~'s Inspec~n. HAA Fee $ ~i~), ~ Date of Payment g-/ /---/ 7_- Receip~ Number ~.. ~,- ~x'~} :%\ tt >;'~ ',.,, Waker F~ $ Date of Pay~ R~i~ Nu~r Client Sample ID Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services LABORATORY ANALYSIS REPORT 94.1461-1 L3A-2,BI CAMPBELLIIEIGIrrs S/D WATER Client Name ANDERSON ENGINEERI2qG WORK Order 77193 Ordered By ALAN ANDERSON Printed Date 04/08/94 (~ 08:49 hrs. Project Name Collected Date 04/04194 ~ 17:00 hrs. Project# Received Date 04104194 ~ 17:20 h~. PWSID UA Sample Remarks: ROUTINE SAMPLECOLLECTED BY: A.tL Technical Director STEPI IEN C. EDE QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 0.11 mg/L EPA 353.2/300.0 10 04/06/94 LLII * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed ,,, U = Undetected, Reported value is the practical ~antification limit. LT = Less 'lhan D -- Sccondl~y c~lulion. G'r= Great er 'lhan ~- {907) 562 2343 Fax: (907) 561-5301 ~ 5633 B Street, Anchorage. AK 99518-1600 --Tel: - ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA. ILUNOIS, MARYLAND, NEW JERSEY, OHIO. UTAH, WEST VIRGINIA