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Home My WebLink AboutEAGLE RIVER VALLEY RANCHETTES LT 11C ' 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 ~ UPGRADE ~ z Manufacturer ~ ~ DISTANCE TO: Well /. j ~ Dwelling PERMIT O Z ~ Manufacturer~-~ Material Liquid capacity in gallons ' Total ef ct' or~ area Length Width Depth -- PERMIf NO. ~ ~ Type of crib Cri e Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: .~ Cla,~ ~,~ ,__~D~ ~ Driller Distance ,o Io, line ,PERMIT NO. ~ BuildinCfoundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: PIPE MATERIALS OTHER ~. ~. ~ ~ . ~ ~ ~T° ~':: ........ Y[¢¢~ 1: ~ I ~ ~ ~F "~' 72-01~;Rev. 3/78) PERMIT NO. r.ll_,.l~-.! I I_--.. I f'XF~L I T'T' I_--IF Rr-~CF^~F:RGP DEF'RRTMENT ,.. 'HERLTH RND ENVIRONMENTRL'rROTECTION :--:25 'L' STREET., RNCHORRGE., RK. -q. 9501 264-4720 C~!"',!--5 T Ti --<~=;il'lFR PFF:i-'I "r T 820244 ) RPPLICRNT LOCRTION LEGRL RON SILVR LllC ER VRLLEY RRNCHETTE BO~< ?i ER LOT SIZE 694-2647 i7955 SQURRE FEET TYPE OF SOIL ABSORPTION SYSTEbl IS: TRENCH MRXIblUM NUMBER OF BEDROOMS = _-< SOIL RRTING (SO FT?BR)= 150 THE REQUIRED SIZE OF THE SOIL RBSORF'TION SYSTEM IS: B, EF'TH= 22 LEI'46TH= '~'-: 8 6 P.. R',,,' E L DEF'TH= 6 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE 'TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF THE GROUN[) RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET H IDTH FOR TRENCHES. THE GRR',/EL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). E:E _r~.-!!J I RED .SEPT I C TRI',-.II-.-f. $ I ZF-- ,,1 r~'-1~:-~O GRLLOI'-,I$ % PERMIT RPPLICRN~ HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DUF.:ING THE INSTRLLRTION INSPECTIONS OF RNY HELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE HELL HILL SERVE. TI.--lO ( 2 ) I I'4SPF~ST I 6~1'-.15 RRE R E _I';~-. U I RED, BRCKFILLING OF RNY SYSTEM HITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT HILL BE SUB,TECT TO PROSECUTION. MINIMUM DISTANCE BETHEEN R HELL AND ANY ON-SITE SEHRGE DISPOSRL SYSTEM IS i00 FEET FOF.: R F'RIVRTE NELL OR 150 TO 2F~0 FEET FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC NELL. MINIr,IUM DISTANCE FROM R F'RIVRTE HELL TO R F'F.:IYRTE SEHER LINE IS 25 FEET AND TO R COMMUNITY SEI4ER LINE IS 75 FEET. OTHER REQUIREMENTS r,IRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGF.:RMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PERt.1 I T E~-~,P I RES DECEME:EI~: __~=::1... :1.9E:2 I CERTIFY THRT l: I RM FRMILIRR HITH THE REQUIREMENTS FOR ON-SITE SEHERS RND HELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I HILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3.: I UNDERSTRND THRT THE ON-SITE SEHER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN _?. BEDROOMS. SIGNED:_R P~LI_.-~SILVR V4. 0 PERFORMED FOR: · EG,,'DESCR,PT,ON: Z_//C 2 4 5 6 7 8 9 10 tl 12 13 14 15 16 17 18 19 20- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG-- PERCOLATION TEST COMMENTS WAS GROUND WATER ENCOUNTERED? SLOPE yb~' SO,LS LOO I-I PERCOLATION TEST O P E IF YES, AT WHAT DEPTH? t'l=. 1457-E SITE PLAN Gross Net Depth to Net Reading . .. Date Time .... Time ..... Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND ~ FT PERFORMED BY: ~a ~ .~",/L/~..~/,,~""/~"//L/~--. 72-008 (6/79) · /'~ .MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES · : . D vision of Env ronmenta Serv ces .... : 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.# (?':/~(" ~K"J;'-I' 1. GENERAL INFORMATION Complete legal descriptioq~. Lot II¢ Eagle River Valley Ranchettes Location (site address or directions) 19025 Man of War Road Propertyowne[ i'.. Alan Davies Mailing address'-'19025 Man of War Road, Day phone Eagle River, AK 99577 696-5691 Lending agency Day phone Mailing address Agent Carolyn Griener/Remax of Eagle River Day phone 694-4200 Address16600 Centerfield Drive, Suite 201, Eagle River, ~ 99577 e e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 '" TYPE OF WATER SUPPLY: Individual well Community well Public water xx× NOTE: If community well system, provide written confirmation from State ADEC attest- ' ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: · Individual~ on-site Holding tank Community on-site Public sewer NOTE: xxx If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) F¢o~t MoAI21 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 wastewa~ter disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & $ ENGINEERING NameofFirm 170341~agleRiv,,,'t-,,2~_-,-_d.%,.%_2~.{ Phone ~'~7~ _,3. cf '7~ Eagle River, Alaska 99577 Address Engineer's signature '?~/.-~,¢ ~-' ---' ~/~/'~7~,~_-- Date 6. DHHS SIGNATURE ~/'"Approved for 1~"-'-~-" ~l:::: Disapproved. Conditional approval for bedrooms. c -**oi ..... t~,~:.., ; ,ii,'-';',;,'" ~ bedrooms, with the foUowin~ stipulations: Additional Comments 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 lhe State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before n certificate is issued. The Municipality of Anchorage is not responsible tot errors or omissions in the professional engineer's work. 72~025 (Rev. 1/91) ~ack MOA 121 RECEIVED, - Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES APR 09 1999 Environmental Services Division 825 L Street, Room 502. Anchorage, Alaska 99501. Health Authority Approval Checklist LegalDescription: L-aT- lit..._ ~-/~C-c~. ~w,~ V/i~.c4~y ParcelI.D.: /~,4/v ct.t ~r~ J A. WELLDATA ' p ~ 6k.~ c. Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~. Date completed Total depth Cased to Cesing h~ov, ground) __ Sanitary seal (Y/N) ~ _ Wl~.~.,.r~fly protected (Y/N) _ __ FROM WELL LOG J AT INSPECTION Well production J g.p.m. __ ~ ' g.p.m. WATER SAMPLE R~ ~:llfo~~__~ Nitrate_ ~ Other bacteda B. SEPTIC/HOLDING TANK DATA Date installed S / ~. / ~ ~ Tank size Foundation claanout (Y~) /~ o ~ Depression (Y~) ~ O , Date of Pumping ~ /~ / q ' Pumper C. ABSORPTION FIELD DATA Dar, inst,,,d / f Length ~ 0 Width Effective absorption area ~g'~ Number of Compartments High water alarm (Y/I~ Soil rating (g.p. dJfF or~[i~ / 5- O Gravel thickness below pipe /~r~ Monitoring Tube present(~¥N) Y~-./ Depression over field (Y~ .bedrooms System type '7- Total depth Date of adequacy test ~( ~/ q~ Results<~!~'lFall) /)a-,r.J For 3 Fluid depth in absorption field before test (in.); ~/' Immediately affer/O.~. 7gal. water added (in.): Fluid depth /"/~ (ins) Minutes later. ,u//,~ Absorpfion rate = ';YJ"O '/ g.p.d. Peroxide treatment (past 12 months) (Y/N) /v~,v4~ /~,v~' If yes, give date 72-026 (Rev, 3/96)' UFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycle~ste~ Size in gallons_ ~ "Pump off' level at* E. SEPARATION DISTANCES SEPARATION DISTA.NC~ES F.,ROM WELL ON LOT TO: Septic/holding tank on lot ' Absorption field on lot Public sewer main ~ ~-'"' Public sewer manhole/cleanout Se~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'- ~ Property line Absorption field Water main/service line }0'-f-* Sudacewater/drainage Joe ~'- WellS on adjacent lots __ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ] o~ Building foundation / 6~ Water main/service line __ / 0 / Surface water ) o o + Driveway. parking/vehicle storage area Curtain drain /~'0,,~ K~/o~ ~ Wells on adjacent lots N/R . F. ENGINEER S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal re~]~J~ the ~l~ms are l,, ,.o,,,o,,.,,,,ce ,,,,th ~o.,, ,-,,~u~de,,,,e, ,,, o,,e,'., o,, th,s ,,,,o. ,~.,~.,". ... ~:~.~'"...~\ En-ineer's Name /~,~,,C~-- C.. C.O~/#,,.P ~, =~ ~, a~,;'c, caw^, · ,, .. .~' ~- ~ Date ¥/~/'~ '/ ~;/,~:-~'. ................ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~ ~F~ Telephone:~ ~ (c) Applicant Address '~, ~ Applicant is (check one): Lending Institution []; Owner/builder I-I; Buyer []; OtherJ~ (explain); (d) Lending Institution ~--~'~ ~/]/~-~/'..-~_-~" Telephone Address ~-~ ~ ~" ~ ~ (e) Real Estate Company and Agent ~ ~ ~ Address Telephone (f) Mail the HAA to the following address: S & S Er.e~neer|ng S~3 19&x TYPE OF RESIDENCE Single- Fa mily~vl ulti-Fa mily Number of Bedrooms Other WATER SUPPLY Individual Well [] ~ Public~ ' Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite C~ Public [] Community I-I Holding Tank r"l Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ENG'INEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my sea~ affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater clisposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ,.." -.T. ,2v..~;n.~,],,3 Address SRB lr;6x Date Eag!e River, Alaska 99577 Telephone DHEP APPRO~_.~ Approved for bedrooms by Approved /~ ' Disapprover~ ~. Condit:~ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection {DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 {11/84) A. WELL DATA MUNICIPALITY OF ANCHORAGE (MO~J HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 MUNICIPAI,I'Pf OF ANCHOIIAG~ DEPT. OF HEAt,TH & EN~IIIONN~NTAI, PROTECTION Legal Descri ~:~7'- ~,rlotJon: Well Classification Well Log Present (Y/N) Total Depth Static Water Level ~C/.-~ "f~ ' ~ B, C, D.E.C. Approved~A~¢~ Date Completed Yield Cased to ~ Depth of Gro,uti~[~/' .- At Casing Height Above Ground Sanitary/E~[I on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: TO Septic/Holding Tank on Lot ~-~'~/ ~'' ; On Adjoining Lots ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line CleanouVManhole Water Sample Collected by Water Sample Test Results Comments ZOC:)I ~' ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date "PVd -¢ B. SEPTIC/HOLDING TANK DATA Date Installed ~ ~Cu,~ ~7_,, Size Standpipes~'~ Air-tight Caps ~l~j Depression over Tank~/~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~~:~-> I'~'' To Property Line //,p To Water Main/Service Line No. of Compartments Foundation Cleanout Date Last Pumped Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Course To Stream, Pond. Lake, or Major Drainage Comments Page 1 of 2 72-026{11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date lnstalled ? ,'~-~ ~"~-- Width of Field ..~_3 ~' //,,.~0 '~'~/~-,.~/(.., Type of System Design '~£/V'(f /'/ Length of Field .,Z//'/~ ~ Depth of Field J / Gravel Bed Thickness ~ j Z./~,~-~_~, ~ Standpipes Present ~ Date of Last Adequacy Test //.,-~.,5'"- ~ ~, Square Feet of Absorption Area Depression over Field ~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~.~..~C:h~~1'' ~-I~ To Building Foundation Lot To Water Main/Service Line '/O ~ ~'' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line JO To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at pVent (Y/N) umping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all,[t4OA a/nd HAA guidelines in effect on the date of this inspection. Corn an SRP, 19~5x P Y- , c- MOANo. ~ ~' ? Date of Payment ~ ~ ~ ~- ~.2,~ ,, ~ Amount: $ ~ ;~/~~a, ~ ~ ~ · ~ ~,~' Page 2 of 2 %'~n'.% ..'~%X~ 72~ (11/~) - APPL~"'~,NT FILLS OUT UPPER HI~ ONLY 3' - /I' P, one Lending I.,4~.on F. P, m, E. Pho. e Realty Co, & Agent pC,~v ~.. ) Phone Address · Zip Code Type of Residence ~ Single Family ~ 3 B Multiple Family No. of Bedrooms [] Other Water Supply I'1 Individual ATTACH WELl. LOG. A well log I$ required for ell wells drilled Since ,June lg75. E~, Community For wells drilled prior to that date, give ~ell depth (attach log II available). [] Public Utility Sewer Disposal e Individual Year Individual In.tailed: I ~ E 2 [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN ~E INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: ~/(,,' ,MUNICIPALfTY OF ANCHORAGE DFPT. O mv,~;~'.',~,>.-~.,o?.cJ~o~ '",'; 1 8 1983 RECEIVED ( '~ APPROVED BEDROOMS 'CONDITIONSOF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' /~[ ~'~ -- ~ '~,'~" Well to Tank Septic Teak Size Ai.. _leANT- DO NOT WRITE BELOW THI~ .NE All Valuation: (square footage) x (cost per square foot) x (regional factor) = Valuation SINGLE FAMILY OR DUPLEX - ALSO LAND USE COMPUTATIONS. Living area x x = $ Garage area x x = $ .... TOTAL VALUATION .., = $ Valuation Valuation Living area x factor = 5 Garage area x factor = +$ Date Paid: Building Permit fee TR# ~ Date Paid: 1. Clot. hes dryer?.- · ,. 2. Bathroom ventilation fans? 3. Range hood? Plan Review Fee (x.50) BUILDING & PLAN REVIEW FEE '- "@4.00+ ~@4.00 + ~ @ 4.00 + =+$ ~ =$ TR# ~ ' 'TR#'" ' TOTAL Mech. TEMPORARY ELECTRIC PERMIT Date Paid T/EFEE 5 =;:-' -. Date Paid GRAND TOTALS COMMERCIAL- PUBLIC BUILDINGS: MISC. STRUCTURES: VALUATION . $ TR# TR# x x =$ x x =5 x x =$ =$ --5 x x =$ Date Paid · Chart Permit Fee TOTAL VALUATION =5 · TR# Date Paid · Plans Review Fee ( ) = $ TR# Total Vents = 5 TR# TOTAL FEES = $ TR# BUILDING PERMIT NO: .~'-'~, TAX CODE~-'IMBER: BOOK PAGE LOT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF PUBLIC WORKS BUILDING SAFETY DIVISION APPLICATION FOR BUILDING PERMIT, ' 3500 EAST TUDOR ROAD LAND USE PERMIT, AND MOBILE HOME PLACEMENT TELEPHONE: 907/263-8234 ALL APPLICANTS COMPLETE PARTS I- V. IDENTIFICATION - NAME MAILING ADDRESS - NO., STREET, CITY, STATE OWNER / m7 CONTRACTOR -c.I - ' * ' JPHONE I ARCHITECT, ENGINEER I PHONE ZIP LOCATION OF BUILDING ADDRESS (Street No., Street. Zip) ILOT//C. IBLOOK 'SUBD,V ,ON TYPE AND USE OF BUILDING ~ ~.~. r~ ~,¢ ~_~ A. TYPE OF BUILDING (Check one) TYPE OF SEWAGE DISPOSAL ~[*NEW BUILDING [] ADDITION [] ALTERATION [] REPAIR OR ,~Private (septic tank. etc.) REPLACEMENT TYPE OF WATER SUPPLY [] RELOCATION. MOVING [] GRADING. EXCAVATION [] OTHER iSpec,ly) B. PROPOSED USE ~] Private (well. cistern) (1) MOBILE HOMES ONLY I MAKE YEAR I SERIAL NO. SQ. FEET f7 ~"-~' SPACE NO. MOBILE HOME PARK SIZE I LEANTO: [] YES NO (2) RESIDENTAL (Write the proposed use of each building, and fill in others.) NUMBER OF STOmES_~ NO. D~,~ELLING . I SQ. FT, LIVING AREA UNITS / I ~,~O ~),.~ ~ (Write In proposed uses ot building end lhe number of square feet of each use; Ior example: (3) NONRESIDENTIAL warehouse -- ~0,000; olfice -- 5,000; elc,) PROPOSED USE SQUARE FEET ADDITIONS AND ALTERATIONS: OWNERS ESTIMATE OF COST S The owner ol Ibis building and Ihe underslgned agree to conlorm Io all applicable laws of Ihl$ Jurisdiction, SIGNATURE I DATE III. IV. 84-00t (Rev 1/82) Parcel I.D. # MUNICIPALI'r~' 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 -~-o H\ HAA# 1. GENERAL INFORMATION Complete'legal description Lot llC; Eagle River Valley Ranchettes Location (site address or directions) Pr0~3ertyowner B~ian & Shauna Olmstead Mailing address 19025':.Man Of War Road Day p.hone Lending agency Mailin. g address Day i~hone Agent Carolyn Greiner' Addres;~·T6600 Centerfield Drive, Su~e 201, Day phone 694-4200 Eagle'River,AK 99577 e e Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 '~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. - X×× If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Front MOA 121 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature $ & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River~ Alask~a 99577 ~ Phone DHHS SIGNATURE ~ Approved for T/-//~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The'Muni¢ipalRy of Anchorage Dep:~r~ment of Health and Hurrah 8ervi¢~ (DHH$) issues Health Aulho~ty Approval ~ertific~te$ ~ only upon lhe repre~ent~lions given in pardgmph ~ above by an independen! prole~sion~l engineer registered in the State. of Alaska. The DHH$ does this as ~ courtesy to pumh~sem of home~ ~nd lheir lending institutions in order to s~tisfy oertmin federal and st~te req uiremen~s. Employee~ of DHH$ do no~ ¢ondum inspe~ions or mn~ly'ze dat~ before a certificate i$ issued. The IVluni¢ipali~y of ^nchomge is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division ~,~5 ..~ ~,~~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) Health Authority ApProval Checklist"'~"~'~- ~'- Legal Description: LoT ;I C_ A. WELL DATA ~3 u~,~., c- Well type Log present (Y/N) Total depth Sanitary seal (~/N) Date of test i[.~,(,. ~. L R ,,~,,. ~ v4,.~.,,, y Parcel I.D.: ,05'0 If A, B, or C, attach ADEC letter. ADEC water system nu~er..~,. Date completed Cased to C~bove ground) ~ properly protected (Y/N) FROM WELL LOG ~ AT INSPECTION Static water level Well pro~uotlen WATER SAMPLE ~ Coliform ,/'" Nitrate Oate.,~a~le: g.p.m, g.p.m. Otherbacterla B. SEPTIC/HOLDING TANK DATA Date Installed 6 / 3,/~; ~ Tank size C. ABSbRPmON FIELD DATA .' '.. "~ 1~-~o Number of Compartments 1~ Cleanouts(~) y * J' Depression (Y~) /v o High water alarm (YF~i). /,' 0 System type ' Total depth Soil rating (g.p.d./ft~ o~ /5" 0 ;t 7=. Gravel thickness below pipe Elfeotlve abSorption area 4fS'-f, ,ct MonllorlngTubepresent(~N). 7'~-f'Oepresslonoverflelcl(Y~ Date of adequacy test H / ~' ( ct q Resultsl~=ail) ,, P~_~ $ For :} Fluid depth In absorption field before test (in.); ~'" Immediately after/O~'?gal, water added (In.): Ruld depth ..~/}'g' (Ins)Minutes later:. '~/'g Abeorptlonrate - zv$ o ~ g.p.d. bedrooms Peroxlde treatment (past12 months) (Y/N) ,v,,~¢ ,~,,e~u,~ Ifyes, glvedate -- 72-026 (Rev. 3/96)' D. UFT STATION Date installed Size in gallons ~ Manhole/Access (Y/N) '~ "Pump off" level at* Hl~h',~er al,ann level at* ~ *Datum, E. SEPARATION DISTANCES F. SEPARATION OISTANCES FROM WELL ON LOT TO: Septlc/l~olding tank on lot Absorption field on lot Public sewer main ~ adjacent lots Public sewer manhole/cleanout lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5- q' Property line $' ~ Absoq~tion field Water main/service fine /0 '-~ .Surface water/drainage ,/oo -/- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ! I) ~ Building foundation / o --/- Water main/service line r Sudace water / eO -/ Driveway, parldng/vehicle storage area Curtain drain ~ o ~ ~. /¢ ~/~ w ~,' Wells on adjacent lots Engineers Name Date ENGINEER'S CERTIFICATION · ~"" ~" ....... ~4 are NAA Fee $. Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)*