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HomeMy WebLinkAboutSAMUELSON LT 5f"I W-..� #051-091-45 72-01 Y (Rev, 3/78) 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 EW ❑UPGRADE MAI LING ADDR ESS 1lo /30x 5r,01 `_C LEGAL DESCRIPTION LOCATION NO. OF BEDROO L) DISTANCE TO: Well Jfy7`,1 Absorption areal /` Dwelling i,n PE . T O Y f ./ 1—z N < Manufacturer /_� � �• �� C� Material Z f^ ' ei No, of compartm ents Liq. capacity in gallons Inside �length 4)C) IF HOMEMADE: Width es Li quid depth 6 Y J a Z DISTANCE TO: Well Dwelling PERMIT NO. = z F Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well �/ �f Foundation �7 / /f Nearest lot line .,� PERMN ZNo. ~ of lines / Length of each I'n sr Total length of.lingsTrench width a Distance betty ep I a/JS m 9 T off tie to finish grade - Material beneath the inches �3—�{� �{ C<'/ ,r �"-J e7l,_S inches Total effective absorption area Lu Length Width Depth PERMIT NO. Q F 0. FL Type of crib Crib diameter Crib depth Total effective absorption area w y DISTANCE TO: Well Building foundation Nearest lot line _jClass W X ,r5 � Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption areas) OTHER PIPE MATERIALS / TEST RATALLER�-y E h v3 %/��'.c' ((( /6,4f REMARK to Ai •••oos•� �g �� ••s •-®®TT" ac � �9 U 68 > @= a q c mCe• o _ - - 6P�a No. 1457-E % , t" ee n•rm ¢tram S� tys NGFESStti^• APS V DATE LEGAL _0 V SRR �lUtr(3, ALASKA 0957? 72-01 Y (Rev, 3/78) TYPE OF SOIL ABSORPTION SYSTEM IS: DRAINFIELD MAXIMUM NUMBER OF DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION A0, OF THE SOIL ABSORPTION 825 'L' STREET:ANCHORAGE, AK 99501 ■P-4 #7 " L'-mE=F=>-r"� 264-4720 cl ir-4 1= P2 F:r=-: Rerl I -r PERMIT NO. 821095 APPLICANT R. B. WOODS PO BOX 90 EAGLE RIVER 99577 694-2255 LOCATION LEGAL L5 SAMUELSON S/DLOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: DRAINFIELD MAXIMUM NUMBER OF BEDROOMS = 2 SOIL RATING (SO FT/BR)= 100 THE RF=EQUIREDH SIZE OF THE SOIL ABSORPTION SYSTEM IS®: ■P-4 #7 " L'-mE=F=>-r"� THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). -IrF:V"K -leaC-11a sMF:il I Cg"� PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BET14EEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. I CERTIFY THAT 1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS. AND WELLS As SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: 1 UNDERSTAND THAT THE ON-SITE SE14ER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INS LUDE MORE THAN 3 BEDROOMS. I 5IGNED:- 4 A I ,:r WOOD ISSUEDlz ------- DATEZ� AL ------- V4. 0 -- 6� // •�4)a,6 3/ S SOILS LOG MUNICIPALITY OF ANCHORAGE • +� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION 825 L. Street, Anchorage, Alaska 99501 .264-4720 TEST SOILS LOG — PERCOLATION TEST PERFORMED FOR: r h (�L-��� / DATE PERFORMED: 12 O c -r Z LEGAL DESCRIPTION:_ �., �3 t`�CJ! �. �C1 %�-/ _S� ., // DEPTH (FE FT) Z � J G 6 �) I- \ 7 - 9- 10 - SLOPE 10 SLOPE 11 WAS GROUND WATER S ENCOUNTERED? �` `�-� L O 12 —7 -- E IF YES, AT WHAT 13 +��n DEPTH? r^�. �� � W 14 _ -j �. rr a o, eoo a a 16 1;0l: 9 A. ShaI r e' cam` No. 1457-E ° = CIO 17 19 .?n PERFORMED BY: 72-008 (6/79) SITE PLAN It W Reading � cQ Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUIN BET EEN CERTIFIED B FT AND (minutes/inch) — FT DATE: rl u t -a I C. T' bEF•ARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION N 825 "L' STREET: ANCHORAGE, AK.. 99501 264-4720 PERMIT NO. 2 9 APPLICANT 14AYNE (_:Oft I NEAT i PO BOX 279 CHS Its I RK 99567 LOCATION LE3AL L5 _AMUELS•C N LOT SIZE 999999 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—=ITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC: WELL. MINIMUM DISTANCE FROM A F'RI'GATE WELL TO A PRIVATE =EWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFIC:ATIONS AND CONSTRUCTION D AVAILABLE TO r INSURE PROPER INSTALLATION. DIAGRAMS ARE I C=ERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS FIND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. AF'FLI - NT ldA`r'tdE SIt I y C1 ISSUED iE[? E'r'_—t y� , / ---1� ----DATE---- 7L <� ---------- /"�f---- V4. 0 C��e t tr �xitttrt � ,x by DOC Co. Gba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 e OWNER OF LAND L ..'.,"f 't',v ; c ` ,f, a � � � ,4 -1DEPTH OF WELL r ADDRESS ,t r" r `f % 6" ! STATIC LEVEL OF WATER FT. LEGAL DESCRIPTION Gf < -- ,� '" z +.• - z k . r j :-5_ _ DATE - Started .'f °-�' Ended �'°' PERMIT NUMBER KIND OF FORMATION: From Ft. to Ft. <r" t� f : rt` a ,12 From 1 Ft. toL`.s Ft._ vi jam!'' •�7 t•ss u From ' "- Ft. to •.5 0 Ft. Ft. to Ft. From Ft. to " FtFt. Ft. 4", Ft. to From -' =a Ft. to % f Ft.- Ft. to Ft. From From Ft. to Ft.' cf7ce - t From Ft. to [ Ft. 3119 tt.),e) From Ft. to Ft. id f" .C. 0 -- From . -From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From - Ft. to Ft. From Ft. to -Ft. MISCL. INFORMATION: DRAW DOWN FT. GALS. PER HR. 0 Jn, KIND OF CASING From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From_-- "(EJR@LL �F HORAGE DEP. OF HEN. From I`FIECTION From Ft. to ;_�®FVS2 °dFt. From - Ft. tioUV1 From FRtCUE I .. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From - Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft DRILLER'S NAME Joy MAS} municipaty of 1ncfibiagh 616ve1001716ht Services Uepartmen Building Safety Division Onsite Water d, WastewaterPropratn • • "` 4700 South Bregaw St. P.O. Box 196650 Anchorage, AK 0051"wo www.a.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 6 Parcell.D. C61-0gj-Q_C) HAA# L5–OMj2 1. GENERAL INFORMATION Expiration Date: T " ' y Complete legal description SAMUELSON SUBDIVISION; LOT 5 Location (site address or directions) 21243 VALLEY AVENUE * CHUMAK AK. 99567 Current Property owner(s) JASON ATKINSON Day phone 694-4200 (AGENT) Mailing address _c/o BROOK STILTNER w/ REMAX PROPERTIES Lending agency Mailing address Day phone Real Estate Agent BROOK STILTNER w/ REMAX PROPERTIES Day phone 694-4200 Mailing address 16600 CENTERFIELD DRIVE • EAGLE RIVER, AK. 99577 Unless. otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ■ Individual On-s@e Individual Water Storage ❑ Individual Holding tank ❑ Community Class—wen ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certKed 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 onsite water supply and/or wastewater disposal system is(ars) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the onsite water supply and/or wastewater disposal system Were) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 1 05— Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for J bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other 13y:� . Original Certificate Date: (Rw. 17101) Municipality of Anchorage 0g e4 ' Development Services Department Building Safety Division < On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST` Legal Description: SAMUELSON SUBDIVISION; LOT 5 Parcel ID: 051-091-45-- A: WELL DATA " Well type PRIVATE if A, B, or C provide PWSID# N/A Well Log (Y/N), YES Date completed 9/1982 p Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 66 ft. Cased to 40+ ft. Casing height (above ground) 12+ in FROM WELL LOG AT INSPECTION a Date of test - 9/1982 12/28/2004 Static water level 31 ft. 31 ft. Well production 7 g.p.m. 5.0+ g.p.m. i WATER SAMPLE RESULTS: s ' Coliform 0 colonies/100 ml. Nitrate 0.10 mgJL Other bacteria 4 colonies/100 ml. - Arsenic: N/A mg./L. Date of sample:12/28/2004 Collected by: GEG, LtD. ! � I B. SEPTIC/HOLDING TANK DATA I i Tank Type/Material STEEL Date Installed 10/16/1982 Tank size 1000 gal, Number of Compartments 2 Cleanouts (Y/N) YES 6 € Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A .. Date of pumping 5/8/2004 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA SELQW EXISTING rRADE I Date installed 10/16/1982 Soil rating (g.p.d./ft'or /bd 100 System type TRENCH Length 62 ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth •2.9 ft. Elf. absorption area 300+ ft° Monitoring tube YES Depression over field NO Date of adequacy test 12/28/2004 Results (Pass/Fail) PASS Forbedrooms a. Fluid depth in absorption field before test 0 in. Water added 568 gal. New depth 0_5 in. } — .. Elapsed Time: 10 min. Final fluid depth 3 in. Absorption rate >= 450+ g,p,d, i Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date Date Installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption Feld on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line *5'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage **01 Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *WAIVER GRANTED "*PORTION OF DRAINFIELD UNDER DRIVEWAY A G. ENGINEER'S CERTIFICATION 1 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 JEFFREY A. GARNESS Date d oY/off HAA Fee $ Date of Payment X05 - Receipt Number (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number 1P O rV1 V u / (a) 49•941 A.M.20A0 N i OAS -ass TO/TO 39Cd b3 XCW3d83NUlI1S 9 8860069LO6T EO:ET 9001/EL/TO 1 (W) .04W :tl74'Z:I OC0 N A.O¢AM.t0000 N _ 1 S aF O O O �iC� it 1 10 y - - � I 1 o •a I, I, 1I / (a) 49•941 A.M.20A0 N i OAS -ass TO/TO 39Cd b3 XCW3d83NUlI1S 9 8860069LO6T EO:ET 9001/EL/TO 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. # 051-091-45 HAA # 1. GENERAL INFORMATION Complete legal description Lot 5, Samuelson SjD , C Location (site -address or directions) 21243 valley Avenue Property owner Susan Price Day phone 688-6733 Mailing address 21243 valley Ave., Chuaiak, AK 99567 Lending agency Day phone Mailing address Agent___ Raney Hardman Day phone 694-4200 Address 16600 Centerfield Dr., Suite 201, Eagle River-, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Holding tank Community on-site — Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev.1/91) Front MOAX21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I 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 & S ENGINEERING Name of Firm 17034 Eagle River Loop Road No. 204 Phone r; �y �� �� Eagle River, Alaska 99577 Address Engineer's signature 6. DHHS SIGNATURE By: J� Approved for TRJE bedrooms. Disapproved. Conditional approval for Additional Comments Date bedrooms, with the following stipulations: (L/.'//'/t� �'V. /fyo � Date U1TIC 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. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (RW. 1/91) Back MOA M21 kECEMU Municipality of Anchorage SEP 10 1998 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OF ANC,'HORAG 825 L Street, Room 502 • Anchorage, Alaska 99501 • (90�7�N49-���4Ices rnv,< 1� Health Authority Approval Checklist Legal Description: LO S S*19M v a s o >z S _ Parcel 1. D.: 0 S—/— O 9/' f 5-- A. A. WELL DATA Well type f A 1v j4 rA- If A, B, or C, attach ADEC letter. ADEC water system number Log presentY�V) \/,O- S Date completed `{ I g 2 Total depth �. (` Cased to Lt 0 t Sanitary seal a/N) y f- S Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform d Date of sample: FROM WELL LOG 011T) 31 7 Nitrate B. SEPTIC/HOLDING TANK DATA g. p. m. Casing height (above ground) 1 4 - Wires Wires properly protected (&N) yf-s AT INSPECTION O • ( Other bacteria Collected by: S & S ENGINEERING 17034 Eagle Piver p KOad No. 204 Eagle River, Alaska 99577 Date installed I o ) / G 19 Tank size /000 Number of Compartments ;L Cleanouts (DN) yE J Foundation cleanoutz( %N,)' "' Depression (YA& h' High water alarm (Y/M ) 0 Date of Pumping 1 01 `6 `Pumper J � s C. ABSORPTION FIELD DATA..._, V iNgt.-ow Date installed 10 Soil rating (g.p.d./ft2 or 2/bdr 100 System type * i Ew C.N Length �' a Width S, Gravel thickness below pipe 0, S- Total depth Effective absorption area /G z �' Monitoring Tube present (YIN) Y¢ I Depression over field (Ya A10 Date of adequacy test Absorption rate = Results fs/Fail) P4 fS For bedrooms Fluid depth in absorption field before test (in.); D 2Y Immediately after 960 gal. water added (in.): Fluid depth r'' 4 (ins) Minutes later: "V /,f Absorption rate = ySO 4- g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date y 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) _ High water alarm level at* Cycles tested E. SEPARATION DISTANCES "Pump on" "Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /00 Absorption field on lot foo �t Public sewer main N T A Size in gallons "Pump off" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer /septic service line a S ¢ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation i Property line 10 ¢ Absorption field Water main/service line 1fl f Surface water/drainage j0n Wells on adjacent lots /o v SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line S Building foundation f o 4- Water main/service line Surface water 100 f Driveway, parking/vehicle storage area S Curtain drain PJ ° ^' k a ° `'' ^l Wells on adjacent lots / d o ,t F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance withnes in effect on this date. Signature C% Engineer's Name Ra/3&,t7— C Ca tv f,) Date 9/01/,1V HAA Fee $ :300-00 Date of Payment' �� ©! L? Receipt Number y �O (6-(3-7) 72-026 (Rev. 3/96)* � OF: Ka the 70 ROBERT G,; UWAN I`i'�,•ti, CE -8§0:1' Iltti+,j.�....;ci^�; �, Waiver Fee $ Date of Payment Receipt Number are Mmicipality of Anchorage Department of Health and Human Services'—� 825 "L" Street Rick Mystrom, Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.ci. anchorage. ak. us S & S Engineering ATTN: Robert Cowan, P.E. 17034 Eagle River Loop Road, Suite 204 Eagle River, AK 99577-0000 September 16, 1998 Subject: Waiver Request for SAMUELSON LT 5 Waiver # WR980060 Lot Line Request for Parcel ID 051-091-45 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater disposal system to the lot line has been approved. The approved separation distance is 5 feet. This waiver approval applies to the current on-site wastewater disposal system and lot line separation only. Any future upgrade to the on-site wastewater disposal system and lot line will require all separation distances to be met or another waiver approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely,�Ar Jeff Poet Engineering Technician III On -Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# 980060 PID# 051-091-45 HA# 980279 Permit # Date Received: 9/10%98 Legal Description: Samuelson Subdivision, Lot 5 Engineer: S&S Robert.C. Cowan Applicant: Susan Price Waiver Requested: 5 feet from absorption field to lot line Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: Date: q - 17 - q% By: Rec #: Amount: $ ewer Date Paid: 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. # fin,\ — Qrl N - HAA # t� Qol fti 91 1. GENERAL INFORMATION Complete legal description Lot 5; Samuetson Subdivision NW % See. 8 T15N R1U1 S.M. Location (site address or directions) 21243 VaUey Avenue Property owner ChaAtu 9 Bevetty Riestand Day phone 564-5229 Mailing address P O.Box 679659 CLu/g.iak, Atahka 994627 Lending agency ALASKA USA FEDERAL CREDIT UNION Day phone 563-4567 Mailing address Agent lki-s Bon i.ng/Ban.bana Gnyden TARGET, INC. Day phone 694-2388 17034 Eag.2e Riven Loop Road Address P O Rnx 774697 Eagle Riven, Ata3ka 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I 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 S & 5 Phone 17034 Eagle River Loop Road No. 204 Address ve , a5 Engineer's signature 6. DHHS SIGNATURE Approved for bedrooms. By: _ Date �. x p �� P eei �nu NPipfi �T' Doe se• ssaa VER J. SHAFER No. 821 r -Z. PROFESS1a�.�� :a Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST _ Legal Description:o Parcel LD A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number �IAc Logpreseno/N) Date completed 2- Driller. tsaCI-A Total depth hsl Casedto � Casing height l ZN� Sanitary seal/N) Wires properly protected (YIN) WATER SAMPLE RESULTS: Coliform b t4)'N^¢• Nitrate ��• Date of sample: G� � C1 , 9,1— Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Other bacteria bacteria S & S ENGINEERING 1'J,D/J F 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Doo Uhl. Compartments Cleanouts (9*) T Foundation cleanout Depression (*/d4 tJ High water alarm (4//�) sJ Alarm tested (Y/N) Date of pumping !% Pumper ..r1; r_�SPao L' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Wells) on lot 1 Do �k On adjacent lots 1 nc� t�- Foundation S To property line 1 Absorption field Z o Water main/service line Surface water/drainage 4 Db t 72-026 (Rev. list) Front CONTINUED ON BACK PAGE FROM WELL LOG AT INSPECTION M Date of test 'eZ lo�l'I-9Z o z Static water level 3 t 3 1, rM - y Well flow g.p.m. s,�} g.p.m..-� _,. Pump level UK V� s 'r 10 SEPARATION DISTANCES FROM WELL TO: c3 " Septic/holding tank on lot JZ' t ~ ; On adjacent lots Absorption field on lot 1 �� t ; On adjacent lots ll I N Public sewer main `1y Public sewer manhole/cleanout Sewer service line 'LS Petroleum tank S ,� WATER SAMPLE RESULTS: Coliform b t4)'N^¢• Nitrate ��• Date of sample: G� � C1 , 9,1— Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Other bacteria bacteria S & S ENGINEERING 1'J,D/J F 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Doo Uhl. Compartments Cleanouts (9*) T Foundation cleanout Depression (*/d4 tJ High water alarm (4//�) sJ Alarm tested (Y/N) Date of pumping !% Pumper ..r1; r_�SPao L' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Wells) on lot 1 Do �k On adjacent lots 1 nc� t�- Foundation S To property line 1 Absorption field Z o Water main/service line Surface water/drainage 4 Db t 72-026 (Rev. list) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical code ) SEPARATI [STANCE FROM LIFT STATION TO: Wel on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Lu- $2. Soil rating System type Length LZ Width `- Gravel thickness L a Total depth 3 a - Total absorption area 3oD Cleanouts present &, N) Depression over field (YAD) Date of adequacy test -O/ Z. Results gas ail) Piss for - l �''�X_,F,Ei'�� bedrooms Peroxide treatment (past 12 months) (Yo lJorle AaWOWI If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot IDa (*- On adjacent lots I Lo'a % A- Property line To building foundation I t -t- To existing or abandoned system on lot rt �A- t �. i1- On adjacent lots 3D Cutbank 3 Water main/service line I ,k Surface water io J ta& g g A?P�,c. ZZ% ��'" —Driveway, parkin /vehicle storage area u--)n9-L_ DalvFWory Curtain drain iA 1pC (W51) E. ENGINEER'SCERTIFICATION l certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 5 & 5 ENGINEERING Signature 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99977 Engineer's Name Date L2 -2A -92 - HAA 2-2'-9Z HAA Fee $ l 7n, AZ-9— Date of Payment Receipt Number Z ZZ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ — Date of Payment Receipt Number ;:'T J. C IMFER E E eoa 'P ROFESSIO - �� C -GL n Time APPLIC `NT FILLS OUT UPPER HAI 'ONLY Propel' Owner .^ J ,r �� C C U Li S Phone Mailing Address Zip Code - Buyer Date Address Zip Code Lending Institution `,- PJ G- /Z (4- L EZ- LL _ r')') 7— .. - / Phone Address L� Z /0,r � Zip Code M Realty Co. 8 Agent '1 (0 D" s A �r-� �-- � sT7*7--� Phone Address ( Z c Zip Code Inspector Legal Description- ��, saf s vd Street Location MUNICIPALITY OF ANCHUUGE Type of Residence -1le Family DFpT C� ENVIR,�'JL:_-A.- ._u.-CiION ❑ Multiple Family No. of Bedrooms ❑ Other Water Supply �7..Individual - ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. log If ❑ Community 7-) )'� - n0 " For wells drilled prior to that date, give well depth (attach available). ❑ Public Utility RECEIVED ( "5) APPROVED BEDROOMS Sewer D'sposal ividual c` r✓ i'i� I 1 �l - LL5°� I D Ito "�S-� Year Individual Installed: z ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank ' NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. - �� C -GL n Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector MUNICIPALITY OF ANCHUUGE Field Notes: 1 DFpT C� ENVIR,�'JL:_-A.- ._u.-CiION J- V 3 1932 RECEIVED ( "5) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area —�( �� Well Log Received Septic Tank Size C '-o �� -f �„_._ Well to Tank 'J-1 c I2-023 (3182)