HomeMy WebLinkAboutROCKY LEDGES LT 3ARoc
ky Ledges
Lot 3A
#050-082-07
V�
UfMunicipality of AnchorageN .. ,,Development Services Department"'°
Building Safety Division '
On-Site Water end Wastewater Program, 4700 S. Bragaw St.
P.O. Boz 196650 Anchorage, AK 99519-6650 PageOf�
www.ci.anchorage.ak.us
t907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL
INSPECTION REPORT
Permit Number: sWOy�� 9 PID Number: ASO-�
��-07
No—
? 1
1 �r STOLk�A14 Wastewater
System: Q@ New ❑ Upgrade
Addy v 0 17e e Lg n � Vel '
P1g11 ABSORPTION FIELD
6 -0 76J NumMr a Bedroom.
(moo O Deep TnnM V(Bnanow Tnncn O Bed O mound
O OIMr
LEGAL DESCRIPTION Bud Rating Tow Depot conp" g".
Bloc A I �C an Gpoxtr
La sYDd�NYM 1 FI.
3 /{IJ —>-"/r'_ Depth to pile poBom hom original a Gmel depth beneath pipe ' I
To scup il. LI/
it
RYge soc on FA added Wove onpnY Pada GnvY Lengm
Ft. 311.
y(.
W _l -_ 14New ❑ Upgrade GrnY wNot. Numbs .N. DNence between ended
S
Clnphctom (pin to.Fit. '�_ Ft
B, C) Tar Ds
V ' DaesdN TOW Weorpbpn aru 3n PIM met"
3a5 Soo Ft. de g Ft s M 03 Fg o
Driller F�
, Dole DNNd Stabil Wet Levy kWaeer Dehe lrWrled
514111' an l i e e l 2-07 3-" 135 q FL
Yird Tu�<< ca '/�
Pump YClient;rClient;Hey nt rourN
De� /.DGPM GnSal C��G
no Ft. TANK
SEPARATION DISTANCES
6K Septic [31-folding ❑S.T.E.P. C) Other.
To Septic Absorption L1ft
From Tank Field Station
Holding 011CIPWate
Tank Sew�e'r••Line
—.-P-,.,
n
e ' (C s �(JO cY
well / x \ 13' ` V O I
-�" J 'f-
MCNnr
140 PE Numoar OI Cpmp. mYhle
swf,uos wel«
1-
+
LIFT STATION
^�+
La Lift Q \ /� � i� � \
:e .�D l.G r
//
" lvrl(eiP%a
Foundeuon
yo` 6 ` SO\i !
SGS
Purrpon'Nrel ; ump ow to al�� Nryh volar rYm r
N (JJ
Cunrn Drrn �L ,^
in n
mil Ma a a ei ElepCncaei�e,eepacaone wormed br
Remerke
M,0 -A • ^r5f 4'r, �
BENCH MARK
• n •••
pt.1 r(,.N CHAr G. Q, ON 7/7 /C4 IFn-
Lorabon and Daempbon l
h?12o dec
nP r-
•
Egglpencien rip
—
�'LOFq
�
'�� �••,....„..a rS.ZC1a
S i S ENGINEERING
Inspections performed by: 1�0>4 Eagle Rlwr tLM11 Road, No 1” -7-7-04
wr, a •���
,ltd �� a
•fv �ti���..•.,ie
} x r.
•
Developme t Services Department Approval
ROBERT C. COWAN
Cr
Reviewed and approved by: Date: i n /rr./
llC:-8801
Ott �
17,M)
.(Rw
CD
PERMIT No. SW040069
PAGE 2 OF 3
Municipalit of Anchora e
DEPARTMENT OF HEATH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 *Anchorage, Alaska 99519-6650 • Tel hone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 3A, ROCKY LEDGES S/D P.I.D. No. 050-082-07
C0
P 1
LOT 10
O
C
M
1
1 20' BUILDING
L SETBACK
1
0 Z \ /
O aTn
o
£ A \ /
r B FCO
s \ \\o. /
• STI
NEW 1300 GALLON • ST2 \ <
HDPE SEPTIC TANK MH TMT \ / `
THytA Y
NEW 550 GALLON MT1
FAT ALBERT S.T.E.P. TANK / \
V?
// 4? \�
/ /ATH#2 /• Q �'� / rC� ��" ••. S� l+
...........:r
ROBERT C. COWAN
CE -8 01.i
O
LOT 2 +i�rf�/�i/$r..-' ?s
PERMIT N0. SW040069
PAGE 3 of 3
Municipa(it of Arnchora e
DEPARTMENT OF HEATH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 *Anchorage, Alaska 99519-6650 • Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 3A, ROCKY LEDGES S/D P.I.D. No. 050-082-07
INSULATION
95.7'
MT2=105.8
FINAL GRADE
/-99.1
NEW 1300 GAL.
POLY. TANK
95.4'
99.2'
Ih" DISCHARGE PIPE
550 GALLON FAT ALBERT
WITH PUMP ASSEMBLY
MTI
MT1=107.3'
FINAL GRADE
_i2" INSULATION
SR DISTRIBUTION PIPE=102.2
i
NIT2 = 98.2'. . MT1, = 98.3'
NO WATER FOUND
92.2' B.O.H.
PRESSURE DISTRIBUTION SYSTEM:
PUMP = 20 OSI 05HH - 5 STAGE (-30 GPM)
1 LATERAL 61'LONG = 30 GPM/LAT.
30 HOLES (2.1' O.C.) = -1 GPM/HOLE
1/4"0 HOLES FACED DOWNWARD
1'o LATERAL
1 1/4"0 SOLID MANIFOLD
T G/afro c" r, F4--AAri
N. T. S.
Sop s 3s a Electric
907-223-3933
To, S 8L S Engineering,
Re: Stackhouse home at 1200 Dee Lane. Legal L 3a Rocky Ledges Subd'
The septic lift station Installed by Tweed
nrlsion.
Journeyman electrician was wired by aAn Alaska licensed
employed by Spate, we are licensed b
municipalhy ofAnchor we y the state of Alaska, and the
as an electrical contractor.
ge
Thankyro�
d?X)4�)-O
Kipling Dam, owner 3
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Apr 21, 2004
Expiration Date: Apr 21, 2005
Permit Number: SW040069 Parcel ID: 050-082-07
Legal Description: VOCKY LEDGES SUBDIVISIOWLOT 3A 9
Design Engineer: 0003 S & S Engineering Site Address: 12000 DEE LANE
Owner Name: BRUCE STOCKHOUSE Lot Size: 90926 SQ. FT.
Owner Address: 12000 DEE LANE Total Bedrooms: 5 Permit Bedrooms: 5
EAGLE RIVER. AK 99577 -
This permit is for the construction of:
❑.r Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy El Private Well Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specked 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 (24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By.
Issued By:
72
Date: f /9.1 /d y
Date:
Municipality of Anchorage
-- Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION -
FOR A SINGLE FAMILY DWELLING
092 0
Parcel I.D. O S O —=V — r � Permit Number SW 0400(0 9
Property owner(s)_Er(z(Le 5foc ik ONS- Day phone b -/b-6-706
Mailing address (1) Q03Q0 Phl Lld-1 ArciL~)A u
slTr:995
o0 77
0la+l+rd address (2) � f,uC
,,le P h 12D DEf L&I Zip Code
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot Sizet Acre(!D
THIS APPLICATION IS FOR:
Number of Bedrooms 5
Sewer Only 19 Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable
leENGINEERING
Municipal
des.
S ENGINER
S
17034 Eagle Loop Road No. 204
[� Eagle
River, Alaska 99577
(Signature of property owner or authorized agent)
Permit Fees: I o _& C?- ✓ Waiver Fees:
Date of Payment: V // 3 A Y Date of Payment:
Receipt Number: 0 S b �- b Receipt Number:
(Rev. 12/00)
(r210 Nw04S3
S&
nq ROBERT C COWAN P.E.
April 12, 2004
CMLENGINEERS
(907)694-2979
FAX(907)694-1211
W -WH RHCRITV MUNICIPALITY OF ANCHORAGE
APPROVALS Department of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
SEWERMATER
WATER
MNNE%TENSIOPS REFERENCE: Lot 3, Rocky Ledges S/D
SEWERSWATER It is requested that you issue a permit to install a septic system to serve the proposed
INSPECTION five bedroom dwelling on the referenced property.
Two test holes were excavated and percolation tests performed. The approximate locations
ENG INEERINGSTuOIES of the test holes are located on the attached site plan. At the time of excavation, 1122/00,
"REPORTS water was not found. After ground water monitoring, the tube was dry.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
WELLINSPECTION areas or drainage patterns by the installation of the proposed septic system. The
SPLOWTEST construction of this system will not prevent any future development on any of the adjacent
properties.
SITE PIANS If you require additional information, please contact us.
Sincerely,
ROAD DESIGN
vZ
ortCowanG
SOIL TEST RCC/bjj
Enclosure
PERCOLATION
TEST
STRLICTLRALa
MECNNJICAL
INSPECTIONS
ONSITE
WASTEWATER
OISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER. ALASKA 99577
1" = 40' DESIGN SITE—PLAN
e-
0) KI
O)N UN to t=
AUS V: Ln00 70
ops VND
rt ',�
meo FVf�OPfO zOTSI 1�, 7 �e'�"' V'
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NUyl� �..~y� �tlN� ••1
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TRACT B-1 d
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jo
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a
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L\ o�\�P�SfO A
.00
�4 ss
T\ �o
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TI
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/ • y wp
=o
wo
1" = 60' DESIGN SITE—PLAN
not__ _ _ 9Fe
ACS _Cn F�a Ln to
�(IIpO 'ni•'�=��
ANO O ::E r1 0 ES
l
Z O �y �p
TI I"1
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VVK ...I\�1 .N. 1Npu0
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ro3s M • 3
10.
\\.
/�.L `YN✓✓�.. 1DD WELL RADIUS I
9S r o
/ y-
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/•/ ny ^rF \\ \\ xrpn �
N
m
Od0 \\\\ 0\
L
Qp=p ,€�,�[[ I ro a
(ENGINEER'S SEAL)
7F1 S
Municipality of Anchorage�f •�
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
,;y> ,,- •' ( ( `G;;''c CE - 8801
DATE PER FOR ME;
PERFORMED FOR: l"X)q.--Z 4)
k%r,Ur1 )1
LEGAL DESCRIPTION: L.07"� e—OCG 4_q 4�t>L-y,:5 Township, Range, Section: 1114 -�,Z,� 111-
3
Date
Gross
Time
Net
Time
A
Net
Drop
4
.■■■.■■
5
d�•
6
2
67
7
�.
j
8-
9-
9
10-
1011
/0 Al
11
■REEME■■■■
12
Q ,
13-
_ G5
0
14
61 0A
15-
16-
17-
18-
19-
20
5 1617181920 t__]
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED? �
i 5
IF YES, AT WHAT P1 i� L
DEPTH? ( P
E
Depthto Wale
Monitoring?
Monitoring? Oate:
SITE PLAN
I■■■■■■■
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
.■■■.■■
■
2
/0 Al
■REEME■■■■
■■■■■.■■■■
■■■moo■■■■
■■■E■■■■■■
■■MEM■■■■■
■■■■■■■■■■
■■■■M■■■■■
.■■■■■■N■11
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
2
/0 Al
` w
PERCOLATION RATE 3 (minutes/inch) PERC HOLE DIAMETER �`'
TEST RUN BETWEEN S FT AND 41 FT
PERFORMED BY: S & S ENGINEERINGI eX It ' CERTIFY THAT THIS TEST WAS PERFORMED IN
17034 Eagle River Loop Road No. 204 1 y/ y n / c
ACCORDANCE Wif Ai et,$TVA�tTEA( Mt#ffoAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85) E rt,
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
(ENGINES SEAL)
0d��
/J
Alc
��
�Z /- �`c;; /CE - 8801
PERFORMED FOR: ,b(3 ���� DATE PER FORM
LEGAL DESCRIPTION: 4'r3 lZoel`y bg 4qo� Township, Range, Section:
SLOPE SITE PLAN
1 �
2
3 n(�t
16
17
18
19
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT J014,
DEPTH?
Depth to Water AfWr_,/ /('-40Monitoring? T- Date:
S
L
O
P
E
Q
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
5
�o
o
Q�
6-
7-
78
8-
7-
9
9-
(r*
-3 ^+.
10-
1011
11-
12-
1213
13-
J;
14-
4
V
15
15
—
r%• l h�
16
17
18
19
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT J014,
DEPTH?
Depth to Water AfWr_,/ /('-40Monitoring? T- Date:
S
L
O
P
E
Q
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
P
�o
o
7-
1J ,h
(r*
-3 ^+.
20 -�
11._ JI PERCOLATION RATE 3G'�� (minutes/inch) PERC HOLE DIAMETER _
TEST RUN BETWEEN q, S-
FT AND 375-- FT
COMMENTS
PERFORMED BY: S S ENGINEERING :2W -Sl e e-2zy-, CERTIFY THAT HIS TEST WAS PERFORMED IN
17034 Eagle River LOOP KiDa1
ACCORDANCE WITH T �� /a `'
6b� TAI � $fQp11f�7GU1DELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2750
OWNER OF LAND:
ADDRESS:
LEGAL DESCRIPTION. 07 `
I Z 16
DATE:
PERMIT NUMBER: 1000C Date of Issue - / - 01
TAX IDENTIFICATION NUMBER: 0/- —
Is well located at approved permit location? &fes 'J No
Method of Drilling:,L jarr rotary J cable tool
Depth of well ' i1Z'Kt
Casing Type 376e Wall Thickness " :5 inches
Diameter_ / inches, depth -� feet
Liner Type: A)S-� *"J
Casing Stickup Above Ground: .0 feet
Static Water Level: 3 -:57 feet
Recover Rate: g pm
Method of Testing: d T&AL
Well Intake Opening Type: J open end 4L,@j5e'n hole
Screened; Start feet Stopped feet
,j Perforations Start fe& Stopped feet
Grout Type: tic= r �' C Volume i
Depth: from (9 feet, to p feet
Well Disinfected Upon Completion? J Yes J No
Method of Disinfection:
BORE HOLE DATA
DEPTH
From To
131
1 31 13
Q a
of Sl
Comments:
�O z 44 1
60 E4131 Rio LF �
:3, zVo c x_- rte
Driller's Name�� 1t,.
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality
of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough:
Department of Environmental Conservation.
6,et-z,64
Seig —)z
%Z.
136+9�eaCr�
A!Ee
a, c&
y/.��,�,J
x3z'o'e ;,c k_
am% s
Driller's Name�� 1t,.
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality
of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough:
Department of Environmental Conservation.
P.O. BOX 670272, CHUGIAK, ALASKA 99567 ® TELEPHONE 688-2750
OWNER OF LAND: r? X13 ,h ' Z"^J' BORE HOLE DATA
ADDRESS:
LEGAL DESCRIPTION: 46 f 1 -K 1 9-2c.K 1
4+ 4 cex
DATE: 3 1 la / a,D'0 /
PERMIT NUMBER: D 1000 (A�' Date of Issue /
TAX IDENTIFICATION NUMBER: DSD -OR/ -
Is well located at approved permit location? _jYes j No
Method of Drilling: ' rotary j cable tool
Depth of well: -2 "'�
Casing Type ( ` 'L Wall Thickness —inches
dr
Diameter inches, depth feet
Liner Type: Ap
Casing Stickup Above Ground:
feet
Static Water Level: 45 -
feet
Recover Rate: _ I gpm
Method of Testing: i Ai -,i d o'eo
Fll rg':"1
Well Intake Opening Type: {:fin end rJ open hole
J Screened; Start feet Stopped feet
Perforations Start feej Stopped feet
Grout Type: /9 °� � L Volume
d 00 4,8
Depth: from C feet, to v20 I' feet
Well Disinfected Upon Completion? ,j Yes a No
Method of Disinfection:
Comments:
134: o'ag ctc C'IG
/mss cq/g act<_ 6 AZ tf i
136-yifaGt�
04:V 4 V- c,k C44Y'
Driller's Name /
/3 6RAY
6/?A � Plj
blXtfY
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality
of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. Matsu Borough:
Department of Environmental Conservation.
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
0
ON
, , W STEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued: Jan 10, 2001
Expiration Date: Jan 10, 2002
Permit Number: SW010006
Legal Description: Lot 3 Block 1 Rocky Ledges
Design Engineer: 0003 S & S Engineering
Owner Name: Robert Johnson
Owner Address: PO Box 770456
Eagle River , AK 99577-0456
Parcel ID: 050-081-81
Site Address: 11944 Dee Lane
Lot Size: 94653 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
E Disposal Field ❑� Septic Tank F-] Holding Tank ❑ Privy Private Well Water Storage
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
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
3 -13 iL1,rI 1 �9�i��ea.�i� - /04
oI14E LCA &5�PS TO T ILL IA, 077Wrg L.1VlL .91 )-HF,
L 004r<oAr ro #E w/jejeE ®iei6.1,qj, twnt sere is Opt, rwe Fa,,6.
PL lq P.
Received By:
Issued By:
Date: i 10 ` �
Date: / - /a - d�
Municipality of Anchorage
e Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
®®� (907) 343-7904
O ITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
SAETY
Parcel I 05.0 - 08/ — 8/ Permit Number SWO/0006
Property owner(su r3 ii 2 T T 0 ]w S 0.-J Day phone % g ,� -" , `� 3
Mailing address (1) f • 0. 6 O X• -7 -7Q � S- i'4c `'iL R',r,(c /L I k
Mailing address (2)__// 744 DEE L ApE Zip Code 9 c? 3- 7 7
Legal description (Lot, Block & Sub'd.) )_0-7- 3 fP.K I R a c J< Y L 9�0 G;L s
Legal description (Section, Township & Range)
Lot Size
THIS APPLICATION IS FOR:
Number of Bedrooms 'z
Sewer Only ❑ Well Only ❑
Sewer and Well X Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
5 &SENGINEERING
L
17034 Eagle River Loop Road No. 204
iia le River, Alaska 49577 9V2
(Signature of property owner or authorized agent)
Z -A ,v -
Permit Fees:
Waiver Fees:
Date of Payment: Q %� Date of Payment:
Receipt Number: 0 417 Receipt Number:
(Rev. 12/00)
r
/
Municipality of Anchorage
1
3. TYPE OF WATER SUPPLY:
Development Services Department
Building Safety Division
`•
On -Site Water and Wastewater Program
s ,
— — - -- 4700 South Bragaw St.
❑
P.O. Box 196650 Anchorage. AK 99519-6650
❑
www.ci.anchorage.ak.us
❑
(907)343-7904
❑
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-082-07 HAA#
Expiration Date: 9 //01,2cr.-6
1. GENERAL INFORMATION
Complete legal description Lot 3A; Rocky Ledges Subdivision
Location (site address or directions) 12000 Dee Lane Eagle River, AK 99577
Current Propertyowner(s) RrrnrP Stnrkhnnsp Day phone 6()6-n7oA
Mailing address 4RIIP
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
[
Individual On-site
9
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
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Public Sewer
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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 sample results. (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 certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm S 6 S Engineering Phone
Address 17034 N. Eagle Riva; Loop Ste. 204 Eagle River,
Engineer's Printed Name
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
694-2979
AK 99577
Date __S ///i/v J
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
By: t p,C), Ge Original Certificate Date: lofic-1c' M5
(R.,. OIM2)
Municipality of Anchorage
• ''` Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196550 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lcr '6A -t 2zr0 , sib Parcel ID: 050'-CS2-0?
A. WELL DATA
g
Well type a A2t✓fFit ��j q, g, or C provide PWSID # = Well Log(j9IJ)
*0 1 2-JL7/loot
Date completedr2_-4/,61c, Sanitary seal Wires properly protected (2w)
it I- 3co, . # 1-,jsr 2-t
Total depth*Z-*4ft. Cased tadZ_-eftft. 48 Casing height (above ground) IIZ 4- in.
-1FROM WELL LOG AT INSPECTION
Date of test JS Z
Static water level* (" 35 � - N5 ft. 01-24 *I-aoft.
Well production AI- 46 2- g.p.m. �' I//•12 �t2�.8 9.13 -m -
WATER MPoLE RESULTS: .►t - y ��
Coliformk2- O colonies/100 mi. Nitrate lfZ-N•74ng./l.
isr -Nh a ,>Ialos
Arsenic:rt2• un mg./l. Date of sampleo- 5Ma;
B. SEPTIC/HOLDING TANK DATA ,
Tank Type/Material S Lem fpr tomG
Tank size 13CO gal. / Number of Compartments I
Foundation cleanoull) 2iii Depression over tank (Y/_ _�g
Date of pumping VJEW Pumper
.f. r - C>
Other bacteria*Z- O colonies/100 ml.
Collected by: 54-S fkXz K766QING.
Date installed 7
Cleanouts ttlJ) ` (S S
High water alarm (Y10 N0
C. ABSORPTION FIELD DATA
7
Date installed 0 T Soil rating p.d./ft r ft2/bdrm) • Z System type 500t(LD�k3 "A)04
Length 63' ft. Width S f ft. Gravel below pipe q ft.
Total depth Q ft. Eff. absorption area 1-4-0 ft2 Monitoring tube Y65 Depression over field
Date of adequacy test�? ��KTl;N 1 Results (Pass/Fail) For S 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& type) A.7G If yes, give date —
D. LIFT STATION
Dale installed OfI Size in gallons S50
It n
'Pump on' level at in. "Pump off level at,in.
Datum '9070M Cycles tested tui,
E. SEPARATION DISTANCES
Manhole/Access&N)
High water alarm level at LiQ,n in.
r
Meets alarm 8 circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO: r _ tt►o r�
Septic tank/lift station on lot jE2- 1�'+ On adjacent lots U Z - IOO'
a I - 1008+ z1 - lab I+
Absorption field on lot .. y. - iLV'+ On adjacent lots *%- Wool -
Public sewer main N 14 Public sewer manhole/cleanout N�
xt-no+
Sewer /septic service line AS'+- Holding tank W tQ
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
W I
Building foundation q0t Property line W Absorption field I t7
Water main
r
t' -11k Water service line 10 1- Surface water (00
14,
Wells on adjacent lots loo 1.,L
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I
Property line )lq Building foundation b 2 Water main
A) W
Water Service line 1014- Surface wataK4 l E 40 I + Driveway. parkingNehicle storage 104
Curtain drain Aft -*6 CJu1Gur► t Wells on adjacent lots 100 t{
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that I have determined through fled inspections and
review of Municipal records M44haVbove systems pre in
conformance with MOA HAA ouidelifnesin a fect(on is da(
Engineer's Printed Name
Date
N
HAA Fee $ 57-5a
Date of Payment a, to t-7-
ReceiptNumber678Zz
(Rev. 12/01)
Waiver Fee $
Date of Payment
Receipt Number
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9.cf2
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tiN .. ,•w .0 ,
r.•'. ::!' 1. is !}� .
Robert C.. :!as>,n f'+''• .
r
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r�n� •.Yl.>\
ASL i/ry1'1 i' ..'r
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AS -BUILT
71 hereby certify that 1 have surveyed the fssllsswing described
property: L 07' A y
F;ye_k/\1 Lt; pF Cs !ye'll., _
I,Y/k'/./>F, 2: w,1 -t-i,
Anchorage Recording precinct, Alaska, and that the Improve•
ments situated thereon are within the property lines and do not
overlap or encroach on the property lying adjacent thereto, that
no improvements on property lyingR adjacent thereto encroach
on the premises In question and tFsat there are no roadways,
tranembslon lines or other visible easements on said property
except as indicated hereon.
Dated at Eagle River, Alaska
this _B=? davof Mer fk 21N1?
ROBERT C. 101INSON 7 e cry
SCALE: Registered land Surveyor No. Rett -LS
Box 77.04;6, Eagle River, Alaska 99577
Phone (91x7)644.2543