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HomeMy WebLinkAboutCOLONIAL PARK BLK 3 LT 5 S2Colonial Park Block 3 Lot 5 52 #050-301-15 MUNICIPALITY OF ANCHORAGE - DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION . ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME 'S PHONE tIEW 6 Y33� ❑UPGRADE MAI LING AD Y�ux is LEGAL DESCRIPTION _ LS 63 LOCATION • NO. OF 7ROOMS Uy DISTANCE TO: Well ® Abso -tion area i. Dwelling -7 / PERMIT i107S F_ z N � Manufacturer Y2 e /� Materj��' No. of compartments a! Liq. ca�pcity in gallons IF HOMEMADE: Inside length "Width Liquid depth oz DISTANCE TO: Well Dwelling PERMIT NO. Oz < Manufac a i capa ' m= DISTANCE TO: Well Foundation Nearest lot I- a hatch PERMIT NO. /(© a z 1- Q H No. of AS Length of each a G2 Top of tile to finish grade i Total length f lines Trench widt inches Material beneath tile lnehes Distance between lines 10 Totalffective absorption area W C7 Length Width Depth PERMIT NO. d n w Type of crib Crib diameter Crib depth Total effective absor - re w e TAN CE TO: B ngfoundation of line J W ass Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foun ation Sewer Imt Septic tank 'q 100 Absorption area(s) �O OTHER r PIPE MATERIALS D3a3 y SOIL TEST RATING O (D INSTALLE REMARKS r PPROVED DATE LEGAL loaf 1 L5 g 3 ��-feu-�Ll� d� 72-013rev. 3/18) S � by DOC Co, tlba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759 OWNER OF LAND Feg-,d 47Z e4h,crr TJ DEPTH OF WELL 3 el el y ADDRESS (<EnJ Qx:L Tr .e • STATIC LEVEL OF WATER FT. LEGAL DESCRIPTION L 6iiCK 3 CO AI'V / 1- 7fs DATE -Started Ended / PERMIT NUMBER KIND OF FORMATION: DRAW DOWN FT. GALS. PER HR Goff KIND OF CASING 0 From 0 Ft. to---.'4--Ft. 2y=`'''�d'P���"� From Ft. to Ft. From ? Ft. toFt. iSs?0111"-J From Ft. to Ft. FromL2 Ft. to � Ft. 5/9:1[1 SiJ 6�F�1c KC From Ft. to Ft. From .?L_Ft. to 39 Ft. 5%i/`J From Ft. to Ft From33-q--Ft.toJjQ2—Ft From Ft. to Ft From4_Z,-_2Ft.to-iij--Ft: !�ATU.fq%—!W /i1 iRt�7/��✓ From Ft. to Ft. From Zig Ft. toJ[ r Ft. GZ f f -9 From Ft. to Ft. From r 3 &�- Ft. to -/ii -Ft. _ Jr�'� ,6 ¢ �a$✓�G From Ft. to Ft. From %44 Ft. to IN Ft GSL,f 7' 4"l-44=4 2� 40CA er'f rom Ft. to Ft. PAGE From 1FFt. to�74 Ft. 'T1[NT Y* -u® W l'l i'/From NICIPALITf G ��I& Ft. cPT CroolA L?H &`-volt' From 270 Ft. to_,T�Ft. i/GrrT .S/5/xJt? From 3/4_Ft. to 338 Ft. r4 -'J'4 r 6"14c;'4 - From -?J2Ft. to -352 Ft. 'C4,Pflo ! 6.edl 4 From X73 Ft. to3gi-Ft. F/n� E SA ✓ 0 From Ft. to Ft. Ce uEG. 41, From 74.2 Ft: to—;1.5' Ft. r*Ai 0 G4o4 Jc'L j� From Ft. to Ft. AV 4T�L MISCL. INFORMATION: From Ft. To Ft. From Ft. to 'q.`r From Ft. to ___nkc� Y From Ft. to Ft. From Ft. From Ft. From Ft. May.25.2017 02 : 02 PM SULLIVAN 9076882259 PAGE. 1/ 1 r rX ztu i *Mi ng .94ng by• DOC Co.dbq SULLIVAN WATER WELLS r '•- • ;� P.0.BOX 272,CHUGIAK,ALASKA 89567 • TELEPHONE 6882769 OWNER OF LAND �L,�w��,,r,i S // � � _ DEPTH OF WELL . ADDRESS w aL f' • STATIC LEVEL OF WATER FT. _ 'gd LEGAL DESCRIITION_ L'o4o."JIr¢t 7c•le -5,31 DRAW DOWN FT, DATE-Started Ended /6/40 / GALS. PER HR Gdo PERMIT NUMBER KIND OF CASING ._� p0r4 • KIND OF FORMATION: From Ft,to--•j__—Ft. •44400-00 From_. Ft. to Ft. From- Ft.to_hj Ft. From Ft. to Ft. Ftom j.Ft.to * 1 Ft, t L From Ft. to Ft. Prom _Ft.t o Ft. 19h1Q . �G --�--••---��'� . From Ft. to _Ft. FromFt. to I/a Ft. .ti fXO From, Ft.to Ft Prom /1p2 Ft.to._1 .Ft., T.ird, /y ���.i/ tram–. Ft.to Ft. i From,f _Ft. toFt.�CA'J' • ��'r'�� From .._Ft. to From �---Ft• �C.� Ft, to my Ft. c ' From Ft. to Ft. From _Ft. to O ' tom �rom Ft. to Ft. From_ y 7 FFt. / ? S .u� v�G � '� From Ft.to _Ft. From_x21A Ft. to, / Ft._ 1L` al0 _ . From Ft. to Ft. From... L Ft.to D Ft. r)` "d d .S/`,.(tf" i . J From _..Ft. to Ft. From__ 2/2._Ft. toLFt. SLI'! d' (p� � From Ft. to Ft. From ?�Ft. to3 L.Ft. 44•-• From_ _Ft, to Ft. r` Prom Ft.to�,Ft. r From to � Ft. to Ft. • �,�Ft. S �*iO G S/p•J�� ' From °rom-- Ft.to T Ft. to Ft. Ft. �/ – From_____Ft.�,Ft.to FI _ IISCL.INFORMATION: DRILLER'S NAME r 1 L'rt! I e=_ I F' F =e L_ I T °-c' Cl F= DEPARTMENTHEALTH AND ENVIRONMENTAL OTECTION 1 825 4 STREET: ANCHORAGE, AK. a 1 r -A — �.�[ �� �g 1 � r'�4-4 FE lUL_CC U! � to a = a T' E: = E_ L4 FE F_' F' E �" 1'Y I T' rERMIT NO. '=11075 ? { . . _ I _3L APPLICANT ANDERSON BROS. PO BX 129 ER � f V�Q1.P.d.S�. S .4_ LOCATION ER LEGAL LOT SIZE 150[+0 O tHR EE� TYPE OFF =OIL ABSORPTIONSYSTEM IS: TRENCH Lz MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING c:50 FT/BR?= 100 THE REQUIRED SIDE OF THE SOIL ABSORPTION 'SYSTEM IS: F -F T1-1= 1 1 F rit TF i= s CiF;�!F=t°r°�L_ THE LENGTH DIMENSION THE DEPTH OF A TRENCH GROUND AND THE BOTTOM THERE IS NO SET 14IDTH THE GRAVEL DEPTH IS TI AND THE BOTTOM OF THE IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD OR PIT IS THE DISTANCE BETWEEN THE.SURFAC:E OF THE OF THE EXCAVATION CIN FEET?. FOR TRENCHES. -IE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE EXCAVATION CIN FEET?. FREE"_. —e I F="F=U• _F.= F~T I e=_' -rn"f' =. I �F-= -' e c3f=lLLeDr-4= PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCIES THAT THE IJELL WILL SERVE F= IL T I t ",=: ! i FR � F=" E e_i U I Fes' E� — BACKFILLING OF ANY SYSTEM 14ITHO_tT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC 14ELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REr.UIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'E=F ZM I 'F- EXF' I FZEE EtiE=®= EMEf F= F_" C~_-; -1 !F4 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE _EWER FORTH BY THE MUNICIPALITY OF ANCHORAGE. : I WILL INSTALL THE SYSTEM IPJ ACCORDANCE WITH, THE CODES. 2: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM Mi�,'f REQUIRE RESIDENC:,,I5AFE ELED' TCr INCLUDE MORE THAN 4 ISE ROOMS. SIGNED: ---- ------------------------- PHidDEF'SON .EFvOS AND WELLS AS SET ENLARGEMENT IF THE ISSUED B,------_------ __-_DRTE__.G� _-i--- 4'4. 0 Manic pality of Anchorage Department of Health and Human Services 825 " L" Street Pick Mystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650 Mayor 343-4744 July 20, 1995 Todd L. & Kaylene D. Johnson 19827 1st Street Eagle River, Alaska 99577-8432 Re: S 1/2 of Lot 5 Block 3 Colonial Park Subdivision, P.I.D. 050-301-15 Dear Mr. & Mrs. Johnson: During the recent sale of the South 1/2 of Lot 6 Block 3 Colonial Park Subdivision which is the adjoining lot to the west of your lot, a Health Authority Approval was applied for and granted by this office. The engineer hired by the property owner discovered during the field investigation that your water well is 97 feet from the absorption field portion of the septic system on the South 1/2 of Lot 6. The required separation distance is 100 feet. A file search in this office of the as-built/inspection report of the wastewater system on the South 1/2 of Lot 6 and the well log for your well indicates that when the well was drilled the absorption trench on Lot 6 was in place. This puts the responsibility on you to either obtain a waiver or redrill your well to meet the required 100 feet separation. Please be advised that this office will not issue a Health Authority Approval on your lot for the purposes of refinancing or transfer of ownership until the above requirement is accomplished. Thank you for your cooperation. If you have any questions, please call me at 343-4744. Sincerely, Daniel J. Roth Civil Engineer On -Site Services 16i praoed on recycled paper Municipality of Anchorage Development Services Department • '"� Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Waiver Review Worksheet WR#: 010057 PID#: 050-301-15 HA#: Permit#: Date Received: 7123101 Legal Description: Colonial Park B3 L5 S112 Engineer: Frank D. Rast P.E. R& M Consultants Inc. 9101 Vanguard Dr. Anchorage AK 99507 Applicant: AWWU i Waiver Requested: 45 - 50 ft. from private well to sewer main 5 FwEtt �V*WUVLC 60 S 64. VR ra.4e#.. Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ........................................................... no....... no......... Waiver is Granted: X Waiver is not Granted. List Conditions or Reasons for above: SEF 4?rAu^14a Q Date: /0-2 —0/ By: n!flu Name of Reviewer ...... ........ .............. seem ...... ............. .......... mum ..... .......... Rec#: Amount: $920.00 Date Paid: • • Municipality of Anchorage ',y.` � - On-Site Water and Wastewater Program ry mirrumpik < `mid I a es (907) 343-7904 S+a.'VE T T Certificate of On-Site Systems Appro Parcel I.D. 050-301-15 Expiration Date: i -17 1. GENERAL INFORMATION Complete legal description Colonial Park Block 3 Lot 5 S2 Location (site address) 19827 First Street Current Property owner(s) Kaylene Johnson-Sullivan Day phone Mailing address PO Box 771054 Eagle River, AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNariance request for: Distance: Received b • At •` z Date: - Wi COSA to be released to the engineer, unless otherwise requeste the engineer. COSA Fee $ �j Io I Waiver Fee $ Date of Payment '3 Iia L(1 Date of Payment Receipt Number 01111 ( Receipt Number COSA# O S C t 1 Vk.t 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. In conducting an adequacy test, I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe 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 soil condition,ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 5/18/2017 OF F•AI, Ak - 6. DSD SIGNATURE =��;14 ' ' "• • System #1 Approved for bedrooms . •Seve•n••. ••an• none � �.•. CE-8149 System #2 Approved for bedrooms To+4 •. � Disapproved � FROFESS00"- \\` „tor Conditional approval for bedrooms, with the following stipulations: nk- Arvc) \ 1. f � . \Np,SI p,Q4 oRQCR • •'(-:61T By: , i"-- — Original Certificate Date: c--2 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 sheel . - ,. 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 Colonial Park Block 3 Lot 5 S2 Parcel ID: 050-301-15 A. WELL DATA Well type Private If A, B. or C provide PWSID# Well Log (Y/N) Y I ` -_ Y Date completed 4,114 . Sanitar se. (Y/N) Y Wires properly protected (Y/N) Total dep _eft./.�l Cas-: to . Casing height (above ground) 24+ in. 3 ( FROM WELL LO S AT INSPECTION Date of test 4/1972 5/8/2017 Static water level (-.29 5f ft. 291 ft Well production 10 g.p.m. 4.3 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate 1 .69 mg/L Arsenic ND ug/L Date of sample 5/8/2017 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y/N) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed _ Soil rating (g.p.d./ft2 or ft2/bdrm) System type Length ft. Width ft Gravel below pipe ft. Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test in Water added gal. New depth in. Elapsed Time min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "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 WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building founda . n + Pr..erty line 5+ Absorpt field 5+ Water ma- 10+ Water service line 10+ rface water 100-+ Well n adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service f 0+ Surface water + Driveway ing/vehicle storage 10+ Curtain in 50+ Wells adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION '~��Nak / certify that l have determined through field inspections andP review of Municipal records that the above systems are in jr*: 49 /\ •,* conformance with MOA COSA guidelines in effect on this date. �/ Engineer's Printed Name Steven Pannone —.CC.:Sleveri I. annone • Date 5/18/2017 yO;t9�• CE .8149 •.: /i i� .t •• •;dam ‘tE\S COSA canary sheet_2-6-15.doc I /p "lly'. erg 1 - t 1 1 a y , 7 .76"7 \ 4 rs t tl`• 1 /+ ill 4 41 OS -a• 44. k'11 \i y • • L1 O fs 'V1 • ,,,,, .'"-: filli' :- 0,1 NA . fl a. ' b ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829 I HEREBY CERTIFY THAT I HAVEpSURVEYED THE SCALE: F�,����a4@� ` FOLLOWING DESCRIBED PROPERTY: % OF Rte t� Goo a 4/IG. f J.-CO 5..CaT',f-- ,e;3 DATE. -- S' AND THAT NO ENCROACHMENTS EXIST�EXCEPT AS "EP' .77,7 H..,..A. '�' .....INDICATED. IT IS THE RESPONSIBILITY OF THE ,„:„..0. 47 OWNER TO DETERMINE THF. EXISTENCE OF ANY GRID: s EASEMENTS, COVENANTS, OR RESTRICTIONS f#, . t2 . WHICH DO NOT APPEAR ON THE RECORDED SUBDI- I 4 Duane Mark Seward VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FS' •/y/6� 1 ¢'.- LS-V9I�3 ANY DATA HEREON BE USED FOR CONSTRUCTION _ `� OF FENCE LINES, OR FOR ESTABLISHING BOUND- PRAWN= 4. X, •Mika"; iMUNICIPALITY OF ANCHORAGE 01v 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 Augubt 20, 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 5; Mock 3; Ski CoZonia2 Pank Subdi.v.i.b.ion Location (address or directions) 4721 P.inb.t S.txeei (b) Applicant Name AWka Hou6 inq Telephone: Home Business 564-0353 Applicant Address Anchouge, A2abka (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution A2abka State Banff Telephone Address Anchoxaae, A&,ska (e) Real Estate Company and Agent Re/Max o6 Eagte Riven/V.ing.in i.a Koh4 ietd Address Eaa2e Riven, A2abka Telephone 694-4200 LD (f) I the HAA to the following address: SRB 196X Eagle Riven Road Eaafo Rdvea, ARabka 99577 2. TYPE OF RESIDENCE Single -Family 0 Multi -Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well $X Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite CSR Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 I11/84I 5. ENGINEERING FIRM PROVIDINGSPECTIONS, TESTS, FILE SEARCH, DASAND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, l verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspec9oA.$ ENGINEERING Name of Firm SR B 196X S �e Telephone 9��Z�f ? Addre Date 6. DHEP APPROVALp Approved for 2�� bedrooms by Date L 4Wl Approved Disapproved Conditional / / 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) 0 hh'dtSiclPAllTf op �,P37 )I NICIPALITY OF ANCHORAGE (MOA) . [a?i. o ``�� •t�-' &C. ; HEiALTH AUTHORITY APPROVAL (HAA) EIV`f IROi'N=i 1 i0. P�U? CHECKLIST -FEBRUARY 1984 A. WELL DATA 284-4720 Legal Description: 51 IZ Go t..a,-1 t Well Classification 5-r If A, B, C, D.E.C.Approved (Y/N) Well Log Present ON) Date Completed L/ AlgYield Total Depth 3� R Cased to �''�1 i '} Depth of Grouting -"—' Static Water Level Zs'10# 3jr Pump Set At 0y__ u Casing Height Above Ground 3o Sanitary Seal on Casing (%N) Electrical Wiring in Conduit ON) Separation Distances from Well: Depression Around Wellhead (Y& To Septic/Flat&pg Tank on Lot loo On Adjoining Lots //(v To Nearest Edge of Absorption Field on Lot _A047 t-1� ; On Adjoining Lots To Nearest Public Sewer Line � To Nearest Public Sewer 1 Cleanout/Manhole j? To Nearest Sewer Service Line on Lot } Water Sample Collected by Date 8-24 - S6 Water Sample Test Results I�DT'1S�D-a�szati .tet f/ Comments * 1.jew: B. SEPTIC/NetDtN&TANK DATA Date Installed $ -I-- Size 1Z50 No. of Compartments Standpipes &/N) Depression over Tank (Yt9 Air -tight Caps4D/N) `Z Foundation CleanoutON) pate Last Pumped P 45"2Z —g6 � Pumping/Maintenance Contract on File (Y/N) A ; for Holding Tank High -Water Alarm (Y/N) #DJJA Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/++e+dirtgTank: To Water -Supply Wellyc To Building Foundation )O r` To Property Line t ter ( To Disposal Field S f To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata loe�,'* (FYI"' Type of System Design —T -'a.6" Date Installed ( o — 24 — 0 r Length of Field 4121 r , Width of Field Square Feet of Absorption Area Depression over Field (Y/V — Results of Last Adequacy Test Depth of Field Gravel Bed Thickness v — Standpipes Present&N) Date of Last Adequacy Test $f' r- l5pj' ✓ Separation Distance from Absorption Field: To Water -Supply Well ( C51c>1 To Property Line r To Building Foundation %v { To Existing or Abandoned System on Lot On Adjoining Lots -*a Ik r To Water Main/Service Line To Cutbana(present) p To Stream/Pond/Lake/or Major Drainage Course P t To Driveway, Parking Area, or Vehicle Storage Area 8b— Comments F1le;li_ x� 'fid t A&EhPw-S V3%4 -j.- V -- D. D. LIFT STATION Date Installed Size in Gallons Dimensions Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at A Vent (Y/N) . Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. SignedS & S ENGINEERING Date _S A C /fr /' Comp �R MOA No. B 196X EA1GLE RIVER, K995 0F L % Receipt No. D 9 D D� �{ r p A'�� `gyp Date of Payment A Amount:$ S `� a� �,,9 oSe I,ee . ......... bbb". A. Shes'r t4k, 1159$ i Page 2 of 2 72-026 1111841 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIROLTMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONHENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date f1Z 2-1 (a) Legal Description (include lot, block, subdivision, section, township, range) i;L�JaisJt- J'i1itK Location (address or directions) L._;>., ice. (b) Applicants Name f 1911Z_ j'/�L_K/� Telephone - Home Business Applicants Address (c) Applicant is (check one) Lending Institution Owner/builder ; Buyer F::1 ; other [� (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. S Agents A Address �_1 --t-;, t._c_ l� , �,=,-'.r.._ Telephone its �l RC2. C.'i (f) :fail the HAA to the following address: 2. Type of Residence Single-Familye- Number of Bedrooms 3. Water Supply Individual Well /..- (. -- Multi -Family Other (describ 7 J Community 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 Public Community Holding Tank 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] Ll 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information 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 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 regula- tions in effect on the date of this inspection. Name of Firm Telephone Address m r> ' _U•<•., :^r,. . Date 6. DHEP Approval Approved for Approved Disapproved Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH :AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 0 0 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA Well Classification If A, B, or C, D.E.C. Approved(Y/N) Well Log Present ( ) Date Completed l0 Yiela�� Total Depth Cased to ' Dep of Grouting : Static Water Level Pump Set At Casing Height Above Ground �•, g /Z Sanitary Seal on Casing 1 Electrical Wiring in Conduit Qi) Depression Around Wellhead (Y92 Separation Distances frau Well: To Septic/Hefdir.T-Tank on Lot /GO On Adjoining Lots /,1"q To Nearest Edge of Absorption Field /o Lot /pO �� On Adjoining Lots /Ob /T' To Nearest Public Sewer Line To Nearest Public Sewer Cleancut/Manhole A To Nearest Sewer Service Line on Lot 10 Water Sample Collected By.!5'i T ; Date 4L4 A y Water Sample Test Results 19 71 r 7�viz y ,k & G/n /' J7, 7E5 W c Cz dF % �L �C U B. SEPTIC/BSG TANK DATA 1215-6 /"KI Date Installed (o Size U No. of Ccmpartmerts 2 - Standpipes Standpipes 19N) Air -tight Caps d9N)_ Founda ion Cleanout (YIN) Depression over Tank (YdW Date Last P d Pumping/Maintenance Contract on File (Y/N)"73/ ; for Holding Tank High -Water Alarm (Y/N) N Temporary Holding Tank Permit (Y/N)'`� Separation Distances from Septicg Tank: To Water -Supply Well /bo To Building Foundation To Property Line /0/-/- To Disposal Field -5;- To To Water Main/Service Line Course Comments To Stream, Pond, Lake, cc Major Drainage Ad -G 2gI-G6/ (Page 1 of 21 2-15-84 0 0 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata !F�2 4X�,Type of System Design i�_AJe Date Installed 14;17_/ zez Length of Field 31 Width of Field 30 `` Depth of Field fQ Gravel Bed Thickness Square Feet of Absorption Area 430-0 Standpipes Present YY ) Depression over Field (Ya Date of Last Adequacy Test Results of Last Adequacy 'list Separation Distance from Absorption Field: To Water -Supply Well /CJQ / To Property Line 7 To Building Foundation 22,-, i.f To Existing or Abandoned System of Lot A,/* ; ��joining Lots 30 1 "t � To Water Main/Service Line To Cutbank(if resent) A To Stream/Pond/Lake/cr Major Drainage Course 11-114 To Driveway, Parking Area, or Vehicle Storage Area D. LIFT STATIN Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Dimensions e/Access (Y/N) Off" Level at —Vent (YM) during Adequacy Test. Meets MOA r ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed S A r E nih,-"Ai r. Date (' Zz q 1P SRB 193X Comparl�;ALE ANF7LF" A T.," 77 MOA N KBl/d5/s [Page 2 of 21 a • Rsbarl+A. She . 1,, lAu`7•C ® rRO.. SIU�A 2-15-84 Aak NOW Time e Date Date Date g W Inspector Inspector Inspector Comments Conditional Approval DI V Date Sewer Installed Permit No. Septic Tank Size j Z. tJ ( Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner f 011��f LWIf - Phone Malling Addressiy1®2 Buyer t:,/m f , Address Lending Institutionrr .. T4 �yf"y/ Phone / % qG Address 77 % dT f t/G%'�9!/ C�l�iGW Realty Co. & Agent � 1� pg y�r Phone Address /QI ry tel( Yl �/� _ £Z^ %� �J✓ Legal Description fZ Lo.4 S Ytk 3 0- L ow 1K 1j vA, Street Location `Jf Typt99f Residence .AS.Single Family ❑ Multiple Family No. of Bedrooms ❑ Other Watgr Supply i I 5; 1 ✓�!�A# WELL LOG. A log is for drilled June Individual (5V t) ATTACH well required all wells since ❑ Communityj� 1975. For wells drilled prior to that date, give well depth (attach log If ❑ Public UtilityDfI available. Sawa a Disposal Sawa I Year Individual Installed: -. ❑ Public Utility - When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.